Therapeutics - Hypertension (Ginzburg) Flashcards
what is a normal BMI and what is considered obses
around 19-25
obese is over 30
(between 25 and 30 is overwight)
what is considered normal BP
systolic less than 120 and diastolic less than 80
what numbers are considered “ELEVATED” blood pressure (not hypertension yet)
120-129 systolic
less than 80 diastolic
what numbers are considered stage 1/stage 2 hypertension?
stage 1: 130-139 systolic
80-89 diastolic
stage 2: 140 and over
90 and over diastolic
3 general organs/systems that can be affected by high blood pressure
cardiovascular disease
kidney disease
retinopathy
explain how high BP affects the cardiovascular system
double the risk for stroke and heart attack for every 20 points systolic and 10 points diastolic over 115/85
how are high BP and kidney disease related
CKD can cause HBP and HBP can cause CKD
how does HBP affect vision
can lead to bleeding, blurred vision, or complete vision loss
true or false
being male is a risk factor for HBP
true
is diabetes a risk factor for HBP?
Is it considered modifiable?
yes and yes
name a class of drugs that is a risk factor for developing HBP
NSAIDS like naproxen
can also affect the kidneys and cause renal issues
prior to assigning a HBP diagnosis, it is very important to do what?
DO NOT RELY ON JUST 1 NUMBER!!!!!!
ask the pt if they had caffeine, smoked, or exercised in past 30 mins, potentially have white coat HTN and need to check at hoome as well
also make sure the BP was taken properly and recheck 15-20 min later
true or false
caffeine is a risk factor for developing hypertension
FALSE
it can increase the numbers if you drink it right before taking, but it won’t actually cause HTN
explain how to get an ACCURATE BP reading
dont talk. empty bladder, put cuff on BARE ARM and use correct size
support the arm at heart level
do not cross legs, support your back and feet
true or false
being in pain does not affect blood pressure readings
FALSE - it does significantly
can environmental exposures be the cause of high BP?
YES
ie - having too much salt, not enough K, Ca, mgphysically inactive, or drinking tooo much alc
can genetic predisposition be a cause of high BP?
yes
true or false
drugs cannot be the cause of hypertension
FALSE - they van!!
so many drugs can cause - NSAIDS, drinking LOT of caffeine a day, immunosuppressants, PO contraceptives (only high doses), oral corticosteroids, amphetamines, etc
name 2 types of “out of office” blood pressure monitoring
ambulatory care pressure monitoring - continuous readings every 24 hours (best method)
home BP monitoring (more practical)
best NON pharmacologic interventions for preventing AND treating hypertension
weight loss, DASH diet, reduced sodium and enhanced potassium, physical activity, reduce alc intake
what is DASH diet
fruit, vegetables, whole grains, decreased salt and fat
to prevent/treat HBP, men should reduce alcohol to ____ drinks daily what about women>
men - 2 or less
women - 1 or less
salt can be changed to what other seasoning
fresh herbs and spices, onion powder, garlic powder, mrs dash
name 4 seasonings that should be avoided
sazon
adobo
onion salt
garlic salt
how many mg sodium is maximum:
-per day
-per meal
-per snack
per day - 1500mg or less
meal - 500mg or less
snack - 140mg or less
true or false
if a can of soup says “heart healthy” recommend a patient to purchase it
FALSE - you need to look at the ingredients
most are still extremely high in salt
true or false
high potassium levels can be a cause of HBP
FALSE
low potassium levels
name some causes of secondary hypertension
renal disease
drugs
OSA (sleep apnea)
cushings
thyroid
alodosteronism
what are some basic lab tests that should be conducted for someone wiht primary HTN
glucose - check for diabetes
lipids
serum creatinine
sodium, postassium, calcium levels
TSH
urinalysis
CBC
electrocardiogram for baseline
3 OPTIONAL tests for primary hypertension
echocardiogram
uric acid
albumin: creatinine
what is considered the “trifecta” and all should be checked for if a patient has 1 of the 3 conditions
hypertension
hyperlipidemia
diabetes
if the patient has a normal BP, what is the action taken?
promote lifestyle habits for prevention (optional) And reassess them in 1 year
patient has ELEVATED bp
what is the plan of action?
what numbers are considered “elevated”
120-129 systolic and less than 80 diastolic
nonpharm therapy, and reassess in 3-6 months
NO DRUGS YET
patient has stage 1 HTN
what is plan of action?
as recap - what numbers are considered stage 1 hypertension
130-139 systolic
80-89 diastolic
use the risk calculator for 10 year CV disease risk
if GREATER THAN 10% — non pharm therapy AND start BP lowering medication and reassess in 1 month
if LESS than 10% — nonpharm therapy and reassess in 3-6 months
as mentioned, if a patient has stage 1 hypertension and a CV disease risk over 10%, we start nonpharm therapy, AND a BP lowering medication and reassess them in 1 month
what happens at this 1 month visit
if the BP goal has been met, reassess them in 3-6 months
if it hasn’t been met - assess their adherence and consider raising dose
patient has stage 2 hypertension
what is the plan of action?
what numbers are considered stage 2?
140 and greater over 90
non pharm therapy AND Bp lowering medication — 2 agents of different classes
then we reassess in 1 month, and follow same plan as greater than 10% risk in stage 1
patient is a candidate for pharmacologic treatment for their hypertension
they have no compelling indication (ie - caused by chronic kidney disease)
what are considered the 1st line agents?
thiazide (chlorthalidone preferred - most potent)
dihydropyridine calcium channel blocker
ACE inhibitor or an ARB (NEVER BOTH)
if the hypertensive patient ahs chronic kidney disease (esp albuminuria) also, what drug(s) is (are) recommended? why?
an ACE inhibitor or an ARB
because they decrease thhe progression of CKD and also help with the blood pressure
hypertensive patient has diabetes with albuminuria (over 30)
what is recommended treatment
ACE inhibitor or ARB
if no albuminuria - any of the 3 1st line agents
antihypertensive treatment can be initiated with TWO agents, especially if,,,,,,
the systolic is over 20 and the diastolic is over 10 above goal
note to self
i skipped all the specific conditoins - waiting for email back
true or false
meds alone are enough to recommend to a patient to lower their BP
FALSE
the meds must go along with lifestyle modifications
true or false
if a patients BP is controlled, they can be weaned off the medicaiton
FALSE
the meds are typically life long
if you stop, the BP will shoot up again
since they are life long, make sure the pt is adherent and give combo pills if available
name 4 thiazide/thiazide-like diuretics
chlorthalidone
hydrochlorothiazide
indapamide
metolazone
ALL of the thiazide/thiazide-likes are doses how?
once a day
usual dosage range for chlorthalidone
12.5-25
usual dosage range for HCTZ
25-50
usual dosage range for indapamide
1.24-2.5 mg ( a day)
usual dosage range for metolazone
2,5-10mg/day
why is chlorthalidone considered the preferred diuretic
has a long half life and better potency - proven in trials to lower the risk of CV disease
4 things that should be monitored when a patient is on a thiazide diuretic
hyponatremia
hypokalemia
high uric acid and calcium levels
thiazide diuretics should be used in caution in which patients
with history of acute gout!
(unless pt is on uric acid lowering therapy)
bc diuretics can increase uric acid levels
MOA thiazide diuretics and where do they work
inhibit Na and Cl reabsorption into the body in the aascending loop of henle (in the DCT)
thiazide diuretics:
which is ineffective at an eGFR below 30mL/min?
which can be used until the eGFR is all the way down to 10mL/min?
HCTZ cannot be used below 30
chlorthalidone can be used all the way down to 10
ACE inhibitors should not be used in combo with ___ or ___
ARBS or direct renin inhibitors
ACE inhibitors should NOT be used in patients with a hisotry of….
angioedema!!!!! (with ACE inhibitors)
if they get angioedema wiht an ACE inhibitor, can wait 6 WEEKS and then start ARB
BUT if they get angioedema on an ARM, CANNOT GO ON ACE INHIBITOR OR ARB
increased risk of ____ when on ACE inhibitors, especially in patients….
hyperkalemia
with CKD or on potassium supplements or potassium sparing drugs
ACE inhibitors have a risk of acute ____ in patients with severe bilateral renal artery stenosis
renal failure
true or false
both ACEI’s and ARBSs cannot be used in preganncy
true
when taking ACE inhibitors or ARBS, the patient may get an initial increase in serum creatinine
if the bump is above ____%, it’s an issue, but if lower it’s fine
30%
how often should electrolytes and renal function be monitored for patients on ACE inhibitors and ARBS
baseleine, then 2-4 weeks after starting or increasing therapy, and then just periodically
true or false
ACE inhibitors can be renal protective, yet also renal toxic
TRUE
can be renal protective in diabetic patients - no proteinuria
in a case of shock (LOW pressure in kidney) - can be toxic
dihydropyridine calcium channel blockers should be avoided in patients with _______
ONLY if required, which 2 may be used?
HFrEF
amlodipine or felodipine
dihydropyridine calcium channel blockers are associated with _____ (adverse effect)
is this more common in men or women?
dose-related pedal edema (swelling in feet and ankles)
more common in women
if it happens, cut back dose
true or false
lab monitoring is needed for calcium channel blockers
FALSE - not needed
is dyhydro or nondihydro recommended
dihydro - it’s 1 of the 23 1st lines
which type of calcium channel blockers are centrally acting? which are peripherally acting?
central - non dihydropyridines
peripheral - dihydropyridine
true or false
non dihydropyridine calcium channel blockers are NOT used in patients with HFrEF
true
are nondihydropyridines and beta blockers used together?
not routinely
can increase risk of bradycardia and heart block
major concern with nondihydropyridine calcium shannel blockers
DDI CONCERN!!! majorCYP3A4 substrate and moderate inhibitor of CYP
