Hypertension, Hypertensive Crisis & PAH

Question 1

What is 1st line for HTN treatment in stable Ischemic Heart Disease?

Answer 1

Beta Blockers
2nd line- DHP CCBs

Question 2

What is 1st line for HTN treatment in HF?

Answer 2

avoid non CCBs; diuretics for fluid overload if preserved ejection fraction; ACEi/ARB for elevated BP; BB for elevated HR

Question 3

What is 1st line for HTN treatment in CKD?

Answer 3

Stage 1 & 2 AND albuminuria - ACEi/ARB
Stage 3+ - ACEi/ARB

Question 4

What is 1st line for HTN treatment in Cerebrovascular disease?

Answer 4

for secondary stroke prevention- ACEi/ARB, thiazide diuretic or combo

Question 5

What is 1st line for HTN treatment in Diabetes?

Answer 5

-all
-if albuminuria then ACEi/ARB

Question 6

What are the thiazide diuretics?

Answer 6

chlorthalidone, hydrocholorothiazide

Question 7

What are the potassium-sparing diuretics?

Answer 7

amiloride, triamterene

Question 8

What are the aldosterone antagonist diuretics?

Answer 8

Spironolactone, eplerenone

Question 9

What does a patient have to be on before starting hydralazine or minoxidil?

Answer 9

diuretic and beta-blocker
due to AE’s of palpitations, tachycardia, chest pain, fluid retention, headache, hepatotoxicity

Question 10

What are the central a2-agonists?

Answer 10

clonidine, methyldopa, guanfacine
-taper dose when stopping due to rebound HTN

Question 11

What are the steps for management of resistant HTN?

Answer 11

1. optimize 3-drug regimen (ACEi/ARB, CCB, and diuretic)
2. sub thiazide-like diuretic (Chlorthalidone, indapamide)
3. add mineralcorticoid receptor antagonist (Spironolactone, eplerenone)
4. Beta-Blocker if HR > 70 bpm (if no; consider clonidine or guanfacine)
5. add hydralazine
6. sub minoxidil for hydralazine

Question 12

What are the BP goals for treating hypertensive emergency?

Answer 12

Hour 1: decrease BP by a max of 25%
Hour 2-6: reduce BP <160/100-110
Hours 6-48: reduce BP to goal

Question 13

What are the DHP CCBs used in treating hypertensive emergency?

Answer 13

Nicardipine
Clevidipine (CI in soy, egg allergies)
-both are IV, titratable

Question 14

What are the vasodilators used in treating hypertensive emergency?

Answer 14

Nitroglycerin (nitrates are titratable, tolerance occurs, reflex tachycardia)
Nitroprusside
Hydralazine (IVP; not titratable)

Question 15

What are the Beta Blockers used in treating hypertensive emergency?

Answer 15

Labetalol
Esmolol (Always adjunct; never monotherapy as only decrease HR and not BP)

Question 16

What is the ACEi & a2 central agonist used in treating hypertensive emergency?

Answer 16

Enalalprilat (given IVP; beneficial for renin excess)
Clonidine (only PO)

Question 17

What do patients with HTN emergency & acute decompensated HF w/pulmonary edema get?

Answer 17

-nitrates preferred
-avoid BBs + non-DHP CCBs

Question 18

What do patients with HTN emergency & Aortic dissection get?

Answer 18

-BB + Vasoldilator combo (nicardipine, clevidipine, nitroprusside)

Question 19

What do patients with HTN emergency & Acute coronary syndrome get?

Answer 19

-BBs, nitrates, nicardipine
-caution non-DHP CCBs, avoid BB if HR low, reduced EF, BP low, reactive airway disease or 2nd/3rd degree heart block

Question 20

What do patients with HTN emergency & Acute kidney injury get?

Answer 20

-caution nitroprusside
-avoid enalaprilat

Question 21

What do patients with HTN emergency & Eclampsia/severe pre-eclampsia get?

Answer 21

-hydralazine, labetalol or nicardipine
CI: enalalprilat + nitroprusside

Question 22

What do patients with HTN emergency & stroke get?

Answer 22

-no nitrates
-nicardipine, clevidipine, labetalol

Question 23

What CCBs are used in PAH if positive AVT?

Answer 23

Nifedipine LA 120-240 mg daily
Diltiazem LA 240-720 mg daily
amlodipine 20 mg daily
NO verapamil

Question 24

What are the endothelin receptor antagonists?

Answer 24

Bosentan, Ambrisentation (selective for ETa), macitentan

Question 25

What are the prostacyclins?

Answer 25

epoprostenol (IV), iloprost (inh), treprostinil (IV, SubQ, inh, oral)
IP prostacyclin receptor agonist: Selexipag

Question 26

What is Riociguat?

Answer 26

-soluble Guanylate cyclase stimulator
cannot be used with PDE-5 inhibitor and is indicated as alternative therapy to PDE-5 inhibitors