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NAPLEX (Cardio & Diabetes) > Hypertension > Flashcards

Hypertension Flashcards

1
Q

What are some drugs that can increase BP?

A

1- Stimulants (Amphetamines)
2- Recreational (Cocaine, Caffeine)
3- Decongestants (Pseudoephedrine, phenylephrine)
4-Antidepressants (MAOI, SNRI, TCA)
5-NSAIDs
6- Systemic steroids
7- Cyclosporine

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2
Q

What effect does RAAS have on BP?

A

Increase BP through vasoconstriction (Angiotensin II) and water and sodium retention (Aldosterone)

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3
Q

Which hormones increases so that BP can increase?

A

1- Angiotensinogen
2- Angiotensin 1
3- Angiotensin 2
4- Aldosterone

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4
Q

What is the affect of Angiotensin 2?

A

Increase SVR

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5
Q

What is the effect of Aldosterone?

A

Increase Na and Water reabsorption in collecting duct. Causes an increase in BP

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6
Q

What are the major mechanisms which influence BP?

A

1- RAAS (neurohormones)
2- SNS (Norepinephrine)

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7
Q

What is the role of norepinephrine in BP?

A

1- It acts on the Beta-1 receptors in the heart to increase HR and contractility
2-It acts on the Alpha-1 receptors on the vascular system to increase SVR

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8
Q

What is considered a Normal BP?

A

Systolic: <120 AND
Diastolic: <80

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9
Q

What is considered an Elevated BP?

A

Systolic: 120-129 AND
Diastolic: <80

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10
Q

What is Stage 1 Hypertension?

A

Systolic: 130-139 OR
Diastolic: 80-89

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11
Q

What is Stage 2 Hypertension?

A

Systolic: >= 140 OR
Diastolic: >= 90

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12
Q

What are some Natural Products which MAY help to reduce BP?

A

1- Garlic
2- Fish Oil
3- Coenzyme Q10
4- L-arginine

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13
Q

What are the preferred Drug Classes to initiate treatment of HTN?

A

1- ACE or ARB
2- DHP CCB
3- Thiazide diuretics

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14
Q

When to initiate treatment for HTN?

A

Stage 2: Right Away

Stage 1: If the patient has CVD or ASCVD >=10 years, initiate treatment. If no, lifestyle modification.

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15
Q

What is the goal BP in hypertension?

A

< 130/80 mmHg

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16
Q

Which HTN medication is a preferred first-line drug for black patients?

A
  • Thiazide
  • DHP CCB

*No CKD in these patients

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17
Q

Which HTN medication is preferred in patients with Stage 3 CKD and/or Albuminuria?

A

ACE or ARB

*Stage 3 CKD is eGFR < 60
*Albuminuria is urine albumin >= 30

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18
Q

Which anti-HTN medications is contraindicated in pregnancy?

A

ACE
ARB
Direct renin inhibitor (E.g. Aliskiren)

These medications have a Boxed Warning for fetal toxicity

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19
Q

Which HTN medications is recommended for use in pregnancy?

A

Labetalol (preferred)
Nifedipine ER (preferred)
Methyldopa

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20
Q

How does Thiazide diuretics work?

A

These inhibit sodium reabsorption in the distal convoluted tubules, causing an increased secretion of sodium, chloride, potassium and water.

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21
Q

What are the Thiazide diuretics?

A

1- Chlorthalidone (12.5-25 mg) preferred
2- Hydrochlorothiazide (12.5-50 mg)
3- Chlorothiazide
4- Indapamide
5- Metolazone

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22
Q

Who should not use Thiazide diuretics?

A

1)Those who have a hypersensitivity to sulfonamide-derived drugs.

*Thiazide diuretics are ineffective in eGFR < 30

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23
Q

What are the electrolyte abnormalities of Thiazide diuretics?

A

Decrease in Na, K, Mg
Increase in Ca, uric acid, Blood glucose, TG and LDL levels

*Thiazides may exacerbate gout, diabetes and dyslipidemia!

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24
Q

What are other side effects of thiazides?

A

Photosensitivity, impotence, dizziness

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25
Q

Drug interactions of Thiazide Duiretics?

A

Lithium, Dofetilide

*Thiazides increase the serum concentrations of these medications in the body.

26
Q

How do Calcium-channel blockers work?

A

They inhibit Ca ions from entering the vascular smooth muscle and myocardial cells.

27
Q

What is the difference between DHP and non-DHP CCB?

A

Dihydropyridine CCB has a selectivity for vasculature, resulting in peripheral arterial vasodilation. Used in HTN, angina and Raynaud’s phenomenon.

Non-DHP CCD has a greater selectivity for myocardium cells, resulting in slowed cardiac conduction and contractility. Used in arrythmias, angina, HTN.

28
Q

What are the DHP CCB?

A

‘ipine’

Amlodipine (Norvasc) - preferred
Nifedipine ER (Procardia XL) - preferred
Nicardipine
Felodipine
Isradipine
Nisoldipine ER

IV: Nicardipine - preferred
Clevidipine

29
Q

When should we avoid the use of DHP CCB?

A

Hypotension
Heart Failure
Severe Aortic Stenosis

30
Q

What are the side effects of DHP CCB?

A

Peripheral edema, palpitations, reflex tachycardia, gingival hyperplasia

31
Q

Which formulation of Nifedipine to avoid?

A

Avoid immediate release formulations. Only use ER!

32
Q

What is special about Clevidipine formulation?

A

It is in a lipid emulsion.

Therefore CI if allergic to soy, eggs or soyabeans.

33
Q

What are the non-DHP CCB drugs?

A

Verapamil, Diltiazem

34
Q

What are the contraindications of non-DHP CCB?

A

Hypotension
2nd or 3rd degree heart block
Heart failure
Bradycardia

35
Q

Why are RAAS inhibitors used in hypertension?

A

They decrease blood pressure by inhibiting the effects of Angiotensin II.

36
Q

What are the RAAS Inhibitors?

A

ACE, ARB, Direct renin inhibitor (Aliskiren)

37
Q

When are ACE/ARB preferred?

A

1) CKD (eGFR < 60)
2) Heart failure rEF

38
Q

How does ACE & ARB slow the progression of CKD?

A

They vasodilate of efferent arterioles, resulting in decrease workload in the glomeruli.

  • Blood enters via. Afferent Arteriole, and exits via. Efferent Arteriole. This causes a decrease in the filtration pressure in the glomerulus, decreasing the work of the kidneys.
39
Q

How does ACE & ARB reduce morbidity and mortality in Heart Failure?

A

Angiotensin II contributes to cardiac remodeling which further worsens cardiac function. ACE & ARBs work to block these effects

40
Q

How does ACE inhibitors work?

A

This inhibits the conversion of Angiotensin I to Angiotensin II, by blocking the enzyme ACE. They also block the degradation of bradykinin (causing accumulation), resulting in vasodilation

41
Q

What are some of the main ACEi meds?

A

Lisinopril (Zestril)
Ramipril (Altace)
Benazepril (Lotensin)
Enalapril (Vasotec)
Quinapril (Accupril)

42
Q

What are the Boxed Warning and Contraindications of RAAS inhibitors?

A

-Do NOT use in Pregnancy
-Angioedema
-36 hour washout period of Entresto (Sacubitril/valsartan) use (not ARBs)
-Hyperkalemia

43
Q

How do ARB work?

A

They block Angiotensin II from binding to the AT1 receptor in the vascular smooth muscle, preventing vasoconstriction.

44
Q

What are some ARB drugs?

A

Losartan (Cozaar)
Valsartan (Diovan)
Irbesartan (Avapro)
Olmesartan (Benicar)

45
Q

How does direct renin inhibitors work?

A

Aliskiren (Tekturna) directly inhibits renin, which is responsible for the conversion of Angiotensinogen to Angiotensin I

46
Q

How do Potassium-sparing diuretics work?

A

These act on the collecting duct and distal convoluted tubule. They inhibit the sodium channels, leading the decreased reabsorption of sodium and water.

47
Q

What are the Potassium-sparing diuretic medications?

A

-Triamterene
-Amiloride
-Spironolactone (Aldactone)
-Eplerenone

*Triamterene and Amiloride are used to combat hypokalemia associated with diuretics, due to its potassium sparing properties.

*Spironolactone and Eplerenone are used in resistant hypertension and heart failure.

48
Q

What are some major side effects of Spironolactone?

A

Gynecomastia
Breast tenderness
Impotence

*If patient cannot tolerate this medication due to side effects, they can switch to Eplerenone.

49
Q

How do Beta-blockers work?

A

They decrease blood pressure by competitively blocking Beta 1 and/or Beta 2 adrenergic receptors, resulting in decreased HR and myocardial contractility.

50
Q

Which Beta-blockers are Beta 1 selective?

A

-Atenolol (Tenormin)
-Esmolol (Brevibloc) - IV ONLY!
-Metoprolol tartrate (Lopressor)
-Metoprolol succinate XL (Toprol)
-Nebivolol (Bystolic)

These decrease HR & contractility

51
Q

Which beta-blockers are non-selective (Beta 1 & Beta 2)?

A

-Propranolol (Inderal)
-Nadolol
-Timolol

These decrease HR & contractility + bronchoconstriction.

These are contraindicated in asthma.

52
Q

Which beta-blockers are more non-selective (Beta 1 & 2, Alpha 1)?

A

-Carvedilol (Coreg)
-Labetalol

These decrease HR & contractility + bronchoconstriction + decrease SVR

53
Q

What is the dose conversion for metoprolol tartrate?

A

Converting from IV to PO
1:2.5 (1 IV = 2.5 Oral)

54
Q

Important points about Beta Blockers

A

1) Do not discontinue abruptly; taper over 1-2 weeks
2) Use with caution in diabetes since BB may worsen hypoglycemia AND mask the associated symptoms

55
Q

How do the Centrally-acting Alpha-2 agonists work?

A

They decrease BP by stimulating Alpha-2 receptors in the brain and reducing sympathetic outflow of norepinephrine, which decreased SVR and HR.

Clonidine, Guanfacine, Methyldopa

56
Q

Important information about Clonidine and Guanfacine

A

1) Do not d/c abruptly; taper over 2-4 days (can cause rebound hypertension)

57
Q

What are the Direct Vasodilators?

A

-Hydralazine
-Minoxidil

*These directly vasodilate arterioles.

58
Q

What is a main side effect of peripheral vasodilators?

A

Peripheral edema, Reflex tachycardia

(DHP CCB, direct vasodilators)

59
Q

What is the Boxed Warning for Minoxidil?

A

Peripheral effusion and Angina

-This is because it is a potent vasodilator.
-This agent should be reserved for Resistant Hypertension!
-If this agent is used, it should be given with a beta-blocker to prevent tachycardia, as well as a diuretic to prevent fluid retention!

60
Q

How do Alpha Blockers work?

A

They work by blocking alpha-1 receptors which results in peripheral vasodilation or arterioles and veins.

Doxazosin, Prazosin, Terazosin

*These are not recommended for Hypertension. They are associated with worse CV outcomes.

*These may be used if the patient also have BPH.

61
Q

What is a Hypertensive Crises?

A

This is acute and severe BP elevation (>= 80/120 mmHg). It can either be an urgency or an emergency, depending on if there is end organ damage.

Emergency is end-organ damage. We use IV to treat.

62
Q

What anti-hypertensive meds can be used to treat a Hypertensive Emergency?

A

IV meds only: Decrease BP by 25% in first hour. Then by 160/100 in the next 2-6 hours.

-Chlorothiazide
-Clevidipine
-Nicardipine
-Enalaprilat
-Esmolol
-Labetalol
-Hydralazine
-Diltiazem
-Verapamil
-Metoprolol tartrate
-Propranolol
-Nitroglycerin
-Nitroprusside

NAPLEX (Cardio & Diabetes) (9 decks)

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