Hypertension Flashcards
Drugs That Can Increase BP
-ADHD (amphetamine)
-Decongestants (pseudoephedrine, phenylephrine)
-Recreational (cocaine, caffeine)
-Antidepressants (TCA, SNRI, MAOI)
-NSAIDs
-IS (cyclosporine)
-Systemic steroids
-Epoetin alfa
-Oral contraceptives (estrogen)
-VEGF (bevacizumab, sunitinib)
ADRIAN SEE BS
HTN Diagnosis
Average of at least 2 BP readings obtained on at least 2 separate occasions
-White coat syndrome: out of office BP monitoring preferred
ACC/AHA Categories of BP
Normal: SBP < 120 + DBP < 80
Elevated: SBP 120-129 + DBP < 80
HTN:
-Stage 1: SBP 130-139 or DBP 80-89
-Stage 2: SBP 140+ or DBP 90+
Correct Way To Take BP
Do
-Empty bladder prior
-Sit, both feet on the floor, back supported, rest for 5 min
-Correct cuff size
-Support the arm at heart level
-Wait 1-2 min between readings
Don’t
-Talk
-Lie down, sit without back support
-Drink caffeine/exercise/smoke 30 min prior
-Use a finger/wrist to monitor
Lifestyle Management
-Weight loss (1 kg wt loss decreases BP by 1)
-Heart healthy diet (DASH)
-Reduced Na intake (< 1500 mg/day)
-Physical activity
-Limit alcohol (1 d/d w, 2 d/d m)
HTN Guideline Recommendations: when to start, BP goal, drug selection, monitoring
What to start treatment:
-Stage 1 HTN + any of the following:
*Clinical CVD (stroke, HF, CHD)
*ASCVD risk 10%+
*Does not meet BP goal after 6 months of lifestyle modifications
-Stage 2 HTN
BP GOAL: < 130/80
*KDIGO: BP and CKD goal < 120
Initial drug selection:
-Thiazide diuretics
-DHP CCB
-ACEi/ARB
*CKD: ACEi/ARB
*Start 2 drugs from preferred classes when baseline average BP is > 20/10 above goal (>150/90)
Monitoring:
-Check BP monthly and titrate
Pregnancy and HTN
-NO ACEI/ARB (BBW fetal toxicity)
-Drug initiated if SBP > 140, DBP >90
-Labetalol, nifedipine ER, methyldopa are first line (methyldopa less effective for BP)
-SBP maintained 120-139, DBP 80-89
Gestational HTN (new onset HTN after 20 weeks), preeclampsia (same + proteinuria or organ dysfunction)
-IV agents: labetalol, hydralazine
-High risk for preeclampsia (preHTN, renal disease, diabetes, previous preeclampsia: daily baby aspirin after first trimester
Thiazide Diuretics: MOA, CI
Inhibit Na reabs. in DCT, increases excretion of Na/Cl/K/water
CI: Hypersensitivity to sulfonamide derived drugs
Warning: exacerbate gout, dyslipid, diabetes
AE: (PS CaL has GUTS)
-Decrease K, Mg, Na
-Increase Ca, UA, LDL, TG, BG (GUT CaL)
-Photosensitivity
-Sexual dysfunction
Note: diminished effect when CrCl < 30 (except metolazone)
Take EARLY to avoid nocturia
Chlorothiazide is the only thiazide diuretic available IV
Chlorthalidone is considered most effective
Chlorthalidone Dosing
12.5-25 mg daily
(daily doses › 25 mg/day have limited clinical benefit and more risk of adverse effects)
Hydrochlorothiazide Dosing
12.5-50 mg daily
(daily doses › 50 mg/day have limited clinical benefit and more risk of adverse effects)
Chlorothiazide Dosing
500-2000 mg daily in 1-2 divided doses
Metolazone Dosing
2.5-5 mg daily
Thiazides: DDI Considerations
-Can dec lithium renal clearance, inc risk of lithium tox (dec lithium dose)
-Can inc dofetilide (CI), inc risk of QTcP
CCBs: DHP vs NON DHP
DHP: more selective for vascular smooth muscle = arterial vasodilation
NON DHP: more selective for myocardium, less potent dilators
-Negative inotropic, negative chronotropic
NONE WITH GFJ
DHP CCBs: CI/W
DIPINES
CI: nicardipine = aortic stenosis
Warning: hypotension
-Nifedipine IR NOT for HTN in non-pregnant adults (hypo/death)
AE: NICAS and NIFIR are PREG hAF
-Peripheral edema
-Headache
-Flushing
-Palpitations
-Reflex tachycardia
-Gingival hyperplasia
Notes:
-Nifedipine ER DOC in pregnancy
-Amlodipine safe in HFrEF
Amlodipine (Norvasc): Dosing
2.5-10 mg
Nicardipine (Cardene IV): Dosing
5 mg/hr, incr by 2.5 mg/hr every 5-15 min to max dose of 15 mg/hr
Nifedipine (Procardia XL, Adalat CC): Dosing
ER: 30-90 mg daily
Clevidipine (Cleviprex): CI/AE/Notes
CI: allergy to soybeans, soy products, eggs
Warning: clev is (STERIL 2-12 hours)
-Hypotension
-Reflex tachycardia
-Infections
AE:
-High TG
Notes:
-Lipid emulsion (provides 2 kcal/ml), milky white color
-Use aseptic technique (d/t infection risk)
-Max time of use after vial puncture is 12 hours
NON DHP CCBs: CI/W/AE
Diltiazem, Verapamil (ASH in GC about DV)
CI:
-Hypotension (SBP < 90)
-AV bloc, sick sinus
Warning:
-Worsen HF
-Bradycardia
AE:
-Constipation (more with verapamil)
-Gingival hyperplasia
Diltiazem (Cardizem, Tiazac): Dosing
120-360 mg daily
Verapamil (Calan): Dosing
120-480 mg daily
ACEI: CI/W/AE
BBW: fetal toxicity
CI: (AA PAWK the CAR)
-Pregnancy
-Angioedema history
-No use within 36 hr of Entresto
-No use with aliskiren
AE:
-High K
-Angioedema
-Renal impairment
-Cough
-Hypotension
ACEI: Dosing
Ramipril: 2.5-20 mg
Enalapril: 5-40 mg PO, 0.625-5 mg IV Q6h
Lisinopril: 5-40 mg
Benazepril: 10-40 mg
Quinapril: 10-80 mg
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