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344 > Hypertension 2 > Flashcards

Hypertension 2 Flashcards

1
Q

SPRINT trial

Primary Outcome
Secondary Outcomes

A

• For those >50yo (without DM/stroke/CHF), “best” BP
targets to reduce CV morbidity and mortality unknown
• Does a lower systolic BP goal (<120 mmHg) reduce
clinical events more than standard goal (<140 mmHg)?
• Randomized, controlled, open-label, conducted in US
• Primary Outcome: all CV events; composite of:
• Non-fatal MI, stroke and acute decompensated HF,
ACS, death from CV cause
• Secondary Outcomes: each component of primary +
renal outcomes in CKD population

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2
Q 
Inclusion Criteria
Excluded those with:
1. Prior stroke
2. DM
3. CHF
4. Standing SBP<110
5. eGFR<20 mL/min
6. Reside in nursing home
A
  1. Age ≥ 50 years
  2. Baseline systolic BP 130-180 mmHg
  3. High risk:
    a. Age ≥75 years*
    b. Clinical cardiovascular disease (CVD)*
    c. Subclinical CVD (calcium score, ABI, LVH)
    d. CKD (GFR = 20-59 ml/min)*
    e. 10-year FRS ≥15%
    * Targeted enrolment
ABI = ankle brachial index
LVH = left ventricular hypertrophy
FRS = Framingham risk score
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3
Q

what was the primary outcome

A

cumulative hazard Lower than anticipated over 3 years

More risks intensifying therapy

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4
Q

New Thresholds/Targets for the High-Risk Patient

Post-SPRINT: Who does this apply to?

A

Clinical or sub-clinical cardiovascular disease
OR
Chronic kidney disease (non-diabetic nephropathy, proteinuria <1 g/d, *estimated glomerular filtration rate 20-59 mL/min/1.73m2)
OR
†Estimated 10-year global cardiovascular risk ≥15%
OR
Age ≥ 75 years

There was an increased risk of renal deterioration, potassium abnormalities and hypotension with intensified therapy
• Patients with one or more clinical indications should consent to intensive management…..MONITORING IMPORTANT!!!

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5
Q

New Thresholds/Targets for the High-Risk Patient

Post-SPRINT: Who does this NOT apply to?

A

Limited or No Evidence:
• Heart failure (EF <35%) or recent MI (within last 3 months)
• Indication for, but not currently receiving, a beta blocker

• Institutionalized elderly
Inconclusive Evidence:
• Diabetes mellitus
• Prior stroke
• eGFR < 20 ml/min/1.73m2

Contraindications:
• Patient unwilling or unable to adhere to multiple medications
• Standing SBP <110 mmHg
• Inability to measure SBP accurately
• Known secondary cause(s) of hypertension

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6
Q

Useful Dual Combinations

A

For additive hypotensive effect in add-on therapy,
combine an agent from
Column 1 with any in Column 2
Beware caveat!!!

Column 1: • ACE Inhibitor
• ARB
• Beta adrenergic blocker

Column 2: • Long-acting calcium channel
blocker *
• Thiazide diuretic

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7
Q

Ratio of Incremental SBP lowering effect at

“standard dose”– Combine or Double?

A

Should i adda 2nd agent at starting doses before maxmizing doses
Doubling dose of one single drug will get you about 20% lower

Add 2nd drug can double the amount of bp lowering

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8
Q

Dose Response for Antihypertensive

Agents (on sBP in mmHg)

A

You never double the SD lowering
Decrease by 10% for any bp lowering
If not enough, may need a 2nd drug

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9
Q

Nocturnal Dosing

A

• Two trials (MAPEC, n=2100 and HYGIA, n=19 084) showed dosing at least 1 antihypertensive drug at hs
reduces composite CV event rate by 45-50%.
• Asleep BP reduced in HS dosing group
• Increased proportion of BP “dipping” at night
• Huge methodological flaws, making results questionable.
• This approach NOT recommended in guidelines.
• BED-MED Study in AB in progress now as well as
TIME trial (UK).

At least one at bedtime
Promote nighttime dipping
Only 1 study and there are flaws
May do it depending of individual data
Cautious of diuretics at bedtime, need to go to washroom
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10
Q

Treatment in the absence of compelling indications for specific therapies

2 choices

A

No other associate risk factors, diseases, CV organ disease
= absense of compelling indicaitons

  1. Treatment of Systolic/Diastolic hypertension without
    other compelling indications
  2. Treatment of Isolated Systolic hypertension without
    other compelling indications
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11
Q

First Line Treatment of Adults with Systolic/Diastolic
Hypertension Without Other Compelling Indications
options

A

Either ACEI or ARB not both

High HR, beta blocker can decrease it
Can be used over 60 for compelling indication

Dihydropyridine CCBs are used over non-dihydro

BB not first line for 60 or above
Other options on left of BB have same degree of bp lowering
40-50 really high bp, may use BB to control high bp
Can still use

**Recommended SPC choices are those in which an ACE-I is combined with a CCB,
an ARB with a CCB, or an ACE-I or ARB with a diuretic

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12
Q

Advantages of Single Pill Combinations (SPCs)

A

• SPC therapy is associated with better adherence
vs. free combinations1
• A regimen featuring initial prescription of SPC leads to better BP control2
• Initial combination therapy is associated with ↓ risk of CV events than monotherapy
Know which combinations exist and adapt the prescription to 1 combo pill

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13
Q

drugs in thiazide class

A

Hydrochlorothiazide 12.5-25 mg daily
Indapamide 0.625-2.5 mg daily
Chlorthalidone 12.5-25 mg daily

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14
Q

ACE Inhibitors (ACEi)

A 
Perindopril 4-8 mg daily
Ramipril 2.5-20 mg daily
Lisinopril 5-40 mg daily
Enalapril 2.5-40 mg daily
(may dose bid)
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15
Q

Angiotensin Receptor Blockers (ARBs)

A

Telmisartan 20-80 mg daily
Irbesartan 75-300 mg daily
Valsartan 80-320 mg daily
Candesartan 8-32 mg daily

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16
Q

Calcium Channel Blockers (CCB)

A

Amlodipine (DHP CCB) 2.5-10 mg daily

Diltiazem (NDHP) 120-360 mg daily

17
Q

Beta-Blockers

A

Bisoprolol 2.5-10 mg daily

Metoprolol 12.5-100 mg bid

18
Q

Thiazides and thiazide-like

whats the difference

A

Thiazide like is now more prominent in guidelines
Greater degree of bp lowering
Thiazide is shorting acting

19
Q

Chlorthalidone
Indapamide
Metolazone

which class of drugs?

A

Thiazide-Like

20
Q 
Hydrochlorothiazide*
*this is only agent available in Canada
Chlorothiazide
Methychlothiazide
Polythiazide
Bendroflumethiazide
A

Thiazides

21
Q

Diuretic Type Meta-Analysis vs. Placebo

what did diuretics reduce?
what did only thiazide-like diuretics reduce

A

• Both types of diuretics reduced CV events, cerebrovascular
events, and HF
• Only thiazide-like diuretics additionally reduced coronary
events and all-cause mortality

22
Q

half life of chlorthalidone vs HCTZ

A

Chlorthalidone Thiazide-like 45-60 hrs
Indapamide Thiazide-like 14-18 hrs
Hydrochlorothiazide Thiazide-type 6-15 hrs

NOTE: Hydrochlorothiazide is available in many combos (so commonly
used); consider BP control if already on (before considering switch).

23
Q

dosage form chlorthalidone is avail in

A

Avail in canada only in 50mg tablet but we must split it in half or quartering the tablet

24
Q

Beta-blockers (BB)

reduction in what?

A

Compared to placebo or no tx (in those >60):
no reduction in mortality, but reduction in CV
event rate
• Atenolol compared to other 1st line agents:
– increase risk of stroke [HR 1.16, 95%CI 1.04-1.30]
– Not shown when other BB used (smaller #’s)
• ABCD rule….A + B not as synergistic for BP
lowering. Only use if compelling indication.
BB decreases HR

25
Q

why is ACEi + ARB = Not Good Combo

A

telmisartan, ramipril, tel + ram barely different after 5 years
Increase in SE does not justify them used together

26
Q

what are compelling indications

A

• Compelling indications:
– Ischemic Heart Disease
– Recent ST Segment Elevation-MI or non-ST Segment Elevation-MI
– Left Ventricular Systolic Dysfunction
– Cerebrovascular Disease
– Left Ventricular Hypertrophy
– Non Diabetic Chronic Kidney Disease
– Renovascular Disease
– Smoking
• Diabetes Mellitus
– With Nephropathy
– Without Nephropathy
• Global Vascular Protection for Hypertensive Patients
– Statins if 3 or more additional cardiovascular risks
– Aspirin once blood pressure is controlled

27
Q

see flowchart on slide 31

A

ok

28
Q

Hypertension Treatment in
those with Diabetes

Threshold equal or over 130/80 mmHg and TARGET below 130/80 mmHg

A

with Nephropathy and/or CVD or CV risk factors
–> ACEi or ARB
w/o nephropathy:
–> 1. ACEi or ARB
2. . DHP-CCB or Thiazide/thiazidelike diuretic

A combination of 2 first line drugs may be considered as initial therapy if the blood pressure is >20 mmHg systolic or >10 mmHg diastolic above target. Combining an ACEi and a DHP-CCB is recommended.

> 2-drug combinations (preferrable combo: RAASi + DHP-CCB

29
Q

diabetes mellitus: summary

If Creatinine over 150 µmol/L or creatinine clearance below 30 ml/min what will happen?

A

Monitor serum potassium and creatinine carefully in patients with CKD prescribed an ACEI or ARB
Combinations of an ACEI with an ARB are specifically not recommended in the absence of proteinuria

If Creatinine over 150 µmol/L or creatinine clearance below 30 ml/min ( 0.5 ml/sec), a loop diuretic
should be substituted for a thiazide diuretic if fluid volume overload

30
Q

Refractory Hypertension:
Additional Agents
Once first-line drugs/combos considered, if BP still
not at target, use one or more of following:

A

– Low-dose spironolactone (12.5-50 mg/day) (high serum potassium)
– Alpha blocker (doxazosin 2-16 mg/day)
– Furosemide (if renal failure and fluid retention)
– Clonidine 0.1-0.3 mg po bid
– Hydralazine 10-50 mg po qid
– Methyldopa 250-500 mg po bid-tid
– Nitropatch 0.2-0.8 mg/hour transdermal
– Minoxidil 10-40 mg po daily, dosed bid ($$$)

31
Q

Pregnancy HTN and goal

A 
Definition:
– BP≥140/90
– Non-severe: BP 140/90 but < 160/110
– Severe: BP ≥160/110
Goal: DBP<85 mmHg
32
Q

Pregnancy

• Drugs of Choice (Grade C):

A 
– Methyldopa
– Labetalol
– Nifedipine long-acting
– Beta-blockers
• Second line (Grade D):
– Hydralazine, clonidine, thiazides
• ACEi and ARB are contra-indicated
• Note: BP may go down in pregnancy; best drug is no
drug, but need to weigh risk:benefit and monitor
closely
33
Q

Erectile Dysfunction (ED)

A

Incidence in general population: 8-10%
• Incidence in men with HTN: 15-46%’
• CV-risk predictor
• Associated with hypertension itself; extension of
vascular disease; also associated with smoking
• Drug therapy is associated with ED; disease-induced or drug-induced???
– Beta-blockers (non-selective > cardioselective), diuretics and alpha-blockers felt to be biggest culprits
– CCBs and ACEi/ARBs less-culprit (& may improve ED)

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