Therapeutics of Hypertension Flashcards
What are the long term complications of HTN?
Left Ventricular Hypertrophy, MI, Heart Failure, Stroke, CKD, Retinopathy.
What is Essential Hypertension?
Elevated blood pressure with an unknown etiology?
What is Secondary Hypertension?
Elevated blood pressure do to concurrent medical conditions or medications [Identifiable]
What is Isolated Systolic Hypertension?
Systolic BP levels are high BUT not diastolic BP is not
What is Resistant Hypertension?
Failure to attain goal BP while having at least 3 agent at max dose or when 4 or more agents are needed.
What is Orthostatic Hypotension?
A systolic blood pressure decrease of > 20mmHg, a distolic blood pressure decrease of > 10mmHg within three minutes of changing position
What are the risk factors associated with HTN?
Modifiable: Increased Na Intake, Obesity, Increased OH Intake, Decreased K Intake
Non-modificable: Age, Gender, Genetics, Race
Substances that can Increase Blood Pressure?
Ilicit Drugs [Cocaine, Ecstasy], Caffeine, Nicotine, Decongestants [phenylephrine, Psudeophed], Amphetamines, NSAIDS [Ibuprofen, neproxan…], Steriods, Contraceptives.
Measurements of Blood Pressure?
In Office: Should take 2 reading five minutes apart
Ambulatory: for “White Coat HTN” & may help with nighttime dippings
Home: for “White Coat HTN” & may help with adherence and response
What patterns are seen with the measurements of HTN?
Normotensive: NO HTN anywhere
Sustained: HTN both
Masked: HTN at Home
White Coat: HTN at Clinic
What is the classifications of Blood Pressure?
Normal: <120 / <80
Elevated: 120-129 / <80
Stage 1: 130-139 / 80-89
Stage 2: >140 / >90
[If one or the other falls down into a different category, always pick the higher]
What is the Blood Pressure reduction strategy for a Normal Pressure?
Keep promoting a health lifestyle and check back in 1 YEAR.
What is the Blood Pressure reduction strategy for an Elevated Pressure?
Start a NON-PHARM therapy and check back in 3-6 months
What is the Blood Pressure reduction strategy for Stage 1 Hypertension?
Check the patients ASCVD risk AND if they have any comorbidity:
Yes: Start NON-PHARM & PHARM and check back in 1 months
No: Start NON-PHARM and check back in 3-6 months
What are the comorbidities of HTN?
-Clinical CVD or ASCVD risk > 10%, Age > 45, Diabetes, Stoke, MI, Heart Failure, CKD [>130/>80]
-No Clinical CVD and ASCVD risk > 10%, Secondary Stroke Prevention [>140/>80]
What is the Blood Pressure reduction strategy for Stage 2 HTN?
`Start NON-PHARM & 2 MEDICATIONS and check back in 1 month
Blood Pressure Goals?
ACC/AHA: <130/80
- Elderly <140/90
ADA: <140/90
KDGO: <120/80
What happened within the SPRINT trial?
Tested patients WITHOUT diabetes or prior to stroke. Showed that CV problems were decrease by 25% in the intensive group = this is the reason why we use to medications
What are some Non-pharmacological treatment options for HTN?
Weight loss, DASH diet, exercise, decrease Na, Increase K, Decrease OH…
What is the ACC/AHA recommendation for the Initial Antihypertensive medicaiton?
Thiazides
-CCB, ACE-I, and/or ARBs are also considered first line treatment too.
Why are Thiazides considered the first line therapy?
Due to the ALLHAT trial; it showed that cholthalidone [diuretic] worked better than the other medications at preventing stroke, HA, and HF.
*Most patients are going to need combo therapy for HTN
Are all combinations acceptable?
NO ACEi/ARBs
-Only CCB/Diuretic are acceptable
-Preferred: ACE/CCB, ARB/CCB, ACE/Diuretic, ARB/Diuretic
Can you give an ACE with and ARB?
NO!
-Too many adverse effects for CV and Renal
Patient specific factors for Stable Ischemic Heart Diseases?
First Line: Beta-Blockers [Can also use ACE or ARBs]
- If uncontrolled use CCBs
Patient specific factors for Heart Failure?
No really medications, just manage symptoms
-Diuretics: Fluids; ACE/ARBs: BP; Beta-Blockers: HR
*DO NOT USE NON-DHP: no clinical benefit
Patient specific factors for CKD?
CKD stage 1 or 2 AND albuminuria: use ACEi
CKD stage 3 or higher: use ACEi
*After transplant: use CCB [Improved liver
function]
*ARBs are only used when intolerant to ACEi
Patient specific factors for Cerebrovascular Disease?
Start with Thiazide Diuretics then add ACEi/ARBs
*Could use a combo of both
Patient specific factors for Diabetes?
ALL first-line therapies are good
*If albuminuria: ACEi/ARBs
Patient specific factors for Pregnancy?
Preferred to use Methyldopa, Labetalol, Nifedipine
*CONTRAINDICATED: ACEi, ARBs, Renin Inhibitors
Patient specific factors for Race?
In black adults: use thiazide or CCB UNLESS they have HF or CKD
What are the Thiazide Diuretics?
HCTZ, Chorlthalidone, Inpadaide, Metolazone
-Chlorthalidone is more potent than HCTZ
Are the Thiazides the first line therapy?
YES!
-ALLHAT trial proves this
When should Thiazide Diuretics be taken? What is the frequency of Thiazide Diuretics?
Taken ONCE in the morning to avoid nighttime urination
What are the side effects of Thiazides?
Changes in electrolytes [Low K, Low Mg, High Ca], Hyperuricemia, increase in triglycerides
*CONTRAINDICATED: sulfa allergy
What are the Loop Diuretics?
Furosemide, Torsemide, Bumetanide, Ethacrynic Acid [not a sulfa]
Are the Loop Diuretics first-line therapy for HTN?
NO!
-Can be used in management for Heart Failure
What is the dosing Loop Diuretics and when should they be taken?
Furosemide & Bumetanide are ONCE or BID while Torsemide is ONCE daily.
-Should be taken in the AM or afternoon
What are the side effects of Loop Diuretics?
Low Ca, Low K, Low Mg, Low urea
*CONTRAINDICATION: sulfa allergy
What are the Aldosterone Antagonists?
Spironolactone, Eplerenone
What is Spironolactone preferred in?
Resistant HTN
What is the frequency of spironolatcone
and when should it be dosed?
Both are taken ONCE or BID and should be taken within the AM or afternoon
What are the side effects of Aldosterone Antagonist?
Hyperkalemia [consider holding], hyponatremia, gynecomastia [spironolactone only]
What are the drug interactions with Aldosterone Antagonist?
ACEi, ARBs, Renin Inhibitors, NSAIDS
-Will increase Hyperkalemia
What are the Potassium Sparing Diuretics?
Amiloride, Triamterne
How are the Potassium Sparing Diuretics used?
Have a minimal BP affect, SO use with Thiazides to minimize Hypokalemia
What is the frequency and how are Potassium Sparing Diuretics used?
Both are taken ONCE or BID and should be taken in the AM to reduce the nighttime urination.
What are the ACEi?
The “-prils”
-Benazepril, Captopril, Enalaprol, Fosinopril, Lisinopril, Moexipril, Perindopril…
What are the ACEi good in?
-Diabetes with Proteinuria
-HF [Management]
-MI [Ishcemia]
-CKD [All stages]
What is the frequency and when should the ACEi be used?
-Should be taken in the PM to reduce BP dipping
-Most are ONCE or BID but Captopril is BID or TID
What is the MOA of ACEi?
They inhibit the production of Angiotensin II from Angiotensin I
What are the side effects of ACEi?
Dry Cough (20%), Angioedema, Hyperkalemia, Acute Renal Failure
*CONTRAINDICATION: Hx of Angioedema, Pregnancy/Breastfeeding
What are the ARBs?
The “-sartans”
-Azilsartan, Candesartan, Eprosartans, Irbesartan, Losartan, Olmesartan, Telmisartan, Valsartan
What are the ARBs good with?
-Can be used if ACEi intolerance
-Doesn’t cause the breakdown on bradykinin = no dry cough
-Can use with Hx of Angioedema by ACEi
What is the frequency and when should ARBs be taken?
-All are dosed ONCE daily except for Eprosartan & Losartan; they can be dosed ONCE or BID.
-They should be taken at PM to reduce BP dipping
What are the side effects of ARBs
Have the same AE as ACEi just without the Dry Cough; [Hyperkalemia, angioedema]
*CONTRAINDICATIONS: angioedema with ARB, Pregnancy/Breastfeeding
What should you do if a patients K is too high while taking a ACEi or ARB?
Hold it until K levels go back down
What are the Direct Renin Inhibiters?
Aliskiren
What is the MOA of the Direct Renin Inhibitors?
Blocks the conversion of Angiotensinogen to Angiotensin I = Stoping the production of Angiotensin II
What is unique about the Aliskiren?
-NOT first line = very expensive
-Does not break down Bradykinin = not dry cough
-Should not use with ACEi or ARBs in diabetes
What is the frequency and the dosing for Aliskiren?
Should be taken ONCE daily and taken in the AM?
What are the side effects of the Direct Renin Inhibitors?
Diarrhea, Dizziness, Headache, Hyperkalemia, Orthostatic Hypotension
*CONTRAINDICATED: pregnancy
What are some counseling tips for the ACEi, ARBs, and Aliskiren?
-DO NOT take while pregnant
-Hyperkalemia: AVOID high potassium foods
-ACEi and ARBs are often preferred
What is the MOA for the Calcium Channel Blockers [CCB]?
They inhibit the influx of Calcium across cardiac and smooth muscle cell membranes causing vasodilation
What are the 2 subclasses of CCB?
Dihydropyridines & Non-dihydropyridines
What are the Dihydropyridines?
The “-pines”
-Amlodipine, Felodipine, Isradipine, Isradipine SR, Nicardipine SR, Nifedipine LA, Nisoldipine
What are the DHP beneficial in?
Good in patients that have Raynauds Syndrome & Elderly Patients with Isolated Systolic HTN
*More potent than Non-DHP
What are the side effects of DHP?
Reflex Tachycardia [Short Acting], Flushing Headache, Dizziness, Edema
What are the drug interactions with DHP?
CYP3A4, Grapefruit Juice
How are the DHP taken?
ALL are taken ONCE daily except for Isradipine & Nicardipine SR; they are taken BID
What are the Non-DHP?
Verapamil and Diltiazem
What are Non-DHP beneficial in?
Patients with Afib and those with angina who can’t tolerate a Beta-Blocker
What is the MOA of Non-DHP?
Will slow down the SV node causing a decrease in heart rate = decreasing CO = decreasing BP
What is the frequency of Verapimil and Diltiazem?
Both are taken ONCE or BID
What are the side effects of Non-DHP?
Bradycardia [Slowing down the HR], Headache Dizziness, Constipation [Ver > Dil]
*CONTRAINDICATION: Heart Block, Left Ventricular Dysfunction
What are the Drug interaction of Non-DHP?
Grapefruit Juice, CYP3A4, Heart Block [Electrical impulses are disrupted]
What if a CCB is needed in HF?
Use Amlodipine
Are the Beta-Blockers first-line therapy?
No, they are not first-line UNLESS the patient has HF or CAD
What is the MOA of Beta-Blockers?
They will decrease the HR [B1] along with the force of contraction [decrease CO] = decrease in BP
What are the Cardioselective Beta-Blockers?
The “-olol” [B1]
-Atenolol, Betaxolol, Bisoprolol Metoprolol, Nebivolol
What is unique about the Cardioselective Bete-Blockers?
Since they are B1 selective they will affect the Heart more so it will DECREASE CO better.
What are the Nonselective Beta-Blockers?
Nadolol, Propranolol
What is unique about the Nonselective Beta-Blockers?
They affect both B1 and B2… so; it will decrease the HR along with causing possible Bronchospams [Avoid in bronchospastic airway disease]
What are the Intrinsic Sympathomimetic Activity Beta-Blockers?
Acebutolol, Penbutolol, Pindolol
What is unique about the ISA Beta-Blockers?
They are to be avoided in patients that have HF and IHD
-Pindolol and Acebutolol are partial agonist
What are the mixed Alpha/Beta-Blockers?
Carvedilol, Labetalol
What is unique about the Mixed Alpha/Beta Blockers?
They have A1 so it will cause vasodilation due to the inhibition of Nor-Epi = Decrease VR & CO = Decrease BP
What are the side effects of the Beta-Blockers?
Bradycardia, Bronchospasms, Fatigue, Exercise Intolerance, Depression.
What are the Direct Arterial Vasodilators?
Minoxidil, Hydralazine
When should Direct Arterial Vasodilators be used in therapy?
LAST LINE
What should be used with Direct Arterial Vasodilators and why?
Use a diuretic and a beta-blocker
-Diuretic: because of the increased H2O retention
-B-Blocker: because of the reflex tachycardia
What is the frequency of the Direct Arterial Vasodilators?
Minoxidil: ONCE - TID
Hydralazine: BID - 4 TIMES DAILY
What are the side effects of Direct Arterial Vasodilators?
Tachycardia, Headache, GI Upsets, Chest pain
-Lupus like symptoms/Rash [Hydralazine]
-Hair Growth [Minoxidil]
What are some warnings about Direct Arterial Vasodilators?
-Should be maxed out on diuretics and 2 antihypertensives before starting
-Need to be use with a Diuretic and Beta-Blocker
What are the Alpha-1 Blockers?
The “-zosins”
-Prazosin, Doxazosin, terazosin …
Are the Alpha-1 Blockers a first line therapy?
NEVER a first-line therapy for HTN
What do Alpha-1 Blockers work best in?
Orthostatic Hypertension [Especially in the Elderly]
What are the Central Alpha-2 Agonists?
Clonidiene, Methyldopa, Guanfacine
When should the Central Alpha-2 Agonists be used in therapy?
Last line in HTN due the the side effects
What are the side effects of the Central Alpha-2 Agonist?
dizziness, fatigue, bradycardia, tachycardia, fluid retention
What is the importance of Methlydopa?
Can be used in pregnancy
What is Resistant Hypertension?
Failure to lower BP with 3 maxed out agents or using 4 or more agents at once
What is the management of Resistant HTN?
-Maximize Lifestyle [Non-pharm] or Optimize 3-drug regimen (ACEi, ARBs, Diuretics, CCB)
-Change out thiazides [HCTZ to Chlorthalidone]
-Add aldersterone antagonist [spironolactone, eplerenone]
-Add Beta-Blocker if HR >70 bpm [use Alpha-2 if BB is contraindicated]
-Add Hydralazine
-Switch Hydralazine to Minoxidil
