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Hypertension Flashcards

1
Q

What is a normal BP reading?

A

SBP < 120 mmHg and DBP < 80 mmHg

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2
Q

What is an elevated BP reading?

A

SBP 120-129 mmHg and DBP < 80 mmHg

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3
Q

What reading indicates Hypertension Stage 1?

A

SBP 130-139 mmHg or DBP 80-89 mmHg

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4
Q

What reading is Hypertension Stage 2?

A

SBP >= 140 mmHg or DBP >= 90 mmHg

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5
Q

When do you want to start treatment for hypertension?

A
  • Stage 1 HTN and any of the following:
    1. Clinical CVD (stroke, HF, and CAD)
    2. 10-year ASCD risk >= 10%
    3. Does not meet BP goal after 6 months of lifestyle modifications
  • Stage 2 HTN
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6
Q

What is the BP goal for a HTN patient?

A

< 130/80 mmHg

*for CKD: SBP 120 mmHg

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7
Q

What is the treatment guideline for HTN?

A

Use an agent from one of the preferred classes:
1. Thiazide diuretics
2. DHP CCB
3. ACE or ARB
* Start 2 drugs from the preferred classes when baseline average BP is > 20/10 mmHg above goal

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8
Q

For CKD patients, what is the treatment guideline?

A

ACE or ARB

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9
Q

Which antihypertensives have a boxed warning for fetal toxicity?

A

ACE, ARBs, and the aliskiren (direct renin inhibitor)

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10
Q

What are the first line treatments for pregnant patients?

A
  • Labetalol
  • Nifedipine ER
  • Methyldopa
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11
Q

What is the BP goal for pregnant patients?

A

SBP 120-139 mmHg and DBP between 80-89 mmHg

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12
Q

Gestational hypertension

A

New-onset hypertension after 20 weeks after gestation

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13
Q

What is the treatment of preeclampsia?

A

IV labetalol or hydralazine

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14
Q

What is the MOA for thiazide diuretics?

A

Inhibit sodium reabsorption in the distal convulated tubule, causing increased excretion of Na, Cl, H20, and K

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15
Q

What are some thiazide diuretics?

A
  • Chlorthalidone
  • Hydrochlorothiazide
  • Chlorothiazide
  • Indapamide
  • Metolazone
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16
Q

What is the dosing for Chlorthalidone?

A

12.5-25 mg daily

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17
Q

What is the dosing for Hydrochlorthiazide?

A

12.5-50 mg daily

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18
Q

What is the dosing for Metolazone?

A

2.5-5 mg daily

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19
Q

What are the side effects of thiazide diuretics?

A
  • Decrease electrolytes: K, Mg, Na, Cl
  • Increase electrolytes: Ca, UA, LDL, TG, BG
  • Volume depletion
  • Photosensitivity, sexual dysfunction, dizziness, rash
  • Hypotension
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20
Q

What should we monitor for when on thiazide diuretics?

A
  • Electrolytes
  • Renal function
  • BP
  • Fluid status
  • BG
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21
Q

What is a contraindication to thiazide diuretics?

A

Hypersensitivity to sulfonamide-derived drugs

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22
Q

What are some warnings when using thiazide diuretics?

A

Exacerbate conditions such as SLE, gout, dyslipidemia, and diabetes

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23
Q

Which thiazide diuretic is only available IV?

A

Chlorothiazide

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24
Q

Which thiazide diuretic is considered more effective at lowering BP?

A

Chlorthalidone

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25
What are some drug interactions with thiazide diuretics?
* Drugs that can cause sodium and water retention * Thiazide can decrease lithium renal clearance and increase risk of lithium toxicity * Can increase dofetilide serum concentrations, leading to increase risk of QTc prolongation
26
What is the MOA of Dihydropyridine Calcium Channel Blockers?
* More selective for vascular smooth muscle * Causes peripheral arterial vasodilation and coronary artery vasodilation
27
What are dihydropyridine CCBs used for?
* HTN * Chronic stable and vasospastic angina * Raynaud's phenomenon
28
What is the brand name of Amlodipine?
Norvasc
29
What is the brand name of Nicardipine?
Cardene IV
30
What is the brand name of Nifedipine?
Procardia (XL)
31
What is the dose of amlodipine (Norvasc)
2.5-10 mg daily
32
What is the dose of nicardipine (Cardene IV)?
* IV: 5 mg/hr, increase by 2.5 mg/hr every 5-15 min to max dose of 15 mg/hr * IR: 20-40 mg
33
What is the dose of nifedipine (Procardia XL)?
ER: 30-90 mg daily
34
What are the side effects of DHP CCBs (and for clevidipine only)?
* Peripheral edema * Headache * Flushing * Palpitations * Reflex tachycardia * Fatigue * Nausea * **Gingival hyperplasia** * Clevidipine: Hypertriglyceridemia, headache, **afib**, nausea
35
What do you monitor when on DHP CCBs?
* Peripheral edema * BP * HR
36
What are some contraindications in DHP CCBs?
* Nicardipine should not be used in advanced aortic stenosis * Clevidipine: Allergy to soybeans, soy products, or eggs; **defective lipid metabolism**; severe aortic stenosis
37
What are some warnings in DHP CCBs?
* Hypotension, worsening angina and/or MI, **severe hepatic impairment**, use caution in HF * Nifedipine IR: Do NOT use for chronic hypertension or acute BP reduction in non-pregnant patients * Clevidipine: Hypotension, reflex tachhycardia, **infections**
38
Which DHP CCBs is considered safe to use to lower BP in patient with reduced ejection fracture?
Amlodipine
39
Which DHP CCBs is safe to use in pregnancy?
Nifedipine ER
40
Which DHP CCBs leave a ghost tablet in the stool?
Procardia XL
41
Fast Facts of Clevidipine
* DHP CCBs * Lipid emulsion (provides 2kcal/mL) * Max time of use after vial puncture is 12 hours--needs to replaced) b/c of infection risk
42
What is the MOA of Non-DHP CCBs?
* More selective for the myocardium, making them less potent vasodilators * Decrease in BP is due to negative ionotropic (decrease force of ventricular contraction) and negative chronotropic (decrease HR) effects
43
What is non-DHP CCBs used for?
* Rate control in certain arrythmias (e.g., afib) * Sometimes used for HTN and chronic stable and vasospastic angina
44
What is the brand name of diltiazem?
Cardizem, Tiazac ## Footnote Can also be given IV!!
45
What is the brand name of Verapamil?
Calan SR
46
What is the dose of diltiazem (Cardizem, Tiazac)?
120-360 mg daily * IR: daily dose given in 4 divided doses * ER: daily dose given in 2 divided doses
47
What is the dose of Verapamil (Calan SR)?
120-180 mg daily * IR: daily dose given in 3 divided doses * ER: daily dose can be given in 1-2 divided doses * Verelan PM: daily dose given QHS
48
What are some side effects of non-DHP CCBs?
* Constipation (more with verapamil) * **Gingival hyperplasia** * Edema (more with diltiazem) * Headache * Dizziness * **Cutaneous hypersensitivity reactions (diltiazem)**
49
What do you monitor when on non-DHP CCBs?
* BP * HR * ECG * LFTs
50
What are some contraindications of non-DHP CCBs?
* Hypotension (SBP < 90 mmHg) or cardiogenic shock * 2nd or 3rd degree AV block or sick sinus syndrome (unless patient has a functioning artificial ventricular pacemaker) * Concurrent use with an IV beta-blocker (IV CCBs only) * Diltiazem: Acute MI and pulmonary congestion * Verapamil: Severe left ventricular dysfunction
51
What are some warnings of non-DHP CCBs?
* HF * Bradycardia * Hypotension * Acute liver injury/increase in LFTs * Cardiac conduction abnormalities (diltiazem) * Hypertrophic cardiomyopathy (verapamil)
52
What are some drug interactions with non-DHP CCBs?
* Use caution with other drugs that can decrease HR, including beta-blockers, digoxin, clonidine, amio * Are major substrates of CYP3A4. Do not use with grapefruit juice * Substrates and inhibitors of P-gp and moderate inhibitors of CYP3A4. They can increase concentrations of many other drugs like statins (simvastatin and lovastatin)
53
What is the MOA of ACE inhibitors?
Block the conversion of Ang I to Ang II * Resulting in decrease vasoconstriction and aldosterone secretion
54
What is the brand name of benazepril?
Lotensin
55
What is the brand name of enalapril?
Vasotec
56
What is the brand name of lisinopril?
Zestril
57
What is the brand name of quinapril?
Accupril
58
What is the brand name of ramipril?
Altace
59
What is the brand name of captopril?
Capoten
60
What is the dose of benazepril (Lotensin)?
10-40 mg daily in 1-2 divided doses
61
What is the dose of enalapril (Vasotec)?
PO: 5-40 mg daily in 1-2 divided doses IV: 0.625-5 mg q6h
62
What is the dose of lisinopril (Zestril)?
5-40 mg daily
63
What is the dose of quinapril (Accupril)?
10-80 mg daily in 1-2 divided dose
64
What is the dose of ramipril (Altace)?
2.5-150 mg daily in 1-2 divided doses
65
What is the dose of captopril (Capoten)?
12.5-150 mg daily in 2-3 divdided doses
66
What do you monitor for when on ACE inhibitors?
* BP * K * Renal function (increase SCr) * S/sx of angioedema
67
What is the boxed warning of ACE inhibitors?
Can cause injury and death to the developing fetus when used in 2nd or 3rd trimesters
68
What are some contraindications of ACE inhibitors?
* Do not use with history of angioedema * Do not use within 36 hours of sacubitril/valsartan (Entresto) * Do not use with aliskiren in patients with diabetes
69
What are the warnings of ACE inhibitors?
* Angioedema * Hyperkalemia * Renal impairment (increase risk with bilateral renal artery stenosis [avoid use]) * Hypotension/dizziness
70
What is the MOA of ARBs?
Block Ang II from binding to the angiotensin II type-1 (AT-1) receptor on vascular smooth muscle * Prevents vasoconstriction, and on the arterial gland, prevents aldosterone secretion and subsequent sodium and water retention
71
What is the brand name of Irbesartan?
Avapro
72
What is the brand name of Losartan?
Cozaar
73
What is the brand name of Olmesartan?
Benicar
74
What is the brand name of Valsartan?
Diovan
75
What is the dose of irbesartan (Avapro)?
150-300 mg daily
76
What is the dose of Losartan (Cozaar)?
25-100 mg daily in 1-2 divided doses
77
What is the dose of olmesartan (Benicar)?
20-40 mg daily
78
What is the dose of valsartan (Diovan)?
80-320 mg daily
79
What is a warning for olmesartan?
Sprue-like enteropathy - severe, chronic diarrhea with substantial weight loss * can occur months to years after drug initiation
80
What is the MOA of aliskiren?
Inhibits renin from converting angio to ang 1
81
What is the brand name of aliskiren?
Tekturna
82
What is the dose of aliskiren (Tekturna)?
150-300 mg daily
83
What are some patient counseling points for aliskiren (Tekturna)?
* Take w/ or w/o food but be consistent in administration with regard to food * Avoid high fat foods (reduces absorption) * Must be protected from moisture
84
What are some contraindications of aliskiren (Tekturna)?
Do not use with ACEs or ARBs in patients with diabetes
85
What are some drug interactions of RAAS inhibitors?
* ACE and ARBs can decrease lithium renal clearance and increase risk of lithium toxicity * Increase risk of hyperkalemia
86
What is the MOA of triamterene and amiloride?
* Directly inhibits sodium channels in the **late distal convoluted tubule and collecting duct** of the nephron * Increase sodium and water excretion but conserves potassium
87
What is triamterene and amiloride used for?
Used in combination with thiazide diuretic to counteract the mild potassium loss seen in thiazide diuretics
88
What is the MOA of spironolactone and eplerenone?
Indirectly inhibits sodium channels by blocking the **aldosterone receptor site** and are the preferred add-on drugs for resistant hypertension
89
What is the spironolactone and eplerenone used for?
First line in HF
90
What is the brand name of spironolactone?
Aldactone
91
What is the brand name for triamterene?
Dyrenium
92
What is the brand name of eplerenone?
Inspra
93
What is the dose for spironolactone (Aldactone)?
25-100 mg daily in 1-2 divided doses
94
What is the dose of triamterene (Dyrenium)?
50-300 mg daily in 1-2 divided doses
95
What is the dose of eplerenone (Inspra)?
50-100 mg daily in 1-2 divided doses
96
What are the side effects of potassium-sparing diuretics?
* Hyperkalemia * Increase SCr * Dizziness * Hyperchloremic metabolic acidosis (rare) * Spironolactone: Gynecomastia, breast tenderness, amenorrhea
97
What should we monitor for when on potassium-sparing diuretics?
* BP * K * Renal function * Fluid status
98
What is the boxed warning in potassium-sparing diuretics?
Amiloride and triamterene: Hyperkalemia (K > 5.5 mEq/L) - more likely in patients with diabetes, renal impairment, or elderly patients
99
What are some contraindications of potassium-sparing diuretics?
Do not use with hyperkalemia, severe renal impairment, Addison's disease (spironolactone), or taking a strong CYP3A4 inhibitor (eplerenone)
100
What are the beta-1 selective blockers?
* Atenolol * Esmolol * Metoprolol * Acebutolol * Betaxolol * Betoptic * Bisoprolol
101
What is the brand name of atenolol?
Tenormin
102
What is the brand name of esmolol?
Brevibloc
103
What is the brand name of metoprolol tartrate?
Lopressor
104
What is the brand name of metoprolol succinate?
Toprol XL
105
What is the dose of the atenolol (Tenormin)?
25-100 mg daily in 1-2 divided doses
106
What is the dose of esmolol?
500 mg/kg IV bolus followed by 50 mcg/kg/min continuous infusion; titrate as needed to a max of 300 mcg/kg/min
107
What is the dose of metoprolol tartrate (Lopressor)?
IR: 50-200 mg BID
108
What is the dose of metoprolol succinate (Toprol XL)?
XL: 25-400 mg daily
109
What are the side effects of beta-1 selective blocker?
* Bradycardia * Hypotension * CNS effects * Sexual dysfunction * Cold extremities (can exacerbate Raynaud's)
110
What do we monitor for beta-1 selective blocker?
HR and BP
111
What is the boxed warning for beta-1 selective blocker?
Do not abruptly discontinue * Gradually taper dose over 1-2 weeks to avoid acute tachycardia, hypertension, and/or ischemia
112
What are some contraindications in beta-1 selective blocker?
* Severe bradycardia * 2nd or 3rd degree AV block or sick sinus syndrome (unless permanent pace maker is placed) * Overt cardiac failure or cardiogenic shock * Esmolol: Pulmonary hypertension; use of IV non-DHP CCBs
113
What are some warnings with beta-1 selective blocker?
* Use caution with diabetic patients: can worsen hypoglycemia and mask it * Use caution with bronchospastic disease * Use caution with Raynaud's disease (requires slow dose titration) and pheochromocytoma (use alpha-1 blocker first) * Can masks signs of hyperthyroidism
114
What are some counseling points with beta-1 selective blocker?
* Oral drugs: titrate dose every 1-2 weeks (as tolerated), take w/o regard to meals (except Lopressor and Toprol XL must be taken immediately after food) * Metoprolol tartrate IV is not equivalent to PO (IV:PO ratio is 1:2.5) * When switching from metoprolol tartrate to succinate, the same total daily dose of metoprolol should be used * Toprol XL can be cut in half but should NOT be crushed or chewed
115
What is the MOA of Nebivolol?
Beta-1 selective blocker with nitric oxide-dependent vasodilation
116
What is the dose of nebivolol?
5-40 mg daily **CrCl < 30 mL/min or moderate liver impairment, start at 2.5 mg daily**
117
What is the brand name of nebivolol?
Bystolic
118
What are some contraindications of Nebivolol (Bystolic)?
Severe liver impairment (Child-Pugh Class B or C)
119
What are some side effects of Nebivolol?
* Fatigue * Headache * Nausea * Diarrhea * **Increase TGs, decrease HDL**
120
What are the beta-1 and beta-2 blockers (non-selective)?
* Propranolol * Nadolol * Pindolol * Timolol
121
What is the brand name of Propranolol?
Inderal LA, Inderal XL
122
What is the brand name of Nadolol?
Corgard
123
What is the dose of propranolol (Inderal LA, Inderal XL)?
IR: 80-640 mg in 2-4 divided doses LA: 80-640 mg daily XL: 80-120 mg daily
124
What is the dose of nadolol (Corgard)?
40-320 mg daily
125
What is the contraindication in beta-1 and beta-2 blockers?
Bronchial asthma
126
What are the nonselective beta-blockers and alpha-1 blockers?
Carvedilol and Labetalol
127
What is the brand name of Carvedilol?
Coreg
128
What is the dose of Carvedilol (Coreg)?
IR: 6.25-25 mg BID CR: 20-80 mg daily
129
What is the dose of labetalol?
PO: 100-1200 mg BID IV: 10-20 mg bolus, followed by 20-80 mg every 10 minutes or 0.5-2 mg/min continuous infusion titrated to a max dose of 10 mcg/min
130
What are some side effects of non-selective beta-blockers and alpha-1 blockers?
* Labetalol: nausea * Carvedilol: Weight gain, edema
131
What is a contraindication of non-selective beta blocker and alpha-1 blocker?
Carvedilol: Severe hepatic impairment
132
What are the warnings of non-selective beta blockers and alpha-1 blocker?
Intraoperative floppy iris syndrome (IFIS) has occurred in cataract surgery in patients who were given alpha-1 blocker
133
What are some counseling points for non-selective beta blocker and alpha-1 blocker?
Carvedilol: * Take with food to decrease absorption and the risk of hypotension * Dosing conversion is not 1:1 (Coreg 3.125 mg = Coreg CR 10 mg daily)
134
What are some drug interaction of beta blockers?
* Mask hypoglycemia symptoms * Carvedilol, propranolol, metoprolol and nebivolol are major substrates of CYP2D6 * Carvedilol and propranolol are inhibitors of P-gp and can increase serum concentrations of P-gp substrates (e.g., cyclosporine, dabigatran, digoxin, and ranolazine)
135
What is the MOA of centrally-acting alpha adrenergic agonist?
Decrease BP by stimulating presynaptic alpha-2 adrenergic receptors in the brain * Decreases sympathetic outflow of norepi which leads to a reduction in SVR
136
What is the dose of Clonidine?
IR: 0.1-0.2 mg PO BID, max dose 2.4 mg daily ER: 0.17 mg QHS, max dose 0.52 mg QHS Catapres patch: 0.1 mg/24hr every 7 days; can titrate every 2-4 weeks up to 0.3 mg/24hr
137
What is the brand name of Clonidine?
Patch- Catapres TTS Kapvay - for ADHD
138
What is the brand name for Guanfacine ER?
Intuniv ## Footnote For ADHD
139
What is the dose for Guanfacine?
0.5-2 mg QHS
140
What are the side effects of clonidine and guanfacine?
* Dry mouth * Somnolence * Fatigue, dizziness * Constipation * Decrease HR * Hypotension * Impotence
141
What are the side effects of methyldopa?
* Drug-induced lupus erythematous (DILE) * Edema or weight gain (control with diuretics) * Increase prolactin levels * Transient sedation * Headache
142
What is the contraindication for methyldopa?
Concurrent use of MAO inhibitors and active liver disease
143
What are the warnings of centrally-acting alpha adrenergic agonist?
Clonidine & Guanfacine: * Do not discontinue abruptly (rebound hypertension) Methyldopa: * Risk for hemolytic anemia, hepatic necrosis
144
What are some direct vasodilators?
* Hydralazine * Minoxidil
145
What is the dose of hydralazine?
PO: 10-50 mg QID, max dose is 300 mg daily IM, IV: 10-20 mg q4-6h prn
146
What are the side effects of hydralazine?
* Peripheral edema/headache/flushing/palpitations/reflex tachycardia * N/V * Peripheral neuritis * Blood dyscarsias * Hypotension
147
What do you monitor when on Hydralazine?
* BP, HR, ANA titer
148
What are some contraindications for hydralazine?
Mitral valvular rheumatic heart disease, CAD
149
What is the warning for hydralazine?
Drug-induced erythematosus (DILE)
150
What are the boxed warning and contraindications for minoxidil?
* Potent vasodilator - can cause peripheral effusion (due to fluid retention) and angina exacerbations (due to reflex tachycardia) * Pheochromocytoma
151
Hypertensive emergency
Pt has acute target organ damage that may be life threatening (e.g., encephalopathy, stroke, acute kidney injury, acute coronary syndrome) * Defined as an acute and severe BP elevation (generally ≥ 180/120 mmHg)
152
Treatment of hypertensive emergency
Decrease BP by on more than 25% (w/in the first hour), then if stable, decrease to ~160/100 mmHg in the next 2-6 hrs

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