Hypertension Kaakeh Exam 3 Flashcards
True or false: Low sodium intake and high potassium intake are both risk factors for developing HTN.
False–its the other way around. High sodium, low potassium intake.
Which gender has a higher prevalence of HTN 45yo?
Male 45
Name other risk factors for developing HTN.
Elderly age, AA ethnicity, obesity, excess alcohol intake, genetic predisposition.
What technique must be used to diagnose HTN?
Two readings at least 5 minutes apart, sitting in chair, confirmed in contralateral arm.
What BP measurement techniques may help to evaluate “white coat” HTN?
Ambulatory BP monitoring and self-monitoring
What stage of hypertension does 135/94 fall into?
Stage 1 because of diastolic BP
An increase of 20/10mmHg ____ the risk of CVD over 115/75.
doubles
What is the number needed to treat to prevent 1 death by lowering BP was 10mmHG over 10 years?
11
Humoral, neuronal, vascular endothelial, electrolyte regulation defect, and peripheral autoregulation defect are all theories regarding the cause of _____ HTN.
Primary
Name causes of secondary HTN.
Sleep apnea, CKD, renal artery stenosis, chronic steroid therapy, cushing’s syndrome, primary aldosteronism, pheochromocytoma, coarctation of the aorta, thyroid disease, parathyroid disease, food, drugs.
What OTC drugs can elevate BP?
NSAIDs, pseudoephedrine, ephedrine, high sodium meds, licorice, cocaine, ketamine, caffeine, nicotine, ecstasy, smokeless tobacco, some herbals.
What Rx drugs can elevate BP?
NSAIDs, corticosteroids, estrogens, OCs, sympathomimetics, erythropoietin, ketoocnazole, others!
Patinet KJ has HTN that is still uncontrolled even with three medications and you discovered that she is hypokalemic. She also has a father with HTN diagnosed at 35. What should KJ be tested for?
Primary aldosteronism.
How is primary aldosteronism treated?
Pretreatment for 3-4 weeks with spironolactone 100mg-400mg PO once daily, then surgical removal of adrenal tumor.
Which is usually harder to pick up on–HTN secondary to hyperthyroidism or hypothyroidism?
HTN secondary to hypothyroidism–HTN secondary to hyperthyroidism usually shows obvious signs of thyrotoxicosis. Hypothyroidism mechanism mediated by local control failure as basal metabolism falls–vasoconstriction.
What drug class primarily affects SV?
Diuretics
What drug classes primarily affect HR?
Beta blockers, non-DHP CCBs
What drug classes primarily affect peripheral resistance?
ACEIs, ARBs, hydralazine, sympatholytics.
How do you calculate MAP?
1/3(SBP) + 2/3(DBP) – especially important in ICU/CCU, septic shock, head injury, AAA
What are the five target organs that can be hurt by elevated BP?
Heart (CHD, CHF, LVH), brain (hemorrhage, TIA), eye (retinopathy, AV nicking), kidney (renal failure, CKD, proteinuria), blood vessels (PVD, AAA)
Why should we care about prehypertension?
Because prehypertension alone raises the risk of stroke by about 50%. Also may lead to HTN.
Which guideline was more aggressive–JNC7 or JNC8?
JNC 7
When should you consider a 2-drug combination, according to JNC7? According to JNC8?
JNC7: when patient is in stage 2 HTN
JNC8: same or SBP >20mmHg above and DBP >10mmHg above
What was the drug class of choice in JNC7?
Thiazide diuretics
What are the preferred drug classes in CKD? (JNC7)
ACEI/ARBs
What are the preferred drug classes in heart failure? (JNC7)
Thiazides, BBs, ACE/ARB, aldosterone antagonist
What are the preferred drug classes post-MI? (JNC7)
BB, ACEI, aldosterone antagonist
What are the preferred drug classes in recurrent stroke prevention? (JNC7)
Thiazides, ACEIs
What are the preferred drug classes in diabetes? (JNC7)
ACEI/ARB, maybe CCB
Which blood pressure is more important in predicting CVD risk according to JNC7?
Systolic
Which HTN guideline had a more stringent selection process for clinical trials included and graded recommendations?
JNC8
Which HTN guideline included lifestyle modifications and compelling indications?
JNC7
Which HTN guideline addressed racial, CKD, and diabetic subgroups?
JNC8
Which HTN guideline addressed secondary HTN and resistant HTN?
JNC7
Which HTN guideline has a higher treatment goal for patients > or = 60 years old? What is that goal?
JNC8;
What is the blood pressure goal in all other patients except those >/= 60 years old without comorbidities?
What are the four first-line drug classes according to JNC8?
Thiazide diuretics, ACEIs, ARBs, CCBs
What initial treatment should be used in the black population?
Thiazide diuretics or CCBs (if no DM/CKD)
What drug classes are recommended with CKD, regardless of race of DM status?
ACEI or ARB
What drug classes are recommended with DM, regardless of race or CKD status?
ACEI or ARB
Why might chlorthalidone be used over HCTZ?
More potent, longer half-life, shown to reduced morbidity/mortality in literature. However, might be more expensive.
According to JNC8, when should BP be assessed after initial treatment?
1 month after–can either increase dose or add 2nd
What first line therapies should not be used together?
ACEIs and ARBs
When should you consider other second-line classes of drugs?
If goal not met with 3 medications, or if contraindication to a class.
There are five main targets of non-pharmacologic therapy: weight reduction, DASH diet, dietary sodium reduction, aerobic physical activity, and moderation of alcohol consumption. Which of these can have the greatest impact on blood pressure?
Weight reduction – 5-20mmHg/10kg lost
What is the recommendation for alcohol limitation in men? women?
Men: 2 or less drinks per day
Women: 1 or less drinks per day
What is the goal for aerobic physical activity?
30 minutes per day, most days of the week
What foods are emphasized on the DASH diet? Which are limited?
Increase vegetables, fruits, fat-free or low-fat dairy, whole grains, fish, poultry, beans, seeds, nuts, veggie oil
Decrease sodium, sweets, sugary beverages, red meats
What is the sodium intake recommendation for most patients?
What is the sodium intake recommendation for patients over 51 years old, with HTN, with DM, with CKD, or black descent?
What first line HTN therapy may be beneficial in osteoporosis?
Thiazide diuretics
What are some negative effects of thiazides?
DM, gout, renal insufficiency, hyponatremia, effect on lipids
When should thiazides be dosed?
In morning to avoid initial noctural diuresis.
At what CrCl are loops more effective?
What is an appropriate initial dose of chlorthalidone? Max dose?
Initial: 12.5 mg/day
MAX: 100 mg/day (clinical max closer to 25-50)
Why should addition of another agent be considered when increasing a thiazide dose?
Dose response curve plateaus–not necessarily more efficaceous.
What are potential adverse effects of thiazides?
Hypokalemia, hypomagnesemia, hypercalcemia, hyperuricemia, hyperglycemia, hyperlipidemia, sexual dysfunction. Lithium toxicity.
CI: sulfa allergy, anuria
What is the name of the primary clinical trial that showed reduction in fatal CHD, nonfatal MI, HF, and stroke with thiazides?
ALLHAT – basis of thiazide recommendation in JNC7
What loop diuretic is not contraindicated in sulfa allergy? Why is it not preferred?
Ethacrynic acid; higher incidence ototoxicity
Which of the workhorse diuretics does not come to equilibrium and lose its diuretic effect after a few weeks?
Loop diuretics
What is an appropriate initial dose of furosemide? Max?
Initial: 20mg in 1-2 doses
MAX: 80mg in 1-2 doses
What is the initial dose of torsemide? Max?
Initial: 2.5mg/day
MAX: 10mg/day
What is the initial dose of bumetanide? Max?
Initial: 0.5mg in 1-2 doses
MAX: 2mg in 1-2 doses
What is the initial dose of ethacrynic acid? Max?
Initial: 50mg in 1-2 doses
MAX: 200mg BID
What are adverse effects of loop diuretics?
Hypokalemia, hypomagnesiemia, hypocalcemia, ototoxocity, hyperuricemia, sulfa allergy.
Why are potassium-sparing diuretics generally reserved for diuretic-induced hypokalemia patients?
Because they are weak diuretics and only really used in combination for hypokalemia benefit.
How is amiloride dosed initially? Max?
Initial: 5mg/day
MAX: 20mg/day
How is triamterene dosed as monotherapy? In combination? Max?
Monotherapy initial: 100mg in 1-2 doses
Combination initial: 37.5mg, 1-2 times a day
MAX: 300mg/day
What are adverse effects of potassium sparing diuretics?
Hyperkalemia (esp in combo with ACEI/ARB/K supplements). Avoid in CKD/DM patients.
How is spironolactone dosed initially? Max?
Initial: 12.5mg/day
MAX: 50mg/day in 1-2 divided doses
How is eplerenone dosed initially? Max?
Initial: 50mg/day
MAX: 50mg BID
In what patients is eplerenone contraindicated?
Patients with T2DM and proteinuria, CrCl
What are adverse effects of aldosterone antagonists?
Hyperkalemia (esp with ACEI/ARB/K+ supp), avoid in CKD/DM, gynecomastic with spironolactone.
What is a common cause of diuretic resistance?
NSAID coadministration
What are common drug interactions with diuretics?
Digitalis, lithium, ACE/ARB (with K sparing), corticosteroids, NSAIDs, etc.
What should patients starting diuretic therapy be educated on?
Encourage lifestyle modifications, check BP frequently, take in AM to avoid nocturia, monitor BS if relevant
What are monitoring parameters for diuretics?
BP, BUN/SCr, serum electrolytes, cholesterol/TGs, skin rash, uric acid if gout.
What are the pharmacodynamic effects of ACEI/ARBs?
Vasodilation, reduced PVR, reduced BP, no change HR, no change CO, minimal diuresis.
What angiotensin inhibitor class is best post-MI and in LVD?
ACEIs
What angiotensin inhibitor class is best in CHF?
ARBs
What conditions are contraindications for ACEI/ARB therapy?
Pregnancy, nursing, hx angioedema, bilateral renal artery stenosis, pre-existing severe kidney dysfunction, hyperkalemia.
Why must a physical exam be conducted before initiation of ACEI/ARB therapy?
Need to look for renal artery stenosis. First bruits look for, then imaging.
What are the compelling indications for ACEI use?
CKD patients, left ventricular hypertrophy
What are adverse reactions from ACEIs?
Cough (dry, usually b/c increase bradykinin), angioedema, hyperkalemia, neutropenia, agranulocytosis, proteinuria, glomerulonephritis, acute renal failure, loss of taste.
When should K and SCr be monitored after initiation or dose increase?
Within 4 weeks
What are adverse effects of angiotensin receptor blockers?
Orthostatic hypotension, renal insufficiency, hyperkalemia, less cough than ACEIs
What patients may benefit from a 50% initial dose?
Patients at high hypotension risk–patients taking diuretic, volume depleted patients, and elderly
What patients are at highest risk for acute kidney failure with an ACEI/ARB?
Patients with severe bilateral renal artery stenosis or severe stenosis in artery to solitary kidney.
What unique SE does aliskiren have compared to ACEI/ARBs? How is it dosed?
Diarrhea; 150mg-300mg PO daily
What are the monitoring parameters for angiotensin inhibitors?
SCr, BP, serum K, angioedema, dizziness, cough
What should patients be educated on with angiotensin inhibitors?
Educate on HTN, compliance, BP measurement, K rich food, pregnancy precautions, ADRs (angioedema especially)
When are non-DHP CCBs contraindicated?
Preexisting bradycardia, conduction defects, HF due to systolic dysfunction
What CCBs can be used for arrhythmias?
non-DHPs
What effect do DHP CCBs have on heart rate?
Reflex tachycardia, but no direct effect.
When are DHP CCBs contraindicated?
Heart block
What are ADEs from DHP CCBs?
Reflex sympathetic discharge, tachycardia, dizziness, HA, flushing, peripheral edema, gingival hyperplasia.
What are some special situations that make CCBs preferred?
Raynaud’s syndrome, older patients with isolated systolic HTN, potent vasodilators.
What situations are diltiazem and verapamil effective in? What different ADRs do they have?
Supraventricular tachyarrhythmias. SE: bradycardia, HA, dizziness, AV block, systolic HF, constipation.
How are diltiazem ER and verapamil ER dosed?
Initial: 120mg/day PO for both
MAX: 360mg/day for diltiazem
480mg/day for verapamil
What drug class should not be used with non-DHP CCBs because of effect on heart rate?
Beta-blockers
What are the monitoring parameters for CCBs?
BP, HR (non-DHP), peripheral edema (DHP), constipation (non-DHP)
What should patients starting CCB therapy be educated about?
Frequent BP monitoring, lab testing (?), edema, constipation prevention
What compelling indication would lead you to use a beta blocker?
Angina, post-MI, reduced mortality HF, arrhythmias, migraine, thyrotoxicosis, perioperative HTN
What are ADEs for beta blockers?
Bronchospasm, bradycardia, mask hypoglycemia, impaired peripheral circulation, fatigue, decreased exercise tolerance, depression, withdrawal–dont stop suddenly. Caution asthma/COPD, renal insufficiency, DM, HF exacerbation, 2nd or 3rd degree heart block.
What agents are reserved for last-line therapy in patients with special indications or difficult to control BP?
Hydralazine, minoxidil
What are ADEs for hydralazine?
Drug-induced rash, SLE, fluid retention, reflex tachycardia, palpitations, chest pain, GI, HA, hepatotoxicity
How is hydralazine dosed initially? Max?
Initial: 10mg PO QID (target 25-100mg/day PO)
MAX: 300mg/day PO divided
IV: 10-50mg IV q30min prn
How is minoxidil dosed?
2.5-80mg daily in 1-2 divided doses
What are the side effects of minoxidil?
Hypertrichosis/hirsutism, fluid retention, all others that hydralazine has without SLE. Black box warning pericarditis/tamponade, exacerbate angina, should be given with diuretic and beta blocker.
When should the direct vasodilators not be used? Used with caution?
CI: dissecting aortic aneurysm
Caution: CVA (permissive HTN), renal impairment, CAD, liver disease, SLE (hydralazine)
What antihypertensive is preferred in pregnancy? How is it dosed? Second line therapies?
Methyldopa (Aldomet)
Initial: 250mg PO BID-TID (usual target 250mg BID)
MAX: 3g/day
IV: 250-100mg q6-8h (MAX 1g IV 16h)
Second line: beta blockers and vasodilators
At what frequency should HTN be followed up after goal reached?
q3-6mos
What agents are recommended in AA patients?
Thiazides and CCBS (B blockers next?)
What patients are at high risk of fall due to postural hypotension? How should their BP be monitored?
Elderly patients; monitor in upright position
What cognitive disorder does BP control halt progression of?
Dementia
What medicine puts women at higher risk of HTN?
OCs
In what conditions is permissive hypertension okay?
Stroke and MI, especially if patient at high risk
Define hypertensive urgency. What should be addressed first?
Mark BP elevation (>180/120) and NO TOD.
Look for drugs, pain, anxiety, cocaine, withdrawal 1st.
How is hypertensive urgency treated? What is the goal?
Hospitalization not required, can be treated with short acting oral therapy (avoid SL and IM) like clonidine, labetalol, captopril.
Goal: decrease BP to “normal” within 24-48 hours to avoid TOD (stroke)
Define hypertensive emergency.
Marked BP elevation (>180/120) AND TOD (includes encephalopathy, MI, unstable angina, pulmonary edema, eclampsia, stroke, head trauma, life-threatening arterial bleeding, aortic dissection, diminished renal clearance).
How do you treat hypertensive emergency? What is your goal?
Treat with parenteral antihypertensive therapy to decrease MAP ~25% within 2 hours. If stable, continue to decrease BP over 2-6 hours. May take days! Do NOT want to lead to hyperperfusion.
What drugs are helpful in pheocromocytoma?
A-1 blockers to counteract catecholamine surge.
What are the active ingredients in Tribenzor?
Olmesartan, amlodipine, and HCTZ (PO once daily)
What are the active ingredients in Exforge HCT?
Valsartan, amlodipine, HCTZ (PO once daily)
What are the active ingredients in Amturnide?
Aliskiren, amlodipine, HCTZ (PO once daily)
What are pros and cons for combination products?
May decrease pill burden by decreasing pills and simplifying dosing regimen. However, higher cost.
What situation is resistant HTN?
Uncontrolled BP even after 3 medications at maximally tolerated doses. Must rule out nonadherence, secondary causes, salt intake, etc.
What are possible causes of resistant HTN?
Improper BP measurement, excess sodium intake, medication (inadequate doses or interactions with OTCs), excess alcohol intake, secondary causes.
