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MCP: Cardiovascular Part 1-HTN Flashcards

1
Q

HTN Definition

A
  • Persistently elevated arterial BP
  • Patients actively taking antihypertensive medications are considered to have HTN (regardless of BP)
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2
Q

HTN Prevalence

A
  • 1 in 3 Americans
  • Often has no symptoms
    • “Silent Killer”
    • Some symptomsm might include: dizzy spells, dull HA, nosebleeds
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3
Q

Impact of HTN

A
  • BP correlates directly to risk of cardiovascular morbidity and mortality
  • Leads to damage of blood vessels and target organs
    • Heart
      • Heart disease
        • Coronary artery disease
      • ​​CV events
        • MI
      • Chest Pain (Angina)
      • Heart Failure
    • Brain
      • Cerebrovascular Events
        • Stroke
    • ​Kidney
      • Kidney Disease
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4
Q

HTN: As a Major Risk Factor

A
  • Major risk factor for heart disease
    • The 1st leading cause of death for all Americans
    • High BP, 3x more likely for heart disease
  • Major risk factor for stroke
    • The 4th leading cause of death for all Americans
    • High BP, 4x more likely for stroke
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5
Q

Lifestyle Modifications

A
  • Increased physical activity
  • Weight loss
  • DASH diet
  • Reduced alcohol intake
  • Smoking cessation
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6
Q

DASH Diet

A
  • Reduce risk of HTN and reduce blood pressure for those with HTN
  • Limit sodium consumption to 2300mg/day
    • Ideally 1500mg/day
  • Diet rich in fruits and vegetables
    • Increase in minerals such as potasium, calcium and magnesium
    • Increase in fiber
  • Low in saturated fats, choleseterol, and total fat
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7
Q

Modification and BP Reducation

A
  • Weight Loss
    • 5-20 mmHg
  • DASH
    • 8-14 mmHg
  • Limit Sodium
    • 2-8 mmHg
  • Physical Activity
    • 4-9 mmHg
  • Moderation of Alcohol Consumption
    • 2-4 mmHg
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8
Q

JNC-7 BP Diagnostic Ranges

A
  • Normal: 120/80
  • Pre-HTN: 120-139/80-89
  • HTN Stage 1: 140-159/90-99
  • HTN Stage 2: >160/>100
  • HTN Crisis: >180/>110
  • Goal BP with comorbidities: <130/80
    • DM, MI, CKD
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9
Q

JNC-8 New Blood Pressure Goals

A
  • 18-59 yo with no commorbidities
    • 140/90
  • 60 yo with no commorbodiities
    • 150/90
  • 18 to <70 yo with CKD or DM
    • 140/90
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10
Q

JNC7/JNC8 Difference in a Nutshell

A
  • Definition of HTN and pre-HTN were not specifically addressed in JNC8
    • Thresholds for BP treament were adopted that were consistent with JNC-7 definition
  • JNC8 advice higher BP goals in certain populations and decreased use of several antihypertensives
    • follow a different classification system based on age and commorbidities
  • Promote safer use of ACE inhibitors and ARBs, no longer promotes beta blockers and aldosterone agonists as a first and second line treatment.
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11
Q

Screening vs. Diagnosis

A
  • Elevated BP results in screening do not constitute diagnosis
  • ​Proper HTN diagnosis:
    • Multiple high BP readings on different days at office visits
      • Some consideration for diagnosis of HTN based on at home BP monitoring
        • 12-14 reading, both morning and evening reading, over 1 week
  • ​​Multiple other physical exam procedures to check cardiac function and HTN complications
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12
Q

BP Management and Monitoring

A
  • HC Provider Monitoring:
    • Monthly BP checks until reach goal
      • More frequent visits if stage 2 HTN
  • ​Self-Monitoring:
    • Various studies have shown that home monitoring can increase medication concordance and BP control
  • Management:
    • Lifestyle recommendations recommended for those with pre-HTN and HTN (encouraged for everyone)
    • ​JNC-7
      • Stage 1 HTN: At least one anti-htn med
      • Stage 2 HTN: 2 anti-HTN medications recommended
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13
Q

General Counseling Points

A
  • Always encourage a healthy diet and lifestyle
  • Time to Effect:
    • May take 2-3 weeks to see sustained effects in blood pressure, though they may feel side effects in the first couple of days
  • Concordance:
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14
Q

Medications Used for Hypertension

A
  • Thiazide diuretics
  • Angiotensin Converting Enzyme Inhibitors (ACE I)
  • Angiotensin II Receptor Blockers (ARBs)
  • Calcium Channel Blockers (CCB)
  • Beta Blockers
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15
Q

Thiazide Diuretics: Indications, MOA

A
  • Indications:
    • HTN
    • Mild edema
  • MOA:
    • Inhibits Na and Cl reabsorption from teh distal tubule nephron –> increased urinary excretion of water
    • Water follows salt
    • Reduces blood volume in order to reduce blood pressure
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16
Q

Thiazide Diuretics: Side Effects

A
  • Polyuria
  • Orthostatic hypotension
  • Hypokalemia
  • Photosensitivity
  • Hyperglycemia and dyslipidemia (more common at higher doses)
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17
Q

Thiazide Diuretics: Counseling Points

A
  • Dose in morning to avoid disturbing sleep
  • Rare: Sulfa allergies
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18
Q

Thiazide Diuretics: Monitoring

A
  • Blood pressure
  • Potassium
  • Blood Glucose (those with DM)
  • Dyslipidemia (standard monitoring, but may watch more carefully)
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19
Q

Thiazide Diuretics: Agents

A
  • ​Hydrochlorothiazide (Microzide, HCTZ)
    • High doses are associated with increased adverse effects without added clinical benefits
  • Chlorthalidone (Hygroton)
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20
Q

Angiotensin Converting Enzymes (ACE) Inhibitors: Indications and MOA

A
  • Indications:
    • Hypertension
    • Heart Failure
    • Prevention/Treatment of Diabetic Nephropathy
  • MOA
    • Suppresses renin-angiotension-aldosterone system by blocking the conversion of angiotensin I to angiotensin II (potent vasocontrictor)
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21
Q

ACE Inhibitors: Side Effects

A
  • Dry cough
  • Hyperkalemia
    • Caution with potassium suplements of potassium sparing diuretics
    • Avoid combining with ARB
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22
Q

ACE Inhibitors: Notes and Monitoring

A
  • Notes:
    • Contraindcated in pregnancy (Category X)
    • Acute renal failure (rare)
  • Monitoring:
    • Blood pressure
    • Renal function (SCr), potassium
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23
Q

Benazepril

A
  • ACE
  • Lotensin
24
Q

Enalapril

A
  • ACE
  • Vasotec
25
Lisinopril
* Prinivil, Zestril * ACE
26
Ramipril
* ACE * Altace
27
Angiotensin II Receptor Blockers (ARBs): Indications, MOA
* Indications: * HTN * Heart failure (for those not tolerant to ACEI) * Prevention/treatment of diabetic nephropathy * MOA: * Suppresses renin-angiotensin-aldosterone system by blocking the angiotensin II receptor--\>inhibits vascontrictive effects
28
ARBs: Side Effects
* Generally well tolerated * Hyperkalemia * Orthostatic hypotension * Angioedema
29
ARBs: Notes and Monitoring
* Notes: * Minimal effect on bradykinin--\>alternative for patients who experience ocuge with ACEI * Avoid in pregnancy (Cat D) * Monitoring: * Blood Pressure * Renal function (SCr), potassium
30
ACE Inhibitors: Drugs
* Benazepril * Enalapril * Lisinopril * Ramipril
31
ARB: Drugs
* Candesartan * Irbesartan * Losartan * Valsartan
32
Candesartan
* ARB * Atacand
33
Irbesartan
* Avapro * ARB
34
Losartan
* Cozaar * ARB
35
Valsartan
* ARB * Diovan
36
Calcium Channel Blockers (Dihydropyridines): Indications and MOA
* Indications: * HTN * Chronic stable angina * MOA * Inhibits calcium movement across membranes, relaxing coronary vascular smooth muscle--\>vasodialation and increasing myocardial oxygen supply
37
CCB-Dihydropyridines: Side Effects
* Flushing, dizziness, lightheadness * HA * Peripheral edema
38
CCB-Dihydropyridines: Notes and Monitoring
* Notes: * Nifedipine: Avoid immediate release formulation for HTN * Monitoring: * Blood pressure * Swelling of extremities
39
CCB-Dihydropyridines: Drugs
* Amlodipine * Nifedipine
40
Amlodipine
* CCB * Norvasc
41
Nifedipine
* CCB * Procardia XL * IR has increased risk of morbididty
42
CCB (Non-dihydropyridines): Indications and MOA
* Indications * HTN * Heart rate control (AFib) * Angina * MOA: * Similar to dihydropyridines except with negative ionotropic effects * Depress impulse formation and conduction velocity in the AV node * Reduces ability of the heart to contract
43
CCBs-Non-Dihydropyridines: Side Effect
* Diltiazem: bradycardia, hypotension, peripheral edema, nausea, gingival hyperplasia * Verapamil: same as diltiazem, constipation
44
CCBs-Non-Dihydropyridines (Counseling Points)
* Diltiazem: Take on an empty stomach * Verapamil: Sustained release must be taken with food * Lots of drug interactions * Avoid in patients with heart failure or acute MI
45
CCB-Nondihydropyridines: Monitoring
* Blood Pressure * Heart Rate * ECG: Conditions being treated also involved * e.g. arrhythmia * Liver Function Tests
46
CCB (Non-Dihydropyridines): Drugs
* Verapamil * Diltiazem
47
Verapamil
* Calan * CCB Non-dihydropyridines
48
Diltiazem
* Cardizem * CCB: nondihydropyridines
49
Beta Blockers: Indications and MOA
* Indications: * HTN (not first line) * Angina * Arrythmia * MI * Non-cardiovascular conditions (glaucoma, stage fright (propranolol) * MOA: * Block beta-adrenergic receptors--\>decrease heart rate, decrease BP, decrease myocardial oxygen demand and myocardial contraction
50
BB: Side Effects
* Bradycardia * Fatigue * Dizziness * Propranolol (most), Atenolol (least) * Acute Heart Failure * Bronchoconstriction (non-selective or selvetice at high doses)
51
BB: Couseling points, notes, monitroing
* ​Counseling Points * Avoid abrupt discontinuation--\>withdrawl syndrome * Increase BP, tachycardia, nervousness/sweating, and MI * ​Notes * Caution in patients with DM and asthma * Monitoring * BP * Heart Rate * ECG
52
BB: Drugs
* Atenolol * Carvedilol * Metoprolol * Propranolol
53
Atenolol
* Tenormin * Cardio-selective for B1 * BB
54
Carvedilol
* Coreg * IR and ER * BB
55
Metoprolol
* Tartrate (Lopressor) * Succinate (Toprol XL) * BB * Cardio Selective for B1
56
Propranolol
* Inderal * BB

Pharm 586 (5 decks)

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