Hypertension Flashcards
What are two major drivers of elevated BP?
Obesity and vascular stiffness
What complication can result from elevated BP?
Cardiovascular and renal complications
What cardiovascular consequences can result from high blood pressure?
Stroke
Myocardial infarction
Atrial fibrillation
Heart failure
Chronic Kidney Disease
Dementia
What blood pressure target is typical for home BP monitoring?
<135/85
What blood pressure threshold for home BP measurement warrants the start of antihypertensive therapy?
≥135/85
What is the blood pressure target for the general patient population?
<140/90
What is the blood pressure threshold for starting antihypertensive therapy for patients with low CV risk?
≥160/100
What is the blood pressure threshold for starting antihypertensive therapy for patients with CV risk factors present?
≥140/90
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
What blood pressure target is designated for patients with diabetes?
<130/80
What blood pressure threshold indicates the need for antihypertensive therapy in diabetic patients?
≥130/80
What blood pressure target is indicated for patients with high risk of CV events?
SBP <120
What blood pressure threshold would indicate the need for antihypertensive therapy for patient with high risk of CV events?
SBP >130
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%
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.
What is the blood pressure target for isolated systolic hypertension?
SBP<140
What is the blood pressure threshold where you have to start antihypertensive therapy for isolated systolic hypertension?
SBP>140
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
What two diet factors can aggravate hypertension?
Salt (high-intake)
Licorice root
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
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
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
What is the benefit of out-of-office measurement?
White coat hypertension
Masked hypertension
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.
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
