hypertensive meds Flashcards
PMH: your patient has stage 2 hypertension and is at risk for type 2 diabetes. At the follow up appointment you note that He/she has lost a small amount of weight, has an improved diet, and has begun to exercise on a regular basis. You noted a small decrease in blood pressure. After confirming your diagnosis you initiated treatment with an ACE Inhibitor. On the next follow up appointment you note that blood pressure was reduced by about 10 mmHg after 2 months of treatment. Based on your interview and the patients response you are confident that patient adherence is to diet, exercise and medication is high. Your patient is unaware of any side effects from the ACE inhibitor. However blood pressure remains elevated. You decide it is time to change therapy for hypertension. Your next step should be to:
A. Continue diet, exercise and ACE inhibitor therapy. Add a medication having a different mechanism of action and different side effects such as a thiazide diuretic.
B. Keep raising the dose of ACE inhibitor until the patients reaches blood pressure goal.
C. Stop the ACE inhibitor and initiate treatment with a calcium channel antagonist.
D. Stop the ACE inhibitor and initiate treatment with the newest medication available.
A. Continue diet, exercise and ACE inhibitor therapy. Add a medication having a different mechanism of action and different side effects such as a thiazide diuretic.
Name the mechanism of action of these drugs
thiazide type diuretics
beta andrenergic antagonists
angiotensin converting enzyme inhibitors
calcium channel blockers
thiazide type diuretics: acts on the distal tubule to reduce sodium reabsorption
beta adrenergic antagonists: reduces the activity of the sympathetic nervous system
angiotensin converting enzyme inhibitors: reduces the activity of the renin system
calcium channel antagonists: relaxes vascular smooth muscle and reduces total peripheral resistance
what are the clinical benefits of these medications
thiazide type diuretics
beta andrenergic antagonists
angiotensin converting enzyme inhibitors
calcium channel blockers
thiazide type diuretics: demonstrate improvements in mortality in most patients. Also useful to reduce fluid retention caused by vasodilators
beta andrenergic antagonists: particularly useful in patients with chronic kidney disease, diabetes, HF, post MI
angiotensin converting enzyme inhibitors: reduce mortality post MI and in HF. Prevent reflex tachycardia assosciated with use of vasodilators
calcium channel blockers: use of short acting agents in this class are associated increase risk of MI and increased mortality
Which classes ofantihypertensive medications are most effective in low renin or volume-expanded forms of hypertension?
A. aldosterone anatagonists
B. ACE inhibitors
C. Thiazide Diuretics
D. Aldosterone antagonists and Thiazide Diuretics
D. Aldosterone antagonists and Thiazide Diuretics
A 73 year old man having a prior medical history of COPD, CKD, and gout is admitted for a MI. Prior to discharge, you plan to start a beta blocker. Which of the following beta blockers would be the best choice based on his history?
A. Atenolol
B. Esmolol
C. Nadolol
D. Propranolol
A. Atenolol
Because of the patient’s COPD, a beta-1 selective agent would be preferred over a non-selective agent. Of the agents listed, atenolol and esmolol are beta-1 selective, however, esmolol is only available in an IV formulation, therefore atenolol is the correct answer.
A 59 year old man with Chronic Kidney Disease (CKD) (baseline CrCl 30-35 mL/min) was diagnosed with HTN and started on lisinopril 5mg PO QD (taken at 0800). He does not like taking medications, but has a very high health literacy and takes this new medication very regularly. He reliably and accurately monitors his blood pressure at home since his diagnosis. After a month of therapy, he returns for a follow up visit and reports his 0700 SBP ranges 140-160 mmHg, his 1400 BP ranges 100-120s mmHg, and his 2100 SBP ranges 130-150 mmHg. Given his preferences about avoiding multiple medications and also his medical history, what medication change should be made at this time?
A. Increase lisinopril to 10mg PO QD
B. Continue lisinopril 5mg, add HCTZ 25mg PO QD
C. Continue lisinopril 5mg, add amlodipine 5mg QD
D. Was not on appropriate medication initially, switch to amlodipine 5mg PO QD
A. Increase lisinopril to 10mg PO QD
An ACEI inhibitor (or ARB) is indicated in this patient with CKD per JNC 8 guidelines. ACE inhibitors have a “flat dose response,” and the patient is achieving mid-day blood pressures at goal but there are BP elevations in the PM. Therefore, the dose should be increased to sustain response for 24 hours. Polypharmacy should be minimized when possible (especially in a patient with a stated preference), and thiazides might be less effective in a patient with a reduced CrCl.
