Hypertension Flashcards
Causes of primary HTN
Unknown but usually a combo of obesity, sedentary lifestyle, excessive salt intake, smoking, family history, diabetes, dyslipidemia
Causes of secondary HTN
renal disease, adrenal disease, obstructive sleep apnea, or drugs
What are the ACC/AHA categories for HTN?
Normal: <120/<80
Elevated: 120-129/<80
Stage 1 HTN: 130-139 systolic OR 80-89 diastolic
Stage 2 HTN: >140 systolic OR >90 diastolic
What should sodium intake be reduced to in someone with HTN to help lower BP?
<1500mg daily
What medications can increase BP?
Amphetamine and ADHD drugs Cocaine Decongestants Erythropoiesis-stimulating agents (ESA) Immunosuppressants NSAIDs Systemic steroids Oral contraceptives Some oncology meds Antidepressants
What medications are not recommended by the guidelines but have some evidence for lowering BP?
fish oil, coenzyme Q10, L-arginine, garlic, fiber, potassium
What medications are preferred first line treatment for HTN?
ACEi
ARBs
CCBs
Thiazide diuretics
When should you start HTN treatment?
Stage 2 HTN
Stage 1 HTN with Clinical ASCVD or 10 year ASCVD >10%
What is initial drug selection for treatment of HTN in patients who are Non-black Black CKD (all races) Diabetes with albuminuria (all races) Stage 2 HTN
Non-black: TZD, CCB, ACEi, ARB Black: TZD, CCB CKD: ACEi, ARB DM+A: ACEi, ARB Stage 2: 2 first line drugs
What medications can be used in pregnancy for HTN?
labetalol and nifedipine (first line) and methyldopa
What medications have BBW for fetal toxicity in pregnancy?
ACEi, ARB, aliskiren
What is the goal BP for someone with HTN during pregnancy and at what point would you treat them for HTN?
Goal: 120-160/80-110
Treat if >160/>105
Brand name for
lisinopril/HCTZ
Zestoretic
Brand name for
losartan/HCTZ
Hyzaar
Brand name for
Olmesartan/HCTZ
Benicar HCT
Brand name for
Valsartan/HCTZ
Diovan HCT
Brand name for
Benazepril/Amlodipine
Lotrel
Brand name for
Valsartan/Amlodipine
Exforge
Brand name for
atenolol/chlorthalidone
Tenoretic
Brand name for
bisoprolol/HCTZ
Ziac
Brand name for
Triamterene/HCTZ
Maxzide, Diazide
Thiazide diuretic MOA
inhibit sodium reabsorption in the distal convoluted tubule causing an increased excretion of sodium, chloride, water, and potassium
What drugs are thiazide diuretics
Chlorthalidone, HCTZ, Chlorothiazide, Indapamide, Metolazone
thiazide diuretic contraindications, Side effects
CI: Sulfonamide-derived drug allergy (not likely to cross-react); anuria
SE: Decreased K, Mg, Na; Increased Ca, UA, LDL, TG BG
Which diuretic is effective when CrCl < 30?
Loop
What is the only thiazide diuretic that is available IV
Chlorothiazide
Thiazide drug interactions
Lithium - decreased lithium clearance and increased risk of toxicity
Increases dofetilide serum concentration and increases risk of QT prolongation
Examples of dihydropyridine CCBS
Amlodipine, nicardipine, nifedipine
-pine
Examples of non-dhydropyridine CCBs
Diltiazem, verapamil
DHP CCB MOA
inhibit calcium ions from entering vascular smooth muscle causing peripheral arterial vasodilation
CCB Side effects and clinical notes
SE: peripheral edema, HA, flushing, palpitations, reflex tachycardia, gingival hyperplasia
Amlodipine is safest in HF
Which CCB is drug of choice in pregnancy?
Nifedipine ER
Which CCB is CI if allergy to soybeans, soy, or eggs?
clevidipine
Which CCB IV formulation contains lipid emulsion and how many kcal of fat per mL?
Clevidipine
2 kcal/mL
Non DPH CCB Warnings and SE
Warnings: HF, bradycardia
SE: edema, constipation (verapamil), gingival hyperplasia
CCB drug interadtions
Use with caution with Beta blockers, digoxin, clonidine, amiodarone and precidex
CCB are CYP3A4 substrates (no grapefruit juice)
ACEi MOA
prevent conversion of angiotensin I to angiotensin II, resulting in decreased vasoconstriction and decreased aldosterone secretion
ACEi BBW ,CI, warnings, and SE
BBW: injury and death to the developing fetus when used in 2nd and 3rd trimesters
CI: hx of angioedema, use within 36 hours of Entresto
Warnings: angioedema, hyperkalemia, hypotension, renal impairment, bilateral renal artery stenosis
SE: cough, hyperkalemia, increased SCr, hypotension
ARB MOA
block angiotensin II from binding to the angiotensin II type 1 receptor on vascular smooth muscle, preventing vasoconstriction
ACE vs ARB
Which have less cough, less angioedema, and no washout period between Entresto use?
ARB
What drug is a direct renal inhibitor?
Aliskiren
Aliskiren contrindications
do not use with ACE inhibitors or ARBs in patients with diabetes
What electrolyte abnormality do all RAAS inhibitors cause?
hyperkalemia
Why should you only use one RAAS inhibitor at a time?
increased risk of renal impairment, hypotension, and hyperkalemia
How long is the washout period between Entresto and an ACE and an ARB
ACE: 36 hours
ARB: no washout required
Which aldosterone antagonist is selective and which is non selective?
Selective: eplerenone
Non-selective: spironolactone (also blocks androgen)
Potassium-spring diuretics BBW, CI, and SE
BBW: hyperkalemia (K>5.5)
CI: hyperkalemia, severe renal impairment, addison’s disease
SE: hyperkalemia, increased SCr, dizziness (spironolactone: gynecomastia, breast tenderness, impotence)
Which potassium sparing diuretic is a major substrate of CYP3A4
eplerenone
Which disease states are beta blockers recommended first line?
post-MI, stable ischemic heart disease, HF
Beta blocker BBW, Warnings, SE
BBW: do not d/c abruptly
Warnings: caution in patients with diabetes (can mask hypoglycemia), use with caution in bronchospastic disease
SE: bradycardia, fatigue, hypotension, dizziness, depression, impotence
What is the IV to PO ratio of metoprolol tartrate?
IV:PO
1:2.5
Which BB crosses the BBB and has more CNS effects?
propranolol (migraine prophylaxis)
What is the BB of choice for pregnancy?
Labetalol
What are beta 1 selective blockers?
Atenolol Exmolol Metoprolol Acebutolol Betaxolol Bisoprolol
What are beta 1 selective blockers with nitric oxide-dependent vasodilation
Nebivolol
Beta 1 and beta 2 blocker (non-selective)
Propranolol, nadolol, pindalol, timolol
Non-selective beta-blockers and alpha-1 blockers
Carvedilol and labetalol
What beta blockers are a CYP substrate and what CYP do they act on?
Carvedilol, propranolol, metoprolol, nebivolol
CYP2D6 substrate
What drugs are alpha 2 adrenergic agonists?
Clonidine, guanfacine, methyldopa
Alpha 2 adrenergic agonist warnings, SE, notes
Warnings: do not d/c abruptly, hemolytic anemia (methyldopa)
SE: dry mouth, somnolence, fatigue, dizziness, constipation, decreased HR, hypotension; skin rash/pruritus/erhythmia (clonidine patch)
Methyldopa contrindication
concurrent use with MAO inhibitors
What drugs are direct vasodilators?
Hydralazine and minoxidil
Warnings and SE for hydralazine
Warning: drug-induced lupus erythematosus
SE: peripheral edema, HA, flushing, palpitations, reflex tachycardia
CI and SE for minoxidil
Boxed warning: potent antihypertensive
SE: fluid retention, tachycardia, hair growth
HTN emergency vs urgency
Emergency: acute target organ damage
Urgency: no target organ damage
HTN emergency treatment
IV medications
Decrease BP by 25% within the first hour then decrease to 160/100 mmHg over next 2-6 hours
HTN urgency treatment
Oral medications
Decrease BP over 24 to 48 hours
