Hypertension Flashcards
What are the first line classes for HTN?
Thiazides, ACEi, ARBs, and CCBs
Why are first line Rx’s considered first line Rx’s?
- *Double check w/ lecture recording**
1) Able to prove ↓ M/M in long-term
2) Not a great deal of SE
1) What is the BP goal for HTN + stable ischemic heart dz (SIHD), HF, CKD, and DM? JNC8
2) ACC/AAHA?
JNC8 <140/90 mmHg
ACC/AHA < 130/80 mmHg
2) They Have HTN + known CVD and/or ASCVD risk >/= 10%
What two Rx’s are used for HTN with angina
- BBs or 2. dhpCCBs
What Rx is used for HTN with MI or ACS?
BBs
What Rx is used for HTN with CAD?
BBs and/or ANY CCB
What are the 7 BBs proven beneficial in SIHD?
- Carvedilol N
- Metoprolol tartrate
- Metoprolol succinate
- Nadolol N
- Bisprolol
- Propanolol N
- Timolol N
What are the Rx’s to use in HTN + HF?
- ACEi/ARB/ANRI
- BB’s (carvedilol, metoprolol succinate, or bisprolol)
- Aldo Antag’s
1) What Rx’s should you avoid in HTN + HF?
2) Why?
1) CCBs
2) Negative inotropy, especially verapamil
1) What Rx’s can be used in HTN + CKD/DM?
1) (+) albuminuira = ACEi or ARB
2) (-) albuminuria = any 1st line
Why are African Am populations at greater risk for HTN complications (vs. other sub pop’s)?
1) HTN at younger age
2) Absolute pressures often higher
DIET Lifestyle etc…
1) Most effective HTN Rx therapy for African Am?
2) Less effective?
1) Thiazides AND CCBs
2) BBs, ACEi, ARBs
What are the preferred Rx’s for Chronic and gestational HTN during pregnancy?
- Magnesium ACUTE???
labetalol, nifedipine (long-acting) methyldopa
Alternatives to preferred Rx’s for HTN during pregnancy?
- Other BB’s and CCBs
What Rx’s contraindicated in pregnancy?
Why?
- ACEi, ARB, and direct renin inhibitors
teterogenic
1) JNC 8 HTN Goals for >/= 60 yo?
2) ACC et. al HTN Goals for >/= 65 yo?
1) <150 / <90
2) <130 / <80
What Rx’s to generally avoid in >/= 65 (elderly) Pts with HTN?
Central and peripheral alpha blocking agents –> risk of orthostasis, falls, and Duke having to do q15 neurochecks and V/S
How is hypertension different in the elderly?
How should you guide treatment?
1) Present often with isolated systolic HTN
2) No specific agent more effective, follow general guidelines
3) Start secondary Rx’s @ lower doses
What two things should be considered with HTN in children/adolescents?
1) Fatty’s more common to have HTN
2) 2nd HTN more common so look for kidney dz
What Rx’s are supported by evidence to use in children and adolescents?
- HTN first lines
ACE/ARB/CCB/Thiazides
and BB’s
What criteria qualifies for non pharmalogic management of HTN IN JNC and ACC/AHA
everything above normal includes non pharmacologic therapy.
Which diuretic is the best of the diuretic class for idiopathic HTN?
Thiazides
When are loop diuretics best used for HTN?
Only for high BP r/t vol overload (CKD)
When are K-sparring diuretics used for HTN?
To prevent K-wasting from other diuretics (has weak anti-HTN effect)
When are Aldo Antag’s used in HTN?
Not really used, little long-term data on M/M
How are thiazides used in HTN?
- Used in combo
- Offsets Na retention of other HTN agents
How do thiazides lower BP?
- Initially ↓ BP via diuresis
- Then probably ↓ PVR by Na/H2O movement from arteriolar walls
Thiazide diuretic names
Hydrochlorothiazide, chlorthalidone, metolazone
What is the best thiazide dosing and why is it best at that level?
1) 25 mg/day
2) Most SE are dose related and most ADRs limited at 25 mg/day even though 50 mg/day is most effective dose
What is the advantage of using ACEi/ARB for HTN?
Treats HF comorbidity at the same time
What are the ADRs for all ACEi/ARBs?
- Hyperkalemia
- Orthopnea
- ARF
What are the 3 dosing considerations for ACEi/ARBs?
1) start low and titrate up
2) 1/2 starting dose if risk of HoTN
- vol depleted, HF exacerb, super old, taking other vasodil or diuretics
3) 1/2 starting dose if risk of severe renal dz
- old, current CKD
What are the dihydropyridine CCBs?
- amlodipine
- felodipine
- isradipine
- nicardipine
- nifedipine
- nisoldipine
What action is common to all CCBs?
All CCBs relax arterial/coronary SM and produce peripheral/coronary vasodilation –> ↓ BP
What two effects distinguish DHP CCBs from non-DHP CCBs?
1) Strength of inotropy: both are inotropes, but baroreceptor-mediated ↑ SNS tone offsets DHP CCB inotropic effect = non-DHP are stronger inotropes
2) Cardiac conduction effects: DHP CCBs have very weak AV conduction effects while non-DHP CCBs ↓ SA node rate and ↓ AV conduction
What acute reaction can DHP CCBs cause?
Which drug causes it the most?
Why do other DHP CCBs not cause this as much?
1) Reflex tachycardia
2) Short-acting nifedipine
3) All others are longer sustained-release and have longer DoA –> less “peak effect”
What kind of efficacy can you approx from CCB peak levels?
Vasodilatory efficacy
What is a common SE of verapamil?
Constipation
What is a common SE of DHP CCBs?
What can you used to correct this?
1) Peripheral edema
2) Intermittent doses of diuretic
What should always be done when D/C’ing BB’s?
Why is this necessary?
1) Taper the doses over 1-2 weeks
2) Sudden D/C –> Rebound HTN d/t upregulation of agonist, beta receptors, and sensitivity
What are the Non cardioselective BBs?
What are the selective BBs?
1) Have B1+B2 or B1+A XXX ilol, Carvedilol alol Labetalol,
and these exceptions Nadolol, Propanolol, Timolol
2) Primary B1 only except at higher doses
XXX.olol
What phenomena occurs as BB dose is increased?
Cardioselective properties decrease and they become more non-selective
Peripheral alpha blockers
XXX.azosin Pr, Ter, Dox block peripherial A norepi receptors
Central alpha blockers
Methyldopa, Clonidine Prevent Norepi release by stimulating central A Norepi receptors
What are the AHA/ACC definitions for HTN
How do you treat
Normal <120/<80 reassess 1 year
S incriments of 10
D any increase stage 1 then 10
Elevated 120-129/<80 lifestyle mods
Stage 1 130-139/80-89 IF ASCVD risk <10 lifestyle mods, If ASCVD >10 throw a drug at it + Life mods
Stage 2 >140/>=90 throw 2 drugs at it + Life mods
How should HTN be classified if S and D pressures are in different stages?
Use highest stage.
What are the JNC8 reference ranges for HTN
Normal <120/<80 reassess 1 yr
S incriments of 20 D increments of 10
Prehypertension 120-139/80-89 Life mods
Stage 1 140-159/90-99 Life mods +1 drug
Stage 2 >160/>=100 Life mods +2 drugs
what is the expected change in SBP after completing this test?
decrease >20 SBP
JNC Goals
get everyone down into preHTN 140/90
Healthy Old people >60 can be 150/90
AHA /ACC Goals
<130/80
if ASCVD >10 Recommended <10 Reasonable
A Agonist not first line
Used in combination with other drugs
HoTN common side effect
Old people fall when going to bathroom at night makes Marc do paperwork so should be first line screw the old people and Marc!!
What are the 3 ISA BB’s
What does Intrinsic Sympathomimetic Activity mean.
Acebutolol
Penutolol
Pindolol
Can be overridden by body when needed….. Exercise
