Lecture 4 Hypertension Flashcards
Gestational hypertension non severe and severe
Non-severe : BP 140/90 but < 160/110
Severe : BP >160/110
Women who are hypertensive during pregnancy are at higher risk of subsequent hypertension and cardiovascular disease
Hypertension Pregnancy first line and second line therapy, what is contraindicated? What is best?
First line: Methyldopa, Labetalol, nifedipine long acting, beta blockers
Second line: hydralazine, clonidine, thiaizides
ACEi and ARBs are contraindicated
BEST is not drug, but need to weigh risk: benefit and monitor closely
Incidence of erectile dysfunction in patients without and with hypertension? What are the drug therapy associated with ED
Incidence in general population : 8-10%
Incidence in men with HTN : 15-46%
Beta blockers ( non selective> cardio selective), diuretics and alpha blockers felt to be biggest culprits
CCBs and ACEi/ARBs less culprit
New ESC guidelines recommend a higher SBP target of 140-150 if…….
Pre treatment symptomatic orthostatic hypotension
Age >85
Clinically significant moderate to severe frailty
Limited predicted lifespan (<3 yrs)
Main take home for hospitalized patient
Managing BP may not be a focus because it can be impacted by infection, pain and stress/anxiety there treat if there is a hypertensive emergency
Drug therapy monitoring ( diuretics therapy, thiazide mainly/loop) , and when?
Electrolyte disturbances: decrease in pottasium, decrease sodium, decrease magnesium
Renal function : Scr
Symptoms: more urination in first 2-3 weeks, then returns baseline
When: baseline, after initiation, with dose change (2-4weeks after changes)
What mechanism to use to minimize hypokalemia: thiazide induced
- Combine with ACEi/ARB or spironolactone
- add potassium sparring diuretic - amiloride or traimterene
- add potassium supplement
- reduce dose of thiazide
** IMPORTANT FLASHCARD*****
What is drug therapy monitoring for ACEi and ARB include vitals, H&N, Resp, Renal
VITALS
AE:hypotension
Monitoring: BP, symptomatic hypotension
H&N:
Adverse effects: angioedema
Monitoring: symptoms
Respiratory
Adverse effects: Dry cough
Monitoring : symptoms
Renal:
Adverse effects: Hyperkalemia, high Scr, Lower eGFR
Monitoring: labs for K & Scr. Baseline, 7-10D with increase dose, q3-6 month routine
ACEi- induced Angioedema
ACEi are leading cause of angioedema but it is rare (0.1-0.7%)
Risk is 5-fold higher in black individuals
Common symptoms: facial, lips, tongue and upper airway swelling
Airway compromise is life threatening consequence
Protective effect of ACEi or ARB on kidneys
Decreases damage done by eliminating proteinuria, thickening of basement membrane, fibrotic scaring also reducing effect of angiotensin 2
ACEi and ARBs are contraindicated in patients who have……
Bilateral renal artery stenosis
Drug therapy monitoring, ACEi or ARB - Hyperkalemia: Tips for Managment
Evaluate baseline Scr and K+
Combine with loop or thiazide diuretic
When GFR is low, add or switch to loop
Avoid or use caution when eGFR <30ml/min - assess clinical situation
If K+ is consistently above 5.5, should stop drug or refer to specialist to consider k+ binding drug
Drug therapy monitoring DHP-CCB- dihydropyridines
Generally well tolerated
Dose related: pedal edema, non pitting, headache
No lab monitoring required
Drug therapy monitoring CCB- Non-dihydropyridines
Dose dependent: HR, constipation
Use caution when combing with beta blocker or digoxin cumulative negative inotropic effects
Drug therapy monitoring: Beta Blockers ( vitals, CV, Respiration, Endo, other
Vitals
Adverse effects: Hypotension, bradycardia
Absolute increase : 1-5%
CV
Adverse effects: fatigue
Absolute increase: 1-10%
Resp
Adverse effects: claudication, Bronchospams
Absolute increase: 1-5%
Endo
Adverse effects : Erectile dysfunction
Absolute increase: 1-10%
Other
Adverse effects: Vivid bizarre dreams
Absolute increase: unknown
What are the advantages of single pill combination
Better Bp control
Improved adherence
Lower Cost
Options for combinations
- ACEi/ARB + thiaizide ( preferred in past stroke or TIA)
- ACEi/ARB + DHP-CCB (preferred in diabetes or CAD)
- DHP-CCB + Thiazide
Triple combination therapy
ACEi/ARB + DHP-CCB + Thiazide
Typically one combination tablet + single
What is the least synergistic combo
ACEi or ARB + BB
Approaches to stop antihypertensives
ACEi/ARB, Diuretics, DHP-CCB no tapering required
Beta-blockers - taper recommended with moderate-high doses, usually over 3-7 days, decrease dose q3-4 days untill lowest, then stop
