Hypertension Flashcards
What classifies normal blood pressure?
<120mmHg/<80mmHg
What classifies elevated blood pressure?
120-129mmHg/<80mmHg
What is the classification of stage 1 hypertension?
130-139mmHg/80-89mmHg
What is the classification of stage 2 hypertension?
140+ mmHg/ 90+ mmHg
What is Isolated Systolic Hypertension (ISH)?
a condition in which SBP is 130+ mmHg, but DBP is < 80 mmHg that is associated with increased risk of cardiovascular events, stroke, and kidney disease progression
What is the relationship between blood pressure and CV morbidity/mortality?
there is a strong correlation between BP and CV morbidity and mortality
-the risk of negative outcomes is lowest at a BP of 115/75mmHg
-above 115/75mmHg, with each increment of 20mmHg SBP or 10 mmHg DBP, the risk of CV DOUBLES
What is primary hypertension?
aka essential HTN and accounts for 95% of cases, linked to: genetics, environmental factors, and aging
What are causes of secondary HTN?
-chronic kidney disease
-renovascular disease
-primary aldosteronism
-obstructive sleep apnea
-pheochromocytoma
-cushing’s syndrome
-hyper/hypothyroididm
-coarctation of the aorta
What substance/drugs may elevate blood pressure?
-alcohol
-antidepressants
-caffeine
-calcineurin inhibitors
-cocaine, amphetamines, other illicit drugs
-corticosteroids
-dietary supplements
-erythropoietin
-hormones
-NSAIDs, COX inhibitors
-oral decongestants
-stimulants
-vascular endothelial growth factor inhibitors
What are the complications associated with hypertension?
-heart disease
-stroke or transient ischemic attack (TIA)
-nephropathy/chronic kidney disease (CKD)
-retinopathy
-peripheral arterial disease (PAD)
-carotid artery disease (CAD)
-aortic aneurysm (AA)
What are modifiable risk factors for hypertension?
-current cigarette smoking and/or secondhand smoke exposure
-diabetes mellitus (DM)
-dyslipidemia
-overweight/obesity
-physical inactivity
-unhealthy diet
What are the relatively fixed risk factors for hypertension?
-CKD
-family history
-increased age
-low socioeconomic/educational status
-male sex
-obstructive sleep apnea
-psychosocial stress
How is blood pressure diagnosed?
use proper blood pressure technique and obtain 2 readings obtained on 2 or more occasions to estimate and classify BP
What is the optimal BP for someone with hypertension and <65 yo?
<130/80 mmHg
What is the target BP for someone with DM?
<130/80 mmHg
What is the target BP for someone with Kidney Disease?
SBP < 120 mmHg
What is the optimal BP for someone with hypertension and >65 yo?
140/90 mmHg
What is treatment for a pt with stage 1 HTN and ASCVD risk < 10%?
nonpharm therapy only and reassess in 3-6 months and initiate drug therapy if not at goal by 6 months
What is treatment for a pt with stage 1 HTN and ASCVD risk > 10% OR pt has DM or CKD?
initiate drug therapy
What is treatment for a pt with stage 2 HTN?
initiate drug therapy with at least 2 medications from different drug classes
What is the treatment for secondary prevention of HTN?
initiate drug therapy (typically at 130/80) where the number and type of drugs are influenced by co-morbid conditions
What drugs are Thiazides and Thiazide-like Diuretics?
-cholorothiazide
-hydrochlorothiazide
-chlorothalidone
-indapamide
-metolazone
What is the mechanism of action of Thiazide Diuretics?
blocks sodium (Na+) reabsorption in the distal tubule -> increased Na+/H2O excretion, K+ excretion, and decreased blood volume
What are the adverse effects of Thiazide Diuretics?
-hyperuricemia (elevated uric acid)
-hyperglycemia (high blood sugar)
-hypercholesterolemia (high cholesterol)
- hypertriglyceridemia (high triglycerides)
-hypokalemia (low potassium) THIS IS DOSE DEPENDENT
What labs must be monitored when taking Thiazide Diuretics?
potassium (K+)
Thiazides + ___________ have been shown to reduce the incidence of recurrent stroke.
ACE inhibitors
What diuretic may be preferred on the basis of it’s long half-life and proven CVD risk reduction?
chlorothalidone
Thiazides are generally ineffective in patients with a eGFR ________.
< 30 mL/min
Thiazide Diuretics must be used in caution with what disease state?
gout, if not on uric acid lowering therapy
What are the drug interactions of Thiazide Diuretics?
NSAIDs can weaken BP-lowering effects
What drugs are Loop Diuretics?
-bumetanide
-ethacrynic acid
-furosemide
-torsemide
What is the mechanism of action of Loop Diuretics?
block sodium (Na+) reabsorption in the ascending loop of Henle -> increased Na+/H2O excretion, K+ excretion, and decreased blood volume
What are the adverse effects of Loop Diuretics?
-hyperuricemia (high uric acid)
-hyperglycemia (high blood sugar)
-hypercholesterolemia (high cholesterol)
-hypertriglyceridemia (high TG)
-hypokalemia (low potassium) THIS IS DOSE DEPENDENT
What labs must be monitored while taking Loop Diuretics?
potassium (K+)
__________ is preferred for symptomatic relief in patients with heart failure or those at risk for fluid overload.
Loop Diuretics
What are the drug interactions of Loop Diuretics?
NSAIDs
What drugs are Potassium-sparing Diuretics?
amiloride and triamterene
What drugs are Aldosterone Antagonists?
spironolactone and eplerenone
What is the MOA of Potassium-sparing Diuretics?
interferes with the potassium sodium exchange in the distal tubule/collecting duct, excretes Na+ and H2O while retaining potassium (K+)
What are the adverse effects of Potassium-sparing Diuretics?
-hyperkalemia (high potassium)
-gynecomastia
-rash
-GI disturbances
What disease states should Potassium-sparing Diuretics not be used in?
renal dysfunction or pt at risk for hyperkalemia
What are the drug interactions of Potassium-sparing Diuretics?
-K+ supplements or other K+ sparing diuretics
-ACE inhibitors
-angiotensin II receptor blockers (ARBs)
-direct renin inhibitors
Spironolactone is especially useful as __________________________.
add-on therapy for patients with treatment resistant HTN
What drugs Angiotensin Converting Enzyme Inhibitor (ACEI)?
-pril’s
-benazepril
-lisinopril
-ramipril
What is the mechanism of action of angiotensin converting enzyme inhibitors (ACEIs)?
inhibit angiotensin converting enzyme (ACE), blocking the conversion of Angiotensin I to Angiotensin II which causes increased vasoconstriction, Na+/H2O retention, and increased aldosterone
What are the adverse effects Angiotensin Converting Enzyme Inhibitors (ACEIs)?
-hyperkalemia
-cough (kinin-mediated)
-angioedema
-acute renal failure in patients with bilateral RAS
-increased fetal mortality
What are the monitoring parameters for Angiotensin Converting Enzyme Inhibitors (ACEIs)?
-potassium (K+)
-serum creatine
What pt may benefit from ACEIs?
-pt in the remodeling phase post MI
-high coronary risk pts
-can reduce proteinuria and retard the progression of kidney disease in both diabetic and nondiabetic nephropathy
What are the contraindications of ACEIs?
-pregnancy and breastfeeding
-bilateral RAS
-history of angioedema secondary to prior ACEI use
What are the drug interactions of ACEIs?
-K+ supplements
-K+ sparing diuretics
-angiotensin II receptor blockers (ARBs)
-direct renin inhibitors (DRIs)
What drugs are Angiotensin II Receptor Blockers (ARBs)?
-sartan
-irbesartan
-losartan
-olmesartan
-valsartan
What are the contraindications of ARBs?
-pt with bilateral RAS
-pregnancy and breastfeeding
What is the mechanism of action of Angiotensin II Receptor Blocker (ARBs?
directly antagonize angiotensin II receptors, sparing angiotensin converting enzyme (ACE)
What are the adverse effects of Angiotensin Receptor Blockers (ARBs)
-hyperkalemia (high potassium)
-angioedema
-acute renal failure in patients with bilateral RAS
-increased fetal mortality
What are the indications of Angiotensin II Receptor Blocker (ARBs)?
-delayed the progression of kidney disease in type 2 DM
-high coronary risk pt, but not demonstrated superiority over ACEIs
-pt who are intolerant to ACEIs due to cough, but NOT angioedema!
What are the drug interactions of ARBs?
-K+ supplements
-K+ sparing diuretics
-direct renin inhibitors (DRIs)
What drugs are Beta Blockers (BBs)?
-olol
-atenolol
-metoprolol tartate/succinate
-propranolol
What is the mechanism of action of Beta Blockers?
directly block adrenergic stimulation of beta receptors resulting in decreased chronotropy and intropy
What are the adverse effects of Beta Blockers?
-bradycardia
-fatigue
-depression
-decreased exercise tolerance
-bronchospasm
-mask signs and symptoms of hypoglycemia
-insomnia
-impotence
-hypertriglyceridemia
-worsening HF
What are the monitoring parameters for ARBs?
-potassium (K+)
-serum creatine
What are the monitoring parameters for Beta Blockers?
heart rate
What disease states are Beta Blockers contraindicated in or should be used with caution?
-relatively contraindicated in asthma and COPD
-contraindicated in pt with 2nd and 3rd degree heart block
-caution with DM
What are the indications of Beta Blockers?
no longer recommended as initial therapy for hypertension in the absence of certain co-morbid conditions!
-prevent re-infarction in post-MI pts
-angina
-tachycardia
-Afib
-pt who also have migraines
What drugs are Calcium Channel Blockers (CCBs)?
-non-DHPs: diltiazem and verapamil
-DPHs: -ipine; amlodipine, nifedipine
What is the mechanism of action of Calcium Channel Blockers (CCBs)?
impair the transport of calcium through voltage-sensitive calcium channels- NON-DHPs work directly on the myocardium and DHPs work on the peripheral vasculature
What are the adverse effects of Calcium Channel Blockers (CCBs)?
-peripheral edema (DHP, dose related and more common in women)
-constipation (verapamil is the worst offender)
-bradycardia (non-DHP)
-reflex tachycardia (DPH)
What are the monitoring parameters for Calcium Channel Blockers (CCBs)?
heart rate
What are the indications of Calcium Channel Blockers (CCBs)?
effective at lowering BP in all racial/ethnic groups!
-long-acting DHPs reduce CV events and stroke in pt with HTN
-non-DHP may be useful in pt with tachycardia and Afib, but are contraindicated in HFrEF but could be used in HFpEF
-non-DHP reduce proteinuria and can be used if pt are intolerant to ACEI or ARB
-improve GFR and kidney survival following renal transplant
What drugs are Alpha1 Blockers?
-azosin
-doxazosin
-prazosin
-terazosin
What is the mechanism of action of Alpha1 Blockers?
inhibit adrenergic stimulation on peripheral alpha1 receptors resulting in reduced peripheral vascular resistance and vasodilation
What are the adverse effects of Alpha1 Blockers?
-syncope/orthostatic hypotension
-dizziness
-headache
-drowsiness
-reflex tachycardia
What drug should Alpha1 Blockers be combined with to be maximally effective?
diuretics
Alpha1 Blockers may be especially useful if pts have concomitant ________ or in ________ HTN.
BPH, treatment resistant
What drugs are Alpha-Beta Blockers?
-carvedilol
-labetalol
What are the adverse effects of Alpha-Beta Blocker?
-bradycardia
-orthostatic hypotension
-dizziness
-headache
Labetalol, given IV, is used for ____________.
hypertensive emergencies
What drugs are centrally acting Alpha2 Agonists?
clonidine
What are the adverse effects of centrally acting Alpha2 Agonists?
-drowsiness
-sedation
-fatigue
-depression
-dry mouth
-orthostasis
-bradycardia
-heart block
-rebound hypertension
Clonidine, given orally, is used in _____________.
hypertensive urgencies
What drugs are direct vasodilators?
-hydralazine
-minoxidil
What are the adverse effects of direct vasodilators?
-reflex tachycardia
-headache
-dizziness
-lupus-like symptoms (at high doses)
-edema
What is the black box warning associated with Minoxidil?
concomitant antihypertensive use needed to prevent tachycardia and edema
What drugs are direct renin inhibitors?
aliskiren
What are the side effects of direct renin inhibitors?
-diarrhea
-abdominal pain/dyspepsia
-cough
-angioedema
-rash
-hyperkalemia
For black patients, initial treatment for HTN should include __________.
thiazide diuretic or calcium channel blocker
What drug classes indicated for HTN should be avoided in pregnancy?
ACEIs, ARBs, aliskiren
What drug classes indicated for HTN should be avoided in pt with recent MI?
beta blockers with ISA, atenolol, and DHP calcium channel blockers
Define: Hypertensive Urgency
BP > 180/120 mmHg and not associated with acute or immediately progressing target organ injury
What short acting oral antihypertensives can be given acutely for hypertensive urgencies?
-captopril 25-50mg po every 1-2h
-clonidine 0.2mg po every hour
-labetalol 200-400 mg po every 2-3h
Define: Hypertensive Emergency
BP > 180/120 mmHg and is associated with acute or immediately progressing target organ injury
Indication for parenteral drug for hypertensive emergency, clovidipine:
calcium channel blocker
-acute pulmonary edema
-perioperative HTN
-acute renal failure
Indication for parenteral drug for hypertensive emergency, enalaprilat:
ACEI
-acute left ventricular failure
-high plasma renin activity
Indication for parenteral drug for hypertensive emergency, esmolol:
beta blocker
-aortic dissection
-perioperative
-acute coronary syndrome
Indication for parenteral drug for hypertensive emergency, hydralazine:
vasodilator
-eclampsia
-preeclampsia
Indication for parenteral drug for hypertensive emergency, labetalol:
alpha/beta blocker
-acute coronary syndrome
-aortic dissection
-eclampsia
-preeclampsia
Indication for parenteral drug for hypertensive emergency, nicardipine:
calcium channel blocker
-acute renal failure
-eclampsia
-preeclampsia
-perioperative
-acute sympathetic dischange
Indication for parenteral drug for hypertensive emergency, nitroglycerine:
vasodilator
-coronary ischemia
-pulmonary edema
-perioperative
Indication for parenteral drug for hypertensive emergency, phentoamine:
alpha blocker
-acute sympathetic discharge (drug overdoses or clonidine withdrawal)
Indication for parenteral drug for hypertensive emergency, sodium nitroprusside:
vasodilator
DRUG OF CHOICE
-pulmonary edema
