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Cardio > Hypertension Dr. Higsmith > Flashcards

Hypertension Dr. Higsmith Flashcards

Dr. Higsmith EXAM II

1
Q

Signs for secondary HTN

A

-Onset age < 30y
-Abrupt onset
-excessive hypokalemia
-drug-resistant HTN
-palpitation, headaches, sweating
-severe vascular disease

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2
Q

Diseases - Secondary Causes of HTN

A

-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

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3
Q

Drugs - Secondary Causes of HTN

A

-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

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4
Q

Lifestyle - Secondary Causes of HTN

A

-Inactivity, high salt diet, obesity, alcohol, smoking

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5
Q

Mean arterial pressure (MAP)

A

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)

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6
Q

Pulse pressure

A

difference between SBP and DBP

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7
Q

White coat HTN

A

-affects 15-20% of patients
-BP is higher in clinic than at home
-minimal increase in CV risk
-may lead to overtreatment

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8
Q

Masked HTN

A

-BP higher at home than in clinic
-Undertreatment of HTN
-increased CV risk, similar to sustained HTN

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9
Q

ACC/AHA 2017 Guidelines - BP

A

Normal: <120/<80
Elevated: 120-129 / <80
Stage 1: 130-139 / 80-90
Stage 2: >140 / >90

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10
Q

Initiate therapy - ACC/AHA 2017

A

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

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11
Q

Initiate therapy - JNC 8 2014

A

-Age over 60: >150/90
-Age under 60: >140/90
Diabetes w/o CKD: >140/90
-CKD w/o Diabetes: >140/90

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12
Q

Treatment: Patient with Stage 1 HTN

A

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

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13
Q

Treatment: Patient with Stage 2 HTN

A

BP: >140/>90
Nonpahrm therapy + Medication
-> Reassess in 1 mo

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14
Q

When to consider treatment based on JNC 8 guidelines?

A

Age over 60 (>150/90) or under 60 (>140/90)
-check CKD and diabetes

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15
Q

BP Goals: JNC 8 vs ACC/AHA

A

-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

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16
Q

Goals for elderly

A

JNC 8: <150/90
ACC/AHA: SBO <130

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17
Q

Which non-pharmacologic intervention has the biggest impact?

A

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

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18
Q

SBP reduction for diet

A

-DASH diet: 8-14 mmHg SBP reduction
-reduce salt: 5-6 mmHg SBP reduction

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19
Q

Evidence for ACEi/ARBs

A

-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

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20
Q

ADE of ACEi/ARB

A

-Increase in SCr: Vasodilation of efferent arteriole -> lower GFR -> more SCr in the blood
-Hyperkalemia
-Angioedema (bradykinin)
-cough (ACEi)

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21
Q

Direct Renin inhibitor

A

Aliskiren (Tekturna)
-no benefit or outcomes data
-not recommended!

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22
Q

Evidence for diuretics

A

-increased SCr/BUN
-increase in Ca2+
-decrease in K+, Na, Mg

-Hypotension due to volume depletion
-possible worsening of gout, DM, lipids

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23
Q

What is the most effective diuretic to treat HTN?

A

Thiazides
-Chlorthalidone over HCTZ
-Twice as potent
-reduced HF in African Americans (better than CCB)

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24
Q

Which diuretic is effective in removing fluid?

A

Loops
-used for HTN when caused by edema
-consider loops for HTN when GFR is <30-50 ml/min

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25
Q

When are K+-sparing diuretics considered?

A

-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

26
Q

ADE of Aldosterone Antagonist

A

-Spironolactone, Eplerenone
-gynecomastia
-amenorrhea
-erectile dysfunction
-electrolyte abnormalities

27
Q

Calcium Channel blocker: DHP

A

DHP: Amlodipine (Norvasc), Felodipine (Plendil), Nifedipine (Adalat)

-Peripheral: Relaxation of arterial smooth muscle -> decreasing peripheral resistance

28
Q

Calcium Channel blocker: Non-DHP

A

Verapamin (Calan), Diltiazem (Cardizem)
-Central:
-> Vasodilator of coronary vessels -> increases blood flow
-> depresses AV node conduction -> decreasing HR

29
Q

When to consider CCB

A

-Angina
-may be more effective in isolated systolic HTN (often elderly)
-Afib rate control (non-DHP)

30
Q

ADE of CCB

A

-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)

31
Q

Selectivity of ß-blockers

A

Cardioselective: Metoprolol, Nebivolol, Bisoprolol, Atenolol

Mixed-selective: carvedilol, labetalol

Non-selective: propranolol, nadolol

32
Q

ADE of ß-blockers

A

-Rebound HTN (taper)
-orthostatic hypotension
-mask hypoglycemia

33
Q

When to consider ß-blockers?

A

-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

34
Q

Which ß-blocker should be used in heart failure?

A

-Metoprolol succinate (long-acting, Toprol XL)
-Carvedilol (mixed-selective)
-Bisoprolol (Cardioselective)

-if respiratory issues use cardioselective (BEAM)

35
Q

Other drugs for HTN - Alpha-2-agonists

A

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

36
Q

Alpha-1-blocker and direct vasodilator

A

-prazosin, terazosin, doxazosin
-Used most commonly if concomitant BPH

-direct arterial vasodilator: - hydralazine and minoxidil -> may cause edema and water retention

37
Q

When is monotherapy or a two-drug therapy recommended?

A

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

38
Q

Treatment HFrEF or Ischemic heart disease

A

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

39
Q

Treatment compelling indication Diabetes

A

ACEi/ARB
CCB
Thiazide

if albuminuria: only ACEi or ARB

40
Q

Treatment CKD

A

ACEi or ARB

41
Q

Treatment secondary stroke prevention

A

Thiazide
Thiazide with ACEi

42
Q

Which drug should be avoided in Gout?

A

Diuretics, thiazides
-being poorly hydrated increases the risk of gout

43
Q

Which drug should be avoided in asthma and heart failure?

A

-ß-blocker for patients with asthma

-CCB (diltiazem, verapamil) for heart failure, A-V block, LV dysfunction

44
Q

Which drug to avoid in pregnancy?

A

-ACEi, ARBs
-aslo in hyperkalemia
-renal artery stenosis (blockage of the renal artery)

45
Q

When to avoid ARBs?

A

-pregnancy
-hyperkalemia
-renal artery stenosis

46
Q

When should spironolactone or eplerenone be avoided?

A

-Acute or severe renal failure (GFR 30-50) -> use loops
-Hyperkalemia

47
Q

Which drug to avoid in tachyarrhythmia?

A

CCB (DHP): bc they cause a drop in BP -> causing reflex tachycardia

-also avoid in heart failure (non-DHP and DHP)

48
Q

Which drugs to use in two-drug therapy?

A

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

49
Q

ACEi Dosing

A

Enalapril: 5mg -> 20mg (1-2x daily)
Lisinopril: 10mg -> 40mg (1x daily)

50
Q

ARB Dosing

A

Losartan: 50mg -> 100mg (1-2 daily)
Valsartan: 40-80mg -> 160-320mg (1x daily)

51
Q

ß-blocker dosing

A

Metoprolol: 50mg -100mg (1-2 daily)

52
Q

CCB dosing

A

Amlodipine: 2.5mg -> 10mg (1 daily)
Diltiazem ER: 120-180mg -> 360 mg (1 daily)

53
Q

Thiazide Dosing

A

Chlorthalidone: 12.5 mg -> 12.5 - 25mg (1 daily)

54
Q

Special Population: Pregnant

A

-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

55
Q

Special Population: Elderly

A

-often isolated systolic hypertension (ISH)
-Chlorthalidone reduces stroke and CV events but
consider physiological changes (electrolyte changes, renal function, risk of falling)

56
Q

Special Population: Diabetes

A

1st line: ACEi/ARBs - for renal benefit
2nd line: CCB or thiazide
BB masks hypotension

57
Q

Special Population: CHF (congestive heart failure)

A

-ACEi or ARB + neprilysin inhibitor (Entresto)
-BB: metoprolol succ, carvedilol, bisoprolol)
-Aldoblocker & diuretic preferred

58
Q

Special Population: African American

A

-CCB and thiazides are more effective
-ACEi/ARBs are still a great choice for HTN and diabetes

59
Q

Special Population: CKD

A

ACEi/ARB
consider loop if GFR <30-50

60
Q

Drugs for treatment-resistant HTN

A

-Spironolactone
-ß-blocker
-clonidine

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