Hypertension Therapy Flashcards
what is the step line therapy for HTN in stable ischemic heart disease
-first line: beta blockers
may also use ACEi, ARB
-CCBs can be used if BP still uncontrolled
what is the step line therapy for HTN in heart failure
-reduced ejection fractions: follow most recent HF guidelines. avoid non DHPs
-preserved ejection fraction: diurectics, ACEi/ARB, beta blocker
what is the step line therapy for HTN in CKD
-CKD stage 1 or 2 and albuminuria: ACEi or ARB
-CKD stage 3 or higher: ACEi or ARB
what is the step line therapy for HTN in cerebrovascular disease
ACEi/ARB, thiazide diuretic, or combo
what is the step line therapy for HTN in diabetes
all first line classes are good options
if albuminuria use ACEi or ARB
what is the step line therapy in HTN for pregnancy
methyldopa, nifedipine, labetalol
contraindications: ACEi, ARB, direct renin inhibitors
what HTN therapy works best in black patients
Thiazide or CCB unless HF or CKD
thiazide diuretic drug choices
HCTZ, chlorthalidone, indapamide, metolazone
thiazide adverse effects
-hypokalemia
-hyperuricemia
-sexual dysfunction
-increase in lipids
thiazide DDIs
lithium toxicity w/ concurrent use
thiazide contraindications
sulfa allergy
anuria
aldosterone antagonists drug choices
spironolactone, eplerenone
aldosterone adverse effects
-hyperkalemia
-hyponatremia
-gynecomastia
aldosterone DDIs
ACEi/ARB/renin inhibitors/NSAIDs
increase risk of hyperkalemia
aldosterone contraindications
concomitant use of potassium sparing diuretics
Potassium sparing diuretics agents
amiloride, triamterene
diuretic clinical pearls
-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)
ACEi mechanism
inhibits conversion for angiotensin I to angiotensin II
ARB mechanism
block effects of angiotensin II by binding to target receptors
renin inhibitors mechanism
inhibits conversion of angiotensinogen to angiotensin I
ACEi agents
“prils”
ACEi adverse effects
-angioedema
-cough
-hyperkalemia
-acute renal failure
ACEi contraindications
-history of angioedema on an ACEi
-concomitant use of aliskiren in patients with DM
-pregnancy/breastfeeding
ACEi clinical pearls
-first line HTN treatment
-PM dosing to ensure BP dipping overnight
-HTN effects via vasodilation, reduced PVR, and increased diuresis
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
ARB drug agents
sartans
ARB adverse effects
hyperkalemia
angioedema (less likely)
acute renal failure
ARB contraindications
-angioedema on ARB
-concomitant use of aliskiren
-pregnancy/breastfeeding
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%
direct renin inhibitors agents
aliskiren
renin inhibitor clinical pearls
-not first line
-very expensive
-avoid in pregnancy
renin inhibitor monitoring
-potassium
-BUN
-SCr
renin inhibitor adverse effects
diarrhea
musculoskeletal effects
dizziness
headache
hyperkalemia
renal insufficiency
orthostatic hypertension
calcium channel blocker agents
DHPs: “pines”
non DHP: verapamil and diltiazem
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
DHP CCB adverse effects
reflex tachycardia
flushing
dizziness
headache
peripheral edema (high doses)
DHP CCB warnings and DDIs
-increased risk of angina/MI in patients with coronary disease (IR CCBs only)
-grapefruit juice and CYP3A4
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
non DHP CCB adverse effects
bradycardia, headache, dizziness, AV node block, constipation (verapamil)
non DHP CCB DDIs and contraindications
DDIs: use of BB, grapefruit juice, CYP3A4
CI: heart block, left ventricular dysfunction
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
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
cardioselective beta blockers
atenolol, betaxolol, bisoprolol
metoprolol, nebivolol
nonselective beta blockers
nadolol
propranolol
avoid in bronchospastic airway diseases
intrinsic sympathomimetic activity beta blockers
acebutolol
penbutolol
pindolol
avoid in HF
mixed alpha/beta beta blockers
carvedilol
labetalol
more BP lowering
beta blocker contraindications
second or third degree heart block
decompensated HF
Post MI
severe bradycardia
sick sinus syndrome
reactive airway diseases
direct arterial vasodilator agents
hydralazine, minoxidil
beta blocker adverse effects
bronchospasm, bradycardia, fatigue, exercise intolerance, depression
CAN MASK SIGNS OF HYPOGLYCEMIA
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
alpha-1 blockers
doxazosin, prazosin, terazosin
always second line with concomitant BPH
associated with orthostatic hypotension
direct arterial vasodilator adverse effects
palpitations
tachycardia
GI side effects
headache
lupus like syndrome (hydralazine)
hair growth (minoxidil)
minoxidil black box warning
may cause pericarditis
exacerbation of angina
should be given with diuretic and BB
central alpha-2 agonists
clonidine, methyldopa, guanfacine
last line due to AEs (CNS depression)
avoid abrupt cessation
methyldopa is preferred in pregnancy
what are the steps of resistant HTN therapy
- maximize life style and optimize 3 drug regimen
- substitute optimized thiazide like diuretic
- add spironolactone
- add BB if HR > 70 bpm (may consider clonidine patch if BB contraindicated or HR < 70 bpm
- add hydralazine
- substitute minoxidil for hydralazine
