Hypertension Flashcards
Staging of BP: normal
<120/80
Staging of BP: prehypertension
120-135/80-89
Staging of BP: Stage I HTN
140-159/90-99
Staging of BP: Stage II HTN
>/= 160/100
BP target for >/=60yo
<150/90mmHg
BP target for <60yo
140/90 mmHg
BP targets for all adults w/CKD or DM
<140/90 mmHg
AHA/ASA position on higher BP targets for older adults?
Do not endorse
Recommended 1st line treatment for non black, all ages, +/- DM
thiazide, ACEi, ARB, CCB
Recommended 1st line treatment for Black +/- DM
thiazide, CCB
Recommended 1st line treatment for CKD, any race, +/- DM
ACEi, ARB
Why is HTN a risk for AAs?
not higher risk of mortality
higher risk of EOD
HTN mgmt guidelines: what if goal is not reached in 1mth?
Increase dose or add recommended drug
HTN mgmt guidelines: can ACEis and ARBs be used concomitantly?
No!
HTN mgmt guidelines: what if goal is not achieved w/2 drugs?
add and titrate 3rd recommended drug
HTN mgmt guidelines: what if goal is not achieved even w/3rd drug?
- Consider referral to HTN specialist
- Use drugs from other classes
Non first line HTN drugs
- Loop diuretics
- K-sparing diuretics including aldosterone receptor antagonists
- Direct renin inhibitors
- Central-acting alpha2 agonists
- Beta-blockers including those with alpha-blocking or vasodilating effects*
- Alpha-blockers**
- Nitrates
- Direct vasodilators
- Peripherally-acting adrenergic antagonists
*Beta blocker vs. ARB study: outcome
Atenolol (Beta blocker) associated with increased risk of composite CV death, MI, stroke compared to Losartan (ARB)
Alpha blocker vs. Thiazide Diuretics study
Doxazosin associated with increased rate of cerebrovascular events, heart failure and composite CVD events
Thiazide-type diuretics: Agents
- Microzide (hydrochlorothiazide)
- Chlorthalidone
- Indapamide
- Zaroxolyn (metolazone)
Thiazide-type diuretics: MOA/PK
Early: depletes sodium stores by blocking Na/CL transporter in renal distal convoluted tubule –> decreases blood vol. & CO
Late: CO normalizes, systemic vasc. Resistance decreases
Thiazide-type diuretics: ADRs
- Hyponatremia
- Hypokalemia
- Metabolic alk
- Photosensitivity
- Hyperuricemia
- Hyperglycemia
- Weakness
Thiazide-type diuretics: monitor
electrolytes, BP, fluid status
Thiazide-type diuretics: special considerations (e.g., renal impairment, possible allergies, dose timing)
- *Less effective in setting of renal impairment
- *Sulfa drug!
- *counsel patient to avoid taking close to bedtime (or they will get up all night to pee!)
Loop diuretics: agents
Lasix (furosemide)
Demadex (torsemide)
Bumex (bumetanide)
Loop diuretics: MOA
Block Na/K pump in renal loop of Henle
Loop diuretics: ADRs
- Hyponatremia
- Hypokalemia
- Hypomagnesemia
- Dehydration
- Hyperuricemia
- Oxtotoxicity!
- Photosens.
- Rash
Loop diuretics: are they sulfa drugs?
All are sulfa drugs (EXCEPT Edecrin)
Loop Diuretics: PT counseling
* Counsel patients to avoid taking close to bedtime (or they will get up all night to pee!)
Loop diuretics: considerations for lasix, demadex, bumex
*Lasix-also available IV (2:1 conversion from PO)
*Demadex-CYP2C9 substrate
*Bumex-also available IV (1:1 conversion from PO)
Potassium Sparing diuretics: Agents
Aldactone (spironolactone)
Inspra (eplerenone, also CYP3A4 substrate)
Amiloride
Triamterene
Potassium Sparing diuretics: MOAs
- Aldosterone receptor antagonist (aldactone & eperenone)
- Epithelial sodium channel blocker (amiloride, triameterene)
Potassium Sparing diuretics: ADRs
Hyponatermia
Hyperkalemia
Gynecomastia (spironolactone)
Amiloride & Triamterene
Hyponatremia
Hyperkalemia
Metabolic acidosis
Special considerations: aldactone
aldosterone antagonist
(K+ sparing)
Special considerations: Eplerenone
aldost. antag. CYP3A4 substrate
(K+ sparing)
Angiotensin-converting enzyme inhibitor (ACEI): Agents
- Capotan (captropril)
- Accupril (quinapril)
- Prinivil (lisinopril)
- Alface (rarripril)
- Lotensin (benezapril)
- Vasotec (enalapril, enalaprilaf)
ACEi: MOA
Prevent conversion of angiotensin I > angiotensin II, thereby inhibiting angiotensin II induced vasoconstriction and aldosterone secretion
ACEi: ADRs
- Hyperkalemia
- Dry cough
- Angioedema
- Rash
- Dysgeusia
ACEis: metabolism
*most oral forms are pro-drugs requiring hepatic activation through hydrolysis
ACEis and AAs
* AA’s diminished efficacy increased risk for angioedema
ACEis and pregnancy
avoid in pregnancy, women of childbearing potential
ACEi: cough
*if dry cough occurs, trial another ACEI or switch to ARBs (less associated with cough d/t lack of effects on bradykinin)
ACEi: what to do if angioedema
angioedema occurs, avoid all ACEI and ARBs
ACEi: what to do if kidney issues
* hold in setting of AKI, however have beneficial effect on CKD (dx stabilization and decreased proteinuria)
ACEi: what is important about captopril? (duration, SEs, PK)
short-acting; rare neutropenia, CYP2D6 substrate
ACEi: which is IV formulation
enalopril (Vasotec)