M4 Group HTN and Dyslipidemia

Question 1

What type of drug is amlodipene and when might it be used?

Answer 1

is a dihydropyridine calcium channel blocker, that in this discussion was used to bring down pressure in an urgent situation

Question 2

How do we discriminate between urgent and emergent cases of hypertension.

Answer 2

emergent cases will have evidence of end organ damage

note in the case of urgent cases, looking for secondary causes would occur after first efforts to bring down the BP with meds and monitoring

Question 3

What class of drug is catopril?

Answer 3

ACE-I (shortest half-life)

Question 4

Should ACE-I be used with people with kidney damage?

Answer 4

ACE-I , compared to non-ACE-I treatment have demonstrated a decrease in the rate of progression of kidney disease at every level of achieved blood pressure, even in patients with non-diabetic kidney disease; ACE-Is are also effective in preserving renal function, especially in patients with proteiniuria (this is a fine balance with possible worsening kidney function also a possibility)

Note, ACE inhibitors result in a decrease in GFR by efferent vasodilation (usually stabilizes after 2mo and is only of concern if increase in creatinine is greater than 30%)

Question 5

What types of patients would you use extra caution with when using an ACE-I?

Answer 5

african americans- because of the risk of angioedema
asthmatics- because of the risk of bradykinin induced hypersensitivity of the air ways
patients at risk for hyperkalemia, ACE-I may increase potassium which stabilizes after 1 week

Question 6

What are the word endings for ACE-I and ARBs?

Answer 6

ACE-I end in “…pril”
ARB end in “…sarten”

ARBs and ACE-I are similar in their efficacy as a monotherapy or in combination with diuretics and CCBs

Question 7

When would an aldosterone blocker be particularly useful and would you use it combination with other drugs?

Answer 7

used especially in resistant hypertension and obese patients, spironolactone is particularly effective when given together with with thiazide-type diuretic

limited “sexual” side effects - breast tenderness, gynecomastia, menstrual abnormalities and ED– to limit side effects use eplerenone

if using amiloride and triamterene (K+ sparing diuretics) combine with hydrochlorothiazide

Question 8

What caution is important when understanding when to use direct renin inhibitors?

Answer 8

(shut down the whole cascade)

have dose dependent diarrhea and a black box warning about aliskiren should not be used with patients that have diabetes and to avoid combining with ACEI or ARBs in patients with renal impairment

Question 9

When are loop diuretics indicated?

Answer 9

(are ventilators and potent natriuretic agents that reduce preload, extracellular fluid volume and BP) especially in the setting go decompensated heart failure and /or chronic kidney disease

Question 10

When are Thiazide diuretics particularly helpful and what side effects should you look out for?

Answer 10

useful and cost effective, can additively reduce pressure with other drugs by reducing extracellular fluid volume and dilating peripheral arterioles

hypokalemia, hyponatremia can occur, thiazides increase serum lipids and fasting glucose and are associated with an increase in diabetic incidence, increase calcium and ototoxicity

Question 11

Do dihydropyridine CCB or non-dihydropyridine CCB have a greater effect on HR?

Answer 11

dihydropyridine CCB (i.e.. amlodipine) have little effect on resting heart rate, but can cause relax tachycardia in response to lowering BP

non-dihydropyridine (diltiazem, verapamil) can effect nodal conduction, esp with B blockers or digoxin

Question 12

What are common side effects of calcium channel blockers?

Answer 12

inhibit hepatic CYP3A4 and increase blood levels of common meds (statins, cyclosporine and digoxin)

Question 13

Describe the two classes of B-blockers and give examples.

Answer 13

non-selective B-blockers block both B1 and B2 (examples carvedilol and propanolol) (more risk of bronchospasm or CNS effects) ; may reduce HDL and increase plasma TG

selective B-blockers block only B1 (heart specific) (examples atenolol and metoprolol)

note B-blockers are not recommended as the sole agent for first line treatment of HTN except with co-morbidities of hx. of MI, CAD, angina and heart failure

Question 14

What is intrinsic sympathomimetic activity?

Answer 14

a quality that some B-blockers (i.e. pindolol) process that causes weak B-adrenergic activation (partial agonists), decrease resting HR less effectively but prevent catecholamine stimulation during exercise or stress

Question 15

Would you typically give a diabetic patient a B-blocker?

Answer 15

not recommended for Type I DM that are poorly controlled because it may block the physiologic response to hypoglycemia

Question 16

Why are vasodilator medications considered 4th or 5th line HTN tx?

Answer 16

due to side effects and dose frequency, also can cause compensatory responses including increased sympathetic nervous activity and increased RAAS activity (tachy and edema)

Question 17

When is hydrazine typically used?

Answer 17

used parenterally for hypertensive emergencies, metabolism varies based on N-acetyltransferase activity in the liver

directly relaxes vascular SM, risk for lupus-like rxn

Question 18

How is minoxidil administered?

Answer 18

more potent vasodilator that is rapidly absorbed through GI, used in patients with advanced kidney disease

adverse effects include: edema, ST depression, T-wave changes, pericardial effusion, elevated pulmonary artery pressures and hpyertrichosis

Question 19

What is the main action of a-adrenergic receptor blockers when treating HTN? What drugs should they be used in combo with?

Answer 19

selective a antagonist, mediate vasoconstrictive actions of NE (doxazosin and terazosin)

use in combo with a1 antagonist with diuretic, can cause congestion, dizziness and postural hypotension

Question 20

Give two examples of central sympatholytics (a2 agonists) that act by directly reducing sympathetic outflow to the heart and blood vessels by acting on the brainstem.

Answer 20

methyldopa- use din hypertensive pregnancy

clonidine- rapid once of action, sudden discontinuation can cause rebound HTN

adverse effects include somnolence, sedation, ED, depression and dry mouth (caries)

Question 21

Name 5 conditions which warrant a compelling indication regarding drug regimen to treat HTN.

Answer 21

heart failure
post MI/ CAD ** some patients will need a BB base on LV function 
DM
chronic kidney disease
recurrent stroke prevention

mostly start an ACEi or ARB and add CCB or (thiazide) diuretic)

Question 22

Which drugs have shown to be less effective in AA populations?

Answer 22

ACEi, ARB and B-blockers, response is improved with use of combined use of diuretic or reductions in dietary sodium reduction

Question 23

Name 4 vasodilators that can be used in hypertensive emergency or urgency as well as 2 adrenergic inhibitors.

Answer 23

nitroprusside, hydrazine, nitroglycerine, enalapril

lebetalol (a,B blocker) and esmolol (B1 selective)

Question 24

Which are the preferred and contra-indicated drugs in treating HTN in pregnant women?

Answer 24

a-methyldopa, lebetalol (2nd line)

all RAAS medications are contraindicated

(eclapmsia is a medical emergency requiring intravenous medications and prompt delivery

Question 25

Name 8 categories of patients that are associated with resistant HTN.

Answer 25

older age, obesity, LV hypertrophy, sodium/volume retention, females, Afro-am., DM, CKD

Question 26

Given a loop diuretic and thiazide diuretic, which is preferable to reduce HTN?

Answer 26

generally speaking, thiazide is much better with reducing HTN, most commonly used with patents with CHF

Question 27

Give the equation for calculating LDL-C

Answer 27

LDL-C= TC-HDL-C- (TG/5)

Question 28

Differentiate the following as non-specific or pertaining to a particular dyslipidemia: tendon xanthoma, xanthoma palmare stratum, xanthelasm, arcus corneas, cataracts and tuberous xanthomas.

Answer 28

tendon xanthomas: FH
xanthoma palmare striatum: dysbetalipoproteinemia (Type III)
xanthelasmas: non specific
arcus corneus: non specific
cataracts: low HDL (type IV)
tuberous xanthomas: FH

Question 29

High TG is associated with large/small LDL size?

Answer 29

small

Question 30

In familial hypercholesterolemia, how would you expect VLDL levels to be?

Answer 30

VLDL levels low due to related inversely to size of LDL- in this case they would be low