Hypertension Flashcards
What is primary (essential) HTN?
the cause is unknown, but a combination of risk factors is usually present
What are risk factors for HTN?
- obesity
- sedentary lifestyle
- excessive salt intake
- smoking
- family history
- diabetes
- dyslipidemia
What is secondary HTN?
identifiable underlying cause, such as renal disease, adrenal disease (excess aldosterone secretion), obstructive sleep apnea, or drugs
What is the pathophysiology of HTN?
activation of the sympathetic nervous system(SNS) and renin-angiotensin-aldosterone system(RAAS), resulting in an increase in neurohormone levels (NE, angiotensin II, aldosterone)
What drugs increase blood pressure by increasing sympathomimetic activity?
- ADHD drugs (amphetamine)
- decongestants (pseudoephedrine, phenylephrine)
- recreational substances (cocaine, caffeine)
- antidepressants (TCAs, SNRIs, MAO inhibitors)
What drugs increase blood pressure via increased sodium and water retention?
- NSAIDs
- immunosuppressants (cyclosporine)
- systemic steroids
What drugs increase blood pressure via increased blood viscosity?
erythropoietin stimulating agents (epoetin alfa)
What other drugs classes are known to increase blood pressure?
- oral contraceptives (higher estrogen content)
- VEGF inhibitors
How is HTN diagnosed?
based on the average of at least 2 readings on separate occasions
What type of blood pressure monitoring is preferred?
out-of-office BP monitoring with an ambulatory BP monitor or automated home device; BP readings in a clinical setting may be falsely elevated
What blood pressure reading is normal?
<120/<80
What blood pressure reading is elevated?
120-129/<80
What blood pressure reading is stage 1 HTN?
130-139 OR 80-89
What blood pressure reading is stage 2 HTN?
≥140 OR ≥90
What should be done before BP readings to ensure accuracy?
- goto the restroom and empty the bladder
- sit in a chair (both feet on the ground supported) and relax for at least 5 minutes
- use the correct cuff size
- support the arm at the heart level (rest on a desk)
- wait 1-2 minutes between measurements
What can reduce the accuracy of BP readings?
- talking
- lying down/sitting without back support (on the examination table)
- drink caffeine, exercise, or smoke 30 minutes prior
- use a finger or wrist monitor (unless necessary, incorrect cuff size for obese patient)
How should patients monitor BP when using an ambulatory BP monitoring device?
typically worn continuously during activities and sleep (24 hours), obtains readings every 15-60 minutes; bring device and BP log to clinic visits
How should patients monitor BP when using a home BP monitoring device?
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
What are lifestyle modifications to treat HTN?
- weight loss (1kg loss–> 1mmHg decrease)
- heart-healthy diet (DASH diet; high in fruits vegetables fiber and low-fat dairy, low in saturated fat and sugar)
- adequate dietary potassium intake or supplementation if not CI (CKD)
- sodium intake <1,500mg/day
- limited alcohol consumption (<1 drink woman and ≤2 men per day)
- tobacco cessation
- diabetes and cholesterol mamangement
What natural products can be used to treat (or supplement) hypertension?
garlic and fish oil; counsel patients that both products can increase the risk of bleeding (stop before procedures, etc)
Which anti-HTN medications have boxed warnings for teratogenicity and should be discontinued if family planning or pregnant?
- ACE/ ARB
- Aliskiren (direct renin inhibitor)
What oral antihypertensives are preferred in pregnancy?
- labetalol
- nifedipine
- extended-release methyldopa (less effective at lowering BP)
What is the BP goal for pregnancy?
120-139/80-89
What is the difference between gestational HTN and preeclampsia?
both defined as new onset HTN after 20 weeks gestation; preeclampsia also has proteinuria and significant end-organ dysfunction
What IV antihypertensive agents may be used in severe cases of gestational HTN, preeclampsia, and chronic HTN in pregnancy?
- IV labetalol
- IV hydralazine
What are ACC/AHA HTN treatment principles?
- emphasize lifestyle modifications
- treatment initiation is based on stage and ASCVD risk
- QD regimens and combination products preferred for adherence
- agents for the 4 preferred classes should be used first
- 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
When should HTN treatment be initiated?
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
What are the 4 preferred drug classes for HTN?
- Thiazide diuretic (may be preferred in self-identified black patients)
- Dihydropyridine CCB (may be preferred in self-identified black patients)
- ACE inhibitor
- ARB
What are the preferred drug classes in stage 3 CKD (eGFR <60) or albuminuria ≥ 30mg/day)?
ACE or ARB
What should 2 drugs be initiated at once?
When BP is >20/10mmHg above goal (>150/90)
How often should BP be monitored by a clinician?
every months and titrate medications to goal BP
What is goal BP in those with HTN and CKD?
<130/80; (2021 KDIGO BP in CKD goal SBP <120 if tolerated)
What is the MOA of thiazide diuretics?
inhibit sodium reabsorption in the distal convoluted tubule causing increased sodium, chloride, potassium, and water excretion
What is the dosing for chlorthalidone?
12.5-25mg QD
What is the typical dosing for hydrochlorothiazide?
12.5-50mg daily
What is the typical dosing of chlorothiazide?
500-2000mg QD 1-2 doses
What is the typical dosing for indapamide (thiazide)?
1.25-2.5mg QD
What is the typical dosing for metolazone (thiazide)?
2.5-5mg
What are CIs to using thiazides?
- hypersensitivity to sulfonamide drugs (not likely to cross-react)
- anuria
What are warnings with thiazides?
- can precipitate/ exacerbate other conditions like lupus, gout, dyslipidemia, and diabetes
- severe renal disease (can precipitate azotemia; build-up of nitrogenous waste products)
- progressive liver disease (fluid and electrolyte changes can precipitate hepatic come)
- transient myopia or acute angle glaucoma
What are SEs with thiazides?
- decreased K,Mg,Na
- increased Ca, LDL, TG, BG, UA
- photosensitivity (including a small risk of non-melanoma skin cancer)
- impotence
- dizziness
- rash
What should be monitored with thiazides?
- electrolytes
- renal function
- fluid status (input and output, weight)
- BP
Which thiazide diuretic is available IV?
chlorothiazide
Why should thiazide diuretics (except metolazone) not be used with CrCl <30?
diminished diuretic effect
What are counseling points on administration of thiazide?
- take early in the morning to avoid nocturia
- encourage intake of vitamin-rich foods or supplement to avoid hypokalemia; may consider K-sparing diuretic if not at goal
Which diuretic is considered more effective at lowering BP due to its longer duration of action and increased potency?
chlorthalidone
What drugs can decrease the effectiveness of thiazide diuretics due to sodium and water retention?
NSAIDs (avoid in cardiovascular disease if possible)
What drugs interact with thiazides requiring dosage adjustment?
lithium; decreased renal clearance of Li increases risk of toxicity
What drug can increase risk of QT prolongation and should not be used with thiazide diuretics?
increased dofetilide concentration
Chlorthiazide
Diuril
Lisinoprol/ Hydrochlorothiazide
Zestoretic
Losartan/ HCTZ
Hyzaar
Olmesartan/HCTZ
Benicar HCT
Bezapril/HCTZ
Lotensin HCT
Candesartan/ HCTZ
Atacand HCT
Enalapril/HCTZ
Vaseretic
Azilsartan/HCTZ
Edarbyclor
Irbesartan/HCTZ
Avalide
Telmisartan/HCTZ
Micardis HCT
Benazepril/Amlodipine
Lotrel
Valsartan/ Amlodipine
Exforge
olmesartan/amlodipine
Azor
perindopril/amlodipine
Prestalia
Atenolol/chlorthalidone
Tenoretic
Bisoprolol /HCTZ
Ziac
Triamterene/HCTZ
Maxzide, Maxzide-25
Spironolactone/ HCTZ
Aldactazide
Olmesartan/Amlodipine/HCTZ
Tribenzor
Valsartan/Amlodipine/HCTZ
Exforge HCT
What is the MOA of DHP CCBs (-pine)?
more selective for vascular smooth muscle –> peripheral arterial vasodilation–> decreases systemic vascular resistance (SVR) and BP
What are the indications for DHP CCBs?
- HTN
- chronic stable and vasospastic angina
- Raynaud’s phenomenon (cold/blue fingertips secondary to peripheral vasoconstriction)
What are CIs with DHP CCBs?
Nicardipine should not be used in advanced aortic stenosis
What are the warnings with DHP CCBs?
- hypotension (especially with advanced aortic stenosis)
- worsening angina and/or MI
- severe hepatic impairment
- caution in HF
What are the warnings with Nicardipine IR?
do not use for chronic hypertension or acute BP reduction in non-pregnant adults
What are SEs with DHP CCB?
- peripheral edema
- headache
- flushing
- palpitations
- reflex tachycardia
- gingival hyperplasia (or over growth)
- fatigue/nausea
What should be monitored when taking DHP CCBs?
- peripheral edema
- BP
- HR
Which DHP CCB is the DOC in pregnancy?
Nifedipine ER
Which DHP CCB is considered safe if a CCB must be used in someone with HFrEF?
Amlodipine
Which DHP CCB can leave a ghost tablet that patients need to be counseled on?
Procardia XL: OROS/gel matrix formulation
Amlodipine
Norvasc
Katerzia (suspension)
Norliqva (solution)
Nicardipine
Cardene IV
Nifedipine
Procardia XL
Adalat CC (brad d/c)
Clevidipine
Cleviprex
Which DHP CCB is dosed BID?
felodipine
Nisoldipine ER
Sular 17-34mg
What are CIs to using clevidipine?
- allergy to soybean, soy products, or eggs
- defective lipid metabolism (lipoid nephrosis, hyperlipidemia with acute pancreatitis)
- severe aortic stenosis
What are the warnings with clevidipine?
- hypotension
- reflex tachycardia
- infections (strict aseptic technique due to infection risk; maximum time of use after vial puncture if 12 hours) 4. milky white in color
What are SEs with clevidipine?
- hypertriglyceridemia
- headache
- AF
- heache
How much nutritional value is in clevidipine?
2kcal/mL
What is the MOA of non-DHP CCBs?
more selective for myocardium; negative inotrope (decreased force of contraction) and chronotropic (decreased heart rate) effects
What indications are non-DHP CCBs most commonly used for?
- control HR in certain arrhythmias (AF)
- chronic stable and vasospastic angina
- hypertension
What are CIs to using non-DHP CCBs?
- hypotension (SBP<90) or cardiogenic shock
- 2nd or 3rd degree AV block
- sick sinus syndrome (unless patient has a functioning artificial ventricular pacemaker)
- AF/atrial flutter and accessory bypass tract
- concurrent use with IV beta-blocker (IV CCBs only)
- acute MI and pulmonary congestion (diltiazem))
- severe left ventricular dysfunction (verapamil
What are warnings with non-DHP CCBs
- HF (may worsen symptoms)
- bradycardia
- hypotension
- acute liver injury/ elevated LFTs
- conduction abnormalities (diltiazem)
- hypertrophic cardiomyopathy (verapamil)
What are SEs with non-DHP CCBs?
- constipation (moe with verapamil)
- gingival hyperplasia
- edema (more with diltiazem)
- cutaneous hypersensitivity reactions (diltiazem)
- headache
- dizziness
What is monitored with non-DHP CCBs?
- BP
- HR
- ECG
- LFTs
Diltiazem
Cardizem
Tiazac
Which non DHP CCBs are available as injections?
diltiazem and verapamil
Verapimil
Calan SR
Verelan
Verelan PM
