Hypertension Flashcards
AHA goals
Most with CVD :<140/90
Drugs that cause or worsen hypertension
ACTH, alcohol, amphetamines, appetite suppressants, caffeine, Calcineurin antagonists (cyclosporine, tacrolimus), corticosteroids, decongestants, erythropoietin stimulating agents, estrogen, herbals (ginseng, guarana, St. John’s wort), mirabegron (mybetriq), NSAIDs, oncology drugs, SNRIs, thyroid hormone
Lifestyle modifications
- Weight control
- Eating: DASH (high in fruits and veggies, low fat dairy, reduced sat. And total fat, reduced salt)
- Reduced sodium intake: <2.4g /day
- Inc. Physical activity
- Alcohol limits 1/day women and 2/day men
- Smoking cessation
- CONTROL GLUCOSE AND LIPIDS TO REDUCE CV RISK
First line per JNC8
- African Americans and elderly: CCB or thiazide
- White: ACE, ARB, CCB, THIAZIDE
- CKD/Diabetes: ACE or ARB
Goals per JNC 8
REVIEW
Thiazides
Inexpensive, effective
MOA: work on DCT of the nephron and cause vasodilation (inhibit Na re absorption in the DCT causing inc. Sodium , potassium, H+ and water excretion)
Drugs: chlorthalidone (thalitone), HCTZ (microzide), metolazone (zaroxolyn), indapamide
Contra: hypersensitivity to Sulfa, anuria, and renal decompensation
Warning: sulfa allergy, electrolyte disturbances
Side effects: hypokalemia, hyperuricemia, elevated lipids, hyperglycemia, hypercalcemia, hyponatremia, hypomag, dizziness, photosensitivity, rash
Notes: May not be effective in pts with CrCl <30
Pregnancy category B
Loops
Waste more potassium than others (May need supplement)
Mostly used for fluid in HF
MOA: inhibit reabsorption of Na and Cl in the thick ascending loop of Henle thus inc water excretion
Drugs: furosemide (lasix), bumetanide, torsemide (demadex), ethacrynic acid (edecrin)
Equivalency: (40:1:20:50)
BBW: profound dieresis
Warnings: sulfa allergy on all but ethacrynic acid
Side effects: hypokalemia, orthostatic hypotension, dec (Na, Mg, Cl, Ca), metabolic alkalosis, hyperuricemia, hyperglycemia, inc cholesterol, photosensitivity, ototoxicity, including hearing loss, tinnitus and vertigo (most with ethacrynic acid)
Monitoring: renal function, fluid status, BP, electrolytes, hearing
Notes: IV formulations are light sensitive (amber bottle); IV:PO for torsemide and bumetanide 1:1
Potassium Sparing Diuretics
MOA: compete with aldosterone in DCT and collecting ducts increasing Na and water excretion while conserving potassium and H+
Drugs: amiloride (midamor), triamterene (dyrenium)(+ HCTZ is maxzide or dyazide), spironolactone (aldactone), eplerenone (inspra)
BBW: tumor risk (spironolactone)
Contra: renal impairment (CrCl <30), hyperkalemia
Side effects: hyperkalemia, inc. SCr
Spironolactone specific SE: gynecomastia, breast tenderness, impotence
Monitoring: check K+ before starting, BP, Scr/BUN
Diuretic drug interactions
Loops can inc the ototoxic potential of other ototoxic drugs such as aminoglycosides and vancomycin and should not be used in comb with ethacrynic acid
Monitor if used win lithium as can inc toxicity
Avoid with NSAIDs as they inc Na & h2o retention
RAAS inhibitors
Reduce vasoconstriction, decrease aldosterone release, and some agents have shown benefit in renal protection and heart failure
Caution if using two RAAS agents together such as an ace inhibitor, ARB, and Aliskiren. (monitor renal function, BP and potassium carefully)
Major side effects with an ACE inhibitor or an ARB
Cough and angioedema (more common with an ace inhibitor)
Angioedema is a contraindication to any other agent in this class
Angioedema is most common in black patients and signs and symptoms include swelling of the lips, mouth, tongue, face, or neck
Pregnancy considerations with RAAS inhibitors
Contraindicated
ACE-Inhibitors
MOA: inhibit the angiotensin-converting enzyme preventing the conversion of angiotensin I to angiotensin II a potent vasoconstrictor thereby reducing blood pressure
Drugs: benazepril (Lotensin), captopril (Capoten), enalapril (Vasotec), lisinopril (prinivill, zestril), quinapril (accupril), Ramipril (Altace)
Benazepril and enalapril are twice-daily dosing most others are once daily
Blackbox warning: discontinue in pregnancy
Contraindications: angioedema, bilateral renal artery stenosis, cannot use concurrently with Aliskiren in patients with diabetes
Warning: caution when using more than one RAAS agent at the same time due to risk of hypertension, hyperkalemia, renal dysfunction
Side effects: cough, hyperkalemia, angioedema, hypotension, dizziness and acute renal insufficiency (captopril has many more SEs such as taste perversion and rash)
Monitoring: blood pressure, potassium, renal function
Notes: pregnancy category D
ARBs
MOA: block angiotensin II from binding to the angiotensin II receptor on vascular smooth muscle and thus preventing vasoconstriction
Drugs: valsartan (Diovan), losartan (Cozaar), irbesartan (Avapro), candesartan (Atacand), Olmesartan (Benicar), telmisartan (micardis), azilsartan (Edarbi)
Blackbox warning: do not use in pregnancy
Contraindications: angioedema, bilateral renal artery stenosis, do not use with Aliskiren in patients with diabetes
Warning: caution with other RAAS agents; (Olmesartan only: spruce like enteropathy (severe diarrhea))
Side effects: angioedema, hyperkalemia, hypertension, dizziness and acute renal insufficiency
Monitoring: BP, potassium, renal function
Notes: pregnancy category D
Direct Renin Inhibitor
MOA: directly inhibits renin which is responsible for the conversion of angiotensinogen to angiotensin one a potent vasoconstrictor thereby reducing BP
Drug: Aliskiren (Tekturna)
Blackbox warning: discontinue in pregnancy
Beta blocker considerations
MOA: inhibits the effects of catecholamines especially norepinephrine at the beta-1 and beta-2 adrenergic receptors causing BP and HR reduction
Used for HTN, post-MI, angina, HF, and migraine prophylaxis (1st line in HTN no longer recommended)
Metoprolol and carvedilol often used for both HF and HTN (note dosage difference)
Beta-blockers with intrinsic sympathomimetic activity (cartelol, acebutolol, penbutolol, pindolol) show both stimulation and blockade at the beta receptor and thus are useful in patients with excessive bradycardia to meet beta blocker therapy
Beta-1 selective agents: (AMEBBA) atenolol, metoprolol, esmolol, bisoprolol, betaxolol and acebutolol
Propranolol has hives look at solubility and therefore penetrates the CNS called and C&S side effects such a sedation, depression, cognitive effects
Carvedilol: must be taken with food and is not milligram per milligram switch between CR and IR
Labetolol: first-line for hypertension in pregnancy
Caution when used in patients with a history of hypoglycemia as it can mask the symptoms (in these patients look for sweating and hunger as these are not masked)
Caution in patients with breathing problems such as asthma /COPD choose beta-1 selective agents in these patients at lower selective dosing
Beta-1 selective beta blockers
Drugs: acebutolol (sectral), atenolol (tenormin), bisoprolol (zebeta), metoprolol tartrate (Lopressor), metoprolol succinate (Toprol XL)
Blackbox warning: do not withdraw abruptly particularly in patients with CAD, gradually taper over 1 to 2 weeks to avoid a cute tachycardia, hypertension, and or ischemia
Contraindications: sinus bradycardia, second or third degree heart block, sick sinus syndrome, or cardiogenic shock
Side effects: decreased HR, hypertension, fatigue, dizziness, depression, decreased libido, impotence, hyperglycemia, hypertriglyceridemia, weight gain, edema
Monitoring: HR, BP
Notes: caution and diabetes with recurrent hypoglycemia, asthma, severe COPD or resting limb ischemia
Caution: IV doses are not equivalent to oral doses
Beta-1 selective blocker and nitric oxide dependent vasodilation
BBW, CONTRA, MONITORING: same for all BB
Drug: Nebivolol (Bystolic)
Side effects: headache, fatigue, dizziness, diarrhea, nausea, bradycardia, hypertriglyceridemia and decreased HDL
Notes: nitric oxide causes peripheral vasodilation
Beta-1 and beta-2 nonselective beta blockers
Drugs: Nadolol (cogard), pentbutolol (levatol), pindolol, propranolol (Inderal LA, InnoPran XL), Timolol
Same considerations as other beta blockers
Nonselective Alpha and beta blockers
Drugs: carvedilol (coreg, coreg CR), labetalol (Trandate)
Same considerations as other beta blockers
Carvedilol must be taken with food
Coreg 3.125=coreg CR 10mg, coreg 6.25=20mg, etc.
Beta blocker drug interactions
- Can enhance the effects of insulin and oral hypoglycemic agents therefore monitor BG carefully
- Carvedilol: inc. digoxin and cyclosporine levels
Dihydropyridine Calcium Channel Blocker
Uses: HTN and angina
MOA: inhibit calcium ions from entering the slow channels or voltage sensitive areas of vascular smooth muscle resulting in peripheral arterial vasodilation and decreasing peripheral resistance
Drugs: amlodipine (Norvasc), nifedipine ER (Adalat CC, Procardia XL, afeditab CR), nifedipine IR (Procardia), nicardipine (Cardene)
Side effects: peripheral edema, headache, Flushing, tachycardia/reflex tachycardia, gingival hyperplasia (least likely with amlodipine)
Monitoring: BP, HR, peripheral edema
Notes: do not use sublingual nifedipine as it may increase the risk of MI
Some capsule shells will be seen in the Feces
Inpatient acute-care dihydropyridine CCB
Drugs: Clevidipine (cleviprex) IV only
other drugs that can be used IV: diltiazem, verapamil, nicardipine
Contraindications: do not using soy or egg allergy, acute pancreatitis, severe aortic stenosis
Side effects: headache, nausea/vomiting and other rare side effects such as hypertriglyceridemia and infections
Monitoring: BP, HR
Notes: in a lipid emulsion therefore it is milky white in color
Non-dihydropyridine calcium channel blockers
Uses: primarily for arrhythmias to control/slow heart rate and sometimes for hypertension and angina
Class effect: negative inotropes that decrease contraction force and Negative chronotopes that decrease heart rate
MOA: inhibit calcium ions from entering the slow channels or voltage sensitive areas of the vascular smooth muscle and myocardium, resulting in coronary vasodilation
Drugs:
- Diltiazem (Cardizem, Cardizem CD, Cardizem LA, Dilacor XR, Dilt – CD, Dilt-XR, Cartia XT, Tiazac, Taztia XT)
- Verapamil (Calan, Calan SR, Covera HS, Verelan)
Contraindications: severe hypotension, second or third degree heart block, sick sinus syndrome, cardiogenic shock, acute MI and pulmonary congestion
Side effects: Adema, headache, AV block, bradycardia, hypertension, arrhythmias, HF constipation (more with verapamil), gingival hyperplasia
Monitoring: BP, HR, ECG
Calcium channel blocker drug interactions
Diltiazem and verapamil are both CYP3A4 substrates and moderate three A4 inhibitors and they will raise the concentration of many other drugs and 3A4 inducers and inhibitors will affect their concentration
Avoid grapefruit juice
Centrally acting alpha-2 adrenergic agonist
MOA: stimulate alpha to adrenergic receptors in the brain which results in reduced sympathetic outflow from the CNS
Drug: clonidine (Catapres, Catapres TTS patch), guanfacine (tenex (for ADHD intuniv)), methyldopa
Clonidine is used commonly for resistant hypertension and patient you cannot swallow due to dysphasia or dementia sets it comes as a patch APPLIED WEEKLY (to upper/outer arm or chest)
Side effects: bradycardia, dry mouth, drowsiness, sedation, lethargy, hypertension, depression, psychotic reactions, nasal stuffiness, sexual dysfunction
Notes: rebound hypertension if stopped abruptly therefore do not stop abruptly you must taper
Direct vasodilators: hydralazine
MOA: calls direct vasodilation on arterioles with little effect veins
Side effects: headache, reflex tachycardia, palpitations, anorexia; rare: lupus like syndrome
Direct vasodilator: minoxidil
Side effects: fluid retention, tachycardia, aggravation of angina, pericardial effusion, hirsutism
Alpha Blockers
MOA: bind to alpha-1 adrenergic receptors which result in vasodilation of arterioles and veins; use mostly from BPH; not first line for hypertension
Drugs: prazosin (minipress), terazosin (hytrin), doxazosin (cardura, cardura XL)
Side effects: orthostatic hypotension, syncope with first dose, dizziness, fatigue, headache, fluid retention, priapism
Notes: caution with concurrent use with a PDE five inhibitors such as sildenafil, vardenafil and avanafil due to additive effects on BP and dizziness
Hypertensive urgency and emergency
Urgency: BP generally >/= 180/110-120 without acute target organ damage
Emergency: urgency plus acute target organ damage such as encephalopathy, myocardial infarction, unstable angina, pulmonary edema, eclampsia, stroke, aortic dissection
Treatment of urgency: oral medication with the onset of action of 15 to 30 minutes; reduced BP gradually over 24 to 48 hours
Treatment of emergency: reduce mean arterial pressure by no more than 25% within minutes to one hour, then if stable, 260/100 with in the next 2 to 6 hours. use IV medication.
Drugs used for hypertensive urgency
Captopril, clonidine, labetalol
Drugs used in hypertensive emergencies
Clevidipine, sodium nitroprusside (Nitropress), nicardipine (Cardene), fenoldopam (corlopam), nitroglycerin, enalaprilat (vasotec IV), hydralazine, labetalol (trandate), esmolol (brevibloc)
