Hypertension Flashcards
what are the different classifications of blood pressure according to JNC 7?
Normal < 120/80
Pre hypertensive 120-139/80-89
Stage 1 HTN 140-159/90-99
Stage 2 HTN >160/>100
when is pharmacological treatment for blood pressure indicated?
Normal: not indicated
Pre-hypertensive: only if patient has compelling indications
Stage 1: yes
Stage 2: yes
what is considered first line therapy for those without compelling indications?
Thiazide diuretics such as hydrochlorothiazide 25mg po qd
what are the BP goals of patients with DM or renal disease?
<130/80
what are the BP goals of patients with CKD AND proteinuria of >1gm / 24 hr?
<125/75
list the compelling indications according to JNC 7
Heart failure post MI high coronary disease risk DM CKD recurrent stroke
list the respective initial antihypertensive agents for patients with each compelling indications?
Heart failure: ACEI, BB, diuretics (fluid overload) post MI: ACEI, BB, high coronary disease risk: BB, ACE I DM: ACEI or ARB CKD: ACEI or ARB recurrent stroke: ACEI or thiazide
what are the sites for target organ damage?
eyes (retinopathy)
Brain (strokes)
Heart (MI, heart failure)
kidneys (nephropathy)
what are the possible causes for hypertension?
Essential:
Genetic factors (parents both having hypertension)
increased sympathetic neural activity
mineralocorticoid excess
increased angiotensin II activity (inc h20 retention, salt uptake etc)
Secondary
primary renal disease
NSAIDS, ETOH, Corticosteroids, etc Oral contraceptive
primary aldosteronism & cushings sydnrome
Hypothyroidism, hyperthyroidism, and hyperparathyroidism
etc.
describe lifestyle modifications of HTN from JNC 7 and the average reduction range
weight reduction if obese or overweight (goal BMI 18.5-24.9
- DASH diet: diet rich in fruits, vegetables, low fat dairy protducts, decrease sat & total fat
- dietary sodium reduction (max 2.4g sodium or 6g sodium chloride), avoid fast food ,canned foods
- increased physical activity (brisk walking 30min per day, most days of the week)
- moderation of alcohol consumption (no more that 2 drinks men, 1 drink women)
- avoid smoking
what are the 2007 AHA blood pressure goals and the first line treatments for patients with high risk CAD , stable angina, unstabele angina/ NSTEMI, stem and LVD/HF?
high risk CAD ACEI or ARB or CCB or thiazide diuretic or combination and <120/80
what was the ALLHAT trial? what did the study results show and what are the clinical implications?
Design: MC, randomized control trial
P: >55 yo patients with stage 1/2 htn and at least one cardiovascular risk factor
I/C: chlorthalidone, amlodipine, lisinopril, doxazosin
O: mortality
MI
Results: chlorthalidone had better blood pressure control SBP < 1mmg vs amlodipine, 2mmhg vs lisinopril. The doxazosin arm was topped early because they had an increase of 25% of combined CVD and 2x rate of HF.
- Patients taking amlodipine had 38 % inc risk of HF bs chlorthalidone but no difference in stroke or combined CVD. no difference in cancer or mortality
- lisinopril group had an increase risk of stroke, HF, angina compared to chlorthalidone
- chlorthalidone results were more remarkable in African americans vs Non-AA. Lisinopril had 40% rates of stroke for AA, rated of combined CVD 19% vs non AA6%
- chlorthalidone had more hypokalemia, higher mean serum cholesterol, higher BG
Importance:When the study was conducted, the newer agents were being used more and there were no studies comparing each of the classes with each other. This was the first large trial that did head-to head compariesons chlorthalidone was superior in preventing CV events vs CCB, ACE and Alpha blocker. The traditional, less expensive diuretic shown to be more effective than newer meds. This trial used to decide DOC for JNC7 due to low cost and positve outcomes vs other agents
what are possible causes of resistant hypertension?
risk factors: older age, high baseline BP, obesity, excess salt intake, chronic kidney disease (CKD), diabetes, left ventricular hypertrophy (LVH), female gender, African-American race, and residing in the Southeast United States.
possible cause: pseudo resistance: false bp readings due to poor technique or white coat hypertension or nonadherecne
patient may be taking other medications that increase blood pressure and counter bp lowering efforts
Additionally diseases such as obstructive sleep apnea, diabetes, pheochromocytoma, Cushing’s, and renal disease can lead to resistant hypertension.
when should BB be used with caution?
Patients with Diabetes because can mask symptoms of hypoglycemia (except sweating or hunger)
Should not be stopped abruptly because can cause exacerbation of angila pectoris, MI, rebound HTN , death
when should BB be contraindicated?
Patients with Atrioventricular block
bronchial asthma
sinus bradycardia
what antihypertensive agents do african americans respond well to?
isosorbide dinitrate and hydralazine
monotherapy: dihydro CCB or thiazide (chlorthalidone
DuO: dydhyrdo CCB + ACE I /ARB
tripple :add potassium sparing diuretic
are thiazide diuretics contraindicated in patients with gout?
not contraindicated but if another alternative such and ACE or ARB can be used instead.. should use it.
if gout happens can treat with allopurinol
Diuretics reduce urate excretion by both directly and indirectly increasing urate reabsorption and decreasing urate secretion
discuss chlorthalidone in resistant hypertension
AHA says chlorthalidone > HCTZ this is because most outcomes trials used chlorthalidone. In a blinded comparison of hydrochlorothia- zide 50 mg and chlorthalidone 25 mg daily, the latter pro- vided greater 24-hour ambulatory blood pressure reduction, with the largest difference occurring overnight.
discuss furosemide in resistant hypertension
Thiazide diuretics are ineffective in patients with renal disease ClCr < 30. Can use furosemide in this instance . Must dose furosemide twice daily due to short half life
discuss spironolactone in resistant hypertension
may be effective
one small study showed dec of 25mmhg SBP and 12 Dbp for patients with resistant hypertension and adding spironolactone
discuss diltiazem in resistant hypertension
MOA: block calcium channels, so calcium influx is blocked leading to vasodilation
-not selective for Ca2+ channels (hit both the heart and peripheral blood vessels)
-negative ionotrope (dec force of contraction) can lead to bradycardia or dec AV conduction
-cyp3A4 inhibitor
-peripheral edema (least
avoid in patients with HF
no dose adjustment in renal function
-more effective than dihydropyridines in lowering BG
discuss clonidine in resistant hypertension
Centrally acting agents are effective antihyperten- sive agents but have a higher incidence of adverse effects and lack outcome data.
discuss hydralazine in resistant hypertension
otent vasodilators such as hydral- azine or minoxidil can be very effective, particularly at higher doses, but adverse effects are common.
discuss minoxidil in resistant hypertension
otent vasodilators such as hydral- azine or minoxidil can be very effective, particularly at higher doses, but adverse effects are common.
With minoxidil especially, reflexive increases in heart rate and fluid retention occur such that concomitant use of a
discuss terazosin in resistant hypertension
x
what antihypertensive agents are preferred in women of childbearing potential ?
(pharmacists Letter) labetalol is first line during pregnancy not associated with dec blood flow to fetus, growth restrictions, or still births.
Methyldopa is preganancy category B and hals long term safety profile. however, require high doses to control blood pressure well so may not be as effective. High doses limited by SEs
Nifedipine XL not associated with strong adverse outcomes. Not enough experience with other CCB
which are contraindicated in women of childbearing potential?
Avoid ACE/ARBs Aliskiren becuase can cause fetal harm
