Hypertension Flashcards by Jbun L

What are two major drivers of elevated BP?

Obesity and vascular stiffness

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What complication can result from elevated BP?

Cardiovascular and renal complications

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What cardiovascular consequences can result from high blood pressure?

Stroke
Myocardial infarction
Atrial fibrillation
Heart failure
Chronic Kidney Disease
Dementia

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What blood pressure target is typical for home BP monitoring?

<135/85

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What blood pressure threshold for home BP measurement warrants the start of antihypertensive therapy?

≥135/85

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What is the blood pressure target for the general patient population?

<140/90

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What is the blood pressure threshold for starting antihypertensive therapy for patients with low CV risk?

≥160/100

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What is the blood pressure threshold for starting antihypertensive therapy for patients with CV risk factors present?

≥140/90

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What are CV risk factors that would influence treatment choices?

Cigarette smoking
Dyslipidemia
Dysglycemia
Females older than 60 years
Males older than 55 years
Poor dietary habits
Sedentary lifestyle
Strong family history of premature CV disease
Truncal obesity

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What blood pressure target is designated for patients with diabetes?

<130/80

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What blood pressure threshold indicates the need for antihypertensive therapy in diabetic patients?

≥130/80

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What blood pressure target is indicated for patients with high risk of CV events?

SBP <120

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What blood pressure threshold would indicate the need for antihypertensive therapy for patient with high risk of CV events?

SBP >130

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What criteria designates a patient as high risk?

≥75 years of age
- presence of clinical or subclinical cardiovascular disease
- chronic kidney disease (eGFR= 20-59)
- estimated 10-year Framingham risk score≥ 15%

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What is isolated systolic hypertension?

When systolic blood pressure is elevated, but your diastolic blood pressure is normal

The most common type of blood pressure in older patients.

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What is the blood pressure target for isolated systolic hypertension?

SBP<140

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What is the blood pressure threshold where you have to start antihypertensive therapy for isolated systolic hypertension?

SBP>140

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What medications can worsen hypertension?

Alcohol (excessive use)
Calcineurin inhibitor (cyclosporine, tacrolimus)
Corticosteroids and anabolic steroids
Erythropoietin
Midodrine
Monoamine oxidase inhibitors (MAOIs)
NSAIDs and COX 2 inhibitors
Oral contraceptives and sex hormones
SSRIs and SNRIs
Stimulants like ADHD meds or cocaine
Vasoconstricting, sympathomimetic decongestant

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What two diet factors can aggravate hypertension?

Salt (high-intake)
Licorice root

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In what scenarios is the diagnosis of hypertension immediate?

Hypertensive emergencies and urgencies (≥180/110)
Hypertensions that is compromising vital organ function (encephalopathy, cardiac or rapidly decreasing renal function)
Major artery dissection
DBP ≥130 mm Hg

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Most diagnosis of hypertension is done in the office. Out of office diagnosis can be done by performing what?

24-hour ambulatory BP monitoring or a home BP series

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How do you complete a home BP series?

2 readings taken each morning and evening for 7 days

Total: 28 readings
Discard the first day readings and use the mean of the remaining 24 readings

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What is the benefit of out-of-office measurement?

White coat hypertension
Masked hypertension

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Labwork is common for hypertensive patients.

If hypertensive patient has high serum creatinine, what should we check for?

When is this an exception?

Check for renal disease

Exception in elderly. High is normal in the elderly as their kidney function declines.

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Labwork is common for hypertensive patients. If hypertensive patient has urinary albumin or protein, what should we check for?

Diabetes Renal disease

Weight loss is a good non-pharm choice for overweight patients with hypertension. What is considered target BMI and waist circumference?

BMI: 18.5-25 Waist circumference <102 cm in men Waist circumference <88cm in women

If patient is above weight targets, what is the weight loss goals if hypertensive?

Weight loss of 4kg or more

What diet is recommended for patients with hypertension?

DASH diet

The diet should be in high in fresh _______ and ___________, ______ fibre and ____-fat dairy products. It should be low in ___________ fats and __________.

fruits and vegetables soluble low saturated sodium

What is the sodium intake target for patients with hypertension?

<2000mg (88mol) per day

Why do we want to incorporate more fruits and vegetables in diet if hypertensive? When do we have to be careful about adding too much dietary potassium?

Helps increase potassium levels which counteract sodium levels This is encouraged as long as patient is not at risk of hyperkalemia (potassium >4.5 mmol/L)

How much daily exercise is recommended for hypertensive patients?

Regular, moderate cardiorespiratory activity for 30-60 minutes on most days

What's the alcohol limit for hypertension?

0-2 standard drinks per week

Which anti-hypertensive drug class should be avoided in Black patients?

Avoid ACE inhibitors or ARBs as first line for Black patients

What is the typical dose titration for BP meds?

Every 4 weeks If severe hypertension, target organ damage, or high CV risk, consider, more frequent titration

Which drug class is indicated as first-line therapy for uncomplicated hypertension?

Low-dose thiazide or related diuretics

Which medications in the diuretic class are indicated?

Long acting diuretics: Chlorthalidone and indapamide preferred over hydrochlorothiazide

Besides uncomplicated hypertension, what other patient population is diuretics good for?

Isolated systolic hypertension Elderly Black patients

What adverse effect do we need to watch out for with diuretic use?

Hypokalemia

If we want to use a diuretic, but we want to minimize the risk of hypokalemia, what can we do?

Use a combo product like hydrochlorothiazide plus a potassium sparing diuretic: - spironolactone - amiloride - triamterene

When do we want to avoid using diuretics as first-line options?

If high risk for serious arrhythmia: -Ex: prolonged QT syndrome

When is high dose of hydrochlorothiazide (>25mg/day) reserved for?

Resistant hypertension unresponsive to treatment with multiple drugs

If patient has renal impairment, what type of diuretic should be used?

Loop diuretic

What are beta-1- adrenergic antagonists?

Beta blockers

When are beta blockers used as first-line therapy?

- Younger than 60 years of age - Stable angina - Heart failure - History of MI

Why are beta blockers only recommended as first line for patients younger than 60 years of age?

Not as effective for primary prevention of CV events in those over 60 years of age

The renin-angiotensin-aldosterone system plays a crucial role in modulating BP, kidney function, electrolyte balance, and vascular and cardiac structure. Which drug classes act on the RAAS system?

ACE inhibitors Angiotensin receptor blockers Direct renin inhibitors Spironolactone

How do diuretics affect the RAAS system?

Diuretics stimulate the RAAS system whereas the other meds like ACEi and ARBs block the RAAS system.

What's a drug that is a direct renin inhibitor? What is the mechanism of action?

Aliskirin Prevents renin from converting angiotensinogen to angiotensin I.

Inhibitors of RAAS are just as effective as those that stimulate RAAS. In fact, it also has additional benefits for patients with?

Heart failure, diabetes, and/or CKD

When are RAAS drugs contrainidcated?

Pregnancy

When do we pick ACEi as our first line agents?

Uncomplicated hypertension and diabetes, ischemic heart disease, recent MI, heart failure, or CKD

When do we pick ARBs as first line agents?

When ACEi are indicated but not tolerated

When are direct renin inhibitors recommended?

Aliskiren is recommended as add-on after all first-line therapies have been tried.

What's a significant drug interaction we have to watch for with aliskiren?

Do not combine with ACEi or ARBs (especially in diabetic patients) as worse adverse effects like hyperkalemia

Which type of long acting calcium channel blocker is good for hypertension?

Dihydropyridine CCBs like amlodipine or felodipine.

When are DHP CCBs recommended as first line?

Elderly patients with isolated systolic hypertension is particularly responsive

What type of CCB should not be used for hypertension?

Short acting CCB formulations (nifedipine) increases risk of CV events Long acting nifedipine is ok though

What is the one exception where you can use short acting nifedipine in hypertension?

Acute management of severe hypertension in pregnancy

When do we begin to consider combo therapy?

If goal is not achieved with moderate doses of first-line agents.

In hypertension, if first line agents don't suffice, do we prefer to add or substitute?

Add --> aka combo therapy Combining drugs from 2 different classes is better than doubling the dose of one drug

In what scenario should we initiate therapy with 2 first-line agents (combo) right off the bat?

If patient's SBP is ≥20 or DBP is ≥10 mm Hg above the recommended target

Which specific class combos show a synergistic effect?

ACEi/ARB + thiazide/thiazide-like diuretic ACEi/ARB + CCBs

If patient is diabetic and combo therapy is required, what's the recommended combo?

ACEi and amlodipine

What hypertension drug combos should we generally avoid as they diminish antihypertensive effects? What's the exception?

ACEi, ARB, beta blockers Exception: ACEi/ARB + beta blockers - Post MI patients or heart failure or - 3-4 drug combos are needed ACEi + ARB - refractory heart failure

What is resistant hypertension?

BP above target despite treatment with 3 drugs (optimally dosed), one of which is a diuretic Typical regimen is ACEi, thiazide like diuretic, and DHP CCB

What could be causes of resistant hypertension?

Adherence issues, sleep apnea, renal dysfunction, diet

What is a blood pressure test you can do to screen for sleep apnea?

24 hour ambulatory BP measurement If no nocturnal dipping found on 24h ABPM, screen for sleep apnea

If sleep apnea is the cause for resistant hypertension, how can we adjust the blood pressure medications?

Moving 1 or more medication doses to the evening

Refresher: What is the optimal 3 class regimen for hypertension?

- Long-acting ACEi/ARB - Thiazide-like diuretic - DHP CCB

If the optimal 3 class regimen is ineffective, what are therapeutic options for add-ons?

- Spironolactone - Amiloride - Bisoprolol - Doxazosin - Clonidine

What drug is used for hypertensive emergencies?

Felodipine - Intermediate-acting drugs with close BP monitoring is safer than short acting drugs that can cause hypotension

Summary: If patient has hypertension without other compelling indications, what is initial therapy?

Thiazide diuretic Beta blocker (<60 y of age) ACEi/ ARB Long acting CCB

Summary: If patient has isolated systolic hypertension without other compelling indications, what is initial therapy?

Thiazide diuretic ARB Long acting DHP CCB

Summary: If patient has diabetes with albuminuria, renal disease, CVD, or other CV risk factors, what is initial therapy?

ACEi or ARB

Summary: If patient has diabetes without previous additional risk factors, what is initial therapy?

ACEi or ARB Long acting DHB CCB Thiazide diuretic

Summary: If patient has coronary artery disease, what is initial therapy?

ACEi or ARB If patient has stable angina, can give beta blocker or CCB

Summary: If patient has recent MI, what is initial therapy?

Beta blocker and ACEi

Summary: If patient has heart failure, what is initial therapy?

ACEi and beta blocker

Summary: If patient has left ventricular hypertrophy, what is initial therapy?

ACEi or ARB Long acting CCB Thiazide diuretic

Summary: If patient has past stroke or TIA, what is initial therapy?

ACEi and diuretic combo

Summary: If patient has chronic kidney disease, what is initial therapy?

ACEi and diuretics if needed

If patient is pregnant, has hypertension, and is at high risk of preeclampsia (includes all patients with chronic hypertension), what should be offered?

ASA 81-162mg at bedtime

What is the dosing schedule of ASA for preeclampsia?

Begin after conception but no later than 16 weeks gestational age. Discontinue around 36 weeks gestation

When should hypertension therapy be initiated in pregnancy?

BP >140/90 that is sustained

What is the blood pressure target for pregnant patients?

120-140/80-90

What are first line agents for pregnancy?

Labetalol Nifedipine XL Methyldopa (less common due to potency and side effects) Beta blockers (not common) IR nifedipine (for severe hypertension)

What are second line agents for pregnancy?

Clonidine Hydralazine Thiazide diuretics

What drugs should be avoided in hypertension treatment in pregnancy?

Atenolol ACEi Spironolactone

If patient is breastfeeding and has hypertension, what are therapeutic options?

Labetalol, long-acting nifedipine, methyldopa ACEi are not common but if must, prefer captopril, enalapril, benazepril, quinapril