Hypertension Flashcards
What are some drugs that can increase BP?
1- Stimulants (Amphetamines)
2- Recreational (Cocaine, Caffeine)
3- Decongestants (Pseudoephedrine, phenylephrine)
4-Antidepressants (MAOI, SNRI, TCA)
5-NSAIDs
6- Systemic steroids
7- Cyclosporine
What effect does RAAS have on BP?
Increase BP through vasoconstriction (Angiotensin II) and water and sodium retention (Aldosterone)
Which hormones increases so that BP can increase?
1- Angiotensinogen
2- Angiotensin 1
3- Angiotensin 2
4- Aldosterone
What is the affect of Angiotensin 2?
Increase SVR
What is the effect of Aldosterone?
Increase Na and Water reabsorption in collecting duct. Causes an increase in BP
What are the major mechanisms which influence BP?
1- RAAS (neurohormones)
2- SNS (Norepinephrine)
What is the role of norepinephrine in BP?
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
What is considered a Normal BP?
Systolic: <120 AND
Diastolic: <80
What is considered an Elevated BP?
Systolic: 120-129 AND
Diastolic: <80
What is Stage 1 Hypertension?
Systolic: 130-139 OR
Diastolic: 80-89
What is Stage 2 Hypertension?
Systolic: >= 140 OR
Diastolic: >= 90
What are some Natural Products which MAY help to reduce BP?
1- Garlic
2- Fish Oil
3- Coenzyme Q10
4- L-arginine
What are the preferred Drug Classes to initiate treatment of HTN?
1- ACE or ARB
2- DHP CCB
3- Thiazide diuretics
When to initiate treatment for HTN?
Stage 2: Right Away
Stage 1: If the patient has CVD or ASCVD >=10 years, initiate treatment. If no, lifestyle modification.
What is the goal BP in hypertension?
< 130/80 mmHg
Which HTN medication is a preferred first-line drug for black patients?
- Thiazide
- DHP CCB
*No CKD in these patients
Which HTN medication is preferred in patients with Stage 3 CKD and/or Albuminuria?
ACE or ARB
*Stage 3 CKD is eGFR < 60
*Albuminuria is urine albumin >= 30
Which anti-HTN medications is contraindicated in pregnancy?
ACE
ARB
Direct renin inhibitor (E.g. Aliskiren)
These medications have a Boxed Warning for fetal toxicity
Which HTN medications is recommended for use in pregnancy?
Labetalol (preferred)
Nifedipine ER (preferred)
Methyldopa
How does Thiazide diuretics work?
These inhibit sodium reabsorption in the distal convoluted tubules, causing an increased secretion of sodium, chloride, potassium and water.
What are the Thiazide diuretics?
1- Chlorthalidone (12.5-25 mg) preferred
2- Hydrochlorothiazide (12.5-50 mg)
3- Chlorothiazide
4- Indapamide
5- Metolazone
Who should not use Thiazide diuretics?
1)Those who have a hypersensitivity to sulfonamide-derived drugs.
*Thiazide diuretics are ineffective in eGFR < 30
What are the electrolyte abnormalities of Thiazide diuretics?
Decrease in Na, K, Mg
Increase in Ca, uric acid, Blood glucose, TG and LDL levels
*Thiazides may exacerbate gout, diabetes and dyslipidemia!
What are other side effects of thiazides?
Photosensitivity, impotence, dizziness
Drug interactions of Thiazide Duiretics?
Lithium, Dofetilide
*Thiazides increase the serum concentrations of these medications in the body.
How do Calcium-channel blockers work?
They inhibit Ca ions from entering the vascular smooth muscle and myocardial cells.
What is the difference between DHP and non-DHP CCB?
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.
What are the DHP CCB?
‘ipine’
Amlodipine (Norvasc) - preferred
Nifedipine ER (Procardia XL) - preferred
Nicardipine
Felodipine
Isradipine
Nisoldipine ER
IV: Nicardipine - preferred
Clevidipine
When should we avoid the use of DHP CCB?
Hypotension
Heart Failure
Severe Aortic Stenosis
What are the side effects of DHP CCB?
Peripheral edema, palpitations, reflex tachycardia, gingival hyperplasia
Which formulation of Nifedipine to avoid?
Avoid immediate release formulations. Only use ER!
What is special about Clevidipine formulation?
It is in a lipid emulsion.
Therefore CI if allergic to soy, eggs or soyabeans.
What are the non-DHP CCB drugs?
Verapamil, Diltiazem
What are the contraindications of non-DHP CCB?
Hypotension
2nd or 3rd degree heart block
Heart failure
Bradycardia
Why are RAAS inhibitors used in hypertension?
They decrease blood pressure by inhibiting the effects of Angiotensin II.
What are the RAAS Inhibitors?
ACE, ARB, Direct renin inhibitor (Aliskiren)
When are ACE/ARB preferred?
1) CKD (eGFR < 60)
2) Heart failure rEF
How does ACE & ARB slow the progression of CKD?
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.
How does ACE & ARB reduce morbidity and mortality in Heart Failure?
Angiotensin II contributes to cardiac remodeling which further worsens cardiac function. ACE & ARBs work to block these effects
How does ACE inhibitors work?
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
What are some of the main ACEi meds?
Lisinopril (Zestril)
Ramipril (Altace)
Benazepril (Lotensin)
Enalapril (Vasotec)
Quinapril (Accupril)
What are the Boxed Warning and Contraindications of RAAS inhibitors?
-Do NOT use in Pregnancy
-Angioedema
-36 hour washout period of Entresto (Sacubitril/valsartan) use (not ARBs)
-Hyperkalemia
How do ARB work?
They block Angiotensin II from binding to the AT1 receptor in the vascular smooth muscle, preventing vasoconstriction.
What are some ARB drugs?
Losartan (Cozaar)
Valsartan (Diovan)
Irbesartan (Avapro)
Olmesartan (Benicar)
How does direct renin inhibitors work?
Aliskiren (Tekturna) directly inhibits renin, which is responsible for the conversion of Angiotensinogen to Angiotensin I
How do Potassium-sparing diuretics work?
These act on the collecting duct and distal convoluted tubule. They inhibit the sodium channels, leading the decreased reabsorption of sodium and water.
What are the Potassium-sparing diuretic medications?
-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.
What are some major side effects of Spironolactone?
Gynecomastia
Breast tenderness
Impotence
*If patient cannot tolerate this medication due to side effects, they can switch to Eplerenone.
How do Beta-blockers work?
They decrease blood pressure by competitively blocking Beta 1 and/or Beta 2 adrenergic receptors, resulting in decreased HR and myocardial contractility.
Which Beta-blockers are Beta 1 selective?
-Atenolol (Tenormin)
-Esmolol (Brevibloc) - IV ONLY!
-Metoprolol tartrate (Lopressor)
-Metoprolol succinate XL (Toprol)
-Nebivolol (Bystolic)
These decrease HR & contractility
Which beta-blockers are non-selective (Beta 1 & Beta 2)?
-Propranolol (Inderal)
-Nadolol
-Timolol
These decrease HR & contractility + bronchoconstriction.
These are contraindicated in asthma.
Which beta-blockers are more non-selective (Beta 1 & 2, Alpha 1)?
-Carvedilol (Coreg)
-Labetalol
These decrease HR & contractility + bronchoconstriction + decrease SVR
What is the dose conversion for metoprolol tartrate?
Converting from IV to PO
1:2.5 (1 IV = 2.5 Oral)
Important points about Beta Blockers
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
How do the Centrally-acting Alpha-2 agonists work?
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
Important information about Clonidine and Guanfacine
1) Do not d/c abruptly; taper over 2-4 days (can cause rebound hypertension)
What are the Direct Vasodilators?
-Hydralazine
-Minoxidil
*These directly vasodilate arterioles.
What is a main side effect of peripheral vasodilators?
Peripheral edema, Reflex tachycardia
(DHP CCB, direct vasodilators)
What is the Boxed Warning for Minoxidil?
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!
How do Alpha Blockers work?
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.
What is a Hypertensive Crises?
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.
What anti-hypertensive meds can be used to treat a Hypertensive Emergency?
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
