Lecture 4 (HTN)-Exam 3 Flashcards
ESSENTIAL (PRIMARY) HYPERTENSION (HTN)
* What are the factors that may implicate? (6)
SECONDARY HYPERTENSION (5-10% OF CASES)
* What are the common and uncommon causes?
What are some medications that can cause HTN?(12)
Screening-USPSTF (BP)
* When do you start?
* What is the frequency?
- What needs to happen if patients fall within two categories based on SBP and DBP?
- BP indicates BP based on what?
- Individuals with SBP and DBP in 2 categories should be designated to the higher BP category.
- BP indicates blood pressure (based on an average of ≥2 careful readings obtained on ≥2 occasions
Calculate 10-year atherosclerotic cardiovascular disease risk:
* What does the calculator help you predict? (3)
This calculator helps predict the 10-year risk of the following hard ASCVD events:
* First occurrence of nonfatal myocardial infarction
* Coronary heart disease death
* Fatal or nonfatal stroke
CALCULATE 10-YEAR ATHEROSCLEROTIC CARDIOVASCULAR DISEASE RISK
This calculator may overestimate risk and a discussion with the patient needs to ensue if there are any questions.
* Risks estimates were developed by what?
* Risk may be underestimated in who?
* Risk may be overestimated in who?
* This calculator has only been validated for what ages?
What is the the low, borderline, intermediate and high risk for ASCVD
What are the treatment goals for HTN? (4)
Reduce mortality and morbidity from cardiovascular events:
* Coronary events
* Cerebrovascular events
* Heart failure
* Kidney disease
lab testing:
* baseline testing to help establish what?
* Serum electrolytes should be monitored when?
- Baseline testing to help establish ASCVD risk and organ function prior to pharmacotherapy initiation
- Serum electrolytes should be monitored 2 to 4 weeks after initiation of a diuretic, ACEI or ARB
What are modifiable risk factors?
What are the fixed risk factors?
What is the first line therapy if not compelling indication?
- ACEI or ARBS
- Calcium channel blockers: DHP or Non-DHP
- Thiazide diuretics: Hydrochlorothiazide or chlorthalidone
First line pharm:
* What does it reduce?
Reduce CV mortality when used for hypertension compared to other agents
Fill in
Combination Therapy
* What do the accomplish trial show about Benazepril plus HCTZ vs benazepril plus amlodipine?
- Both equal BP lowing benefit
- Benazepril plus amlodipine 20% lower CV events – study terminated after 36 months
Combination therapy:
* Low dose combo therapy does greater what?
* Multiple what?
- Low-dose combination therapy greater BP reduction with less adverse effects
- Multiple fixed-dose combination products available
What are the sulfonamide and not sulfonamide thiazide diuretics? where is the site of action?
What is the MOA of thiazide diuretics?
What are the indications of thiazide? (4)
What are the SE of thiazides?
What are the CI of thiazide?
- Anuria
- Sulfonamide allergy
Hydrochlorothiazide vs chlorthalidone
* Both agents are recommended as what?
* 2017 American College of Cardiology / American Hear Associated guidelines recommend what?
- Both agents are recommended as first-line therapies for the treatment of hypertension
- 2017 American College of Cardiology / American Hear Associated guidelines recommend chlorthalidone because it has a longer half-life and proven trial reduction of cardiovascular disease
Hydrochlorothiazide vs chlorthalidone: Hripsak G et al Jama Internal Medicine 2020
* Retrospective, observational comparative cohort study; Jan 2001 to Dec 2018; first-time antihypertensive monotherapy with what/
* what were the results?
* What did chlorthalidone have an increase of?(5)
- Retrospective, observational comparative cohort study; Jan 2001 to Dec 2018; first-time antihypertensive monotherapy with hydrochlorothiazide or chlorthalidone
- 730,225 subjects; no significant difference associated with myocardial infarction, hospitalized heart failure or stroke
- Chlorthalidone had significantly higher risk of hypokalemia, hyponatremia, acute renal failure, CKD, and type 2 diabetes
What are the second line agents for HTN?(6)
Central Alpha-2 agonists (clonidine)
* What does presynaptic vesicles contain?
* NE released into what?
* What will NE stimulate? What will it cause?
- Presynaptic vesicles contain NE
- NE released into the synaptic cleft from the hypothalamic ganglia in the CNS brain Spinal cord
- Released NE will stimulate post synaptic neuron and stimulate alpha-2 receptors
- Stimulation of alpha-2 receptors inhibit further release of NE into the synaptic cleft
Central Alpha-2 agonists (clonidine)
* What does it oppose the effects of?
* Clonidine primary agent in this class used to what? how?
Central Alpha-2 agonists (clonidine)
* What is the route (2)?
* What are the se?
Methydopa:
* Preferentially gets converted to what? What does that cause?
- Preferentially gets converted to methylnorepinephrine
- Methylnorepinephrine builds up in the presynaptic ganglia and pushes NE into the synaptic cleft where it gets degraded by monoamine oxygenase
Methyldopa:
* When stimulating signal comes, what is released instead?
* What can it not activate?
* What can it stimulate?
When stimulating signal comes – methyl NE released instead
* CANNOT activate post synaptic adrenergic receptors
* CAN stimulate alpha-2 receptors – further decreases NE release
What are the se of methyldopa?(7)
What is the normal pathophysio of normal vasodilation?
- Tunica intima – endothelial cells that produce nitric oxide (NO)
- NO produced in tunica intima moves to tunica media and activates guanylyl cyclase that converts GTP to cGMP
- cGMP induces vascular smooth muscle relaxation
Vasodilators - antihypertensives (hydralazine)
* What is the MOA?
* What are the indications (3)
Vasodilators - antihypertensives (hydralazine)
* What are the SE?
Vasodilators - antihypertensives (nitroprusside)
* What is the MOA?
What are the indications of nitroprusside?
- Short-term management of severe HF
- Hypertensive crisis
What are the SE of nitropursside?
HTN
Heart failure with reduced eiection fraction:
* What is first line?
* What is Add on?
First line
* ACEi or ARB then add beta blocker #
* Diuretic if edema present
Add on:
* Mineralocorticoid receptor antagonist
(#) in HFrEF only, use bisoprolol, carvedilol or metoprolol succinate, titrated to the evidence based dose
HTN
Heart failure with preserved ejection fraction
* What is first line?
- ACEi or ARB then add beta blocker
- diuretic if edema present
HTN
Stable ischemic heart disease:
* What is first line?
* What is add on?
- Beta blocker
- Add ACEi or ARB
- Add CCB if angina
- Add thiazide or mineralocorticoid receptor antagonist
HTN
Diabetes mellitus
* What are the different choices for txt?
ACEi, ARB, CCB, or thiazide
* If albuminuria present in diabetes, treat like chronic kindey disease and use an ACEi or ARB titrated to the max tolerated dose
HTN
Chronic kidney disease
* What is first line?
ACEi or ARB
HTN
Secondary stroke prevention:
* What is the first line?
Thiazide or thiazide with ACEi
If a patient has HTN and one of these, what is the first line:
* BPH:
* Migraine:
* Raynaud phenomenon:
- BPH: alpha blocker
- Migraine: beta blocker, CCB
- Raynaud phenomenon: dihydropyridine CCB
What antihypertensive meds cannot be used in pregnancy?
ACRi, ARB, renin inhibitor
DM:
* What is the primary cause of mortality in patients with DM?
* What is first line with and without albuminuria?
Cardiovascular disease is the primary cause of mortality in patients with DM
* All four first-line agents decrease cardiovascular events in patients with DM
* ACEI or ARBs recommended as first-line for patients with persistent albuminuria
CKD
* HTN damages what?
* Usually presents as what?
* BP control can slow down what?
- HTN damages renal tissues and arteries
- Usually presents as albuminuria (urine albumin to creatinine ratio of 30 to 299 mg/g with spot check)
- BP control can slow the decline of kidney function
CKD
* What is first line?
ACEI and ARBS can decrease intraglomerular pressure which can further decrease kidney function decline
* First-line for patients with CKD / albuminuria
Special populations-African american
* Why is the HTN pathophysiolgy different?
* Harder to do what?
Pathophysiology of hypertension in AA population different from that of other ethnicities
* Low renin HTN
* MC associated with abnormal sodium reabsorption
Harder to control – usually requires 2 or more agents to reach the goal of < 130/80 mmHg
SPECIAL POPULATIONS – AFRICAN AMERICANS
* What is inital therapy without compelling indications?
- Calcium channel blocker: MC amlodipine or nifedipine (ER formulations) OR
- Thiazide diuretics
SPECIAL POPULATIONS – AFRICAN AMERICANS
* Initial therapy with compelling indication?
* What is the combo therapy?
Initial therapy with compelling indication:
* Treat as per recommendations for indication
Combination therapy
* Thiazide or CCB with ACEI or ARB