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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
Q

What are some drug interactions with thiazide diuretics?

A
  • 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
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26
Q

What is the MOA of Dihydropyridine Calcium Channel Blockers?

A
  • More selective for vascular smooth muscle
  • Causes peripheral arterial vasodilation and coronary artery vasodilation
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27
Q

What are dihydropyridine CCBs used for?

A
  • HTN
  • Chronic stable and vasospastic angina
  • Raynaud’s phenomenon
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28
Q

What is the brand name of Amlodipine?

A

Norvasc

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29
Q

What is the brand name of Nicardipine?

A

Cardene IV

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30
Q

What is the brand name of Nifedipine?

A

Procardia (XL)

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31
Q

What is the dose of amlodipine (Norvasc)

A

2.5-10 mg daily

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32
Q

What is the dose of nicardipine (Cardene IV)?

A
  • 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
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33
Q

What is the dose of nifedipine (Procardia XL)?

A

ER: 30-90 mg daily

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34
Q

What are the side effects of DHP CCBs (and for clevidipine only)?

A
  • Peripheral edema
  • Headache
  • Flushing
  • Palpitations
  • Reflex tachycardia
  • Fatigue
  • Nausea
  • Gingival hyperplasia
  • Clevidipine: Hypertriglyceridemia, headache, afib, nausea
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35
Q

What do you monitor when on DHP CCBs?

A
  • Peripheral edema
  • BP
  • HR
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36
Q

What are some contraindications in DHP CCBs?

A
  • Nicardipine should not be used in advanced aortic stenosis
  • Clevidipine: Allergy to soybeans, soy products, or eggs; defective lipid metabolism; severe aortic stenosis
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37
Q

What are some warnings in DHP CCBs?

A
  • 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
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38
Q

Which DHP CCBs is considered safe to use to lower BP in patient with reduced ejection fracture?

A

Amlodipine

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39
Q

Which DHP CCBs is safe to use in pregnancy?

A

Nifedipine ER

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40
Q

Which DHP CCBs leave a ghost tablet in the stool?

A

Procardia XL

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41
Q

Fast Facts of Clevidipine

A
  • 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
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42
Q

What is the MOA of Non-DHP CCBs?

A
  • 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
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43
Q

What is non-DHP CCBs used for?

A
  • Rate control in certain arrythmias (e.g., afib)
  • Sometimes used for HTN and chronic stable and vasospastic angina
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44
Q

What is the brand name of diltiazem?

A

Cardizem, Tiazac

Can also be given IV!!

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45
Q

What is the brand name of Verapamil?

A

Calan SR

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46
Q

What is the dose of diltiazem (Cardizem, Tiazac)?

A

120-360 mg daily
* IR: daily dose given in 4 divided doses
* ER: daily dose given in 2 divided doses

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47
Q

What is the dose of Verapamil (Calan SR)?

A

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

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48
Q

What are some side effects of non-DHP CCBs?

A
  • Constipation (more with verapamil)
  • Gingival hyperplasia
  • Edema (more with diltiazem)
  • Headache
  • Dizziness
  • Cutaneous hypersensitivity reactions (diltiazem)
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49
Q

What do you monitor when on non-DHP CCBs?

A
  • BP
  • HR
  • ECG
  • LFTs
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50
Q

What are some contraindications of non-DHP CCBs?

A
  • 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
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51
Q

What are some warnings of non-DHP CCBs?

A
  • HF
  • Bradycardia
  • Hypotension
  • Acute liver injury/increase in LFTs
  • Cardiac conduction abnormalities (diltiazem)
  • Hypertrophic cardiomyopathy (verapamil)
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52
Q

What are some drug interactions with non-DHP CCBs?

A
  • 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)
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53
Q

What is the MOA of ACE inhibitors?

A

Block the conversion of Ang I to Ang II
* Resulting in decrease vasoconstriction and aldosterone secretion

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54
Q

What is the brand name of benazepril?

A

Lotensin

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55
Q

What is the brand name of enalapril?

A

Vasotec

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56
Q

What is the brand name of lisinopril?

A

Zestril

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57
Q

What is the brand name of quinapril?

A

Accupril

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58
Q

What is the brand name of ramipril?

A

Altace

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59
Q

What is the brand name of captopril?

A

Capoten

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60
Q

What is the dose of benazepril (Lotensin)?

A

10-40 mg daily in 1-2 divided doses

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61
Q

What is the dose of enalapril (Vasotec)?

A

PO: 5-40 mg daily in 1-2 divided doses

IV: 0.625-5 mg q6h

62
Q

What is the dose of lisinopril (Zestril)?

A

5-40 mg daily

63
Q

What is the dose of quinapril (Accupril)?

A

10-80 mg daily in 1-2 divided dose

64
Q

What is the dose of ramipril (Altace)?

A

2.5-150 mg daily in 1-2 divided doses

65
Q

What is the dose of captopril (Capoten)?

A

12.5-150 mg daily in 2-3 divdided doses

66
Q

What do you monitor for when on ACE inhibitors?

A
  • BP
  • K
  • Renal function (increase SCr)
  • S/sx of angioedema
67
Q

What is the boxed warning of ACE inhibitors?

A

Can cause injury and death to the developing fetus when used in 2nd or 3rd trimesters

68
Q

What are some contraindications of ACE inhibitors?

A
  • 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
Q

What are the warnings of ACE inhibitors?

A
  • Angioedema
  • Hyperkalemia
  • Renal impairment (increase risk with bilateral renal artery stenosis [avoid use])
  • Hypotension/dizziness
70
Q

What is the MOA of ARBs?

A

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
Q

What is the brand name of Irbesartan?

72
Q

What is the brand name of Losartan?

73
Q

What is the brand name of Olmesartan?

74
Q

What is the brand name of Valsartan?

75
Q

What is the dose of irbesartan (Avapro)?

A

150-300 mg daily

76
Q

What is the dose of Losartan (Cozaar)?

A

25-100 mg daily in 1-2 divided doses

77
Q

What is the dose of olmesartan (Benicar)?

A

20-40 mg daily

78
Q

What is the dose of valsartan (Diovan)?

A

80-320 mg daily

79
Q

What is a warning for olmesartan?

A

Sprue-like enteropathy - severe, chronic diarrhea with substantial weight loss
* can occur months to years after drug initiation

80
Q

What is the MOA of aliskiren?

A

Inhibits renin from converting angio to ang 1

81
Q

What is the brand name of aliskiren?

82
Q

What is the dose of aliskiren (Tekturna)?

A

150-300 mg daily

83
Q

What are some patient counseling points for aliskiren (Tekturna)?

A
  • 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
Q

What are some contraindications of aliskiren (Tekturna)?

A

Do not use with ACEs or ARBs in patients with diabetes

85
Q

What are some drug interactions of RAAS inhibitors?

A
  • ACE and ARBs can decrease lithium renal clearance and increase risk of lithium toxicity
  • Increase risk of hyperkalemia
86
Q

What is the MOA of triamterene and amiloride?

A
  • 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
Q

What is triamterene and amiloride used for?

A

Used in combination with thiazide diuretic to counteract the mild potassium loss seen in thiazide diuretics

88
Q

What is the MOA of spironolactone and eplerenone?

A

Indirectly inhibits sodium channels by blocking the aldosterone receptor site and are the preferred add-on drugs for resistant hypertension

89
Q

What is the spironolactone and eplerenone used for?

A

First line in HF

90
Q

What is the brand name of spironolactone?

91
Q

What is the brand name for triamterene?

92
Q

What is the brand name of eplerenone?

93
Q

What is the dose for spironolactone (Aldactone)?

A

25-100 mg daily in 1-2 divided doses

94
Q

What is the dose of triamterene (Dyrenium)?

A

50-300 mg daily in 1-2 divided doses

95
Q

What is the dose of eplerenone (Inspra)?

A

50-100 mg daily in 1-2 divided doses

96
Q

What are the side effects of potassium-sparing diuretics?

A
  • Hyperkalemia
  • Increase SCr
  • Dizziness
  • Hyperchloremic metabolic acidosis (rare)
  • Spironolactone: Gynecomastia, breast tenderness, amenorrhea
97
Q

What should we monitor for when on potassium-sparing diuretics?

A
  • BP
  • K
  • Renal function
  • Fluid status
98
Q

What is the boxed warning in potassium-sparing diuretics?

A

Amiloride and triamterene: Hyperkalemia (K > 5.5 mEq/L) - more likely in patients with diabetes, renal impairment, or elderly patients

99
Q

What are some contraindications of potassium-sparing diuretics?

A

Do not use with hyperkalemia, severe renal impairment, Addison’s disease (spironolactone), or taking a strong CYP3A4 inhibitor (eplerenone)

100
Q

What are the beta-1 selective blockers?

A
  • Atenolol
  • Esmolol
  • Metoprolol
  • Acebutolol
  • Betaxolol
  • Betoptic
  • Bisoprolol
101
Q

What is the brand name of atenolol?

102
Q

What is the brand name of esmolol?

103
Q

What is the brand name of metoprolol tartrate?

104
Q

What is the brand name of metoprolol succinate?

105
Q

What is the dose of the atenolol (Tenormin)?

A

25-100 mg daily in 1-2 divided doses

106
Q

What is the dose of esmolol?

A

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
Q

What is the dose of metoprolol tartrate (Lopressor)?

A

IR: 50-200 mg BID

108
Q

What is the dose of metoprolol succinate (Toprol XL)?

A

XL: 25-400 mg daily

109
Q

What are the side effects of beta-1 selective blocker?

A
  • Bradycardia
  • Hypotension
  • CNS effects
  • Sexual dysfunction
  • Cold extremities (can exacerbate Raynaud’s)
110
Q

What do we monitor for beta-1 selective blocker?

111
Q

What is the boxed warning for beta-1 selective blocker?

A

Do not abruptly discontinue
* Gradually taper dose over 1-2 weeks to avoid acute tachycardia, hypertension, and/or ischemia

112
Q

What are some contraindications in beta-1 selective blocker?

A
  • 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
Q

What are some warnings with beta-1 selective blocker?

A
  • 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
Q

What are some counseling points with beta-1 selective blocker?

A
  • 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
Q

What is the MOA of Nebivolol?

A

Beta-1 selective blocker with nitric oxide-dependent vasodilation

116
Q

What is the dose of nebivolol?

A

5-40 mg daily
CrCl < 30 mL/min or moderate liver impairment, start at 2.5 mg daily

117
Q

What is the brand name of nebivolol?

118
Q

What are some contraindications of Nebivolol (Bystolic)?

A

Severe liver impairment (Child-Pugh Class B or C)

119
Q

What are some side effects of Nebivolol?

A
  • Fatigue
  • Headache
  • Nausea
  • Diarrhea
  • Increase TGs, decrease HDL
120
Q

What are the beta-1 and beta-2 blockers (non-selective)?

A
  • Propranolol
  • Nadolol
  • Pindolol
  • Timolol
121
Q

What is the brand name of Propranolol?

A

Inderal LA, Inderal XL

122
Q

What is the brand name of Nadolol?

123
Q

What is the dose of propranolol (Inderal LA, Inderal XL)?

A

IR: 80-640 mg in 2-4 divided doses
LA: 80-640 mg daily
XL: 80-120 mg daily

124
Q

What is the dose of nadolol (Corgard)?

A

40-320 mg daily

125
Q

What is the contraindication in beta-1 and beta-2 blockers?

A

Bronchial asthma

126
Q

What are the nonselective beta-blockers and alpha-1 blockers?

A

Carvedilol and Labetalol

127
Q

What is the brand name of Carvedilol?

128
Q

What is the dose of Carvedilol (Coreg)?

A

IR: 6.25-25 mg BID
CR: 20-80 mg daily

129
Q

What is the dose of labetalol?

A

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
Q

What are some side effects of non-selective beta-blockers and alpha-1 blockers?

A
  • Labetalol: nausea
  • Carvedilol: Weight gain, edema
131
Q

What is a contraindication of non-selective beta blocker and alpha-1 blocker?

A

Carvedilol: Severe hepatic impairment

132
Q

What are the warnings of non-selective beta blockers and alpha-1 blocker?

A

Intraoperative floppy iris syndrome (IFIS) has occurred in cataract surgery in patients who were given alpha-1 blocker

133
Q

What are some counseling points for non-selective beta blocker and alpha-1 blocker?

A

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
Q

What are some drug interaction of beta blockers?

A
  • 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
Q

What is the MOA of centrally-acting alpha adrenergic agonist?

A

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
Q

What is the dose of Clonidine?

A

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
Q

What is the brand name of Clonidine?

A

Patch- Catapres TTS
Kapvay - for ADHD

138
Q

What is the brand name for Guanfacine ER?

A

Intuniv

For ADHD

139
Q

What is the dose for Guanfacine?

A

0.5-2 mg QHS

140
Q

What are the side effects of clonidine and guanfacine?

A
  • Dry mouth
  • Somnolence
  • Fatigue, dizziness
  • Constipation
  • Decrease HR
  • Hypotension
  • Impotence
141
Q

What are the side effects of methyldopa?

A
  • Drug-induced lupus erythematous (DILE)
  • Edema or weight gain (control with diuretics)
  • Increase prolactin levels
  • Transient sedation
  • Headache
142
Q

What is the contraindication for methyldopa?

A

Concurrent use of MAO inhibitors and active liver disease

143
Q

What are the warnings of centrally-acting alpha adrenergic agonist?

A

Clonidine & Guanfacine:
* Do not discontinue abruptly (rebound hypertension)

Methyldopa:
* Risk for hemolytic anemia, hepatic necrosis

144
Q

What are some direct vasodilators?

A
  • Hydralazine
  • Minoxidil
145
Q

What is the dose of hydralazine?

A

PO: 10-50 mg QID, max dose is 300 mg daily
IM, IV: 10-20 mg q4-6h prn

146
Q

What are the side effects of hydralazine?

A
  • Peripheral edema/headache/flushing/palpitations/reflex tachycardia
  • N/V
  • Peripheral neuritis
  • Blood dyscarsias
  • Hypotension
147
Q

What do you monitor when on Hydralazine?

A
  • BP, HR, ANA titer
148
Q

What are some contraindications for hydralazine?

A

Mitral valvular rheumatic heart disease, CAD

149
Q

What is the warning for hydralazine?

A

Drug-induced erythematosus (DILE)

150
Q

What are the boxed warning and contraindications for minoxidil?

A
  • Potent vasodilator - can cause peripheral effusion (due to fluid retention) and angina exacerbations (due to reflex tachycardia)
  • Pheochromocytoma
151
Q

Hypertensive emergency

A

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
Q

Treatment of hypertensive emergency

A

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

Naplex (5 decks)

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