hypertension treatment Flashcards
1
Q
What is essential hypertension
A
elevated arterial blood pressure with an unknown etiology
2
Q
what is secondary hypertension
A
elevated arterial blood pressure due to concurrent medical conditions or medications
3
Q
isolated systolic hypertension definition
A
systolic BP values are elevated and diastolic BP values are not.
4
Q
resistant HTN definition
A
fail to attain goal BP while adherent to a regimen including at least 3 agents at max dose (including a diuretic) or when 4 or more agents are needed.
5
Q
orthostatic hypotension definition
A
systolic blood pressure decrease of more than 20 mmHg or a diastolic blood pressure decrease of more than 10mmHg within 3 minutes of positional change and/or increase in heart rate >20bpm
6
Q
what is secondary htn caused by?
A
CKD, renovascular disease, primary aldosteronism, obstructive sleep apnea, drugs, sodium/ethanol, cushing’s syndrome, thyroid diseases
7
Q
which substances increase BP?
A
illicit drugs, caffeine, nicotine, decongestants, amphetamines, antidepressants, clozapine/olanzapine, cyclosporine, oral contraceptives, NSAIDS, steroids, oncology agents
8
Q
normotensive definition
A
no HTN in office, no HTN at home
9
Q
sustained hypertension
A
HTN in office, HTN at home
10
Q
masked hypertension
A
no HTN in office, HTN at home
11
Q
white coat hypertension
A
HTN in office, no HTN at home
12
Q
what and how often should you follow up when patient has normal blood pressure?
A
- promote healthy lifestyle; f/u 1 year
13
Q
what and how often should you follow up when your patient has elevated BP?
A
- initiate non-pharm treatment; f/u in 3-6 months
14
Q
what and how often should you follow up when your patient has stage 1 HTN w/ no comorbidity?
A
- initiate non-pharm treatment; f/u in 3-6 months
15
Q
what and how often should you follow up when your patient has stage 1 HTN w/ a comorbidity?
A
- initiate non-pharm treatment and a medication; f/u in one month
16
Q
what and how often should you follow up when your patient has stage 2 HTN
A
- initiate 2 medications and non-pharm; f/u in one month
17
Q
how often should htn patients at goal have a follow up?
A
every 3-6 months
18
Q
what ASCVD risk and other factor determines that patient needs a medication with stage 1 htn?
A
> 10% ASCVD risk AND/or other comorbidity
19
Q
ACC/AHA BP threshold for treatment initiation for risk >10% and/or clinical CVD
A
> 130/80 (stage 1)
20
Q
ACC/AHA BP threshold for treatment initiation for risk <10% and no clinical CVD
A
> 140/90 (stage II)
21
Q
what blood pressure is targeted with meds for secondary stroke prevention?
A
> 140/90 (stage II)
22
Q
ACC/AHA BP goal
A
<130/80
23
Q
ACA/AHA goal for frail/elderly patient
A
<140/90
24
Q
ADA BP goal
A
<130/80
25
KDIGO BP goal for adults with HTN and CKD
<120/80
26
what patient population was SPRINT trial conducted in?
patients without prior diabetes or stroke
27
what patient population was ACCORD trial conducted in?
type II diabetes and CVD risk
28
non-pharm treatment options
weight loss, DASH diet, decrease sodium intake, increase potassium intake, physical activity, decrease alcohol intake
29
What is first line for htn?
thiazide-like diuretics, ACEi/ARBs, and CCBs
30
takeaways of ALLHAT trial?
- thiazide diuretics should be first line, followed by calcium channel blockers, ACE inhibitors (and ARBs)
- most patients with HTN need more than one drug
31
What is first line antihypertensive agent for stable ischemic heart disease?
Beta-blockers or ACEi/ARBs
32
What are second and last line options for hypertension with stable ischemic heart disease
dihydropyridine CCBs, then thiazide diuretics, then aldosterone antagonists
33
heart failure with reduced ejection fraction guidelines for hypertension
follow heart failure guidelines; AVOID non-dihydropyridine CCBs
34
what drugs can be used for hypertension with heart failure and preserved ejection fraction, and what are their indications?
- diuretics: fluid overload
- ACEi/ARBs: elevated BP
- B-blockers: elevated HR
35
what antihypertensive agent is preferred after a kidney transplant?
CCBs
36
Which medications are preferred in CKD stage 1 or 2 WITHOUT albuminuria?
Any first line options
37
which medications are preferred in cerebrovascular disease for secondary stroke prevention?
- ACE/ARBs
- thiazide diuretics
38
When should ACE/ARBS and thiazide diuretics be initiated for secondary prevention of stroke?
On when BP>140/90
39
which antihypertensives are preferred in patients with diabetes?
any first line agent
40
When are ACE/ARBS preferred in patients with diabetes
in presence of albuminuria >300mg/day
41
Preferred agents in pregnancy
- methyldopa
- nifedipine
- labetalol
42
contraindicated agents in pregnancy
- ACE/ARBs
- direct renin inhibitors (aliskiren)
- thiazide diuretics
43
Stable ischemic heart
disease treatment
ACE-I/ARB and BB first, then CCB can be added if still not controlled
44
HFrEF treatment for HTN
ACE-I/ARB/ARNI, mineralocorticoid receptor antagonists, diuretics and BB first line
45
HFpEF treatment for HTN
Diuretics first line (if symptomatic); if persistent HTN, ACE-I/ARB or BB (if HR elevated)
46
CKD treatment
If albuminuria, ACE-I (ARB if intolerant) first line
47
Renal transplant HTN treatment
CCB (reduces graft loss and maintains higher GFR) first line over ACE-I (anemia,
hyperkalemia and lower GFR may result)
48
Secondary stroke
prevention HTN treatment
Thiazide, ACE-I or ARB or thiazide + ACE-I
*only need to start if BP >140/90
49
Diabetes HTN treatment
Any first line option but ACE-I/ARB if albuminuria
50
AF HTN Treatment
ARB may be useful for prevention of recurrence of AF
51
Aortic disease HTN treatment
BB (help improve survival)
52
Black patients with HTN treatment
Thiazide or CCB unless HF or CKD
53
pregnancy HTN treatment
Methyldopa, nifedipine or labetolol
54
what are the thiazide diuretics used for HTN
hydrochlorothiazide, chlorthalidone, indapamide, metolazone
55
what are the loop diuretics used for HTN?
furosemide, torsemide, bumetanide
56
what are the aldosterone antagonists used for HTN?
spironolactone, eplerenone
57
what are the potassium sparing diuretics used for HTN?
triamterene, amiloride
58
what is the most potent thiazide like diuretic?
chlorthalidone
59
what is the frequency for all thiazide diuretics?
1qd
60
dosing for hctz?
12.5 to 25mg daily
61
dosing for chlorthalidone?
12.5 to 25mg daily
62
what is the frequency for all loop diuretics?
1-2 times per day
63
which loop diuretic can be used with a sulfa allergy?
ethacrynic acid
64
furosemide dosing
20mg to 80mg QD to BID
65
torsemide dosing
2.5mg to 10mg QD to BID
66
bumetanide dosing
0.5mg to 2mg QD to BID
67
frequency for aldosterone antagonists
qd or bID
68
dosing for spironolactone
12.5 to 100mg qd to bid
68
amiloride dosing
5 to 10mg qd to BID
68
dosing for eplerenone
50 to 100mg qd to BID
68
frequency for potassium sparing diuretics
qd to bID
69
ACEi with frequency 1qd
fosinopril, lisinopril, perindopril, trandolapril
69
triamterene dosing
50 to 100mg qd to BID
70
ACEi with frequency of BID to TID
Captopril
71
normal frequency for ARBs
1qd
72
ARBs that can be used qd or BID
eprosartan or losartan
73
aliskiren dosing
150 to 300mg once daily
74
what is the frequency for most dihydropyridine CCBs?
1qd
75
which dihydropyridine CCBS are dosed BID
- isradipine and nicardepine SR
76
nondihydropyridine drugs
diltiazem ER and verapimil ER
77
diltiaem and verapamil frequency
1qd or BID
78
Patient populations with additional benefit from dihydropyridine CCBs
raynauds syndrome, elderly patients with isolated systolic HTN
79
Patient populations with additional benefit from nondihydropyridine CCBs
Afib
patients with angina who cannot tolerate a beta blocker
80
contraindications for nondihydropyridine CCBs
heart block, left ventricular dysfunction
81
what CCB should be chosen in patients with heart failure
amlodipine
82
what drug interaction occurs with all CCBS
CYP 3a4 inhibitors/inducers/grapefruit juice
83
indications for b blocker in HTN
heart failure and CAD
84
populations with benefit for b-blockers in HTN
tachyarrhythmia, tremor, migraine, thyrotoxicosis
85
which cardioselective beta blocker also caused nitric oxide induced vasodilation?
nebivolol
86
which forms of metoprolol are long and short acting?
succinate- long acting
tartrate- short acting
87
what kind of beta blocker is metoprolol
beta-1 selective (cardioselective)
88
how are the b-1 blockers dosed?
1qd
89
how is metoprolol tartrate dosed?
BID
90
what are the non-selective beta blockers
propanolol and nadolol
91
how are nadolol and propanolol LA dosed?
1qd
92
how is propanolol IR dosed?
BID
93
when should non-selective beta blockers be avoided?
bronchospastic airway disease
94
what beta blockers have intrinsic sympathomimetic activity?
acebutolol, penbutolol, pindolol
95
which ISA beta blockers are dosed BID
acebutolol and pindolol
96
which ISA beta blockers are dosed QD?
penbutolol
97
which b blockers have mixed alpha and beta activity?
carvedilol and labetalol
98
what are the direct arterial vasodilators?
minoxidil and hydralazine
99
what should the direct arterial vasodilators be used with?
beta blocker and diuretic
100
when would you use a direct arterial vasodilator?
last line; with resistant HTN or sevre CKD/hemodialysis
101
what is the frequency for hydralazine?
bid to qid
102
what is the frequency for minoxidil?
1qd to tid
103
side effects of both direct arterial vasodilators
palpitations, tachycardia, chest pain, GI effects, headache, hematologic dyscrasia, hepatotoxicity, and fluid retention
104
side effect specific to hydralazine
lupus-like syndrome and rash
105
side effect specific to minoxidil
hair growth on face, arms, back, and chest
106
what is the minoxidil boxed warning for?
- may cause pericarditis and pericardial effusion, may increase oxygen demand and exacerbate angina
107
what are the alpha-1 blockers
terazosin, doxazosin, prazosin
108
when are the alpha-1 blockers used
in patients with BPH
109
what is an AE of alpha-1 blockers
orthostatic hypotension
110
what are the central alpha-2 agonists
clonidine, methyldopa, and guanfacine
111
what is the dosing frequency for clonidine
BID to TID max 2.4mg/day
112
what is the dosing frequency for methyldopa
250-500mg BID
113
what is the dosing frequency for guanfacine
0.5-2mg once daily
114
what are the AE of alpha-2 agonists
CNS depression, dizziness, fatigue, anticholinergic effects, bradycardia, reflex tachycardia, and fluid retention
115
what are the monitoring parameters for ACE/ARBs
BUN/Scr and potassium
116
what are the monitoring parameters for CCBs
heart rate (non-dihydropyridine only)
117
what are the monitoring parameters for aldosterone antagonists
BUN/Scr, potassium
118
what are the monitoring parameters for other diuretics
BUN/SCr, electrolytes (K,Mg, Na), and uric acid (thiazides only)
119
what are the monitoring parameters for beta blockers?
heart rate
120
risk factors for resistant HTN
older age, obesity, CKD, diabetes, and african american
121
what must you rule out to diagnose resistant HTN?
secondary causes, nonadherence, and white coat HTN
122
what agent/class was determined to be the most effective add-on to the maximized 3-drug regimen in adults with resistant hypertension
spironolactone
123
what clinical trial determined spironolactone the best add-on to resistant HTN
PATHWAY-2
124
hypertensive urgency
BP >180/120 with no evidence of end organ damage
125
hypertensive emergency
BP> 180/120 with evidence of organ damage
126
what are symptoms of hypertensive emergency
headache, chest pain, SOB, back pain, numbness/weakness, change in vision, difficulty speaking
127
causes of hypertensive crisis
- chronic hypertension
- medication non-adherence
- medication/substance use
- pregnancy
- renal disease
- endocrine disorders
128
what are the steps for hypertensive emergency treatment?
hour 1: reduce BP by no more than 25%
hours 2-6: reduce BP <160/100-110
hours 6-48: reduce BP to goal
129
pharmacotherapy treatment general statements
IV therapy preferred
therapy with fast onset/offset and titratable preferred
130
what are the DHP calcium channel blockers used for hypertensive emergency?
nicardepine, clevidipine
131
nicardepine info
- titratable IV infusion
- short onset and duration
pro: low risk for AE
cons: contraindicated in severe aortic stenosis, reflex tachycardia
132
clevidipine info
- titratable IV infusion
- short onset and duration
- pro: lack of accumulation in organ impairment
- cons: contraindicated in severer aortic stenosis, contraindicated with soy/egg allergy, elevates triglycerides, need to change IV lines every 12 hours, overall more SE, may induce Afib
133
what are the vasodilators used for hypertensive crisis
nitroglycerin, nitroprusside, and hydralazine
134
nitroglycerin info
- titratable IV infusion
- short onset and duration of action
- pro: beneficial in coronary ischemia
- Cons: tolerance with prolonged use, interact with PDE-5 inhibitors, dose-limited headache and reflex tachycardia.
- Use caution with high ICP, excessive hypotension in hypovolemia
135
sodium nitroprusside info
- titratable iv infusion
- very short onset and duration
- cons: tolerance with prolonged use, interact with PDE-5 inhibitors, dose-limiting headache and reflex tachycardia, caution with high ICP, may cause excessive hypotension.
- cyanide toxicity; do not use with renal/hepatic dysfunction
136
hydralazine info
- IV push
- pros: may be used in patients with bradycardia
- cons: not titratable, less predictable PK, and rebound tachycardia.
137
beta blockers used in hypertensive crisis
labetalol and esmolol
138
labetalol info
- IV push and titratable IV infusion
- short onset and long duration
- pros :decreases HR and BP
- cons: decreases HR, contraindicated with severe bradycardia, HF, and reactive airway disease
139
esmolol info
- titratable IV infusion
- very short duration and onset
- pro: decreases HR, cardioselective (can be used in patients with reactive airway disease)
- cons: NOT MONOTHERAPY, avoid in bradycardia and ADHF
140
ace inhibitors used for hypertensive crisis
enalaprilat
141
enalaprilat info
- IV push
- short onset, long duration
- may be beneficial in emergencies related to renin excess
- cons: delayed onset and peak
- contraindications: pregnancy, AKI, hyperkalemia, acute MI, bilateral renal artery stenosis
142
alpha2 agonist used in hypertensive crisis
- clonidine
143
clonidine info
- oral medication (hypertensive urgency not emergency)
- delayed onset and peak
- pros: can be used when no IV access
- cons: often used inappropriately in emergency settings, can cause hypertensive crisis on withdrawal
144
what are the conditions with specific blood pressure goals
stroke, aortic dissection, severe eclampsia/preeclampsia, and pheochromocytoma crisis
145
what medications are used in crisis for acute decompensated HF with pulmonary edema?
1st line: sodium nitroprusside, nitroglycerin
2nd line: nicardipine, clevidipine
AVOID: beta blockers and non DHP CCBs
146
what medications are used in HTN crisis for aortic dissection
1st line: beta blocker (labetalol, esmolol), then vasodilator (CCB or other vasodilator) (sodium nitroprusside, nicardipine, clevidipine
147
what medications are used in crisis for acute coronary syndrome
1st line: beta blockers (esmolol, labetalol), vasodilators (nitroglycerin, nitroprusside, and nicardipine)
caution with: non DHP CCBs
avoid: beta blockers
148
what medications are used in crisis for AKI
Most IV antihypertensives
caution: sodium nitroprusside
avoid: enalaprilat
149
what medications are used in crisis for eclampsia/ severe preeclampsia?
1st line: hydralazine, labetalol, or nicardipine
AVOID: enalaprilat, nitroprusside
150
what medications are used in crisis for stroke
- 1st line: nicardipine, clevidipine, labetalol
- avoid: nitrates
151
definition of pulmonary hypertension
mean pulmonary arterial pressure > 20 mmHg at rest
- common
152
definition of pulmonary arterial hypertension
progressive disease involving endothelial dysfunction = elevated pulmonary arterial pressure and pulmonary vascular resistance
- rare
153
what are the causes for pulmonary arterial hypertension?
- unknown
- genetic
- drug and toxin exposure
- CHD, HIV, connective tissue disorders
154
treatment for PAH
PAH specific medications, CCB, and lung transplantation
155
difference between PH, and PAH
PAH has a pulmonary artery wedge pressure of <15mmHg and pulmonary vascular resistance of >2 wood units
156
signs and symptoms of PAH
fatigue, fainting or lightheadedness, chest pain, SOB, palpitations, edema
157
What tests should be done to diagnose PAH
echocardiogram (evaluates potential causes, right ventricular function, estimates pulmonary arterial pressure, and pulmonary vascular resistance), right heart catheterization (confirms diagnosis and estimates severity), exercise testing (distance walked in 6 minutes), biomarkers (BNP and NTproBNP)
158
disease progression and vascular injury (what are the signs of endothelial dysfunction)
decreased nitric oxide synthase
decreased prostacyclin production
increased thromboxane production
increased endothelin 1 production
159
What are the WHO functional classes?
Class 1: symptom free when physically active or resting
Class 2: slight limitation of physical activity; comfortable at rest
Class 3: marked limitation in physical activity; less than ordinary activity causes symptoms; comfortable at rest
Class 4: significant symptoms with activity; symptoms at rest
160
what is the 1st step for pharmacotherapy after/during diagnosis for PAH
Acute vasoreactivity testing; positive response? Initiate CCB
161
which agents are used for an acute vasoreactivity test?
inhaled nitric oxide (direct pulmonary vasodilator) and IV epoprostenol (prostacyclin)
162
what indicates a positive vasoreactivity test?
drop in mPAP >10mmHg with PAP <40mmHg and improved cardiac output
163
What are the drug classes mainly used for PAH?
1st line: CCB (if determined by vasoreactivity test)
direct pulmonary vasodilator (used in vasoreactivity test)
PDE-5 inhibitors: sildenafil, tadalafil
Endothelin Receptor antagonists (ERAs): bosentan, ambrisentan, macitentan
Prostacyclins: epoprostenol, iloprost, treprostinil, selexipag
Soluble guanylyl cyclase stimulator: riociguat
164
which calcium channel blockers are used in PAH? and are they DHP or no?
diltiazem - non DHP
amlodipine - DHP
nifedipine - DHP
- no verapamil used due to negative ionotropic effects
165
what to do after adding CCB to WHO FC I or II?
Check for improvement; if none, start additional or alternative PAH therapy
166
What if the functional class II treatment?
Combo therapy with ambrisentan (ERA) and tadalafil (PDE-5) or monotherapy with ERA, riociguat, or PDE-5
167
What is the functional class 3 treatment without rapid progression?
Combo therapy or monotherapy (same as above)
168
which drug classes work in the nitric oxide pathways?
- PDE-5 inhibitors
- soluble guanylate cyclase inhibitor
169
Which drugs work in the endothelin pathway?
ERAs
170
Which drugs work in the prostacyclin pathway
prostacyclins: epoprostenol, iloprost, and treprostinil
IP prostacyclin receptor antagonist: selexipag
171
PDE-5i MOA
decrease conversion of cGMP to GMP
increased cGMP = pulmonary vasodilation
172
PDE-5 indications in PAH
- monotherapy or combo
- first line in FC II and III
173
PDE-5 metabolism
CYP 3a4 substrates
174
Warnings and AEs for PDE-5 i
- avoid with nitrates (hypotension)
- no black box warnings
- ADRs: hearing loss, sudden vision loss, hypotension
175
Frequency for PDE-5i
sildenafil - TID
tadalafil - daily
176
ERA MOA
endothelin receptor antagonist - blocking endothelin = vasodilation
177
when are ERAs indicated in PAH?
used in FC 2-4
can be used in combo with tadalafil
ex) tadalafil & ambrisentan (first line class 2 and 3)
178
ETA and ETb receptor location and function
ETA receptors- located on pulmonary smooth muscle walls; promote vasoconstriction, proliferation, and inflammation
ETb receptors- located on endothelium; promote vasodilation; stimulate NO and prostacyclin
ETb receptors- located on muscle cells; cause vasoconstriction and cell proliferation
179
bosentan dosing, specific SE, metabolism, and selectivity
- dosed BID
- cause abnormal LFTs (liver injury)
- CYP 2C9 and 3A4 substrate (biliary excretion)
- Mixed ETa and ETb selectivity
180
ambrisentan dosing, specific SE, metabolism, and selectivity
- dosed daily (oral)
- causes edema, may cause liver injury
- CYP 3A4 substrate; biliary>urinary excretion
- ETa selective
181
macitentan dosing, specific SE, metabolism, and selectivity
- dosed daily
- may cause kidney injury
- cyp 3A4 substrate, urinary>>biliary excretion
- mixed ETa and ETb selectivity
182
AE of all ERAs
- all cause some peripheral edema (mostly ambrisentan)
- all cause LFT abnormalities (mostly bosentan (hepatotoxicity))
- all cause anemia and decrease hemoglobin
- all cause embryo/fetal toxicity (REMS program)
- do not initiate if LFT >3x ULN
183
monitoring for ERAs
pregnancy tests monthly, LFTs (not for ambrisentan), and hemoglobin
184
what is the soluble guanylate cyclase inhibitor
riociguat (Adempas)
185
What drug can riociguat NOT be used with
PDE-5 inhibitors
186
what was the result of the AMBITION trial
combo therapy (tadalafil and ambrisentan) better than monotherapy (tadalafil or ambrisentan)
- combo therapy also causes more AE than monotherapy
187
TRITON trial results
triple therapy (macitentan, tadalafil, and selexipag) no better than combo therapy (tadalafil and macitentan) unless disease was rapidly progressing
188
Functional class III treatment with rapid progression
parenteral prostanoids (subq or IV treprostinil or IV epoprostanol)
or no parenteral prostenoids (inhaled/oral prostenoid + ERA or PDE-5i)
189
Functional class IV treatment
parenteral prostenoids (SC treprostanil or IV treprostenil or IV epoprostenol)
no parenteral prostenoids (inhaled/oral prostenoid + ERA or PDE-5i)
190
prostacyclins MOA
- stimulate cAMP pathway; increase pulmonary vasodilation
191
prostacyclins indication PAH
- reserved for class III and IV patients
- parenteral first line
- may be used in combination with ERA, PDE-5i, or riociguat
192
prostacyclins AE
hypotension, thrombocytopenia
193
what are the oral prostacyclins
treprostinil and selexipag
194
what are the inhaled prostacyclins
iloprost and treprostinil
195
what is the subQ prostacyclin
treprostinil
196
what are the IV prostacyclins
treprostinil and epoprostenol (must be given continuous IV)
