Hypertension Flashcards
What is the diagnosing criteria for hypertension?
2 elevated readings, at 2 separate visits, at least one month apart
What are factors that can effect blood pressure?
Stress, smoking, caffeine, exercise
What work up should be done prior to initiating drug therapy for hypertension?
UA, lipid panel, EKG, potassium/calcium/creatine levels (effect blood pressure meds), blood glucose (diabetics should be on an ACE-I), C-reactive protein, homocysteine (protein from meat, elevated levels increase risk of heart disease)
When should follow up from initiation of drug therapy happen?
2-4 weeks depending on BP reading
2 weeks for 160/100
4 weeks for 140/90
What hypertension medications are safe for children?
ACE-I, ARBs, CCBs
What is the mechanism of action for the ACE inhibitors?
They inhibit the ACE enzyme from converting angiotensin 1 to angiotensin 2 which promotes vasodilation and decreases peripheral resistence
What are common side effects of ACE inhibitors?
Dry cough, hyperkalemia, fatigue, dizziness, headache, loss of taste
What is a benefit of ACE-I?
Renal protection by decreasing aldosterone levels
What is the ending of the ACE-I’s?
-pril
Who are ACE-I contraindicated for?
Pregnant patients and patients of child bearing age as they have been linked to teratogenic effects
How often can ACE-I be titrated?
Every 2 weeks, but every 4-6 weeks if preferred
If a patient cannot tolerate an ACE-I, what medication can they be transitioned to?
Angiotensin II Receptor Binders (ARBs)
What is the ending for the ARB’s?
-sartan
What is the mechanism of action of ARBs?
They prevent angiotensin 2 from binding to the receptor site thus promoting vasodilation
What are the adverse effects of ARBs?
Dizziness, headaches, drowsiness, N/V/D, elevated potassium
What labs should be monitored with ARBs?
BUN/Cr, BMP (mainly K+)
How often can ARBs be titrated?
Every 2 weeks but 4-6 is preferred
What is the first line therapy for HTN?
Thiazide diuretics
What is the mechanism of action of the thiazide diuretic?
They prevent reabsorption of Na/Cl in the distal tubule this promoting the excretion of Na, Cl, K+, and water, thus decreasing volume in the body and reducing blood pressure
What are the adverse effects of thiazide diuretics?
Hyponatremia, Hypokalemia, dehydration, hyperglycemia (most common with diabetics), hyperuricemia, hypochloremia
Why should thiazides be cautioned with diabetic patients?
The excretion of Na/Cl/K+ promotes the elevation of glucose and uric acid, thus potentially increasing glucose levels to hyperglycemic states in diabetic patients
What should we be aware of with patients with gout on thiazide diuretics?
Thiazides can increase uric acid levels and potentiate gout flares
What is a medication to use in conjunction with the thiazide diuretics to prevent hypokalemia?
Potassium-sparing diuretics such as spironolactone
What are the two types of potassium-sparing diuretics?
Aldosterone antagonists and non-aldosterone antagonists
What is the mechanism of action of the aldosterone antagonists?
They block the aldosterone receptor sites promoting the retention of potassium and the excretion of Na and fluid
What is the mechanism of action of the non-aldosterone antagonists?
They inhibit the sodium/potassium exchange in the distal nephron without interfering with the action/binding of aldosterone
What are the adverse affects of the potassium-sparing diuretics?
Hyperkalemia, N/V, leg cramps
What is a side effect of spironolactone specific to men?
Gynecomastia
What is a side effect of spironolactone specific to women?
Menstrual irregularities
What is the mechanism of action of loop diuretics?
They block reabsorption of Na/Cl at the Loop of Henle
What are adverse effects of the loop diuretics?
Hypokalemia, hyponatremia, hypochloremia, hypotension, dehydration, ototoxicity
Which diuretic is most effective with promoting fluid excretion?
Loop diuretics
Which HTN medication is most effective to black patients due to their genetic makeup?
Calcium channel blockers (CCBs)
What are the two types of CCBs?
Dihydropyridine and the nondihyropridine
What is the ending of the diphydropyridine CCBs?
-pine
What is the mechanism of action of CCBs?
They inhibit the calcium by blocking the receptors thus preventing calcium from getting into the intracellular space thus promoting vasodilation
Which of the CCBs classes has a large effect on cardiac smooth muscle vasodilation?
Nondihydropridine
What are the adverse effects of CCBs?
Dizziness, flushing, orthostatic hypotension, headache, edema, reflex tachycardia
What medication can help prevent reflex tachycardia when using CCBs?
Beta blockers
When are CCBs contraindicated?
Heart failure patients with an EF less than 35% due to the adverse effect of edema
What is the mechanism of action of the beta blockers?
Beta blockers (especially selective beta-1 blockers) block the beta receptors promoting a decrease in HR and contractility thus decreasing cardiac output
What is an adverse affect of the non-selective beta blockers?
They block beta 2 receptors and promote bronchoconstriction
Which patient population should not receive non-selective beta blockers?
Patients with asthma as the bronchoconstriction can induce bronchospasm and asthma attacks
What are adverse effects of beta blockers?
bradycardia, orthostatic hypotension, rebound cardiac excitation, AV blocks (due to the reduction of velocity impulses through the AV node from beta blockade)
What is a non-selective beta blocker?
Propanolol and Carvedilol
What do the selective beta blockers end in?
-olol
What is the mechanism of action of hydralazine?
Selective dilation of the arterioles thus decreasing arterial pressure and peripheral resistance thus promoting an increase in cardiac output and heart rate
What are the adverse effects of hydralazine?
Reflex tachycardia, increased blood volume (edema), lupus-like reaction
When is minoxidil used in practice?
When there is a need for intense vasodilation
Who is minoxidil indicated for?
Patients with severe hypertension unresponsive to other treatments
What is the mechanism of action of minoxidil?
Selective vasodilation of the arterioles thus decreasing arterial pressure and increasing cardiac output
What are the adverse effects of minoxidil?
Reflex tachycardia, fluid and sodium retention, hypertrichosis, pericardial effusion (due to increased fluid retention)
When should patients be referred to a HTN specialist?
When they need 3 or more BP medications to manage their blood pressure
What is the most effective way to manage blood pressure according to the JNC 8?
The use of multi-drug therapy to help promote reduction of blood pressure through various mechanisms of action which can promote using smaller doses of medications
