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Hypertension Therapy Flashcards

1
Q

what is the step line therapy for HTN in stable ischemic heart disease

A

-first line: beta blockers
may also use ACEi, ARB
-CCBs can be used if BP still uncontrolled

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2
Q

what is the step line therapy for HTN in heart failure

A

-reduced ejection fractions: follow most recent HF guidelines. avoid non DHPs
-preserved ejection fraction: diurectics, ACEi/ARB, beta blocker

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3
Q

what is the step line therapy for HTN in CKD

A

-CKD stage 1 or 2 and albuminuria: ACEi or ARB
-CKD stage 3 or higher: ACEi or ARB

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4
Q

what is the step line therapy for HTN in cerebrovascular disease

A

ACEi/ARB, thiazide diuretic, or combo

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5
Q

what is the step line therapy for HTN in diabetes

A

all first line classes are good options
if albuminuria use ACEi or ARB

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6
Q

what is the step line therapy in HTN for pregnancy

A

methyldopa, nifedipine, labetalol

contraindications: ACEi, ARB, direct renin inhibitors

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7
Q

what HTN therapy works best in black patients

A

Thiazide or CCB unless HF or CKD

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8
Q

thiazide diuretic drug choices

A

HCTZ, chlorthalidone, indapamide, metolazone

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9
Q

thiazide adverse effects

A

-hypokalemia
-hyperuricemia
-sexual dysfunction
-increase in lipids

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10
Q

thiazide DDIs

A

lithium toxicity w/ concurrent use

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11
Q

thiazide contraindications

A

sulfa allergy
anuria

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12
Q

aldosterone antagonists drug choices

A

spironolactone, eplerenone

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13
Q

aldosterone adverse effects

A

-hyperkalemia
-hyponatremia
-gynecomastia

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14
Q

aldosterone DDIs

A

ACEi/ARB/renin inhibitors/NSAIDs
increase risk of hyperkalemia

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15
Q

aldosterone contraindications

A

concomitant use of potassium sparing diuretics

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16
Q

Potassium sparing diuretics agents

A

amiloride, triamterene

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17
Q

diuretic clinical pearls

A

-don’t dose at bedtime
-thiazides are first line for most HTN
-spironolactone is first line for resistant HTN
-don’t use potassium sparing as monotherapy
-check CrCl when choosing diuretic
-monitor potassium (and other electrolytes)

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18
Q

ACEi mechanism

A

inhibits conversion for angiotensin I to angiotensin II

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19
Q

ARB mechanism

A

block effects of angiotensin II by binding to target receptors

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20
Q

renin inhibitors mechanism

A

inhibits conversion of angiotensinogen to angiotensin I

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21
Q

ACEi agents

A

“prils”

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22
Q

ACEi adverse effects

A

-angioedema
-cough
-hyperkalemia
-acute renal failure

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23
Q

ACEi contraindications

A

-history of angioedema on an ACEi
-concomitant use of aliskiren in patients with DM
-pregnancy/breastfeeding

24
Q

ACEi clinical pearls

A

-first line HTN treatment
-PM dosing to ensure BP dipping overnight
-HTN effects via vasodilation, reduced PVR, and increased diuresis

25
ARB clinical pearls
-first line HTN treatment -back up if ace is not tolerated -can use with history of angioedema -PM dosing to help with dipping -HTN effects by vasodilation, reduced PVR, and increased diuresis
26
ARB drug agents
sartans
27
ARB adverse effects
hyperkalemia angioedema (less likely) acute renal failure
28
ARB contraindications
-angioedema on ARB -concomitant use of aliskiren -pregnancy/breastfeeding
29
ACEi/ARB monitoring
-baseline potassium and renal function -every 6-12 months potassium and renal function hold or reduce dose if potassium greater than 5.5 or SCr increases >30%
30
direct renin inhibitors agents
aliskiren
31
renin inhibitor clinical pearls
-not first line -very expensive -avoid in pregnancy
32
renin inhibitor monitoring
-potassium -BUN -SCr
33
renin inhibitor adverse effects
diarrhea musculoskeletal effects dizziness headache hyperkalemia renal insufficiency orthostatic hypertension
34
calcium channel blocker agents
DHPs: "pines" non DHP: verapamil and diltiazem
35
DHP CCB pearls
-may benefit reynaud's syndrome and elderly patients w/ isolate systolic HTN -more potent vasodilators than non DHP -avoid short acting DHPs
36
DHP CCB adverse effects
reflex tachycardia flushing dizziness headache peripheral edema (high doses)
37
DHP CCB warnings and DDIs
-increased risk of angina/MI in patients with coronary disease (IR CCBs only) -grapefruit juice and CYP3A4
38
non DHP CCB clinical pearls
-additional benefit in Afib and patients with angina who cannot tolerate BB -slows AV node (negative ionotropic effects) -extended release preferred for HTN
39
non DHP CCB adverse effects
bradycardia, headache, dizziness, AV node block, constipation (verapamil)
40
non DHP CCB DDIs and contraindications
DDIs: use of BB, grapefruit juice, CYP3A4 CI: heart block, left ventricular dysfunction
41
CCB overall clinical pearls
no monitoring necessary first line for HTN peripheral edema is dose dependent extended release formulations are preferred if CCB needed for HF choose amlodipine
42
beta blocker clinical pearls
not first line HTN additional benefit for tachyarrhythmias, tremors, migraines, thyrotoxicosis decreases HR + force of contraction -> decrease in CO avoid abrupt cessation
43
cardioselective beta blockers
atenolol, betaxolol, bisoprolol metoprolol, nebivolol
44
nonselective beta blockers
nadolol propranolol *avoid in bronchospastic airway diseases*
45
intrinsic sympathomimetic activity beta blockers
acebutolol penbutolol pindolol *avoid in HF*
46
mixed alpha/beta beta blockers
carvedilol labetalol *more BP lowering*
47
beta blocker contraindications
second or third degree heart block decompensated HF Post MI severe bradycardia sick sinus syndrome reactive airway diseases
47
direct arterial vasodilator agents
hydralazine, minoxidil
47
beta blocker adverse effects
bronchospasm, bradycardia, fatigue, exercise intolerance, depression **CAN MASK SIGNS OF HYPOGLYCEMIA**
48
direct arterial vasodilator clinical pearls
last line reserved for special indications or uncontrolled BP concomitant therapy w/ diuretic and BB needed *caution with renal impairment*
48
alpha-1 blockers
doxazosin, prazosin, terazosin always second line with concomitant BPH associated with orthostatic hypotension
48
direct arterial vasodilator adverse effects
palpitations tachycardia GI side effects headache lupus like syndrome (hydralazine) hair growth (minoxidil)
49
minoxidil black box warning
may cause pericarditis exacerbation of angina should be given with diuretic and BB
50
central alpha-2 agonists
clonidine, methyldopa, guanfacine last line due to AEs (CNS depression) avoid abrupt cessation methyldopa is preferred in pregnancy
51
what are the steps of resistant HTN therapy
1. maximize life style and optimize 3 drug regimen 2. substitute optimized thiazide like diuretic 3. add spironolactone 4. add BB if HR > 70 bpm (may consider clonidine patch if BB contraindicated or HR < 70 bpm 5. add hydralazine 6. substitute minoxidil for hydralazine

therapeutics 2 (24 decks)

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