Hypertension Dr. Higsmith Flashcards
Dr. Higsmith EXAM II
Signs for secondary HTN
-Onset age < 30y
-Abrupt onset
-excessive hypokalemia
-drug-resistant HTN
-palpitation, headaches, sweating
-severe vascular disease
Diseases - Secondary Causes of HTN
-Obstructive sleep apnea (25-50%)
-Primary aldosteronism (8-20%)
-Renovascular disease (5-35%)
-Renal parenchymal disease (1-2%)
Rare:
Thyroid disease. Cushing’s syndrome, pheochromocytoma, Coarctation of aorta
Drugs - Secondary Causes of HTN
-Corticosteroids - Prednisone, methylprednisolone
-NSAIDs
-Sympathomimetics/stimulants - Amphetamine salts, caffeine
Hormones - Estradiol, conjugated estrogens, testosterone, contraceptives
-Decongestants: Pseudoephedrine
-Antidepressants: venlafaxine, duloxetine, bupropion, MAOIs
-Erythropoiesis stimulating agents: Erythropoietin, darbepoetin
-Immunosuppressants: Cyclosporine, tacrolimus
-Illicit substances: Cocaine, methamphetamine, anabolic steroids
Lifestyle - Secondary Causes of HTN
-Inactivity, high salt diet, obesity, alcohol, smoking
Mean arterial pressure (MAP)
average pressure in the arteries during one cardiac cycle
-2/3 of the cycle is spent in diastole
-1/3 is spent is systole
MAP = (1/3 * SBP) + (2/3 * DBP)
Pulse pressure
difference between SBP and DBP
White coat HTN
-affects 15-20% of patients
-BP is higher in clinic than at home
-minimal increase in CV risk
-may lead to overtreatment
Masked HTN
-BP higher at home than in clinic
-Undertreatment of HTN
-increased CV risk, similar to sustained HTN
ACC/AHA 2017 Guidelines - BP
Normal: <120/<80
Elevated: 120-129 / <80
Stage 1: 130-139 / 80-90
Stage 2: >140 / >90
Initiate therapy - ACC/AHA 2017
Clinical ASCVD: >130 / >80 (Stage 1)
10y risk >10%: >130 / >80 (Stage 1)
10 y risk <10%: >140 / >90 (Stage 2)
Elderly (over 65): SBP >130
Initiate therapy - JNC 8 2014
-Age over 60: >150/90
-Age under 60: >140/90
Diabetes w/o CKD: >140/90
-CKD w/o Diabetes: >140/90
Treatment: Patient with Stage 1 HTN
BP: >130-139/80-89
No ASCVD or 10y risk is <10%: Nonpharmacologic therapy -> Reasses in 3-6 months
ASCVD or 10y risk is >10%: Non-pharm therapy + Medication -> Reasses in 1 mo
Treatment: Patient with Stage 2 HTN
BP: >140/>90
Nonpahrm therapy + Medication
-> Reassess in 1 mo
When to consider treatment based on JNC 8 guidelines?
Age over 60 (>150/90) or under 60 (>140/90)
-check CKD and diabetes
BP Goals: JNC 8 vs ACC/AHA
-depends on the Comorbid disease and age
-Goal by JNC 8:
< 140/90 for comorbidites
<150/90 if over 60y
-Goal by ACC/AHA:
< 130/80 for comorbidites
SBP <130/90 for elderly over 65
Goals for elderly
JNC 8: <150/90
ACC/AHA: SBO <130
Which non-pharmacologic intervention has the biggest impact?
Weight loss: 5-20 mmHg reduction in SBP for every 10kg
-Exercise: 90-150 min/wk –> 5-9 mmHg SBP decrease
-Limit alcohol: no more than 2 drinks for men and 1 drink for women per day - reduction in 2-4 mmHg SBP
SBP reduction for diet
-DASH diet: 8-14 mmHg SBP reduction
-reduce salt: 5-6 mmHg SBP reduction
Evidence for ACEi/ARBs
-Hypertension
-Heart failure
-Primary prevention of CAD
-Secondary prevention of CAD (post-MI), diabetes
-Primary prevention of nephropathy -> diabetes
-less effective in preventing CVA (stroke) than other BP meds
ADE of ACEi/ARB
-Increase in SCr: Vasodilation of efferent arteriole -> lower GFR -> more SCr in the blood
-Hyperkalemia
-Angioedema (bradykinin)
-cough (ACEi)
Direct Renin inhibitor
Aliskiren (Tekturna)
-no benefit or outcomes data
-not recommended!
Evidence for diuretics
-increased SCr/BUN
-increase in Ca2+
-decrease in K+, Na, Mg
-Hypotension due to volume depletion
-possible worsening of gout, DM, lipids
What is the most effective diuretic to treat HTN?
Thiazides
-Chlorthalidone over HCTZ
-Twice as potent
-reduced HF in African Americans (better than CCB)
Which diuretic is effective in removing fluid?
Loops
-used for HTN when caused by edema
-consider loops for HTN when GFR is <30-50 ml/min
When are K+-sparing diuretics considered?
-Spironolactone, Eplerenone
-in combination with K+ wasting diuretics (loops, thiazides)
-good for the treatment of resistant HTN
-add on drug:
reducing CV morbidity
reducing mortality in HFrEF
ADE of Aldosterone Antagonist
-Spironolactone, Eplerenone
-gynecomastia
-amenorrhea
-erectile dysfunction
-electrolyte abnormalities
Calcium Channel blocker: DHP
DHP: Amlodipine (Norvasc), Felodipine (Plendil), Nifedipine (Adalat)
-Peripheral: Relaxation of arterial smooth muscle -> decreasing peripheral resistance
Calcium Channel blocker: Non-DHP
Verapamin (Calan), Diltiazem (Cardizem)
-Central:
-> Vasodilator of coronary vessels -> increases blood flow
-> depresses AV node conduction -> decreasing HR
When to consider CCB
-Angina
-may be more effective in isolated systolic HTN (often elderly)
-Afib rate control (non-DHP)
ADE of CCB
-avoid short-acting CCBs
-DHP-HA: flushing, peripheral edema (due to vasodilation -> more blood -> hydrostatic pressure pushing fluid into tissue)
-Non-DHP:
bradycardia
AV block
potential benefit in Raynaud’s Disease
migraine prophylaxis (verapamil)
arrhythmias (non-DHPs)
Selectivity of ß-blockers
Cardioselective: Metoprolol, Nebivolol, Bisoprolol, Atenolol
Mixed-selective: carvedilol, labetalol
Non-selective: propranolol, nadolol
ADE of ß-blockers
-Rebound HTN (taper)
-orthostatic hypotension
-mask hypoglycemia
When to consider ß-blockers?
-treatment of resistant HTN (also Spironolactone) - 1st and 2nd line didn’t work
-compelling indication (HFreF, Ischemic heart disease, HFpEF after ACEi/ARB)
other compelling indications: tachyarrhythmias, CHF, migraine, tremor, portal HTN, thyrotoxicosis
Which ß-blocker should be used in heart failure?
-Metoprolol succinate (long-acting, Toprol XL)
-Carvedilol (mixed-selective)
-Bisoprolol (Cardioselective)
-if respiratory issues use cardioselective (BEAM)
Other drugs for HTN - Alpha-2-agonists
clonidine, guanfacine, and methyldopa
-Alpha-2-agonists: when activated -> RELAXATION (in the CNS - blocking sympathetic tone)
-Rebound HTN, tremor, agitation, nervousness, headache
-Methyldopa for pregnancy
-Clonidine for treatment-resistant HTN
Alpha-1-blocker and direct vasodilator
-prazosin, terazosin, doxazosin
-Used most commonly if concomitant BPH
-direct arterial vasodilator: - hydralazine and minoxidil -> may cause edema and water retention
When is monotherapy or a two-drug therapy recommended?
Monotherapy: Stage 1 HTN with ASCVD, CKD, diabetes OR 10y risk over 10%
-use ACEi/ARB, CCB, or thiazide
Two-drug: Stage 2 HTN WITHOUT compelling indication and >20/10 mmHg away from goal BP
Treatment HFrEF or Ischemic heart disease
HFrEF: Betablocker (BEAM) OR ACEi/ARB, if edema use diuretic
Ischemic heart disease: Betablocker then add ACEi/ARB, if angina use CCB
add on: Spironolactone
HFpEF: ACEi/ARB then add Betablocker, if edema use diuretic
add on: Spironolactone
Treatment compelling indication Diabetes
ACEi/ARB
CCB
Thiazide
if albuminuria: only ACEi or ARB
Treatment CKD
ACEi or ARB
Treatment secondary stroke prevention
Thiazide
Thiazide with ACEi
Which drug should be avoided in Gout?
Diuretics, thiazides
-being poorly hydrated increases the risk of gout
Which drug should be avoided in asthma and heart failure?
-ß-blocker for patients with asthma
-CCB (diltiazem, verapamil) for heart failure, A-V block, LV dysfunction
Which drug to avoid in pregnancy?
-ACEi, ARBs
-aslo in hyperkalemia
-renal artery stenosis (blockage of the renal artery)
When to avoid ARBs?
-pregnancy
-hyperkalemia
-renal artery stenosis
When should spironolactone or eplerenone be avoided?
-Acute or severe renal failure (GFR 30-50) -> use loops
-Hyperkalemia
Which drug to avoid in tachyarrhythmia?
CCB (DHP): bc they cause a drop in BP -> causing reflex tachycardia
-also avoid in heart failure (non-DHP and DHP)
Which drugs to use in two-drug therapy?
ACEi or ARB with thiazide
ACEi or ARB with CCB
Thiazide with CCB
-in Stage 2 HTN without compelling indication and >20/10 away from goal
ACEi Dosing
Enalapril: 5mg -> 20mg (1-2x daily)
Lisinopril: 10mg -> 40mg (1x daily)
ARB Dosing
Losartan: 50mg -> 100mg (1-2 daily)
Valsartan: 40-80mg -> 160-320mg (1x daily)
ß-blocker dosing
Metoprolol: 50mg -100mg (1-2 daily)
CCB dosing
Amlodipine: 2.5mg -> 10mg (1 daily)
Diltiazem ER: 120-180mg -> 360 mg (1 daily)
Thiazide Dosing
Chlorthalidone: 12.5 mg -> 12.5 - 25mg (1 daily)
Special Population: Pregnant
-Estrogen increases BP -> contraceptives, Premarin (dose-dependent increase)
-bed rest
-initiate txt: >140/90
-Methyldopa (Alpha-2-agonist), Labetalol, clonidine in the third trimester
-diuretics may cause electrolyte abnormalities
-ACEi/ARB are category X
Special Population: Elderly
-often isolated systolic hypertension (ISH)
-Chlorthalidone reduces stroke and CV events but
consider physiological changes (electrolyte changes, renal function, risk of falling)
Special Population: Diabetes
1st line: ACEi/ARBs - for renal benefit
2nd line: CCB or thiazide
BB masks hypotension
Special Population: CHF (congestive heart failure)
-ACEi or ARB + neprilysin inhibitor (Entresto)
-BB: metoprolol succ, carvedilol, bisoprolol)
-Aldoblocker & diuretic preferred
Special Population: African American
-CCB and thiazides are more effective
-ACEi/ARBs are still a great choice for HTN and diabetes
Special Population: CKD
ACEi/ARB
consider loop if GFR <30-50
Drugs for treatment-resistant HTN
-Spironolactone
-ß-blocker
-clonidine
