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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
**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)**
* Out-of-office BP measurements
26
**What is the recommended out-of-office BP measurement? (CHEP)**
* Ambulatory BP monitoring
27
**When is home BP monitoring recommended? (CHEP)**
* Ambulatory BP monitoring not tolerated, not readily available, or because of patient preference
28
**What should be done if the office BP measurement is high and the mean home BP is \<135/85 mmHg? (CHEP)**
* 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**
29
**If the out-of-office measurement is not performed after visit 1, how can hypertension be diagnosed on subsequent visits? (CHEP)**
* 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
30
**How often should patients on antihypertensive drug treatment be seen? (CHEP)**
* Monthly or every 2 months until readings on 2 consecutive visits are below their target * Every 3 to 6 months once at target
31
**What should be done in all patients diagnosed with hypertension? (CHEP)**
* Global cardiovascular risk * Use terms such as “cardiovascular age”, “vascular age”, or “heart age” * SCORE risk calculator
32
**What routine laboratory tests should be performed for the investigation of all patients with hypertension? (CHEP)**
* Urinalysis * Blood chemistry (potassium, sodium and creatinine) * Fasting blood glucose and/or glycated hemoglobin * Lipid panel (fasting or non-fasting) * ECG
33
**How much variation is seen between fasting and non-fasting lipid levels? (CHEP)**
* TC \<2% * HDL \<2% * LDL \<10% * TG 20%
34
**What are two pathophysiologic causes of hypertension that should be investigated in patients newly diagnosed with hypertension? (CHEP)**
* Renovascular hypertension * Endocrine hypertension
35
**Which patients with hypertension should be investigated for renovascular hypertension? (CHEP)**
* ≥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
36
**What are 4 tests that can be done to screen for renal vascular disease? (CHEP)**
* Captopril-enhanced radioisotope renal scan * Doppler sonography * MR angiography * CT angiography (if normal renal function)
37
**Which patients with hypertension should be investigated for hyperaldosteronism? (CHEP)**
* 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
38
**What screening tests should be done for hyperaldosteronism? (CHEP)**
* 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
39
**How should the diagnosis of primary hyperaldosteronism be made? (CHEP)**
* 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
40
**How should the abnormality be localized in patients diagnosed with primary hyperaldosteronism? (CHEP)**
* Adrenal CT or MRI
41
**What is recommended in patients with primary hyperaldosteronism and a definite adrenal mass who are eligible for surgery? (CHEP)**
* Adrenal venous sampling to assess for lateralization of aldosterone hypersecretion
42
**What are 5 situations in which patients with hypertension should be considered for screening for pheochromocytoma or paraganglioma? (CHEP)**
* 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
**How can pheochromocytomas be diagnosed? (CHEP)**
* 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
**How should localization of pheochromocytomas or paragangliomas be performed in patients with positive biochemical screening tests? (CHEP)**
* MRI (preferable) * CT (if MRI unavailable) * Iodine I-131 meta-iodobenzylguanidine scintigraphy
45
**In which patients should home BP monitoring be considered? (CHEP)**
* Diabetes * CKD * Suspected nonadherence * Demonstrated white coat effect * BP controlled in the office but not at home (masked hypertension)
46
**What type of home BP monitoring devices should patients be advised to purchase? (CHEP)**
* 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
**What home BP values should be considered elevated and associated with an increased overall mortality risk? (CHEP)**
* SBP ≥135 mmHg or DBP ≥85 mmHg
48
**In which patients should ambulatory BP monitoring be considered? (CHEP)**
* 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
**What home BP values should be considered elevated and associated with an increased overall mortality risk? (CHEP)**
* Mean awake SBP ≥135 mmHg or DBP ≥85 mmHg * Mean 24-hour SBP ≥130 mmHg or DBP ≥80 mmHg
50
**In which patients with hypertension is echocardiography recommended? (CHEP)**
* Hypertensive patients suspected to have left ventricular dysfunction or CAD * Assess left ventricular mass and systolic and diastolic left ventricular function
51
**What are 7 health behavior management recommendations that can be made for patients with hypertension? (CHEP)**
* 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
**What is the evidence for a reduced salt diet (or sodium restriction) in reducing mortality from CVD? (TFP)**
* 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
**What are 4 risk factors for hyperkalemia in patients with hypertension? (CHEP)**
* RAAS * Other drugs that can cause hyperkalemia (e.g. TMP-SMX, amiloride, triamterene) * CKD (eGFR \<60) * Baseline serum K \>4.5 mmol/L
54
**What are the indications for drug therapy in adults with hypertension without compelling indications for specific agents? (CHEP)**
* 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
**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)**
* SBP ≥160 mmHg
56
**What are 6 possible reasons for poor response to therapy? (CHEP)**
* 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
**What time of day for taking antihypertensive drugs may provide improved CVD outcomes? (TFP)**
* 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
**What is first-line and second-line therapy for individuals with diastolic and/or systolic hypertension? (CHEP)**
* 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
**What adverse effect needs to be avoided in patients treated with thiazide/thiazide-like diuretic monotherapy? (CHEP)**
* Hypokalemia
60
**In which patients would combination therapy using 2 first-line agents for hypertension be considered as initial treatment? (CHEP)**
* SBP is 20 mmHg greater than target OR * DBP is 10 mmHg greater than target
61
**What is first-line and second-line therapy for individuals with isolated systolic hypertension? (CHEP)**
* First-line * Thiazide/thiazide-like diuretic (Grade A) * Long-acting CCB (Grade A) * ARB (Grade B) * Second-line * Combination of first-line
62
**What is the best 4th-line therapy for patients with resistant hypertension? (TFP)**
* 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
**In which patients with hypertension is statin therapy recommended? (CHEP)**
* ≥3 cardiovascular risk factors * Established atherosclerotic disease
64
**What are 4 clinical indications to define high-risk patients that could be candidates for intensive hypertension management? (CHEP)**
* Clinical or subclinical cardiovascular disease * CKD (nondiabetic, eGFR 20 to 59) * Estimated 10-year global cardiovascular risk ≥ 15% * Age ≥75 years
65
**In which high-risk patients could intensive management (target SBP ≤120 mmHg) be considered? (CHEP)**
* Aged ≥50 years * SBP ≥130 mmHg
66
**In which patients would intensive blood pressure-lowering be contraindicated? (CHEP)**
67
**What is the evidence for intensive blood-pressure lowering in high risk patients? (CHEP/TFP)**
* 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
**What are the treatment goals for hypertension in patients not receiving intensive treatment? (CHEP)**
* SBP \< 140 mmHg and DBP \<90 mmHg * Very elderly (80+ years) SBP \<150 mmHg
69
**What is the evidence of a target BP \<150/80 mmHg in the elderly (****≥80 years of age)? (TFP)**
* 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
**What is first-line and second-line therapy for individuals with CAD? (CHEP)**
* First-line * ACEi or ARB (Grade A) * Second-line * ACEi + dihydropyridine CCB (preferred over ACEi + thiazide)
71
**What is first-line therapy for individuals with hypertension and stable angina (but without previous heart failure, myocardial infarction, or CABG)? (CHEP)**
* First-line * Beta-blocker or CCB
72
**What is first-line and second-line therapy for individuals with hypertension who have had a recent MI? (CHEP)**
* 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
**What is first-line and second-line therapy for individuals with heart failure (EF \<40%)? (CHEP)**
* 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
**What is first-line and second-line therapy for individuals with stroke 72 hours after onset? (CHEP)**
* First-line * ACEi and Thiazides/thiazide-like diuretics
75
**What is first-line and second-line therapy for individuals with left ventricular hypertrophy? (CHEP)**
* First-line * ACEi * ARBs * Long-acting CCBs * Thiazide/thiazide-like diuretics
76
**What is first-line and second-line therapy for individuals with nondiabetic CKD? (CHEP)**
* First-line * ACEi * ARB instead of ACEi if intolerance * Second-line * Thiazide/thiazide-like diuretics * Loop diuretics (if volume overload)
77
**What is first-line and second-line therapy for individuals with diabetes? (CHEP)**
* First-line * ACEi or ARB * Second-line * Dihydropyridine CCB (preferred over thiazides)
78
What are the rational first-line drug choices for each indication of hypertension?
_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
**What are the absolute and relative contraindications to ACEi and ARBs?**
* Absolute * Hypersensitivity * Relative * RAS * Pregnancy * Angioedema
80
**What are known AE associated with ACEi or ARBs?**
* Cough * Angioedema * Dizzy * HYPERkalemia * Caution with diuretics, lithium and NSAIDs
81
**What should be monitored in patients on ACEi or ARBs?**
* Cr * Lytes
82
**Which beta-blockers are cardio-selective, non-cardio-selective, and which are mixed alpha and beta?**
* Cardio-selective (MAB) – Metoprolol, Atenolol, Bisoprolol * Non-cardio-selective – Propranolol * Mixed Alpha and Beta – Carvedilol and Labetolol
83
**What are the absolute and relative contraindications to beta-blockers?**
* Absolute * Sinus bradycardia * \>2nd degree heart block * Acute CHF * Pheochromocytoma * Relative * Peripheral arterial disease * Asthma/COPD * Hyperthyroidism * Concurrent non-dihydropyridine CCB or Digoxin
84
**What are 5 known AEs associated with beta-blockers?**
* Fatigue, insomnia, vivid dreams * Masked hypoglycemia – no adrenergic symptoms * Bronchospasm * Mixed have more orthostatic hypotension * AV block
85
**What should be monitored in patients on Beta-blockers?**
* HR * BP
86
**Which CCBs are dihydropyridines and which are non-dihydropyridines?**
* Dihydropyridine – Amlodipine, Felodipine, Nifedipine * Non-dihydropyridine – Diltiazem, Verapamil * More cardiac effect
87
**What are the absolute and relative contraindications to CCBs?**
* Absolute * Hypersensitivity * Non-dihydropyridine * Acute CHF * \>2nd degree heart block * Relative * Concurrent BB or digoxin * Dihydropyridine with CHF
88
**What are 4 known AEs associated with CCBs?**
* Dizzy, flushing, headaches * Peripheral edema * Dihydropyridine – reflex tachycardia * Non-dihydropyridine – AV block
89
**What should be monitored in patients on CCBs?**
* LFTs
90
**What are 4 types of diuretics and examples of each?**
* Thiazides – HCTZ, indapamide, chlorthalidone, metolazone * Loop diuretics – furosemide, bumetanide, ethacrynic acid * Potassium-sparing – amiloride, triamterene * Aldosterone antagonists - spironolactone
91
**What are the absolute and relative contraindications to diuretics?**
* Absolute * Anuria * Hyperkalemia – K spare and Spironolactone * Relative * Gout – Thiazides * Sulfa allergy – Thiazides and Loop * Electrolyte abnormalities
92
**What are 4 known AEs associated with diuretics?**
* Thiazides and Loop * Hypokalemia * Hyponatremia * Low Ca, Mg * Increased uric acid – thiazide * K sparing and Spironolactone * Hyperkalemia
93
**What should be monitored in patients on diuretics?**
* Cr * Lytes
94
**How does hydralazine work and how is it dosed?**
* Direct vasodilator * 10 mg QID, increasing qweek by 10-25 mg/dose to max 300 mg/day
95
**What are the absolute and relative contraindications to hydralazine?**
* Absolute * Hypersensitivity * Rheumatic heart disease * Relative * Volume overload * CAD – reflex tachycardia * Pulmonary hypertension
96
**What are 4 known AEs associated with hydralazine?**
* Orthostatic hypotension * Palpitations * Angina * Peripheral edema
97
**What should be monitored in patients on hydralazine****?**
* BP
98
**Which ACEi and ARBs are true 24h duration?**
* Perindopril * Trandolapril * Irbesartan
99
**Which beta-blocker has the worst evidence for a benefit? (TFP)**
* 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
**Which thiazide/thiazide-like diuretics have the best evidence? (TFP)**
* 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
**What % of thiazide users and ACEi/ARB users experience electrolyte disturbances? What is the evidence for monitoring electrolytes in these patients? (TFP)**
* 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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