Hypertension Flashcards
ARBs are best for which type of patient
heart failure, post MI, diabetes, chronic kidney disease
MOA of adrenergic antagonists
Inhibit sympathetic system by depleting norepinephrine stores in the CNS this results in a decrease in peripheral vascular resistance and a reduction in BP
side effects of thiazides
hypokalemia, hypomagnesemia, hypercalcemia, hyperuricemia, hyperglycemia
tinnitus, paresthesia, and cramps, N/V/D, muscle cramps, weakness, sexual dysfunction
1st line treatment for African Americans with or without DM
CCB or thiazide
How can you recognize an ACE inhibitor medication?
- pril ending
ie. lisinopril, captopril
MOA of beta blockers. (-olol) drugs
Beta-1 receptors are located in the heart, as well as kidneys, and involved in coardiac contractility, rate, and renin release.
Beta blockers bond to beta-1 receptors and are termed cardio selective because they do not interfere or have a major impact on beta-2 receptors
Beta blockers reduce BP by blocking central and peripheral beta receptors which results in decreased cardiac output and sympathetic outflow
central alpha receptor agonists MOA
Stimulates the alpha 2 adrenergic receptors in the brain, they block sympathetic activity by binding and activating alpha 2 adenoreceptors, this reduces sympathetic outflow to the heart, thereby decreasing cardiac output and decreasing heart rate and contractility
When should electrolyte labs be re-evaluated after initiation of diuretic treatment?
4 weeks into treatment
Calcium Channel Blockers MOA
inhibit the movement of calcium ions across the cell membrane, they relax and vasodilator the cardiovascular system
True/False: Over time baroreceptors can adapt to high BP and their responsiveness decreases
TRUE
contraindications for direct vasodilators
Use with caution in pts with CAD or mitral valve rheumatic heart disease
Hydralazine is associated with lupus like syndrome in high doses, dermatitis, drug fever, peripheral neuropathy
Steps of the Renin-Angiotensin-Aldosterone System
- Renin released by kidneys
- Converts angiotensinogen to angiotensin 1
- ACE converts angiotensin 1 to angiotensin 2
- Angiotensin 2 stimulates aldosterone release from adrenal gland
How should beta blocker therapy be discontinued?
NOT abruptly. tapered gradually over 14 days to prevent withdrawal symptoms which included unstable agina, MI, or even death. patients without CAD could experience tachycardia, palpitations, increased sweating and fatigue
MOA of ACE inhibitors
dilate arteries and veins by blocking angiotensin II formation and inhibiting bradykinin metabolism. vasodilation will reduce arterial pressure and affect both preload and afterload of the heart.
it promotes renal excretion of sodium and water by blocking the effects of angiotensin II on the kidney and blocks angiotensin II stimulation of the aldosterone secretion. ultimately it reduces blood volume, venous pressure and arterial pressure.
it inhibits cardiac and vascular remodeling thats associated with chronic hypertension, heart failure, and MI
What are the two major determinants of BP?
- Cardiac output
- Total Peripheral resistance
CO plus TPR = BP
Which Antihypertensives are considered 1st line for white pts >18yrs with HTN?
ACE, ARB, Thiazide, or CCB alone or in combo with another med.
How can you recognize ARBs?
-sartan ending
What are some risk factors for Primary HTN?
Obesity Sedentary Increased Na intake Age Stress Family history Smoking Diabetes
Drawbacks of Potassium sparing diuretics
Less diuresis than the others
Hyperkalemia
Hirsuitism, gynecomastia, menstrual irregularities
The JNC 8 goal for DM pts regardless of race is less than
140/90
MOA of nondihydropyridines CCBs
- verapamil
diltiazem (Cardizem)
decrease heart rate and slow cardiac conduction at the AV node
What are the common side effects of antihypertensives?
HA
Dizziness, syncope
Hypotension
Which pts would benefit from potassium sparing diuretics
Pts with heart failure is its true benefit but can be used for HTN
potential treatment for patients with heart failure and/or post MI
ACE inhibitors
which class of HTN can cause depression that may result from decreased catecholamine and serotonin levels in CNS
Adrenergic antagonists
CCBs are indicated for which patients?
Indicated for diabetic patients as well as those with coronary artery disease
Effective for HTN in African American population
JNC8 recommend treatment in elderly 60 and older for BP less than
150/90
Which drugs shouldn’t be given with ACE inhibitors?
Diuretics (spironolactone)
Lithium; causes lithium toxicity
NSAIDS; causes HTN to worsen
contraindications for central alpha receptor agonists
Use cautiously in pts with severe coronary insufficiency, conduction disturbances, recent MI, cerebrovascular disease, renal failure
List some factors that affect BP besides CO and TPR
Blood viscosity Heart rhythm, rate and contractility Blood vessel elasticity, diameter, thickness PNS and SNS Vasopressin/Antidiuretic hormone Baroreceptors Renin-Angiotensin-aldosterone system (**Mean Arterial Pressure does not affect BP)
MOA of ARBs (angiotensin II receptor blockers)
they block the vasoconstriction and aldosterone-secreting effects of angiotensin II by selectively blocking the binding of angiotensin II to the receptor
they dilate arteries and veins and reduce artierla pressure, effective on preload and afterload. down regulates sympathetic andrenergic activity by blocking the effects of angiotensin II on the sympathetic nerve release and reuptake of norepinephrine
promotes renal excretion of sodium and water by blocking the effects of angiotensin II in the kidney and blocking angiotensin II stimulation of aldosterone secretion
Which HTN med can cause a uric acid retention and should be cautioned in patients with gout?
Thiazides
What is an additional use for Nondihydropyridine CCBs other than HTN?
diltiazem, verapamil
Because of negative inotropic effects:
A.fib (antiarrhythmic effects)
Angina
SVT
Side effects for CCbs
Flushing, headache, excessive hypotension, edema, reflex tachycardia- most commonly seen in the dihydropyridines
What labs should you do before starting an antihypertensive?
Baseline BP, Basic metabolic panel (BUN, creatinine, glucose)
MOA of thiazide diuretics
increase the urinary excretion of sodium and chloride in equal amounts. inhibit reabsorption of sodium and chloride in the ascending loop of Henle and distal tubules
The resulting diuresis with thiazides yields a decreased plasma volume. it affects stroke volume as well as CO, long term, the reduction in peripheral vascular resistance.
contraindications of loop diuretics
high doses are contraindicated in pts with hyperlipidemia, gout, diabetes
pts who are anuric, those who are hypersensitive to these or sulfonylureas, pts with hepatic coma or states of severe electrolyte depletion
Ethacrynic acid is contraindicated in infants
which HTN med is first line treatment in pregnancy
labetalol
Where are the two angiotensin 2 receptor sites?
- vessel walls (vasoconstriction purposes)
2. adrenal cortex (aldosterone release purposes)
Which Antihypertensive is best to avoid in diabetes? Why?
Beta blockers; mask the early signs of hypoglycemia
Contraindications for thiazide diuretics
in patients with a creatinine clearance of less than 30 ml/min or those who have renal decompensation or hypersensitive to thiazides or sulfonamides
1st line HTN med for CKD
ACE or ARB
MOA for alpha blockers - doxazosin, prazosin, terazosin
Block the effect of the sympathetic nerves on blood vessels by binding to alpha adrenergic located receptors on smooth muscles. Act as a competitive agonist by boinding to norepinephrine that is released by sympathetic nerves
What are common causes of secondary HTN?
Oral contraceptives Hypothyroidism Cocaine/other stimulants CKD Sleep apnea Pheochromocytoma
MOA of potassium sparing diuretics
they interfere with sodium reabsorption at the distal tubules in the kidney, and reduce potassium excretion
Which antihypertensive class is considered the GOLD STANDARD?
ACE inhibitors
T/F Most patients with primary HTN have increased peripheral resistance and normal CO
TRUE
What population does CCB medications work especially well on?
Blacks
Which labs should be taken before use of Diuretics?
BUN Creatinine Electrolytes Uric acid Glucose
side effects of direct vasodilators
Reflex tachycardia (use concurrent betablocker, headache, fluid retention (use concurrent diuretic), hypertension -Hydralazine is associated with lupus like syndrome in high doses, dermatitis, drug fever, peripheral neuropathy
Beta blockers should be reserved for which patients
post MI or CHF patients, not considered first line therapy for HTN
Which Antihypertensives are best for patients with diabetes/CKD? Why?
ACE inhibitors and ARBs; renal protective
are loop diuretics safe in pregnancy? lactation?
safe in pregnancy but lactation safety has yet to be established
What physiological changes happen with high BP?
Baroreceptors cause vasodilation
SNS inhibited and PNS increased
Decreased HR, contractility
treatment of alpha blockers is good for which patient
Pts with benign prostatic hypertrophy, usually not prescribed for solely HTN tx
side effects of central alpha receptor agonists
Fluid retention or sedation, potential bradycardia, dry mouth, abrupt cessation can cause elevated BP
First dose can cause dizziness and syncope
Which Antihypertensives are considered 1st line for pts >18yrs with CKD and diabetes?
ACE or ARB alone or in combo. with another med
*pt’s with diabetes with no CKD are the same as the rest of the population >18 with HTN
1st line HTN med for pediatrics if lifestyle modification has failed
ACE inhibitors
side effects of loop diuretics
concerned about electrolytes, monitor for low potassium, magnesium and hyperglycemia, as well as low calcium
1st line HTN med for DM
ACE or ARB considered cornerstone therapy
Which Antihypertensives are considered 1st line for black pts >18yrs with HTN?
Thiazide or CCB alone or in combo with another med
side effects of ARBs
hypotension, fatigue, dizziness, upper respiratory infections and viral infections, can develop a cough, sinusitis and pharyngitis *lower rate of cough and lower risk of angioedema compared to ACEI
Which antihypertensives are best to use in pt’s with heart failure?
ACE/ARB + BB + Diuretic + spironolactone
____ are the treatment of choice in patients with heart failure, post MI, clinical coronary artery disease, diabetes, chronic kidney disease, as well as recurrent stroke prevention
ACE inhibitors
Which type of pts would benefit from loop diuretics
indicated in the presence of edema associated with CHF, hepatic cirrhosis, renal disease. This class is useful when greater diuresis is desired compared to thiazides.
Should be reserved for HTN pts with renal insufficiency or need more diuresis, have a Crcl less than 30
What 2 alterations to therapy can you make if goal BP is not met?
- Max out single dose of single drug
- Add 2nd drug
* If BP is very high initially can start with 2 drugs and choose one to modify
Which population is most likely to have isolated systolic HTN?
Elderly; indicates atherosclerosis
Side effects of potassium sparing diuretics
hyperkalemia, hyponatremia menstrual irregularities, gynecomastia
Beta blockers in pregnancy?
Avoid in early pregnancy d/t risk of fetal growth retardation, avoid atenolol in lactation
Hypertension in >60 years
150/90 or higher
side effects of ACE inhibitors
dry cough, dizziness, risk of angioedema (African americans), hyperkalemia, hypotension
What is considered first line management for hypertension
maintain appropriate body weight DASH diet (low fat, low sodium) restriction of sodium 120minutes/week acitivity reduce alcohol consumption
Side effects of beta blockers
fatigue, drowsiness, bradycardia, AV conduction abnormalities, development of CHF.
*masking of hypoglycemic symptoms- important for diabetic pts to know
Which drugs should NOT be given in conjunction with Nondihydropyridines?
Drugs that further decrease HR (digoxin, beta blockers)
adult patients with HTN and DM, pharmacologic treatment should be started after BP is ____ regardless of age
140/90
Which CCB is most often used for HTN and why?
Amlodipine; few side effects
MOA of direct vasodilators
-hydralazine
minoxidil
Causes arterial smooth muscle relaxation resulting in a lowered BP
MOA of loop diuretics
Inhibit the reabsorption of sodium and chloride but not only in proximal and distal tubules but also in the loop of henele.
Which Antihypertensive is best for patients with migraines or anxiety?
Beta blockers (decrease SNS)
pts who should avoid potassium sparing diuretics
pts with potassium levels of more than 5 mEq/L, have renal insufficiency or diabetes and in patients receiving concurrent treatment with ACE inhibitor, NSAIDS, or potassium supplements
Which other HTN medication can Dihydropyridine CCBs be safely used in combo therapy with?
Beta Blockers
alpha blockers are contraindicated in which patients
Avoid in patients with cardiovascular disease due to increases in mortality
dihydropyridines MOA of CCB
potent vasodilators, all the -pines
which central alpha receptor agonist can result in severe rebound HTN if abruptly discontinued, can cause potential cognitive changes in older adults
clonidine
hypertension in <60 years
140/90 or higher
T/F: CCBs should not be given to patients with heart failure due to their inotropic effect
TRUE; except amlodipine (more for nondyhidropyridines)
CCBs, especially verapamil and diltiazem are contraindicated in which patients?
Avoid in patients with heart failure, left ventricular systolic dysfunction why? Bc EF < 45%, bradycardia
_____ is recommended for women diagnosed with HTN during pregnancy
methyldopa
types of hypertension
primary (essential)- 95% have this- causes is unknown, environment and genetic components
secondary (idiopathic)- CKD, renovascular, hypothyroidism, hyperparathyroidism, primary aldosteronism, medications can increase BP such as birth control, nicotine, steroids, appetite suppressants, andidepressants, nasal decongestants
Which diuretic has the greatest diuresis effect and is specifically indicated for heart failure, cirrhosis and renal disease?
Loop Diuretics
*K sparing also used for these but to a lesser degree
Are ACE inhibitors acceptable during pregnancy?
NO. they’re considered teratogenic
Which Antihypertensives are best for patients who have had past MIs?
ACE in./ARB or Beta blockers
Which component of the renin-angiotensin-aldosterone system acts as a potent vasoconstrictor?
Angiotensin 2
side effects of alpha blockers include
Dizziness, orthostatic hypertension, d/t loss of reflex and vasoconstriction upon standing
Nasal congestion, headache, reflex tachycardia, fluid retention- use diuretic in conjunction
vivid dreams, depression
what is the goal of antihypertensive therapy?
to manage hypertension and reduce cardiovascular disease (including lipid disorders, glucose intolerance or diabetes, obesity, and smoking ) and renal disease
After when is HTN diagnosed
after 3 confirmed readings at least 1 week apart. BP should be obtained after the patient has had time to relax for at least 5 minutes, chair feet on floor uncrossed, not driving caffeine an hour prior. diagnosis should be confirmed at an additional patient visit 1-4 weeks after first measurement
Why would you use an ARB over an ACE? Why would you choose an ACE over an ARB?
ARBs used when pt can’t tolerate ACE in.
ARBs are more expensive than ACE inhibitors
contraindications of ACE inhibitors
pts with bilateral renal artery stenosis, or unilateral b/c of risk of acute renal failure.
Not recommended in combination with ARBs
pts with hx of angioedema
Contraindications for betablockers
avoid in pts with sinus bradycardia, asthma, COPD, heart blocks, or every cardiac failure
Use cautiously in patients with PVD, claudication, systolic CHF, diabetes, depression or reactive airway disease
contraindications for ARBs
pregnancy due to concerns of fetus, don’t use in combination with ace inhibitors or renin inhibitors.
T/F: ACE inhibitors are prodrugs converted to active form in the liver and intestines
TRUE (captopril and lisinopril are safe in liver disease)
