Hypertension Part 3 Flashcards
What are select situations and compelling factors to consider when choosing the correct antihypertensive to prescribe to a patient?
- Children
- African American
- Pregnancy
- Older Adult
- DM
- CV Disease
- HF
- Renal Disease
- Renovascular Disease
Select situations and compelling factors: Children
Children should be referred to a specialist
Select situations and compelling factors: African American
Monotherapy with ACEIs are not effective in African Americans because they have lower renin activity
Select situations and compelling factors: Pregnancy
- BLACK BOX WARNING
Should not be on an ACEI or and ARB if pregnant, tying, or not using protection
BLACK BOX WARNING - Recommended drug of choice for early term HTN: methyldopa (Aldomet)- old drug
- Can also use for early term HTN: labetalol (Trandate)- Beta Blockers
- Can use for second/third term HTN: Beta Blockers
- Teacher recommends generating a consult for a second opinion if family medicine is not already your specialty
Select situations and compelling factors: Older Adult
- Higher risk of having kidney problems resulting in hyperkalemia.
- So ACEIs and ARBs wouldn’t be the best choice
Select situations and compelling factors: DM
First line: Metformin
Select situations and compelling factors: CV Disease
- First drug started after MI: Beta Blocker
2. Second drug started after MI: ACEIs
Select situations and compelling factors: HF
Don’t prescribe CCBs: can cause fluid retention in HF
Select situations and compelling factors: Renal Disease
Important to watch BUN and Creatinine levels very closely (d/t narrow window) if RD patient is on thiazides, ACEs or ARBIs
What puts you at risk for high BP?
- Age
- Genes
- Lifestyle habits
- Sex
- Race or ethnicity
What puts you at risk for high BP?: Age
BP tends to get higher as we get age
What puts you at risk for high BP?: Genes
High BP often runs in families
What puts you at risk for high BP?: Lifestyle habits
- Salt
- Alcohol
- Obesity
- Smoking
- Not enough exercise
What puts you at risk for high BP?: Sex
< 60: more men than women
> 60: more women than men
What puts you at risk for high BP?: Race or ethnicity
- African Americans tend to get it at a younger age
2. Among Hispanic adults, people of Cuban, Puerto Rican and Dominican backgrounds are at higher risk
CASE STUDY: JOHN
- 46 y/o
- African American
- No PMH/problems
- Presented to clinic 3 weeks ago for routine check up
- Was found to have high BP
- Was asked to return in 2 weeks
- 1st BP/HR: 154/92 and 74
- 2nd BP/HR: 162/96 and 72
CASE STUDY: JOHN
- 46 y/o
- African American
- No PMH/problems
- Presented to clinic 3 weeks ago for routine check up
- Was found to have high BP
- Was asked to return in 2 weeks
- 1st BP/HR: 154/92 and 74
- 2nd BP/HR: 162/96 and 72
Why was he asked to return?
He has HTN
Why wasn’t he started on a HTN med at the first visit?
HTN has not yet been diagnosed, rechecking guarantees he didn’t just come in on a bad day the fist time.
Which Category of HTN does John fall into?
He is in stage 1 for the first visit and stage 2 for the second visit
Does he meet the JNC-8 Guidelines to start antihypertensive medication?
Yes
Does he have any compelling factors?
African American
Would you consider lifestyle modifications prior to starting a medication?
I wound start both at the same time
If you start a medication what is the 1st line category and medication you would start John on?
- CCBs or Thiazides.
2. If the first one does not work out try the other.
If you choose not to start the 1st line medication, what is the second line category and medication that you could choose?
Potassium Sparing Diuretic
If John were a diabetic would that change the medication to start him on?
Yes, we could start an ACEI in a diabetic
How would you follow up with John?
- Ask him to come back in a couple of days to have his BP checked
- If he’s doing good ask him to come back in a few weeks.
- If it seems like another medication should be added JNC recommends you wait until 30 days after you started the first.
- A nurse can check the BP and you can call him about the result.
Would you start John on two medications or just one? Why?
- One
2. If there is a adverse reaction you know which medication is causing it.
Any labs that should be monitored prior to starting a medication & any follow up monitoring?
- BUN
- Cr
- Electrolytes
What client education would you assure is provided?
Lifestyle, Med Adherence, etc….
Why are black men at a higher risk for HTN compared to white men?
The black population tend to have a sodium sensitivity
CASE STUDY: SHARON
- 38 y/o
- Hispanic
- Recently moved to US from Peru
- DM2 (5 yrs)
- Presents to the clinic for her 2nd visit
- BP 158/92
CASE STUDY: SHARON
- 38 y/o
- Hispanic
- Recently moved to US from Peru
- DM2 (5 yrs)
- Presents to the clinic for her 2nd visit
- BP 158/92
Which Category of HTN does Sharon fall into?
Stage 1
Does she have any compelling factors?
DM2 (5 yrs)
Does she meet the JNC-8 Guidelines to start a BP medication?
Yes
Would you consider lifestyle modifications prior to starting a medication? Why or why not?
No, she’s had diabetes for 5 years
OR
Yes, she is young
Would you discuss cultural issues that might impact compliance to medications?
Yes
does she believe in American medicine?
do family members make decisions for her?
Etc…
If you start a medication what is the 1st line category & medication you would start?
ACEIs
first line b/c of risk for diabetic neuropathy
If you choose not to start the 1st line medication, what is the 2nd line medication that you could choose?
Why might you do that?
Thiazides work well combined with ACEIs
Next try and ARB
Medication cost considerations?
generic is cheaper than brand name
older is cheaper than newer
lisinopril (generic) is first generation and most likely the cheapest
Should you check any labs prior to starting the medication? Any labs that should be monitored routinely?
- BUN
- Cr
- Electrolytes
What is important to remember when considering cost of mediation when prescribing?
If a medication is too expensive a patient may be embarrassed and lie and tell you they are taking their medication when they are not. Then they suffer very high BP…..
Which HTN med causes a cough?
ACEI
CASE STUDY: JACK
- 82 y/o
- smoker
- HTN
- CAD
- Chronic Systolic HF
- CKD
- recently moved to the area
- presents to the clinic for a new client appointment
CASE STUDY: JACK
- 82 y/o
- smoker
- HTN
- CAD
- Chronic Systolic HF
- CKD
- recently moved to the area
- presents to the clinic for a new client appointment
Does he have compelling factors in r/t his HTN treatment?
- 82 y/o
- smoker
- CAD
- Chronic Systolic HF
- CKD
What medications should Jack be taking because he has CAD?
- Beta Blockers
- Aspirin
- Statins
- ACEIs
- PRN Nitrate
- Isosorbide (long acting nitrate for angina)
What medications should Jack be taking because he has Chronic Systolic HF?
- ACEI
- Beta Blocker
- CCB
- Spironolactone
- Hydrochlorothiazide
- Lasix (if in fluid overload)
What medications should Jack be taking because he has CKD?
ARBIs
What medications should Jack be taking for HTN?
All of the above
How do all these meds related to each other?
they all treat HTN
How do you decide between different diuretics? (for HF)
- Beta Blockers and ACEIs
then if BP tolerates it add…
- Spironolactone
then if BP tolerates it add…
- Hydrochlorothiazide
then if they need to get rid of fluid…
- Lasix
What is Digoxin used for in HF patients?
It wont prolong their life but it may make them feel better
What is Digoxin normally used for?
HR control
Who uses Digoxin? Who does not?
Older MDs use Digoxin and newer MDs will use CCB or Beta Blocker
Is Coreg a Beta Blocker or Alpha Blocker?
It is a Beta Blocker that has a little bit of Alpha Blocker properties as well.
What is one major side effect of Beta Blockers?
Erectile Dysfunction
CASE STUDY: HANNAH
- 24 y/o
- 4 months pregnant
- Presents today at the family clinic for a monthly check up
- BP 162/96
- You have never cared for her before so you review her record before seeing her
CASE STUDY: HANNAH
- 24 y/o
- 4 months pregnant
- Presents today at the family clinic for a monthly check up
- BP 162/96
- You have never cared for her before so you review her record before seeing her
What client history is important for you to review?
- First pregnancy?
- BP Pre pregnancy
- Any comorbidities?
- Lifestyle Etc…
Would you start a medication or just recommend life style changes?
I would refer her to OB
If you start a medication what is the 1st line category & medication you would start?
She could be started on medications by a specialist
They would start with methyldopa or labetalol which are safe in the first trimester and if she waited until her 2/3 trimester she could use beta blockers
If you choose not to start the 1st line medication, what is the 2nd line medication that you could choose? Why might you do that?
If she sees a specialist and needs further care she should be able to go back to her specialist
Should you check any labs prior to starting the medication? Any labs that should be monitored routinely?
Know base labs
In the general population pharmacologic treatment should be initiated when BP is _____.
150/90+
in adults 60 years & older pharmacologic treatment should be initiated when BP is _____.
140/90+
In patients with HTN & DM, pharmacologic treatment should be initiated when BP is ______ regardless of____.
140/90+, age
Initial antihypertensive treatment include …
Non Black:
ACEI, ARB, CCB, thiazide
Black:
CCB, thiazide
If target BP is not reached within 1 month after initiating therapy what should occur?
- dosage of the initial medication should be increased
OR
- a second medication should be added.
As the NP managing a client’s care you are starting the client on a thiazide diuretic. You explain to the client that this medication treats hypertension because it:
A. Increases renin secretion
B. Decreases the production of aldosterone
C. Depletes body sodium & reduces fluid volume
D. Decreases blood viscosity
C. Depletes body sodium & reduces fluid volume
You are caring for a client with Hypertension & Heart Failure who has normal renal function. You start the client on furosemide (Lasix) & explain to the client that they will also need to start:
A. A potassium supplement
B. A calcium supplement
C. A magnesium supplement
D. A phosphate supplement
A. A potassium supplement
A new client presents to the Family Health Clinic. You review their current medications & note that the client is taking propranolol (Inderal). As an NP you are aware that which disease process could be made worse by this medication?
A. Dyslipidemia
B. Asthma
C. Hyperthyroidism
D. Osteoarthritis
B. Asthma
The NP is caring for a 36 y/o female client who carries the diagnosis of Hypertension. She is taking lisinopril (Zestril). This drug should be discontinued immediately if:
A. A dry cough occurs
B. Gout develops
C. Potassium levels decrease
D. Pregnancy occurs
D. Pregnancy occurs
Teacher was a inpatient hospitalist NP and wanted to give a pt blood because idk what was even wrong with him but I felt like the pt needed blood so I said I would donate. It was the late afternoon when the attending came by to talk abotu the pt. I showed him the labs and told him info about the pt…And i asked do you think i should give the pt a unit of blood? and he said well what do you want to do? She said i dont wanna do anything I want you to tell me what to do. And the point is that he made her think and theyre goign to try and make us think in this program. And he asked tell me why you would give the pt blood, now tell me why you wouldnt give the pt blood? and then he asked what do you want to do? She said I think I would like to give the pt 2 units of blood. He said tha sounds like a very good answer to me, lets do that. SO the point is NO it does not matter weather you start the thiazide or the CCB first bc according to the guidelines you can start with iether one.
What are potential side effects or adverse effects to these medications? LOOK UP ALL GENERAL MED INFO
STUDY PHARMACODYNAMICS AND PHARMACOKINETICS AND
ADVERSE/SIDE EFFECTS
there is a algorithm for thiazide medications that tells you what to give for pts with HF?? where?? is there one for other mediations??
