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Primary Care > Hypertension > Flashcards

Hypertension Flashcards

1
Q

What is the leading global risk factor for death and disability? (CHEP)

A
  • Hypertension
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2
Q

How common is hypertension in Canada? (CHEP)

A
  • Affects 1 in 4 (23%) Canadian adults
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3
Q

What benefit can treating hypertension have on the risk of stroke and CVD?

A
  • Reduces stroke by 1/3 and CVD by 15%
  • Treating HTN and cholesterol can reduce CVD by almost half
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4
Q

What are 11 risk factors for hypertension?

A
  • Demographics
    • Age >55
    • Male
    • Southeast Asian, African, First Nations
  • Lifestyle
    • Sedentary
    • Poor diet
    • Obesity
    • Smoking
    • Excessive alcohol
    • Stress
  • Personal medical history
    • Dysglycemia
  • Family medical history
    • CAD <55 in men, <65 in women
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5
Q

In patients presenting with hypertension, what are non-modifiable and modifiable cardiac risk factors that should be asked about? (CHEP)

A
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6
Q

In patients presenting with hypertension, what are 5 organ systems that should be asked about to assess for end organ damage?

A
  • Brain – recent TIA/stroke, intracerebral hemorrhage, aneurysmal sub-arachnoid hemorrhage, dementia (vascular, mixed vascular and Alzheimer’s)
  • Eyes – visual blurring (hypertensive retinopathy)
  • Heart – prior MI/angina, CHF, LVH, CP, SOB
  • Kidney – asymptomatic (CKD)
  • Peripheral Arterial Disease - claudication
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7
Q

What are 8 secondary causes of hypertension and associated signs or symptoms?

A
  • OSA – snores, AM headaches, non-refreshing sleep
  • RAS – asymptomatic, CAD risks
  • Renal insufficiency – CKD, diabetes, or recent strep infection
  • Pheochromocytoma – paroxysmal sweating and headache and palpitations
  • Hyperaldosteronism – weight loss, low energy
  • Cushings – weight gain
  • Hyperthyroidism – weight loss, tremor, heat intolerance, diarrhea, light menses
  • Medications
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8
Q

What are 12 exogenous substances that can induce/aggravate hypertension? (CHEP)

A
  • NSAIDs
  • Steroids
  • OCP/HRT/Testosterone
  • Decongestants
  • Calcineurin inhibitors – cyclosporine, tacrolimus
  • EPO
  • MAOIs, SSRIs, SNRIs
  • Midodrine
  • Licorice root
  • Stimulants/cocaine
  • Salt
  • Alcohol
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9
Q

What are 3 important considerations when performing a physical exam on a patient with hypertension?

A
  • Signs of end organ damage
  • Secondary causes of hypertension
  • Metabolic syndrome
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10
Q

What are 4 organ systems that should be evaluated for end organ damage on physical exam in patients with hypertension?

A
  • Brain – neurologic exam, carotid bruits, dementia
  • Eyes – retinal hemorrhage
  • Heart – loud S2, precordial heave
  • Peripheral vascular – poor pulses, AAA
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11
Q

What are signs on physical exam that could be associated with 7 different secondary causes of hypertension?

A
  • OSA – wide neck, micronathia
  • RAS – abdominal bruits
  • Renal insufficiency - asymptomatic
  • Pheochromocytoma – flank mass, tachycardia
  • Hyperaldosteronism – flank mass
  • Cushings – central obesity, hirsutism, easy bruising, striae
  • Hyperthyroidism – tachycardia, goiter, ophthalmoplegia, hyperreflexia
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12
Q

How is metabolic syndrome diagnosed?

A

≥3 measures to make the diagnosis of metabolic syndrome

Waist Circumference

≥102 cm (Men) / ≥88 cm (Women)

TG

≥1.7 mmol/L

HDL

<1.0 mmol/L (Men) / <1.3 mmol/L (Women)

BP

SBP ≥130 mm Hg and/or DBP ≥85 mm Hg

FPG

≥5.6 mmol/L

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13
Q

What are 4 different scenarios in which BP can be measured?

A
  • Office
    • Non-AOBP
    • AOBP
  • Home
  • Ambulatory
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14
Q

What is the preferred method of measuring in-office blood pressure? (CHEP)

A
  • Automatic office BP (AOBP)
    • Taken WITHOUT patient-health provider interaction
    • Using a FULLY-automatic device
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15
Q

What are the advantages of AOBP over the non-AOBP approach for diagnosing hypertension? (CHEP)

A
  • Eliminates the risk of conversation during readings
  • Reduces the risk of the white coat effect
  • Facilitates multiple measurements with each clinical encounter (and automatically calculates the mean)
  • Closely approximate mean awake ambulatory BP levels
  • Consistent from visit to visit
  • Are not significantly altered by the setting (e.g. ambulatory BP monitoring unit, office waiting room, physician’s examination room, pharmacy)
  • Predict the presence of end-organ damage (carotid intima-media thickness, left ventricular mass index, microalbuminuria) and incidence cardiovascular events
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16
Q

How should BP be measured in the office with non-AOBP?

A
  • Bladder width ~40% of arm circumference
  • Patient resting for 5 minutes, legs not crossed
  • Cuff 3 cm above antecubital fossa, bladder over brachial artery
  • First reading by palpation to evaluate for systolic gap
    • Elevate to 30 mmHg above cessation of radial pulse
    • Slow deflation of the cuff by 2 mmHg each heartbeat
  • No conversation
  • First reading disregarded, average second 2 readings
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17
Q

How should the mean BP be measured in the office with non-AOBP? (CHEP)

A
  • First reading discarded
  • Latter readings averaged
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18
Q

How should BP be measured for home BP measurement? (CHEP)

A
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19
Q

How should BP be measured for ambulatory BP monitoring? (CHEP)

A
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20
Q

How should postural hypotension be assessed? (CHEP)

A
  • Check after 2 minutes of standing (with arm supported)
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21
Q

What levels are considered to be elevated for BP in the 4 measuring scenarios? (CHEP)

A
  • Non-AOBP
    • High = SBP ≥140 mmHg or DBP ≥90 mmHg
    • High-Normal = SBP 130-139 mmHg or DBP 85-89 mmHg
  • AOBP
    • High = SBP ≥135 mmHg or DBP ≥85 mmHg
  • Ambulatory
    • Mean awake SBP ≥135 mmHg or DBP ≥85 mmHg
    • Mean 24-hour SBP ≥130 mmHg or DBP ≥80 mmHg
  • Home
    • High = SBP ≥135 mmHg or DBP ≥85 mmHg
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22
Q

How can hypertension be diagnosed? (CHEP)

A
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23
Q

What are examples of hypertensive urgencies or emergencies? (CHEP)

A
  • Urgency: Asymptomatic diastolic BP ≥130 mmHg
  • Emergency: Severe elevation of BP in the setting of any of:
    • Hypertensive encephalopathy
    • Acute aortic dissection
    • Acute left ventricular failure
    • Acute coronary syndrome
    • Acute kidney injury
    • Intracranial hemorrhage
    • Acute ischemic stroke
    • Pre-eclampsia/eclampsia
    • Catecholamine-associated hypertension
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24
Q

What BP levels can lead to the diagnosis of hypertension on visit 1? (CHEP)

A
  • Mean non-AOBP or AOBP SBP ≥180 mmHg and/or DBP ≥110 mmHg
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25
Q

If the visit 1 mean non-AOBP SBP is 140-179 mmHg and/or DBP is 90-109 mmHg or the mean AOBP SBP is 135-179 mmHg and/or DBP is 85-109 mmHg, what should be done? (CHEP)

A
  • Out-of-office BP measurements
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26
Q

What is the recommended out-of-office BP measurement? (CHEP)

A
  • Ambulatory BP monitoring
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27
Q

When is home BP monitoring recommended? (CHEP)

A
  • Ambulatory BP monitoring not tolerated, not readily available, or because of patient preference
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28
Q

What should be done if the office BP measurement is high and the mean home BP is <135/85 mmHg? (CHEP)

A
  • Repeat home monitoring to confirm home BP is < 135/85 mmHg OR
  • Perform 24-hour ambulatory BP monitoring
  • If repeat is not high, then diagnose white coat hypertension
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29
Q

If the out-of-office measurement is not performed after visit 1, how can hypertension be diagnosed on subsequent visits? (CHEP)

A
  • Visit 2
    • Mean office BP measurement (averaged across all visits) is SBP ≥140 mmHg or DBP ≥90 mmHg
    • Macrovascular target organ damage, diabetes mellitus, or CKD (eGFR <60)
  • Visit 3
    • Mean office BP measurement (averaged across all visits) is SBP ≥160 mmHg or DBP ≥100 mmHg
  • Visit 5
    • Mean office BP measurement (averaged across all visits) is SBP ≥140 mmHg or DBP ≥90 mmHg
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30
Q

How often should patients on antihypertensive drug treatment be seen? (CHEP)

A
  • Monthly or every 2 months until readings on 2 consecutive visits are below their target
  • Every 3 to 6 months once at target
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31
Q

What should be done in all patients diagnosed with hypertension? (CHEP)

A
  • Global cardiovascular risk
    • Use terms such as “cardiovascular age”, “vascular age”, or “heart age”
    • SCORE risk calculator
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32
Q

What routine laboratory tests should be performed for the investigation of all patients with hypertension? (CHEP)

A
  • Urinalysis
  • Blood chemistry (potassium, sodium and creatinine)
  • Fasting blood glucose and/or glycated hemoglobin
  • Lipid panel (fasting or non-fasting)
  • ECG
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33
Q

How much variation is seen between fasting and non-fasting lipid levels? (CHEP)

A
  • TC <2%
  • HDL <2%
  • LDL <10%
  • TG 20%
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34
Q

What are two pathophysiologic causes of hypertension that should be investigated in patients newly diagnosed with hypertension? (CHEP)

A
  • Renovascular hypertension
  • Endocrine hypertension
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35
Q

Which patients with hypertension should be investigated for renovascular hypertension? (CHEP)

A
  • ≥2 of the following clinical clues:
    • Sudden onset or worsening of hypertension and age >55 or <30 years
    • Presence of an abdominal bruit
    • Hypertension resistant to ≥3 drugs
    • Increase in serum creatinine level ≥30% associated with the use of an ACEi or ARB
    • Other atherosclerotic vascular disease, particularly in patients who smoke or have dyslipidemia
    • Recurrent pulmonary edema associated with hypertensive surges
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36
Q

What are 4 tests that can be done to screen for renal vascular disease? (CHEP)

A
  • Captopril-enhanced radioisotope renal scan
  • Doppler sonography
  • MR angiography
  • CT angiography (if normal renal function)
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37
Q

Which patients with hypertension should be investigated for hyperaldosteronism? (CHEP)

A
  • Hypertensive patients with unexplained spontaneous hypokalemia (K <3.5 mmol/L) or marked diuretic-induced hypokalemia (K <3.0 mmol/L)
  • Patients with hypertension refractory to treatment with ≥3 drugs
  • Hypertensive patients found to have an incidental adrenal adenoma
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38
Q

What screening tests should be done for hyperaldosteronism? (CHEP)

A
  • Plasma aldosterone and renin
  • Collected in the morning after the patient has been ambulatory for at least 2 hours
  • Agents that markedly affect the results (aldosterone antagonists, potassium sparing and wasting diuretics) should be withdrawn at least 4-6 weeks prior
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39
Q

How should the diagnosis of primary hyperaldosteronism be made? (CHEP)

A
  • Saline loading tests
  • Plasma aldosterone to PRA ratio
  • Captopril suppression test
    • Administer 25-50 mg captopril PO after the patient has been sitting or standing for 1 hour
    • While seated, renin and plasma aldosterone levels should be measured at time zero and 1-2 hours after ingestion
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40
Q

How should the abnormality be localized in patients diagnosed with primary hyperaldosteronism? (CHEP)

A
  • Adrenal CT or MRI
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41
Q

What is recommended in patients with primary hyperaldosteronism and a definite adrenal mass who are eligible for surgery? (CHEP)

A
  • Adrenal venous sampling to assess for lateralization of aldosterone hypersecretion
42
Q

What are 5 situations in which patients with hypertension should be considered for screening for pheochromocytoma or paraganglioma? (CHEP)

A
  • Paroxysmal, unexplained, labile, and/or severe (BP ≥180/110 mmHg) sustained hypertension refractory to usual antihypertensive therapy
  • Patients with hypertension and multiple symptoms suggestive of catecholamine excess (e.g. headaches, palpitations, sweating, panic attacks, and pallor)
  • Patients with hypertension triggered by Beta-blockers, MAOIs, micturition, changes in abdominal pressure, surgery, or anesthesia
  • Patients with an incidentally discovered adrenal mass
  • Patients with predisposition to hereditary causes (e.g. MEN2A or 2B, NF1, VHL)
43
Q

How can pheochromocytomas be diagnosed? (CHEP)

A
  • 24-hr urinary total metanephrines and catecholamines
    • Concomitant 24-hr urinary creatinine to confirm accurate collection
  • Plasma free metanephrines and free normetanephrines
  • Urinary VMA measurements should NOT be used for screening
44
Q

How should localization of pheochromocytomas or paragangliomas be performed in patients with positive biochemical screening tests? (CHEP)

A
  • MRI (preferable)
  • CT (if MRI unavailable)
  • Iodine I-131 meta-iodobenzylguanidine scintigraphy
45
Q

In which patients should home BP monitoring be considered? (CHEP)

A
  • Diabetes
  • CKD
  • Suspected nonadherence
  • Demonstrated white coat effect
  • BP controlled in the office but not at home (masked hypertension)
46
Q

What type of home BP monitoring devices should patients be advised to purchase? (CHEP)

A
  • Met standards of either:
    • Association for the Advancement of Medical Instrumentation
    • British Hypertension Society protocol
    • International Protocol for validation of automated BP measuring devices
47
Q

What home BP values should be considered elevated and associated with an increased overall mortality risk? (CHEP)

A
  • SBP ≥135 mmHg or DBP ≥85 mmHg
48
Q

In which patients should ambulatory BP monitoring be considered? (CHEP)

A
  • Office-induced increase in BP is suspected in treated patients with:
    • BP that is not below target despite receiving appropriate chronic antihypertensive therapy
    • Symptoms suggestive of hypotension
    • Fluctuating office BP readings
49
Q

What home BP values should be considered elevated and associated with an increased overall mortality risk? (CHEP)

A
  • Mean awake SBP ≥135 mmHg or DBP ≥85 mmHg
  • Mean 24-hour SBP ≥130 mmHg or DBP ≥80 mmHg
50
Q

In which patients with hypertension is echocardiography recommended? (CHEP)

A
  • Hypertensive patients suspected to have left ventricular dysfunction or CAD
    • Assess left ventricular mass and systolic and diastolic left ventricular function
51
Q

What are 7 health behavior management recommendations that can be made for patients with hypertension? (CHEP)

A
  • Physical exercise
    • 30-60 minutes of moderate-intensity dynamic exercise 4-7 days per week
  • Weight reduction
  • Alcohol consumption
    • Limit alcohol to 2 or less drinks per day, and <15 drinks per week for men and <10 drinks per week for women
  • DASH diet
  • Reduce sodium intake to <2000 mg per day
  • Increase potassium intake
  • Stress management

Intervention

Target

Weight loss

BMI <25 kg/m2

Alcohol restriction

< 2 drinks/day

Salt & DASH diet

Salt <2000mg/day, fruits, vegetables, whole grains, plant protein, low-fat

Physical activity

30-60 minutes 4-7 days/week

Smoking cessation

Smoke free environment

Waist circumference

Men <102 cm Women <88 cm

Stress Management

CBT and relaxation therapy

52
Q

What is the evidence for a reduced salt diet (or sodium restriction) in reducing mortality from CVD? (TFP)

A
  • Controversial
  • Cochrane review of 7 RCTs found no difference for outcomes in normotensive and hypertensive patients
    • Subsequent reanalysis combining normotensive and hypertensive patients resulted in significant reduction in CVD (RR 0.80, NNT = 48)
    • Average baseline sodium ~3900 mg reduced to ~3000 mg per day
53
Q

What are 4 risk factors for hyperkalemia in patients with hypertension? (CHEP)

A
  • RAAS
  • Other drugs that can cause hyperkalemia (e.g. TMP-SMX, amiloride, triamterene)
  • CKD (eGFR <60)
  • Baseline serum K >4.5 mmol/L
54
Q

What are the indications for drug therapy in adults with hypertension without compelling indications for specific agents? (CHEP)

A
  • Average SBP ≥160 mmHg or DBP ≥100 mmHg in patients withOUT macrovascular target organ damage or other cardiovascular risk factors
  • Average DBP ≥90 mmHg in the presence of macrovascular target organ damage or other independent cardiovascular risk factors
  • Average SBP ≥140 mmHg in the presence of macrovascular target organ damage
55
Q

What is the SBP threshold for initiating antihypertensive therapy in the elderly (aged ≥80 years) who do not have diabetes or target organ damage? (CHEP)

A
  • SBP ≥160 mmHg
56
Q

What are 6 possible reasons for poor response to therapy? (CHEP)

A
  • Poor adherence
  • Associated conditions
    • Obesity
    • Tobacco
    • Alcohol
    • OSA
    • Chronic pain
  • Drug interactions
    • NSAIDs, OCP, steroids, decongestants, cocaine, amphetamines, EPO, cyclosporine, licorice, OTC dietary supplements, antidepressants
  • Suboptimal treatment regimens
    • Dosage too low
    • Inappropriate combinations of antihypertensive agents
  • Volume overload
    • Excessive salt intake
    • Renal sodium retention
  • Secondary hypertension
57
Q

What time of day for taking antihypertensive drugs may provide improved CVD outcomes? (TFP)

A
  • Bedtime
    • Single RCT with many limitations (poorly described randomization and allocation of patients, lack of blinding, no correction for multiple analysis, higher CVD events than expected
    • NNT = 67 for mortality
    • NNT = 9 for total CVD events
58
Q

What is first-line and second-line therapy for individuals with diastolic and/or systolic hypertension? (CHEP)

A
  • First-line
    • Thiazide/thiazide-like diuretic (Grade A)
    • Beta-blocker (in patients younger than 60 years) (Grade B)
    • ACEi (in nonblack patients) (Grade B)
    • Long-acting CCB (Grade B)
    • ARB (Grade B)
  • Second-line
    • Thiazide + ACEi/ARB/Beta-blocker
    • CCB + ACEi/ARB/Beta-blocker
      • Caution with nondihydropyridine CCB
59
Q

What adverse effect needs to be avoided in patients treated with thiazide/thiazide-like diuretic monotherapy? (CHEP)

A
  • Hypokalemia
60
Q

In which patients would combination therapy using 2 first-line agents for hypertension be considered as initial treatment? (CHEP)

A
  • SBP is 20 mmHg greater than target OR
  • DBP is 10 mmHg greater than target
61
Q

What is first-line and second-line therapy for individuals with isolated systolic hypertension? (CHEP)

A
  • First-line
    • Thiazide/thiazide-like diuretic (Grade A)
    • Long-acting CCB (Grade A)
    • ARB (Grade B)
  • Second-line
    • Combination of first-line
62
Q

What is the best 4th-line therapy for patients with resistant hypertension? (TFP)

A
  • Spironolactone provides largest BP reduction (10/4 mmHg)
    • Compared to bisoprolol and doxazosin
  • NNT = 3 for spironolactone
  • Potassium rises on average 0.4 mmol/L
  • 2% stop due to hyperkalemia (≥5.5 mmol/L)
63
Q

In which patients with hypertension is statin therapy recommended? (CHEP)

A
  • ≥3 cardiovascular risk factors
  • Established atherosclerotic disease
64
Q

What are 4 clinical indications to define high-risk patients that could be candidates for intensive hypertension management? (CHEP)

A
  • Clinical or subclinical cardiovascular disease
  • CKD (nondiabetic, eGFR 20 to 59)
  • Estimated 10-year global cardiovascular risk ≥ 15%
  • Age ≥75 years
65
Q

In which high-risk patients could intensive management (target SBP ≤120 mmHg) be considered? (CHEP)

A
  • Aged ≥50 years
  • SBP ≥130 mmHg
66
Q

In which patients would intensive blood pressure-lowering be contraindicated? (CHEP)

67
Q

What is the evidence for intensive blood-pressure lowering in high risk patients? (CHEP/TFP)

A
  • SPRINT trial randomized 9631 individuals at high risk for CVD (withOUT diabetes or previous stroke) to intensive treatment (target SBP <120 mmHG) or standard control (target SBP <140 mmHg)
  • CVD risk ~20% over 10 years
  • Trial terminated after 3.26 years
  • Attained BP 136/76 vs 121/68
  • Average patient on 2.8 vs 1.8 medications
  • Primary outcome (composite of MI, ACS, stroke, acute decompensated HF, death from cardiovascular cause) was lower with intensive treatment than standard (1.65% vs 2.19% per year, RRR 25%, NNT=61)
  • Death: RRR 27%, NNT=90
  • Individuals with normal kidney function at baseline – intensive treatment increased risk of renal deterioration (NNH = 56, HR 3.49)
  • Serious adverse events similar in both groups
68
Q

What are the treatment goals for hypertension in patients not receiving intensive treatment? (CHEP)

A
  • SBP < 140 mmHg and DBP <90 mmHg
  • Very elderly (80+ years) SBP <150 mmHg
69
Q

What is the evidence of a target BP <150/80 mmHg in the elderly (≥80 years of age)? (TFP)

A
  • HYVET study
    • Large RCT of 3,845 patients, mean follow-up 2.1 years, 60% female, mean age 83.5, BP >160 systolic
    • Placebo or Indapamide +/- Perindopril
    • Target BP <150/80 mmHg
    • NNT = 47 (10% vs 12%) for mortality
    • NNT = 34 (7% vs 10%) for CVD
    • NNT = 35 (1.1% vs 3%) for heart failure
70
Q

What is first-line and second-line therapy for individuals with CAD? (CHEP)

A
  • First-line
    • ACEi or ARB (Grade A)
  • Second-line
    • ACEi + dihydropyridine CCB (preferred over ACEi + thiazide)
71
Q

What is first-line therapy for individuals with hypertension and stable angina (but without previous heart failure, myocardial infarction, or CABG)? (CHEP)

A
  • First-line
    • Beta-blocker or CCB
72
Q

What is first-line and second-line therapy for individuals with hypertension who have had a recent MI? (CHEP)

A
  • First-line
    • ACEi + Beta-blocker
      • ARB instead of ACEi if intolerance
      • CCB instead of Beta-blocker if contraindicated or not effective
        • NOT nondihydropyridine CCBs if heart failure
73
Q

What is first-line and second-line therapy for individuals with heart failure (EF <40%)? (CHEP)

A
  • First-line
    • ACEi + Beta-blockers
      • ARB instead of ACEi if intolerance
      • Hydralazine + Isosorbide dinitrate if ACEi and ARB contraindicated or not tolerated
  • Second-line
    • Aldosterone antagonists (recent cardiovascular hospitalization, acute MI, elevated BNP or NYHA class II-IV symptoms)
    • ACEi + ARB (careful monitoring for hypotension, hyperkalemia and CKD)
74
Q

What is first-line and second-line therapy for individuals with stroke 72 hours after onset? (CHEP)

A
  • First-line
    • ACEi and Thiazides/thiazide-like diuretics
75
Q

What is first-line and second-line therapy for individuals with left ventricular hypertrophy? (CHEP)

A
  • First-line
    • ACEi
    • ARBs
    • Long-acting CCBs
    • Thiazide/thiazide-like diuretics
76
Q

What is first-line and second-line therapy for individuals with nondiabetic CKD? (CHEP)

A
  • First-line
    • ACEi
      • ARB instead of ACEi if intolerance
  • Second-line
    • Thiazide/thiazide-like diuretics
    • Loop diuretics (if volume overload)
77
Q

What is first-line and second-line therapy for individuals with diabetes? (CHEP)

A
  • First-line
    • ACEi or ARB
  • Second-line
    • Dihydropyridine CCB (preferred over thiazides)
78
Q

What are the rational first-line drug choices for each indication of hypertension?

A

Rational First-Line Drug Choices

Indication

ACE/ARB

BB

CCB

Diuretic

Alpha

Hydralazine

Diastolic +/- systolic HTN

non-black

<60years

Yes

*Thiazide

Isolated systolic HTN

Yes

*DHP

*Thiazide

DM (without complication)

*Yes

*DHP

2nd line

*Thiazide

DM (with CAD or CKD)

*Yes

CKD with proteinuria (non-DM)

*Yes

Thiazide

Loop for volume

Angina/CAD

*Yes

Yes

2nd DHP

Post-MI

CHF (EF <40%)

*Yes

*Yes

2nd DHP

*@Aldo antag

If can’t use ACE

LVH

Yes

Yes

Thiazide

Never

A. Fib

Yes

Non-DHP

Post-Stroke

Yes

Yes

Migraines

Yes

Non-DHP

Essential Tremor

Non-cardio

BPH

Yes

Raynaud’s

DHP

Hyperthyroid

Yes

*Grade 1 Evidence

@ recent CAD hospitalization, acute MI, elevated BNP or NYHA class II-IV – caution K

79
Q

What are the absolute and relative contraindications to ACEi and ARBs?

A
  • Absolute
    • Hypersensitivity
  • Relative
    • RAS
    • Pregnancy
    • Angioedema
80
Q

What are known AE associated with ACEi or ARBs?

A
  • Cough
  • Angioedema
  • Dizzy
  • HYPERkalemia
    • Caution with diuretics, lithium and NSAIDs
81
Q

What should be monitored in patients on ACEi or ARBs?

82
Q

Which beta-blockers are cardio-selective, non-cardio-selective, and which are mixed alpha and beta?

A
  • Cardio-selective (MAB) – Metoprolol, Atenolol, Bisoprolol
  • Non-cardio-selective – Propranolol
  • Mixed Alpha and Beta – Carvedilol and Labetolol
83
Q

What are the absolute and relative contraindications to beta-blockers?

A
  • Absolute
    • Sinus bradycardia
    • >2nd degree heart block
    • Acute CHF
    • Pheochromocytoma
  • Relative
    • Peripheral arterial disease
    • Asthma/COPD
    • Hyperthyroidism
    • Concurrent non-dihydropyridine CCB or Digoxin
84
Q

What are 5 known AEs associated with beta-blockers?

A
  • Fatigue, insomnia, vivid dreams
  • Masked hypoglycemia – no adrenergic symptoms
  • Bronchospasm
  • Mixed have more orthostatic hypotension
  • AV block
85
Q

What should be monitored in patients on Beta-blockers?

86
Q

Which CCBs are dihydropyridines and which are non-dihydropyridines?

A
  • Dihydropyridine – Amlodipine, Felodipine, Nifedipine
  • Non-dihydropyridine – Diltiazem, Verapamil
    • More cardiac effect
87
Q

What are the absolute and relative contraindications to CCBs?

A
  • Absolute
    • Hypersensitivity
    • Non-dihydropyridine
      • Acute CHF
      • >2nd degree heart block
  • Relative
    • Concurrent BB or digoxin
    • Dihydropyridine with CHF
88
Q

What are 4 known AEs associated with CCBs?

A
  • Dizzy, flushing, headaches
  • Peripheral edema
  • Dihydropyridine – reflex tachycardia
  • Non-dihydropyridine – AV block
89
Q

What should be monitored in patients on CCBs?

90
Q

What are 4 types of diuretics and examples of each?

A
  • Thiazides – HCTZ, indapamide, chlorthalidone, metolazone
  • Loop diuretics – furosemide, bumetanide, ethacrynic acid
  • Potassium-sparing – amiloride, triamterene
  • Aldosterone antagonists - spironolactone
91
Q

What are the absolute and relative contraindications to diuretics?

A
  • Absolute
    • Anuria
    • Hyperkalemia – K spare and Spironolactone
  • Relative
    • Gout – Thiazides
    • Sulfa allergy – Thiazides and Loop
    • Electrolyte abnormalities
92
Q

What are 4 known AEs associated with diuretics?

A
  • Thiazides and Loop
    • Hypokalemia
    • Hyponatremia
    • Low Ca, Mg
    • Increased uric acid – thiazide
  • K sparing and Spironolactone
    • Hyperkalemia
93
Q

What should be monitored in patients on diuretics?

94
Q

How does hydralazine work and how is it dosed?

A
  • Direct vasodilator
  • 10 mg QID, increasing qweek by 10-25 mg/dose to max 300 mg/day
95
Q

What are the absolute and relative contraindications to hydralazine?

A
  • Absolute
    • Hypersensitivity
    • Rheumatic heart disease
  • Relative
    • Volume overload
    • CAD – reflex tachycardia
    • Pulmonary hypertension
96
Q

What are 4 known AEs associated with hydralazine?

A
  • Orthostatic hypotension
  • Palpitations
  • Angina
  • Peripheral edema
97
Q

What should be monitored in patients on hydralazine?

98
Q

Which ACEi and ARBs are true 24h duration?

A
  • Perindopril
  • Trandolapril
  • Irbesartan
99
Q

Which beta-blocker has the worst evidence for a benefit? (TFP)

A
  • Atenolol
  • Multiple meta-analyses (one Cochrane) have compared beta-blockers to other antihypertensives
    • NNH=461 for stroke, no difference in MI or death
    • Atenolol
      • NNH=130 for stroke
      • NNH=140 for death
  • 2006 meta-analysis stratifying by age subgroup
    • <60 years: no significant difference
    • ≥60 years: increased risk
100
Q

Which thiazide/thiazide-like diuretics have the best evidence? (TFP)

A
  • Chlorthalidone >>> HCTZ
    • Chlorthalidone 25 mg vs HCTZ 50 mg provided superior BP reduction overall (12 vs 7 mmHg on 24-hr monitor) and at nighttime (13 vs 6 mmHg)
    • Large trials using chlorthalidone (ALLHAT and SHEP) have demonstrated cardiovascular improvements whereas HCTZ evidence is less robust
    • Chlorthalidone has longer half-life than HCTZ (50-60h vs 9-10h)
  • Indapamide also has good evidence for reduction in cardiovascular endpoints as first or second-line antihypertensives
101
Q

What % of thiazide users and ACEi/ARB users experience electrolyte disturbances? What is the evidence for monitoring electrolytes in these patients? (TFP)

A
  • Thiazides
    • 4% Hyponatremia (Na <130 mmol/L)
    • 4% Hypokalemia (K <3.2 mmol/L)
  • ACEi/ARB
    • 4% Hyperkalemia (K >5.4 mmol/L)
  • Limited evidence for checking in the first 2-4 weeks after starting, and again after increasing doses of these agents, and at least annually thereafter

Primary Care (12 decks)

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