Hypertension 3 - Compelling indication and Special pop Flashcards
Difference between Hypertensive Urgency vs Emergency?
Both have SBP > 180 or DBP > 120
Difference is if have Target Organ damage or not, if someone has symptoms or not.
Symtoms + Damage = emergency
What to do if Hypertensive Urgency
Make sure taking BP correctly, recheck
Make sure they take meds
Want to lower BP gradually
only do this if having no symptoms
What to do if Hypertensive Emergency?
Hospital or doctor
Lower BP in min/hrs
Have symptoms in this situation. vision issues
What is Resistant Hypertension
Above goal and >3 meds
At goal and >4 meds
Reasons for Resistant Hypertension
Med adherence
White coat HTN
Poor BP measuring technique
Resistant Hypertension Treatment
Remove contributing life factors (Diet, Exercise, etc)
- Discontinue or decrease interfering substances
- Optimize current regimen
- Consider adding other medications
What should be discontinued in Resistant HTN? (can be interfering)
NSAIDs Sympathomimetics (amphetamines / decongestants) Stimulants Oral contraceptives Licorice Ephedra
How to optimize current regimen for Resistant HTN?
Maximize current med dosing
Maximize diuretic therapy
Consider chlorthalidone over HCTZ for better BP lowering response or loop diuretic if severe renal impairment
Consider blister packing, med delivery, combo BP meds to reduce pill burden / improve adherence
Recommend patient take one or more BP meds at bedtime
What drugs can you add for Resistant HTN?
Aldosterone antagonist (spironolactone)
Evidence supports adding spironolactone over other med options to improve BP
Other agent options: Beta blocker, a centrally acting agent (clonidine), an alpha blocker, or hydralazine or minoxidil
Consider HTN Specialist referral
What is White Coat Hypertension?
When a person has elevated blood pressure readings in clinic but have normal readings outside of clinic
How to reduce White Coat Hypertension?
24hr BP monitoring (Gold Standard)
Monitor BP at home
Anti-HTN in Black patients initial treatment?
Thiazide-type diuretic or CCB
Most patients require 2 of more meds
Add ACEi or ARB as add-on w/ compelling indication
BP in Elderly people
Often have Isolated Systolic Hypertension (ISH)
What medications are effective in elderly with ISH?
Dihydropyridine CCBs (Amlodipine, Nifedipine)
Generally used first, tolerated best
Challenges of Treating elderly people?
Poly-pharmacy
Frailty
Cognitive impairment
Variable life expectancy
Which BP side effects are elderly at higher risk?
Orthostatic hypotension
Risk of syncope/falls
Volume depletion
Electrolyte problems
BP goal in elderly people?
Goal = <130/80 IF tolerated well
Modify goal to <140/90 or <150/90 if needed based on pt
Special considerations in elderly people?
consider combo meds with lower doses to reduce side effects
confirm med adherence before increasing dose
counsel patients on ACEI/ARB or thiazide to stay hydrated and avoid NSAIDs
Which medications make ED worse?
Thiazide and Beta blockers
Which medications are pretty neutral for ED?
ACEi’s and CCBs
HTN in pregnancy
Usually goes away once give birth
Preeclampsia can occur -> turns into eclampsia if seizures occur
Preferred medications in Pregnancy HTN
Hydralazine or labetalol to manage severe elevations of BP
Nifedipine
Methyldopa - best data but limited due to potency
Labetalol or nifedipine are more commonly used
Which meds contraindicated in pregnancy HTN?
ACEIs, ARBs, aliskiren, and spironolactone
Heart Failure Goal HTN?
<130/80
1st line therapy for HFrEF
GDMT Beta Blocker + diuretic (loop) + ACEI/ARB/ARNI +/- aldosterone antagonist (Based on LEVF)
Add on if uncontrolled: CCB (DHP)
Patients with HFpEF who present with symptoms of volume overload, what drugs should be prescribed to control HTN?
Diuretics
Adults with HFpEF and persistent hypertension after management of volume overload, what drugs should be prescribed
ACEi or ARBs and Beta Blockers
GDMT Beta Blockers
Metoprolol Succinate
Carvedilol
Bisoprolol
Which CCB should be avoided in patients with HF?
Non-DHP due to negative chronotropic/ionotropic effects
Post MI BP goal?
<130/80
1st line drugs in post-MI HTN?
ACEi/ARBs plus BB
Should use BB w/o intrinsic sympathomimetic activity (usually start with metoprolol)
Usually B1 selective are used
Add on therapy in post MI HTN?
CCB or thiazide
SIDH BP goal?
<130/80
1st line therapy SIHD?
BB and ACEi/ARB
Avoid Atenolol
Add on therapy if HTN uncontrolled SIHD?
w/ angina = DHP CCB
w/o angina = DHP CCB/ Thiazide Diuretic/ or Aldosterone Antagonist
BP goal for diabetes with ASCVD or ASCVD score >15%
<130/80
BP goal for diabetes with ASCVD score <15%
<140/90
Treatment for HTN w/ Diabetes without kidney disease ?
ACEi/ARB, DHP CCB or Thiazide diuretic
Treatment for HTN w/Diabetes with kidney disease
ACEi or ARB will be 1st line therapy
How can ACEi improve Kidney function?
Block AT2, causing dilation of efferent part of nephron and allows for better flow.
improves kidney function
BP goal in Chronic Kidney Disease?
<130/80
Therapy for CKD with UACR >300
ACEi (preferred) or ARB
Add on CCB and Thiazide
Therapy of pt who have already had a stroke?
1st line = ACEi/ARBs, Thiazide or combo of 2
2nd line = CCB and Aldosterone Antagonist
combo ACEi/ARB + Thiazide shown to reduce incidence of recurrent stroke
BP goal for patient who already had stroke?
<130/80
Treating HTN in Black pt with Diabetes?
CCB or Thiazides
Treating HTN in pt with Diabetes and proteinuria?
ACEi/ARB
