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Therapeutics II > Kelly Olynyk Hypertension > Flashcards

Kelly Olynyk Hypertension Flashcards

1
Q

ALLHAT key takeaways

A

-Thiazide diuretics should be first-line
-For patients who cannot take a diuretic, consider prescribing a calcium channel blocker or ACE inhibitor
-Most patients with high blood pressure need more than one drug

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2
Q

ACC/AHA recommendation for choice of initial medication for treatment of HTN

A

For initiation of antihypertensive drug therapy, first-line agents include thiazide diuretics, CCBs, and ACE inhibitors or ARBs

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3
Q

What are the options for combination therapy for HTN

A

-ACEi/CCB
-ARB/CCB
-ACEi/diuretic
-ARB/diuretic
-CCB/diuretic

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4
Q

First-line treatment for stable ischemic heart disease

A

-Beta blockers (reduce CV events and anginal symptoms)
-ACEi/ARBs (reduce MI, stroke, and CVD)
-Dihydropyridine CCBs can be used if still uncontrolled

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5
Q

How to treat heart failure with reduced ejection fraction

A

Avoid non-dihydropyridine CCBs due to no clinical benefit/worse outcomes in patients with HF

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6
Q

How to treat heart failure with preserved ejection fraction

A

-Diuretics: fluid overloaded
-ACEi/ARB: elevated BP
-Beta blockers: elevated heart rate

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7
Q

Which HTN treatment is preferred in patients with CKD stage 1 or 2 AND albuminuria?

A

ACEi (or ARBs) (ACE is better)

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8
Q

Which HTN treatment is preferred in patients with CKD stage 3 or higher?

A

ACEi (or ARBs)

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9
Q

What HTN treatment is preferred in patients post-kidney transplantation?

A

Dihydropyridine CCBs are preferred due to improved GFR and kidney survival

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10
Q

Which medications are used for secondary stroke prevention?

A

-ACEi/ARBs
-Thiazide diuretics
-Combination of above
-Only initiate treatment if BP is over 140/90

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11
Q

What medications should be used for patients with diabetes and albuminuria?

A

ACEi or ARBs

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12
Q

What HTN medications are preferred for pregnant patients?

A

-Methyldopa
-Nifedipine
-Labetalol

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13
Q

What HTN medications are contraindicated for pregnant patients?

A

-ACEi
-ARBs
-Direct renin inhibitors

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14
Q

What HTN medications should be used in black adults without HF or CKD?

A

Thiazide diuretic or CCB

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15
Q

Initial effects of anti-hypertensives

A

Diuresis -> reduced stroke volume -> increase in PVR

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16
Q

Chronic anti-hypertensive effects

A

Stroke volume returns to normal -> decrease in PVR (below pretreatment levels)

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17
Q

Which thiazide diuretic is the most potent and most studied?

A

Chlorthalidone

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18
Q

When are thiazide diuretics more effective than loop diuretics?

A

When the CrCl >30 mL/min

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19
Q

When should diuretics be dosed?

A

In the morning or morning and afternoon to avoid nocturnal diuresis

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20
Q

How often are thiazide diuretics dosed?

A

Once daily in the morning

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21
Q

Adverse effects associated with thiazide diuretics

A

-Hypokalemia
-Hypomagnesemia
-Hypercalcemia
-Hyperuricemia
-Hyperglycemia
-Hyperlipidemia
-Sexual dysfunction
-Increase in triglycerides/cholesterol

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22
Q

Drugs that interact with thiazide diuretics

A

Lithium toxicity with concurrent use

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23
Q

Contraindications to thiazide diuretics

A

-Sulfa allergy
-Anuria

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24
Q

When are loop diuretics preferred?

A

-Heart failure for symptom management
-More effective than thiazide diuretics with CrCl <30 mL/min

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25
Q

When should loop diuretics be dosed?

A

In the morning and the afternoon

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26
Q

How often should loop diuretics be taken?

A

Twice daily

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27
Q

Adverse effects to loop diuretics

A

-Hypokalemia
-Hypomagnesemia
-Hypocalcemia
-Hyperuricemia
-Ototoxicity

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28
Q

Contraindications to loop diuretics

A

Sulfa allergy

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29
Q

Which aldosterone antagonist is preferred with resistant HTN?

A

Spironolactone

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30
Q

When should aldosterone antagonists not be initiated?

A

With potassium >5mEq/L

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31
Q

When should aldosterone antagonists be dosed?

A

In the morning or morning and afternoon to avoid nocturnal diuresis

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32
Q

What are the aldosterone antagonists?

A

-Spironolactone
-Eplerenone

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33
Q

When should aldosterone antagonists be held or reduced?

A

If potassium >5.5 mEq/L

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34
Q

Adverse effects of aldosterone antagonists

A

-Hyperkalemia
-Hyponatremia
-Gynecomastia

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35
Q

What drugs used with aldosterone antagonists increases potassium levels?

A

-ACEi
-ARBs
-Renin inhibitors
-NSAIDs

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36
Q

What are the contraindications for eplerenone?

A

-Impaired renal function (CrCl <50 mL/min or SCr >2 for males and SCr >1.8 for females)
-T2DM and proteinuria
-Concomitant use of potassium-sparing diuretics

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37
Q

What are the contraindications for spironolactone?

A

-Concomitant use of potassium sparing diuretics

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38
Q

What are the potassium-sparing diuretics?

A

-Amiloride
-Triamterene

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39
Q

Why are potassium-sparing diuretics used in combination?

A

They are used with a thiazide to minimize hypokalemia and because potassium-sparing diuretics by themselves do not effect BP much

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40
Q

Which patient populations must potassium-sparing diuretics be used in caution with?

A

Diabetes or CKD (GFR < 45 ml/min)

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41
Q

When are potassium-sparing diuretics given?

A

In the morning or afternoon to avoid nocturnal diuresis

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42
Q

How often are potassium-sparing diuretics given?

A

1 or 2 times a day

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43
Q

Adverse effects of potassium-sparing diuretics

A

-Hyperkalemia
-Increased uric acid
-Hyperglycemia

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44
Q

Diuretics clinical pearls

A

-Do not give at bedtime
-Thiazides are first-line for most HTN patients
-Spironolactone is first-line for patients with resistant HTN
-Do not use potassium-sparing diuretics as monotherapy for HTN
-Pay attention to patient allergies
-Check CrCl when choosing the diuretic class
-Important to monitor potassium and other electrolytes

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45
Q

What is the mechanism of action of angiotensin-converting enzyme inhibitors?

A

Inhibits the conversion for angiotensin 1 to angiotensin 2

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46
Q

What is the mechanism of action of angiotensin 2 receptor blockers?

A

Block effects of angiotensin 2 by binding to target receptors

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47
Q

What is the mechanism of action of renin inhibitors?

A

Inhibits conversion of angiotensinogen to angiotensin 1

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48
Q

What are the first line treatment options for HTN?

A

-ACEi
-ARBs
-Thiazide diuretics
-Calcium Channel blockers

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49
Q

What other conditions do ACEIs provide additional benefit to?

A

-Diabetes with proteinuria
-Heart failure
-Post MI
-Chronic kidney disease

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50
Q

When should ACEis and ARBs be taken?

A

At night to ensure “BP dipping” overnight

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51
Q

What are examples of ACEis?

A

-Benazepril
-Captopril
-Enalapril
-Fosinopril
-Lisinopril
-Moexipril
-Perindopril
-Quinapril
-Ramipril
-Trandolapril

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52
Q

ACEi adverse effects

A

-Angioedema
-Cough (up to 20%)
-Hyperkalemia
-Acute renal failure with severe bilateral renal artery stenosis

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53
Q

ACEi contraindications

A

-History of angioedema on an ACEi
-Concomitant use of aliskiren in patients with DM
-Pregnancy/breastfeeding

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54
Q

Why are ARBs used as back-up to ACEis?

A

-It does not block bradykinin breakdown so there is less of a cough
-It can be used if the patient has a history of angioedema with ACEi

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55
Q

How often should benazepril be taken?

A

once or twice daily

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56
Q

How often should captopril be taken?

A

two or three times daily

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57
Q

How often should enalapril be taken?

A

once or twice daily

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58
Q

How often should fosinopril be taken?

A

once daily

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59
Q

How often should lisinopril be taken?

A

once daily

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60
Q

How often should moexipril be taken?

A

once or twice daily

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61
Q

How often should perindopril be taken?

A

once daily

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62
Q

How often should quinapril be taken?

A

once or twice daily

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63
Q

How often should ramipril be taken?

A

once or twice daily

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64
Q

How often should trandolapril be taken?

A

once daily

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65
Q

What are the ARBs?

A

-Azilsartan
-Candesartan
-Eprosartan
-Irbesartan
-Losartan
-Olmesartan
-Telmisartan
-Valsartan

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66
Q

How often should candesartan be taken?

A

once daily

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66
Q

How often should azilsartan be taken?

A

once daily

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67
Q

How often should eprosartan be taken?

A

once or twice daily

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68
Q

How often should irbesartan be taken?

A

once daily

69
Q

How often should losartan be taken?

A

once or twice daily

70
Q

How often should olmesartan be taken?

A

once daily

71
Q

How often should telmisartan be taken?

A

once daily

72
Q

How often should valsartan be taken?

A

once daily

73
Q

ARB adverse effects

A

-Angioedema
-Hyperkalemia
-Acute renal failure with severe bilateral renal artery stenosis

74
Q

ARB contraindications

A

-History of angioedema
-Concomitant use of aliskiren in patients with diabetes
-Pregnancy/breastfeeding

75
Q

When should ACEi/ARBs be held?

A

If potassium is greater than 5.5 mEq/L or if SCr increases by 30%

76
Q

What are the direct renin inhibitors?

A

Aliskiren

77
Q

Why is aliskiren not first line for HTN?

A

It is very expensive and typically is not better than ACEi/ARBs

78
Q

What is aliskiren contraindicated in?

A

-Pregnancy
-Concomitant use with an ACEi or ARB in patients with diabetes

79
Q

Adverse effects of direct renin inhibitors

A

-Diarrhea
-Musculoskeletal effects
-Dizziness
-Headache
-Hyperkalemia
-Renal insufficiency/ARF
-Orthostatic hypotension

80
Q

How often should aliskiren be taken?

A

once daily

81
Q

Angiotensin inhibitors clinical pearls

A

-Discuss contraceptive methods with women of childbearing age
-Do not combine drug classes due to risk of adverse effects
-Assess patients risk of hyperkalemia (CKD, other medications, etc)
-Educate patient on dietary sources of potassium
-ACEi/ARBs often preferred over other first-line agents in the presence of other compelling indications

82
Q

What is the mechanism of action of calcium channel blockers?

A

Inhibits the influx of calcium across cardiac and smooth muscle cell membranes leading to coronary and peripheral vasodilation

83
Q

Subclasses of calcium channel blockers

A

-Dihydropyridines - more vasodilation
-Nondihydropyridines - more negative inotropic effects
-Overall similar effect on BP

84
Q

Patient populations that benefit from the use of dihydropyridines

A

-Reynauds syndrome
-Elderly patients with isolated systolic HTN

85
Q

Which dihydropyridines should be avoided?

A

Short-acting (IR nifedipine/nicardipine)

86
Q

What are the dihydropyridines?

A

-Amlodipine
-Felodipine
-Isradipine
-Isradipine SR
-Nicardipine SR
-Nifedipine LA
-Nisoldipine

87
Q

How often should amlodipine be taken?

A

once daily

88
Q

How often should felodipine be taken?

A

once daily

89
Q

How often should isradipine be taken?

A

twice daily

90
Q

How often should isradipine SR be taken?

A

Once daily

91
Q

How often should nicardipine SR be taken?

A

twice daily

92
Q

How often should nifedipine LA be taken?

A

once daily

93
Q

How often should nisoldipine be taken?

A

once daily

94
Q

Adverse effects of dihydropyridines

A

-Reflex tachycardia
-Flushing
-Dizziness
-Headache
-Peripheral edema
-Gingival hyperplasia

95
Q

Warnings for dihydropyridines

A

Increased risk of angina/MI in patients with obstructive coronary disease due to reflex tachycardia

96
Q

What do dihydropyridines interact with?

A

-Grapefruit juice
-CYP3A4 enzyme inducers/inhibitors

97
Q

Which patient populations see additional benefits from nondihydropyridines?

A

-Supraventricular tachyarrhythmias
-Patients with angina who can not tolerate a beta blocker

98
Q

What is the mechanism of action of nondihydropyridines?

A

Slows AV node conduction and decreases heart rate leading to negative ionotropic effects

99
Q

Which nondihydropyridines are preferred?

A

Extended-release formulations

100
Q

What are the nondihydropyridines?

A

-Diltiazem ER
-Verapamil ER

101
Q

How often should the nondihydropyridines be taken?

A

once or twice daily

102
Q

Adverse effects of nondihydropyridines

A

-Bradycardia
-Headache
-Dizziness
-AV node block
-Systolic heart failure
-Gingival hyperplasia
-Constipation

103
Q

Interactions with nondihydropyridines

A

-Concomitant use of beta blockers (increases risk of heart block)
-Grapefruit juice
-CYP3A4 enzyme inducers/inhibitors (3A4 substrates)

104
Q

Contraindications of nondihydropyridines

A

-Heart block
-Left ventricular dysfunction

105
Q

CCB clinical pearls

A

-No routine laboratory monitoring required
-Check for drug interactions
-CCBs are first line for HTN
-Peripheral edema is dose-dependent
-Extended release formulations are preferred
-Nondihydropyridine CCB formulations are not interchangeable
-If a CCB is needed in the setting of heart failure choose amlodipine

106
Q

When are beta blockers a first line treatment for HTN?

A

When there is a compelling indication present such as heart failure and CAD

107
Q

Which patient populations have additional benefits when using beta blockers?

A

-Tachyarrhythmias
-Tremors
-Migraines
-Thyrotoxicosis

108
Q

Mechanism of action of beta blockers

A

Decreases heart rate and force of contraction leading to a decrease in cardiac output

109
Q

What are some warnings associated with beta blockers?

A

-Avoid abrupt discontinuation
-Can mask signs/symptoms of hypoglycemia

110
Q

What are the cardioselective beta blockers?

A

-Atenolol
-Betaxolol
-Bisoprolol
-Metoprolol tartrate
-Metoprolol succinate
-Nebivolol

111
Q

How often should atenolol be taken?

A

once daily

112
Q

How often should betaxolol be taken?

A

once daily

113
Q

How often should bisoprolol be taken?

A

once daily

114
Q

How often should metoprolol tartrate be taken?

A

twice daily

115
Q

How often should metoprolol succinate be taken?

A

once daily

116
Q

How often should nebivolol be taken?

A

once daily

117
Q

What are the nonselective beta blockers?

A

-Nadolol
-Propranolol IR
-Propranolol LA

118
Q

How often should nadolol be taken?

A

once daily

119
Q

How often should propranolol IR be taken?

A

twice daily

120
Q

How often should propranolol LA be taken?

A

once daily

121
Q

What are the beta blockers with intrinsic sympathomimetic activity?

A

-Acebutolol
-Penbutolol
-Pindolol

122
Q

How often should acebutolol be taken?

A

twice daily

123
Q

How often should penbutolol be taken?

A

once daily

124
Q

How often should pindolol be taken?

A

twice daily

125
Q

Which cardioselective beta blocker induces vasodilation using nitric oxide?

A

Nebivolol

126
Q

When should nonselective beta blockers be avoided?

A

In bronchospastic airway disease

127
Q

When should beta blockers with intrinsic sympathomimetic activity be avoided?

A

In heart failure and IHD

128
Q

What are the mixed alpha/beta blockers?

A

-Carvedilol
-Labetalol

129
Q

How often should carvedilol be taken?

A

twice daily

130
Q

How often should labetalol be taken?

A

twice daily

131
Q

Adverse effects of beta blockers

A

-Bronchospasm
-Bradycardia
-Fatigue
-Exercise intolerance
-Depression

132
Q

When should beta blockers be used with caution?

A

In patients with peripheral artery disease and reactive airway disease

133
Q

Beta blocker contraindications

A

-Second or third degree heart block
-Decompensated heart failure
-Post-MI (ISA BBs only)
-Severe bradycardia
-Sick sinus syndrome

134
Q

What are the direct arterial vasodilators?

A

-Hydralazine
-Minoxidil

135
Q

When are direct arterial vasodilators used?

A

For patients with special indications or very difficult to control BP (i.e. severe CKD or hemodialtsis)

136
Q

Which direct arterial vasodilator is the most potent?

A

Minoxidil

137
Q

Which other medications must be used along with direct arterial vasodilators?

A

Diuretic and beta blocker needed

138
Q

How often should hydralazine be taken?

A

2 to 4 times daily

139
Q

How often should minoxidil be taken?

A

1 to 3 times daily

140
Q

Adverse effects associated with direct arterial vasodilators

A

-Palpitations
-Tachycardia
-Chest pain
-GI side effects
-Headache
-Hematologic dyscrasias
-Hepatotoxicity
-Lupus-like syndrome/rash (hydralazine)
-Fluid retention
-Hair growth (minoxidil)

141
Q

Boxed warning for minoxidil

A

-May cause pericarditis and pericardial effusion that may progress to tamponade
-May increase oxygen demand and exacerbate angina pectoris
-Maximum therapeutic doses of diuretic and two other antihypertensives should be used before this drug is ever added. Should be given with a diuretic to minimize fluid gain and a beta blocker

142
Q

Which patient populations should direct arterial vasodilators be used with caution in?

A

-CVA
-Renal impairment
-CAD
-Liver disease
-SLE
-Stroke

143
Q

What are the alpha-1 blockers?

A

-Doxazosin
-Prazosin
-Terazosin

144
Q

When are alpha-1 blockers second-line treatment?

A

In patients with concomitant BPH

145
Q

What is a common side effect of alpha-1 blockers?

A

Orthostatic hypotension (especially in the elderly)

146
Q

What are the central alpha-2 agonists?

A

-Clonidine
-Methyldopa
-Guanfacine

147
Q

What are the adverse effects associated with alpha-2 agonists?

A

-CNS depression
-Dizziness
-Fatigue
-Anticholinergic effects
-Bradycardia
-Reflex tachycardia
-Fluid retention

148
Q

Why should you avoid abrupt cessation of alpha-2 agonists?

A

Rebound hypertension

149
Q

How to titrate off clonidine

A

-Slow wean - half dose every 2-3 days
-Concomitant beta blockers prescribed
-Wean BB several days prior to clonidine wean

150
Q

How do you transfer from oral clonidine to a transdermal patch?

A

Overlap oral regimen for 3-4 days

151
Q

How do you transfer from patch to oral clonidine?

A

Consider starting oral clonidine no sooner than 8 hours after patch removal

152
Q

Monitoring parameters for ACEi/ARBs

A

-BUN/SCr
-Potassium

153
Q

Monitoring parameters for CCBs

A

Heart rate (non-dihydropyridine)

154
Q

Monitoring parameters for aldosterone antagonists

A

-BUN/SCr
-Potassium

155
Q

Monitoring parameters for other diuretics

A

-BUN/SCr
-Electrolytes
-Uric acid (thiazides)

156
Q

Monitoring parameters for beta blockers

A

Heart rate

157
Q

What should you do if patient is not at goal?

A

-Consider nighttime dosing of one antihypertensive
-Assess adherence
-Educate on diet, exercise, and smoking cessation
-Rule out white coat hypertension
-Discontinue interfering substances
-Patient may have resistant hypertension

158
Q

What is resistant hypertension?

A

Failure to attain goal BP while adherent to a regimen that includes at least 3 agents at maximum dose or when 4 or more agents are needed

159
Q

Risk factors for resistant hypertension

A

-Older age
-Obesity
-CKD
-Diabetes
-African American

160
Q

Step 1 of the AHA step-wise guidance for the management of resistant HTN

A

-Maximize lifestyle interventions
-Optimize 3-drug regimen (ACEi or ARB, CCB, and diuretic)

161
Q

Step 2 of the AHA step-wise guidance for the management of resistant HTN

A

-Substitute optimized thiazide-like diuretic (chlorthalidone, indapamide)

162
Q

Step 3 of the AHA step-wise guidance for the management of resistant HTN

A

-Add mineralocorticoid receptor antagonist (spironolactone, eplerenone)

163
Q

Results of the PATHWAY-2 trial

A

Spironolactone is better than placebo/doxazosin/bisoprolol as add-on therapy in resistant hypertension

164
Q

Step 4 of the AHA step-wise guidance for the management of resistant HTN

A

-Add BB if heart rate is greater than 70
-Consider central alpha-2 agonist (clonidine patch or guanfacine at bedtime) if BB contraindicated and/or heart rate is less than 70 bpm

165
Q

Step 5 of the AHA step-wise guidance for the management of resistant HTN

A

-Add hydralazine

166
Q

Step 6 of the AHA step-wise guidance for the management of resistant HTN

A

-Substitute minoxidil for hydralazine

167
Q

What should be collected about a patient when discussing HTN?

A

-Patient characteristics
-Patient history
-Home blood pressure readings
-Current medications and prior anti-hypertensive medication use
-Objective data: vitals, lab results

168
Q

What should be assessed about a patient when discussing HTN?

A

-Presence of compelling indications
-HTN-related complications
-10-year atherosclerotic cardiovascular disease risk (ASCVD)
-Current medications that may contribute to or worsen HTN
-BP goal
-Appropriateness/effectiveness of current HTN regimen
-For resistant HTN if taking 3 or more hypertensive medications

169
Q

How should a plan be developed for a patient to treat their HTN?

A

-Tailored lifestyle modifications
-Drug therapy regimen: dose, route, frequency, duration
-Monitoring parameters: efficacy, safety, timeframe
-Education
-Self-monitoring
-Referrals to other providers when appropriate

170
Q

How should the plan be implemented for a patient with HTN?

A

-Provide patient education of treatment plan
-Use motivational interviewing to maximize adherence
-Schedule a follow-up

171
Q

What should be monitored when following up with a patient with HTN?

A

-BP goal attainment
-Adverse effects
-CV events
-Development/progression of kidney disease
-Adherence

Therapeutics II (33 decks)

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