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RxPrep > Hypertension > Flashcards

Hypertension Flashcards

1
Q

What is primary (essential) HTN?

A

the cause is unknown, but a combination of risk factors is usually present

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2
Q

What are risk factors for HTN?

A
  1. obesity
  2. sedentary lifestyle
  3. excessive salt intake
  4. smoking
  5. family history
  6. diabetes
  7. dyslipidemia
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3
Q

What is secondary HTN?

A

identifiable underlying cause, such as renal disease, adrenal disease (excess aldosterone secretion), obstructive sleep apnea, or drugs

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4
Q

What is the pathophysiology of HTN?

A

activation of the sympathetic nervous system(SNS) and renin-angiotensin-aldosterone system(RAAS), resulting in an increase in neurohormone levels (NE, angiotensin II, aldosterone)

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5
Q

What drugs increase blood pressure by increasing sympathomimetic activity?

A
  1. ADHD drugs (amphetamine)
  2. decongestants (pseudoephedrine, phenylephrine)
  3. recreational substances (cocaine, caffeine)
  4. antidepressants (TCAs, SNRIs, MAO inhibitors)
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6
Q

What drugs increase blood pressure via increased sodium and water retention?

A
  1. NSAIDs
  2. immunosuppressants (cyclosporine)
  3. systemic steroids
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7
Q

What drugs increase blood pressure via increased blood viscosity?

A

erythropoietin stimulating agents (epoetin alfa)

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8
Q

What other drugs classes are known to increase blood pressure?

A
  1. oral contraceptives (higher estrogen content)
  2. VEGF inhibitors
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9
Q

How is HTN diagnosed?

A

based on the average of at least 2 readings on separate occasions

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10
Q

What type of blood pressure monitoring is preferred?

A

out-of-office BP monitoring with an ambulatory BP monitor or automated home device; BP readings in a clinical setting may be falsely elevated

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11
Q

What blood pressure reading is normal?

A

<120/<80

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12
Q

What blood pressure reading is elevated?

A

120-129/<80

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13
Q

What blood pressure reading is stage 1 HTN?

A

130-139 OR 80-89

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14
Q

What blood pressure reading is stage 2 HTN?

A

≥140 OR ≥90

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15
Q

What should be done before BP readings to ensure accuracy?

A
  1. goto the restroom and empty the bladder
  2. sit in a chair (both feet on the ground supported) and relax for at least 5 minutes
  3. use the correct cuff size
  4. support the arm at the heart level (rest on a desk)
  5. wait 1-2 minutes between measurements
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16
Q

What can reduce the accuracy of BP readings?

A
  1. talking
  2. lying down/sitting without back support (on the examination table)
  3. drink caffeine, exercise, or smoke 30 minutes prior
  4. use a finger or wrist monitor (unless necessary, incorrect cuff size for obese patient)
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17
Q

How should patients monitor BP when using an ambulatory BP monitoring device?

A

typically worn continuously during activities and sleep (24 hours), obtains readings every 15-60 minutes; bring device and BP log to clinic visits

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18
Q

How should patients monitor BP when using a home BP monitoring device?

A

the patient should measure and record the average of at least 2 readings in the morning and evening before eating or taking any medications; bring device and BP log to clinic visits

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19
Q

What are lifestyle modifications to treat HTN?

A
  1. weight loss (1kg loss–> 1mmHg decrease)
  2. heart-healthy diet (DASH diet; high in fruits vegetables fiber and low-fat dairy, low in saturated fat and sugar)
  3. adequate dietary potassium intake or supplementation if not CI (CKD)
  4. sodium intake <1,500mg/day
  5. limited alcohol consumption (<1 drink woman and ≤2 men per day)
  6. tobacco cessation
  7. diabetes and cholesterol mamangement
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20
Q

What natural products can be used to treat (or supplement) hypertension?

A

garlic and fish oil; counsel patients that both products can increase the risk of bleeding (stop before procedures, etc)

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21
Q

Which anti-HTN medications have boxed warnings for teratogenicity and should be discontinued if family planning or pregnant?

A
  1. ACE/ ARB
  2. Aliskiren (direct renin inhibitor)
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22
Q

What oral antihypertensives are preferred in pregnancy?

A
  1. labetalol
  2. nifedipine
  3. extended-release methyldopa (less effective at lowering BP)
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23
Q

What is the BP goal for pregnancy?

A

120-139/80-89

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24
Q

What is the difference between gestational HTN and preeclampsia?

A

both defined as new onset HTN after 20 weeks gestation; preeclampsia also has proteinuria and significant end-organ dysfunction

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25
Q

What IV antihypertensive agents may be used in severe cases of gestational HTN, preeclampsia, and chronic HTN in pregnancy?

A
  1. IV labetalol
  2. IV hydralazine
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26
Q

What are ACC/AHA HTN treatment principles?

A
  1. emphasize lifestyle modifications
  2. treatment initiation is based on stage and ASCVD risk
  3. QD regimens and combination products preferred for adherence
  4. agents for the 4 preferred classes should be used first
  5. when titrating medications, adding a second medication before reaching the maximum dose of the first can be more effective with fewer SEs
    6.Do not use ACE and ARBs together
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26
Q

When should HTN treatment be initiated?

A

Stage 2 HTN
OR
Stage 1 HTN AND 1 of the following:
1. clinical CVD (stroke, HF, or coronary heart disease)
2. 10-year ASCVD risk ≥10%
3. does not meet BP goal after 6 months of lifestyle modification

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27
Q

What are the 4 preferred drug classes for HTN?

A
  1. Thiazide diuretic (may be preferred in self-identified black patients)
  2. Dihydropyridine CCB (may be preferred in self-identified black patients)
  3. ACE inhibitor
  4. ARB
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28
Q

What are the preferred drug classes in stage 3 CKD (eGFR <60) or albuminuria ≥ 30mg/day)?

A

ACE or ARB

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29
Q

What should 2 drugs be initiated at once?

A

When BP is >20/10mmHg above goal (>150/90)

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30
Q

How often should BP be monitored by a clinician?

A

every months and titrate medications to goal BP

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31
Q

What is goal BP in those with HTN and CKD?

A

<130/80; (2021 KDIGO BP in CKD goal SBP <120 if tolerated)

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32
Q

What is the MOA of thiazide diuretics?

A

inhibit sodium reabsorption in the distal convoluted tubule causing increased sodium, chloride, potassium, and water excretion

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33
Q

What is the dosing for chlorthalidone?

A

12.5-25mg QD

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34
Q

What is the typical dosing for hydrochlorothiazide?

A

12.5-50mg daily

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35
Q

What is the typical dosing of chlorothiazide?

A

500-2000mg QD 1-2 doses

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36
Q

What is the typical dosing for indapamide (thiazide)?

A

1.25-2.5mg QD

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37
Q

What is the typical dosing for metolazone (thiazide)?

A

2.5-5mg

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38
Q

What are CIs to using thiazides?

A
  1. hypersensitivity to sulfonamide drugs (not likely to cross-react)
  2. anuria
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39
Q

What are warnings with thiazides?

A
  1. can precipitate/ exacerbate other conditions like lupus, gout, dyslipidemia, and diabetes
  2. severe renal disease (can precipitate azotemia; build-up of nitrogenous waste products)
  3. progressive liver disease (fluid and electrolyte changes can precipitate hepatic come)
  4. transient myopia or acute angle glaucoma
40
Q

What are SEs with thiazides?

A
  1. decreased K,Mg,Na
  2. increased Ca, LDL, TG, BG, UA
  3. photosensitivity (including a small risk of non-melanoma skin cancer)
  4. impotence
  5. dizziness
  6. rash
41
Q

What should be monitored with thiazides?

A
  1. electrolytes
  2. renal function
  3. fluid status (input and output, weight)
  4. BP
42
Q

Which thiazide diuretic is available IV?

A

chlorothiazide

43
Q

Why should thiazide diuretics (except metolazone) not be used with CrCl <30?

A

diminished diuretic effect

44
Q

What are counseling points on administration of thiazide?

A
  1. take early in the morning to avoid nocturia
  2. encourage intake of vitamin-rich foods or supplement to avoid hypokalemia; may consider K-sparing diuretic if not at goal
45
Q

Which diuretic is considered more effective at lowering BP due to its longer duration of action and increased potency?

A

chlorthalidone

46
Q

What drugs can decrease the effectiveness of thiazide diuretics due to sodium and water retention?

A

NSAIDs (avoid in cardiovascular disease if possible)

47
Q

What drugs interact with thiazides requiring dosage adjustment?

A

lithium; decreased renal clearance of Li increases risk of toxicity

48
Q

What drug can increase risk of QT prolongation and should not be used with thiazide diuretics?

A

increased dofetilide concentration

49
Q

Chlorthiazide

A

Diuril

50
Q

Lisinoprol/ Hydrochlorothiazide

A

Zestoretic

51
Q

Losartan/ HCTZ

A

Hyzaar

52
Q

Olmesartan/HCTZ

A

Benicar HCT

53
Q

Bezapril/HCTZ

A

Lotensin HCT

54
Q

Candesartan/ HCTZ

A

Atacand HCT

55
Q

Enalapril/HCTZ

A

Vaseretic

56
Q

Azilsartan/HCTZ

A

Edarbyclor

57
Q

Irbesartan/HCTZ

A

Avalide

58
Q

Telmisartan/HCTZ

A

Micardis HCT

59
Q

Benazepril/Amlodipine

A

Lotrel

60
Q

Valsartan/ Amlodipine

A

Exforge

61
Q

olmesartan/amlodipine

A

Azor

62
Q

perindopril/amlodipine

A

Prestalia

63
Q

Atenolol/chlorthalidone

A

Tenoretic

64
Q

Bisoprolol /HCTZ

A

Ziac

65
Q

Triamterene/HCTZ

A

Maxzide, Maxzide-25

66
Q

Spironolactone/ HCTZ

A

Aldactazide

67
Q

Olmesartan/Amlodipine/HCTZ

A

Tribenzor

68
Q

Valsartan/Amlodipine/HCTZ

A

Exforge HCT

69
Q

What is the MOA of DHP CCBs (-pine)?

A

more selective for vascular smooth muscle –> peripheral arterial vasodilation–> decreases systemic vascular resistance (SVR) and BP

70
Q

What are the indications for DHP CCBs?

A
  1. HTN
  2. chronic stable and vasospastic angina
  3. Raynaud’s phenomenon (cold/blue fingertips secondary to peripheral vasoconstriction)
71
Q

What are CIs with DHP CCBs?

A

Nicardipine should not be used in advanced aortic stenosis

72
Q

What are the warnings with DHP CCBs?

A
  1. hypotension (especially with advanced aortic stenosis)
  2. worsening angina and/or MI
  3. severe hepatic impairment
  4. caution in HF
73
Q

What are the warnings with Nicardipine IR?

A

do not use for chronic hypertension or acute BP reduction in non-pregnant adults

74
Q

What are SEs with DHP CCB?

A
  1. peripheral edema
  2. headache
  3. flushing
  4. palpitations
  5. reflex tachycardia
  6. gingival hyperplasia (or over growth)
  7. fatigue/nausea
75
Q

What should be monitored when taking DHP CCBs?

A
  1. peripheral edema
  2. BP
  3. HR
76
Q

Which DHP CCB is the DOC in pregnancy?

A

Nifedipine ER

77
Q

Which DHP CCB is considered safe if a CCB must be used in someone with HFrEF?

A

Amlodipine

78
Q

Which DHP CCB can leave a ghost tablet that patients need to be counseled on?

A

Procardia XL: OROS/gel matrix formulation

79
Q

Amlodipine

A

Norvasc
Katerzia (suspension)
Norliqva (solution)

80
Q

Nicardipine

A

Cardene IV

81
Q

Nifedipine

A

Procardia XL
Adalat CC (brad d/c)

82
Q

Clevidipine

A

Cleviprex

83
Q

Which DHP CCB is dosed BID?

A

felodipine

84
Q

Nisoldipine ER

A

Sular 17-34mg

85
Q

What are CIs to using clevidipine?

A
  1. allergy to soybean, soy products, or eggs
  2. defective lipid metabolism (lipoid nephrosis, hyperlipidemia with acute pancreatitis)
  3. severe aortic stenosis
86
Q

What are the warnings with clevidipine?

A
  1. hypotension
  2. reflex tachycardia
  3. infections (strict aseptic technique due to infection risk; maximum time of use after vial puncture if 12 hours) 4. milky white in color
87
Q

What are SEs with clevidipine?

A
  1. hypertriglyceridemia
  2. headache
  3. AF
  4. heache
88
Q

How much nutritional value is in clevidipine?

A

2kcal/mL

89
Q

What is the MOA of non-DHP CCBs?

A

more selective for myocardium; negative inotrope (decreased force of contraction) and chronotropic (decreased heart rate) effects

90
Q

What indications are non-DHP CCBs most commonly used for?

A
  1. control HR in certain arrhythmias (AF)
  2. chronic stable and vasospastic angina
  3. hypertension
91
Q

What are CIs to using non-DHP CCBs?

A
  1. hypotension (SBP<90) or cardiogenic shock
  2. 2nd or 3rd degree AV block
  3. sick sinus syndrome (unless patient has a functioning artificial ventricular pacemaker)
  4. AF/atrial flutter and accessory bypass tract
  5. concurrent use with IV beta-blocker (IV CCBs only)
  6. acute MI and pulmonary congestion (diltiazem))
  7. severe left ventricular dysfunction (verapamil
92
Q

What are warnings with non-DHP CCBs

A
  1. HF (may worsen symptoms)
  2. bradycardia
  3. hypotension
  4. acute liver injury/ elevated LFTs
  5. conduction abnormalities (diltiazem)
  6. hypertrophic cardiomyopathy (verapamil)
93
Q

What are SEs with non-DHP CCBs?

A
  1. constipation (moe with verapamil)
  2. gingival hyperplasia
  3. edema (more with diltiazem)
  4. cutaneous hypersensitivity reactions (diltiazem)
  5. headache
  6. dizziness
94
Q

What is monitored with non-DHP CCBs?

A
  1. BP
  2. HR
  3. ECG
  4. LFTs
95
Q

Diltiazem

A

Cardizem
Tiazac

96
Q

Which non DHP CCBs are available as injections?

A

diltiazem and verapamil

97
Q

Verapimil

A

Calan SR
Verelan
Verelan PM

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