Hypertension 2

Question 1

What drug to initiate patient on?
- No other indications

Answer 1

• ACEi
• ARB
• CCB
• Thiazide Diuretics
• Beta-Blockers (If under 60) (Mainly used if pt has other indications)

Question 2

Thiazide Diuretics

Answer 2

Hydrochlorothiazide
- 12.5-25 mg daily

Chlorthalidone (Long Half Life)
- 12.5-25 mg daily

AE:
- Hypokalemia

Question 3

What combinations to use (Double)

Answer 3

Past Stroke / TIA
- ACEi/ARB + Thiazide

Diabetes / CAD
- ACEi/ARB + DHP-CCB

DHP-CCB + Thiazide

Question 4

What combinations to use (Triple)

Answer 4

ACEi/ARB
+
Thiazide
+
DHP-CCB

Usually one combo pill + one single pill

Question 5

What combinations avoid

Answer 5

Avoid:
- ACEi + ARB
- Non-DHP CCB + BB

• ACEi/ARB + BB (Little effects for lowering BP, more for ischemic heart disease)

Question 6

Dihydropyridines Calcium Channel Blockers

Answer 6

Amlodipine 2.5-10 mg daily

Question 7

Non-Dihydropyridine Calcium Channel Blockers

Answer 7

Diltiazem 120-360 mg daily
- Used in high heart rate

Question 8

Beta-Blockers

Answer 8

Bisoprolol 2.5-10 mg daily

Metoprolol 12.5-100 mg daily

Not really used as monotherapy,, used synergistically for BP lowering
- Reduces CV events, not mortality
- First Line: In heart failure and angina

Question 9

Diabetes Hypertension

Question 10

Refractory Hypertension

Answer 10

Low Dose Spironolactone

Question 11

Pregnancy

Answer 11

Methyldopa
Nifidipine

Avoid: ACEi or ARB

Question 12

Erectile Dysfunction

Answer 12

Avoid:
- Beta-Blockers, Diuretics, Alpha-Blockers

Switch to:
- CCBS, ACEi/ARB

Question 13

Thiazide Diuretics
- Adverse Effects

Answer 13

Lower potassium
Bit lower sodium, magnesium

Increased urination for first few weeks

Increased uric acid (gout attacks)

Transient increase in glucose (no increased rate of diabetes)

Increased sun sensitivity

Question 14

Thiazide Diuretics
- Considerations

Answer 14

If renal function is low (<20) we may switch to a loop diuretic instead

Potassium is neutral if combining a diuretic with
- First Line: ACEi or ARB
- Second Line: Spironolactone
- Third Line : Amiloride (Though is better to use a combo that helps lower BP as well)
- Forth Line: Potassium Supplement
- Fifth Line: Reduce dose

Question 15

ACEi/ARB
- Adverse Effects

Answer 15

Hypotension

Angioedema (Remove offending agent)
- Not antihistamine mediated
- Not epipen mediated

Dry Cough (ACEi > ARB)

Hyperkalemia (Can be used to counteract thiazides)

Increased SCr / Decreased eGFR
- Up to 30% is acceptable

Question 16

ACEi/ARB
- Considerations

Answer 16

Have a renal protective effect
- Decreases Proteinuria and Microalbuminuria by preventing vasoconstriction of efferent arterioles

Contraindicated if patient has bilateral artery stenosis
- Causes serum creatinine to jump up

Question 17

DHP-CCB
- Adverse Effects

Answer 17

• Pedal Edema, Non-Pitting
• Headaches

Question 18

DHP-CCB
- Considerations

Answer 18

Avoid short acting nifedipine
- Drops BP very fast, used in ER
- Use XL formulation if needed

Question 19

Non-DHP-CCB
- Considerations

Answer 19

Causes less pedal edema than DHP-CCB

Avoid use with beta blockers and digoxin

Question 20

Beta Blockers
- Adverse Effects

Answer 20

Hypotension
Bradycardia (50-60 is okay)

Fatigue

Bronchospasms
- May avoid use in asthma
- Good for COPD

Erectile Dysfunction

Weird Dreams

Question 21

Beta Blockers
- Considerations

Answer 21

When discontinuing moderate-high dose tapering is required

Question 22

When to initiate combo pill

Answer 22

When over 10/10 within target

Avoid combo if:
- Moderate-Severe frailty
- Above 85 years old
- Symptomatic orthostatic hypotension

Question 23

SPRINT
- Inclusion Criteria

Answer 23

1. Age > 50
2. SBP > 130-180
3. 1 CV Risk
   - Age > 75
   - CVD
   - CKD

• Subclinical CVD values
• FRS > 15%

Question 24

SPRINT
- Exclusion Criteria

Answer 24

1. Stoke history
2. Diabetes
3. Heart Failure
4. Standing SBP<110
5. eGFR < 20
6. Nursing Homes