Therapeutics of Hypertension Flashcards
1
Q
What is hypertension?
A
Persistently elevated arterial blood pressure
2
Q
What are the symptoms of hypertension?
A
Majority of patients are asymptomatic
3
Q
What is the most significant risk factor for cardiovascular disease?
A
Hypertension
4
Q
By 2030, what percent of Americans are expected to have hypertension?
A
40%
5
Q
What is essential hypertension?
A
Elevated arterial blood pressure with an unknown cause
(hypertension is the main or “essential” disease state)
6
Q
What is secondary hypertension?
A
Elevated arterial blood pressure due to an identifiable cause
(such as concurrent medical conditions or medications)
7
Q
What is isolated systolic hypertension?
A
Systolic BP values are elevated but diastolic BP values are not
8
Q
What patients is systolic hypertension more common in and why?
A
Older patients
-vasculature is not as flexible
9
Q
What are the criteria for diagnosis of resistant hypertension?
A
Fail to attain goal BP while adherent to regimen of at least 3 agents at max dose (must include a diuretic)
OR
When 4 or more agents are needed
10
Q
What are the criteria for diagnosis of orthostatic hypotension?
A
Systolic blood pressure decrease of > 20 mmHg
OR
Diastolic blood pressure decrease of > 10 mmHg within 3 minutes of positional change
OR
Increase in heart rate > 20 bpm
11
Q
What is the equation for blood pressure?
A
BP= CO x TPR
CO= cardiac output
TPR=total peripheral resistance
12
Q
What is the equation for cardiac output?
A
CO=SV x HR
SV= strove volume
HR= heart rate
13
Q
What two factors determine blood pressure?
A
Cardiac output
Total peripheral resistance
14
Q
What two factors determine cardiac output?
A
Stroke volume
Heart rate
15
Q
What are the modifiable hyprtension risk factors?
A
-High sodium intake
-Obesity
-Low potassium intake
-Excess alcohol intake
16
Q
What is considered excess alcohol intake?
A
Men: > 2 drinks per day
Women: > 1 drink per day
17
Q
What are the non-modifiable hypertension risk factors?
A
-Age
-Ethnicity
-Genetic predisposition
-Gender
18
Q
What gender is more likely to develop hypertension?
A
Age < 55: Male
Age 55-64: Female
Age > 64: Female
*menopause plays a role in this
19
Q
What substances increase BP?
A
-Illicit drugs (cocaine, ecstasy)
-Caffeine
-Nicotine
-Decongestants (pseudoephedrine, phenylephrine)
-Amphetamines (methylphenidate, dextroamphetamine)
-Antidepressants (MAOIs, SNRIs, TCAs)
-Atypical antipsychotics (clozapine, olanzapine)
-Immunosuppressants (cyclosporine)
-Oral contraceptives
-NSAIDs (ibuprofen, naproxen, etc)
-Systemic steroids (methylprednisolone, prednisone, prednisolone, dexamethasone)
-Oncology agents (angiogenesis inhibitors, tyrosine kinase inhibitors)
20
Q
What is the in-office blood pressure measurement technique?
A
-Two readings 5 mins apart
-Sitting in chair
-Confirm elevated reading in opposite arm
21
Q
When would ambulatory BP monitoring (ABPM) be indicated?
A
Evaluation of:
white-coat hypertension
masked hypertension
nighttime BP dipping
22
Q
When would home BP monitoring (HBPM) be indicated?
A
Evaluation of:
white-coat hypertension
masked hypertension
response to therapy
*may improve adherence
23
Q
What is masked hypertension?
A
Hypertension not detected in office but detected at home
24
Q
What is the classification of normal blood pressure?
A
Systolic: <120
AND
Diastolic: <80
25
What is the classification of elevated blood pressure?
Systolic: 120-129
AND
Diastolic: <80
26
What is the classification of Stage 1 hypertension?
Systolic: 130-139
OR
Diastolic: 80-89
27
What is the classification of Stage 2 hypertension?
Systolic: > or = 140
OR
Diastolic: > or = 90
28
What is the classification of a hypertensive crisis?
Systolic: >180
AND/OR
Diastolic: >120
29
What is the ACC/AHA strategy for Normal BP (<120/80)
Promote healthy lifestyle
Reassess in 1 year
30
What is the ACC/AHA strategy for Elevated BP (120-129/<80)?
Non-pharmacological treatment
Reassess in 3-6 months
31
What is the ACC/AHA strategy for Stage 1 HTN (130-139/80-90)?
1st: Assess if ASCVD risk >10% OR does the patient have a specific comorbidity?
If yes: Non-pharmacological treatment AND medication
Reassess in 1 month
If no: Non-pharmacological treatment
Reassess in 3-6 months
32
What is the ACC/AHA strategy for Stage 2 HTN (> or = 140/90)?
Non-pharmacological treatment
+ 2 medications!
Reassess in 1 month
33
How often should hypertension patients at goal have their follow-up appointments?
every 3-6 months
34
What is the standard process we follow when scheduling follow-up appointments for hypertension patients?
No high BP: 1 year
Life style modification only: 3-6 months
Medication change: 1 month
35
What is the goal blood pressure for most comorbidities and clinical conditions?
Less than 130/80
36
In what three instances would a patient have a goal blood pressure of 140/90?
No clinical CVD and 10 year ASCVD risk <10%
Secondary stroke prevention
Elderly/frail patients with high comorbidity burden + limited life expectancy
37
What are the specific comorbidities that should be taken into consideration when establishing HTN treatment?
-Diabetes mellitus
-Chronic Kidney Disease
-Heart Failure
-Stable ischemic heart disease
-Secondary stroke prevention
-Peripheral artery disease
38
What is the blood pressure goal for elderly/frail patients with high comorbidity burden and short lifespan?
<140/90
39
What is the blood pressure goal for the majority of people?
<130/80
40
What is the KDIGO systolic blood pressure goal for adults with elevated BP and CKD?
<120
41
What was the SPRINT trial investigating and what were the result?
Intensive (<120) vs Standard (<140) BP goals
*in patients without diabetes*
-Primary composite outcome of cardiovascular issues/ death was reduced in the intensive group
-Intensive goal is difficult to maintain and the trial group did not reach the goal. Also 2.8 medications needed for intensive goal
-Intensive group was at higher risk of kidney injury, hypotension, and electrolyte abnormalities
42
What was the ACCORD trial investigating and what were the results?
Intensive (<120) vs Standard (130-140) BP treatment
*in patients with type 2 diabetes*
Lowering blood pressure under 140/90 has major benefits!
43
If a low blood pressure is shown to be beneficial in the SPRINT and ACCORD trials, why is the blood pressure goal for most people <130/80 and not 120?
Having a stricter goal but not 120 makes it easier for patients to adhere to and achieve the goal
44
By how much should sodium be reduced to decrease blood pressure?
<1500 mg/day OR 1000 mg reduction per day
45
By how much should potassium intake be increased to decrease blood pressure?
3500-5000 mg/day
46
Which intervention has the largest impact on lowering blood pressure?
DASH diet
(-11 mmHg)
47
What foods should be limited in a DASH diet?
-High in saturated fats
-Sugar-sweetened beverages and sweets
48
What are the first-line agent for hypertension?
-Thiazide diuretics
-CCBs (calcium channel blockers)
-ACE inhibitors
-ARBs
49
What is considered the overall first-line hypertension treatment?
Thiazide diuretics
50
What did the ALLHAT trial examine and what are the takeaways?
-Accessed antihypertensive and lipid-lowering treatment to prevent heart attacks
Takeaways:
-*Thiazide diuretics should be first-line*
-For patients who cannot take a diuretic: calcium channel blocker or ACEi
-Most high BP patients need more than one drug
51
If a patient needs to start 2 antihypertensive agents, are all first-line medication combinations acceptable?
NO
52
What are the 4 preferred combination therapies?
ACEi/CCB
ARB/CCB
ACEi/diuretic
ARB/diuretic
53
What is an acceptable but not preferred combination therapy?
CCB/diuretic
54
What is not an acceptable combination therapy?
ACEi/ARB
55
What is the hypertension treatment for Stable Ischemic Heart Disease?
1st Line:
-Beta blocker
-ACEi/ARB
Reduce BP < 130/80
If 1st line agent added and BP goal not met + patient develops angina:
-Add dihydropyridine CCB
If 1st line agent added and BP goal not met but the patient does not develop angina:
-Add dihydropyridine CCB, thiazide, and/or MRA
56
What are the benefits of using beta blockers?
Reduce CV events and anginal symptoms
57
What are the benefits of using ACEi/ARBs?
Reduce:
-MI
-Stroke
-CVD
58
What is the hypertension treatment for heart failure?
Reduced ejection fraction:
-Follow most recent guidelines
-AVOID non-dihydropyridine CCB (no benefit/worse outcomes)
Preserved ejection fraction:
--Use any of the following:
Diuretic (fluid overload) *Loop*
ACEi/ARB (elevated BP)
Beta blocker (elevated heart rate)
59
In heart failure, when would you choose to treat hypertension with a diuretic?
Fluid overload
60
In heart failure, when would you choose to treat hypertension with an ACEi/ARB?
Elevated BP
61
In heart failure, when would you choose to treat hypertension with a beta blocker?
Elevated heart rate
62
What is the hypertension treatment for Chronic Kidney Disease?
Stage 1 or 2 WITH albuminuria:
ACEi (or ARB if not tolerated)
Stage 1 or 2, NO albuminuria:
Normal first-line options
Stage 3 or higher:
ACEi (or ARB if not tolerated)
Post kidney transplant:
Dihydropyridine CCB
(improved GFR and kidney survival)
63
What are the GFR ranges for the different stages of kidney disease?
Stage 1: >90%
Stage 2: 60-89%
Stage 3: 30-59%
Stage 4: 15-29%
Stage 5: <15%
64
What is the hypertension treatment in cerebrovascular disease?
Secondary stroke prevention:
1st: thiazide
2nd: ACEi/ARB
*combination of both
BP Goal: <140/90 (usefulness of lower goal is unknown)
65
What is the hypertension treatment in diabetes?
No Albuminuria:
All first-line classes are useful
(thiazide or CCB)
*ACE/ARB used in combination therapy if needed
Albuminuria:
ACEi or ARB
66
What is the definition of albuminuria?
>300 mg/day
OR
>300 mg/g albumin-to-creatinine ratio
67
What are the preferred agents in pregnancy?
Methyldopa (central alpha-2 agonist)
Nifedipine (dihydropyridine CCB)
Labetalol (beta blocker)
68
What drugs are contraindicated in pregnancy?
ACEi
ARBs
Direct renin inhibitors
69
In black adults with no HF or CKD, what is the initial antihypertension treatment?
Thiazide diuretic or CCB
*this includes black patients with diabetes
70
What are the 4 thiazide diuretics?
-Chlorthalidone
-Hydrochlorothiazide
-Indapamide
-Metolazone
71
What are the 4 loop diuretics?
-Furosemide
-Torsemide
-Bumetanide
-Ethacrynic acid*
72
What are the 2 aldosterone antagonists?
-Spironolactone
-Eplerenone
73
What are the 2 potassium-sparing diuretics?
-Amiloride
-Triamterene
74
What 2 types of diuretics INCREASE potassium levels?
-Aldosterone antagonists
-Potassium-sparing diuretics
75
What 2 types of diuretics DECREASE potassium levels?
-Thiazide
-Loop
76
What are the initial effects of anti-hypertensive agents?
Diuresis -> *Reduced Stroke Volume* -> Increase in Peripheral Vascular Resistance (PVR)
77
What are the chronic effects of anti-hypertensive agents?
Stroke volume returns to normal -> Decrease in *Peripheral Vascular Resistance* (PVR) (to below pre-treatment levels)
78
What is the most potent thiazide diuretic?
Chlorthalidone
(1-2 x more potent than HCTZ)
79
At what CrCl are thiazide diuretics more effective than loop diuretics?
CrCl > 30 mL/min
(thiazide diuretics work in the kidneys and so must have at least some kidney function to work)
80
What time of day should diuretics be taken?
In the morning (avoid nocturnal diuresis)
81
How frequently are ALL thiazide diuretics dosed?
Once daily
82
True or False: MAX doses of diuretics are more effective than lower doses at lowering BP
FALSE
-MAX doses tend not to be more effective at lowering blood pressure and produce more side effects
-MAX doses are rarely used for lowering blood pressure
83
True or False: Thiazide diuretics can cause hyperglycemia and therefore should not be used in diabetic patients
FALSE
-thiazide diuretics CAN cause hyperglycemia, however, this does not prevent us from starting them in patients with diabetes since benefits outweigh risks
84
What are the drug interactions that occur with thiazide diuretics?
Lithium toxicity with concurrent use
85
What are the contraindications of thiazide diuretics?
*Sulfa allergy*
-Anuria (not producing urine)
86
When are loop diuretics preferred for HTN?
-Heart failure for symptom management
-CrCl < 30 mL/min
87
When would the loop diuretic ethacrynic acid be used?
Only in patients with a sulfa allergy
88
Loop diuretics exhibit a high-ceiling dose response curve, what does this mean?
-May need higher doses with severely reduced renal function or fluid overload
-Switching to a different loop diuretic or from PO to IV may help
89
Which loop diuretics have a dosing frequency of 1 or 2?
Furosemide
Bumetanide
90
Which loop diuretic is only dosed once daily?
Torsemide
91
What are the contraindications of loop diuretics?
*Sulfa allergy*
-except ethacrynic acid
92
What is the preferred aldosterone antagonist?
Spironolactone
93
When would we use eplerenone instead of spironolactone?
Switch patient to eplerenone if they develop gynecomastia
94
When are aldosterone antagonists (spironolactone) the preferred treatment option for hypertension?
Resistant hypertension
95
What is one of the most important side effects to know for spironolactone?
Gynecomastia (develops in 10% of patients)
96
At what potassium levels should aldosterone antagonists NOT be initiated?
>5 mEq/L
97
Are aldosterone antagonists diuretics?
YES
-make sure to dose in morning
98
What is the dosing frequency of BOTH aldosterone antagonists?
(spironolactone and eplerenone)
Once or Twice daily
(1 or 2)
99
In what circumstances would we consider holding or reducing the aldosterone antagonist dose?
Potassium > 5.5 mEq/L
SCr increases >25%
100
What are the drug interactions associated with aldosterone antagonists?
ACEi
ARBs
Renin inhibitors
NSAIDs
(all increase risk of hyperkalemia)
101
What are the contraindications associated with aldosterone antagonists?
Eplerenone:
-Impaired renal function
CrCl <50 or SCr >2 (male) or SCr > 1.8 (female)
-Type 2 Diabetes with Proteinuria
Both:
-Concomitant use of potassium sparing diuretics
102
When are potassium-sparing diuretics used?
-Minimal BP effects
-Use in combination with thiazide to minimize hypokalemia
103
Who should potassium-sparing diuretics be used with caution in?
Patients with diabetes or CKD (GFR < 45)
*Patients with uncontrolled gout*
104
What is the dosing frequency for all potassium-sparing diuretics?
Once or twice daily
(1 or 2)
105
When should electrolytes + renal function be monitored with diuretics?
Baseline
1-2 weeks after initiation
3-4 weeks after initiation (loop and aldosterone only)
Every 6-12 months
106
When is spironolactone a first-line option?
Resistant HTN
107
Can potassium-sparing diuretics be used as monotherapy for hypertension?
No
108
What is the mechanism of action of ACEi?
Inhibit conversion for angiotensin I to angiotensin II
109
What is the mechanism of action of ARBs?
Block effects of angiotensin II by binding to target receptors
110
What is the mechanism of action of renin inhibitors?
Inhibit conversion of angiotensinogen to angiotensin I
111
What patients populations may have increased benefits from taking ACEi?
-Diabetes w/ proteinuria
-Heart Failure
-Post MI
-Chronic kidney disease
112
What is an additional benefit of using ACEi or ARBs regarding time-of-day dosing?
Good options for PM dosing
-ensure "BP dipping" overnight
113
How do ACEi and ARBs affect hypertension?
Vasodilation
Reduced pulmonary vascular resistance (PVR)
Increased diuresis
114
Do ACEi need to be titrated?
Need to start at low dose and increase SLOWLY
*Never start on a max dose*
115
What is the only ACEi that does not have once daily dosing?
Captopril
(2 or 3)
116
What are 4 side effects of ACEi?
-Angioedema
-Cough (up to 20%) (due to excess bradykinin, dry and hacky)
-Hyperkalemia
-Acute renal failure w/ severe bilateral renal artery stenosis
117
What are the contraindications associated with ACEi?
-History of angioedema while on an ACEi
-Concomitant use of aliskiren in patients with DM
-Pregnancy/breastfeeding
118
True or False: If a patient has adverse effects on one ACEi we can try starting them on a different one
FALSE, do not try another ACEi
*especially if angioedema
119
Why do ARBs not cause cough like ACEi do?
Do not block bradykinin breakdown
120
True or False: All ARBs offer once daily dosing?
True
121
Which two ARBs have both once daily and BID dosing?
Eprosartan
Losartan
122
What time of day are ARBs given?
Prefer to give at bedtime but can be ok to take in the morning
123
What are the adverse effects of ARBs?
-Angioedema
-Hyperkalemia
-Acute renal failure w/ severe bilateral renal artery stenosis
*same as ACEi except for cough*
124
True or False: ARBs can still be used with history or angioedema due to ACEi
TRUE
-even though angioedema is a side effect of ARBs, they can still be used to replace ACEi in patients with ACEi-related angioedema
125
What contraindications are associated with ARBs?
-History of angioedema on an ARB
-Concomitant use of aliskiren in patients with DM
-Pregnancy/breastfeeding
*basically same as ACEi
126
What two things need to be monitored with ACEi/ARB use?
Potassium
Renal Function
127
In what two scenarios would we consider holding or reducing an ACEi or ARB dose?
Potassium > 5.5 mEq/L
SCr increase > 30%
128
What agent is the only direct renin inhibitor?
aliskiren
129
Why are direct renin inhibitors not first-line agents?
Very expensive and are no better than ACEi/ARBs
130
What are the contraindications for aliskiren?
Pregnancy
Concomitant use with an ACEi or ARB in patients with diabetes
131
What is a down-side to dosing of aliskiren?
Not a lot of dose titration available
132
How frequently is aliskiren dosed?
Once daily
133
What is monitored with aliskiren use?
Potassium
BUN
SCr
134
What broad category do ACEi, ARBs, and Renin inhibitors fall into?
Angiotensin Inhibitors
135
What affect do all angiotensin inhibitors have on potassium levels?
Increase potassium
(hyperkalemia is a risk)
136
Can angiotensin inhibitor drug classes be combined?
NO
Do not combine ACEi, ARBs, or Renin inhibitors
-increased risk of adverse effects
137
What is an important thing to remember about angiotensin inhibitors and women of childbearing age?
Need to discuss contraceptive methods with these women
*If a patient is wanting to become pregnant, do not use these drugs!
138
What is the mechanism of action of calcium channel blockers (CCBs)?
Inhibit influx of calcium across cardiac and smooth muscle cell membranes
-Leads to coronary and peripheral vasodilation
139
What are the 2 subclasses of calcium channel blockers (CCBs)?
Dihydropyridines
Nondihydropyridines
*both have similar effect on BP
140
Which subclass of CCB's is preferred?
Dihydropyridines cause more vasodilation so are preferred
-Nondihydropyridines can cause more negative inotropic effects
141
What patient populations may have added benefits from dihydropyridine calcium channel blockers?
Reynaud's syndrome
Elderly patients w/ isolated systolic HTN (due to vascular stiffness)
*this is because of CCB's ability to cause vasodilation
142
Which subclass of calcium channel blockers causes more vasodilation?
Dihydropyridine CCBs
143
What effect can CCBs have on heart rate?
Vasodilation from CCBs can cause baroreceptor-mediated tachycardia (increased heart rate)
144
What two dihydropyridines should be avoided?
Short-acting dihydropyridines:
-IR Nifedipine
-Nicardipine
145
Which 2 dihydropyridine CCBs have BID dosing?
-Isradipine
-Nicardipine SR
*can also include IR nifedipine in this
**Do not use these due to tachycardia issues
146
Which two dihydropyridine CCBs do not have negative inotropic effects?
-Amlodipine
-Felodipine
(do not affect heart rate)
147
What are the side effects of dihydropyridine CCBs?
-Reflex tachycardia
-Flushing
-Dizziness
-Headache
-Peripheral edema (dose related)
-Gingival hyperplasia
148
What warning is associated with dihydropyridine CCBs?
Increased risk of angina/MI in patients with obstructive coronary disease due to reflex tachycardia
149
What are the drug interactions associated with dihydropyridine CCBs?
-Grapefruit juice
-CYP3A4 enzyme inducers/inhibitors
150
What dihydropyridine CCB is preferred in patients with angina?
Amlodipine
151
What patient populations may have additional benefit from using a nondihydropyridine CCB?
Supraventricular tachyarrhythmias (Afib)
Patients with angina unable to tolerate a beta blocker
152
What effects do nondihydropyridine CCBs have on heart rate?
Slow AV node conduction
Decrease heart rate
(negative inotropic effects)
153
What are the 2 nondihydropyridine CCBs?
Diltiazem ER
Verapamil ER
*ER forms are preferred
154
What is the frequency of dosing for both diltiazem ER and verapamil ER?
Once or Twice daily
(1 or 2)
155
What drug interactions are associated with nondihydropyridine CCBs?
-Concomitant use of beta blockers (increase risk of heart block)
-Grapefruit juice
-CYP3A4 inducers/inhibitors (3A4 substrates)
156
What contraindications are associated with nondihydropyridine CCBs?
-Heart block
-Left ventricular dysfunction
157
What labs should be checked with CCBs?
None, no routine monitoring required
158
True or False: Nondihydropyridine CCB formulations can be interchanged?
FALSE
-not interchangeable due to differences in release mechanisms and bioavailability
159
If a CCB is needed in the setting of heart failure, which one do we choose?
Amlodipine
160
Which medication class is more likely to cause edema in an ankle? CCB, ARBs, or ACEi?
CCB
CCB can cause peripheral edema (usually in lower limbs) whereas ARBs and ACEi can cause angioedema (swelling of face, throat, or groin)
161
What are 2 compelling indications to use a beta blocker for HTN?
Heart Failure
CAD
162
What patient populations may have additional benefits from using a beta blocker?
-Tachyarrhythmias
-Tremors
-Migraines
-Thyrotoxicosis
163
How do beta blockers work?
Decrease both heart rate and force of contraction which leads to a decrease in cardiac output (CO)
164
True or False: Beta blockers need to be titrated?
TRUE
-Avoid abrupt cessation
-titrate off to avoid rebound increase in heart rate + BP or heart events
165
What are the *cardioselective* beta blockers?
Atenolol
Betaxolol
Bisoprolol
Metoprolol tartrate
Metoprolol succinate
Nebivolol
166
What is the only cardioselective beta blocker with BID dosing (not once daily)?
Metoprolol Tartrate
(short-acting form of metoprolol)
167
What is the only beta blocker that causes nitric oxide induced vasodilation?
Nebivolol
168
What are the 3 nonselective beta blockers?
Nadolol
Propranolol IR
Propranolol LA
169
What is the only nonselective beta blocker with BID dosing (not once daily)?
Propranolol IR
170
When would nonselective beta blockers be used instead of cardioselective beta blockers?
If we are trying to treat two conditions with one beta blocker
-Such as both blood pressure and migraine
171
When should nonselective beta blockers be avoided?
In bronchospastic airway disease
(asthma and COPD)
172
What are the 3 beta blockers with intrinsic sympathomimetic activity (ISA)?
Acebutolol
Penbutolol
Pindolol
173
Which beta blocker with intrinsic sympathomimetic activity (ISA) is the only one with once daily dosing?
Penbutolol
174
When should beta blockers with intrinsic sympathomimetic activity (ISA) be avoided?
Heart failure
Ischemic Heart Disease (IHD)
175
When should beta blockers with intrinsic sympathomimetic activity (ISA) be used?
-Do not decrease heart rate, just prevent it from going up
-In theory, use these in patients with low heart rate
-In reality, DO NOT PUT PATIENTS ON THESE (unknown effects)
176
What are the two mixed alpha/beta beta blockers?
Carvedilol
Labetalol
177
What is the frequency of both of the mixed alpha/beta blockers?
BID (2)
178
When would we use mixed alpha/beta blockers?
If blood pressure is close to goal but not quite there
179
What adverse effects are associated with all beta blockers?
-Bronchospasm
-Bradycardia
*Fatigue*
-Exercise intolerance
-Depression
*Masked signs of hypoglycemia*
180
Why can beta blockers cause fatigue?
Patients notice this in the first few weeks of starting the medication, occurs because heart rate is prevented from increasing which would occur normally with physical tasks
*this goes away after the patient gets used to the medication
181
In patients with peripheral artery disease, which beta blocker is preferred?
Carvedilol
182
In which groups of patients should beta blockers be used with caution?
-Peripheral artery disease
-Reactive airway disease
183
In patients with reactive airway disease, which beta blockers are preferred?
Selective beta blockers
184
What contraindications are associated with all beta blockers?
-Second or third degree heart block
-Decompensated heart failure
-Post-MI
-Severe bradycardia
-Sick sinus syndrome
185
What is the last-line therapy for hypertension?
Direct Arterial Vasodilators
186
What are the 2 direct arterial vasodilators?
Hydralazine
Minoxidil
187
Who do we use direct arterial vasodilators in for hypertension?
Reserved for patients with special indications (severe CKD or hemodialysis)
OR
Very difficult to control BP
188
Which direct arterial vasodilator is the most potent?
Minoxidil
189
Can direct arterial vasodilators be used as monotherapy for HTN?
NO
need to be used concomitantly with a DIURETIC and BETA BLOCKER
*loop diuretic preferred
190
Why do direct arterial vasodilators need to be used as a combination therapy?
-They cause vasodilation which increases heart rate and ultimately ends up in more fluid retention due to sodium
*need to prevent this
191
Which diuretic is preferred for concomitant use with minoxidil and why?
Loop diuretics are preferred
-these diuretics move more fluid which is needed since minoxidil is very potent
192
What is the dosing frequencies of hydralazine and minoxidil?
Hydralazine: 2-4
Minoxidil: 1-3
**higher dosing regimens are common, can cause adherence issues
193
Why do we prefer to avoid minoxidil in women and children?
Can cause unwanted hair growth
194
What are the adverse effects of direct arterial vasodilators?
-Palpitations
-Tachycardia
-Chest pain
-GI side effects
-Headache
-Hematologic dyscrasias
-Hepatotoxicity
*Fluid retention
*Lupus-like syndrome/rash (hydralazine) [joint pain, weakness, fevers]
*Hair growth (minoxidil)
195
What is the boxed warning for minoxidil?
-May cause: pericarditis and pericardial effusion that can progress to tamponade
-Can increase oxygen demand and exacerbate angina pectoris
196
Who should we use direct arterial vasodilators with caution in?
-CVA
-Renal impairment
-CAD
-Liver disease
-SLE
197
How many other drugs need to be used before trying minoxidil?
Maximum therapeutic doses of a diuretic + 2 other antihypertensives
198
What are the 3 alpha-1 blockers?
-Doxazosin
-Prazosin
-Terazosin
199
True or False: Alpha-1 Blockers are never considered first-line for HTN
TRUE
200
When do we use alpha-1 blockers for HTN?
Second-line for patients with concomitant benign prostatic hyperplasia (BPH)
201
What is a common side effect of alpha-1 blockers? (especially in the elderly)
Orthostatic hypotension
202
What is another use for the alpha-1 blocker prazosin?
Nightmares, especially associated with PTSD
203
What are the 3 central alpha-2 agonists?
-Clonidine
-Methyldopa
-Guanfacine
204
What drug class is considered last-line therapy for hypertension?
Alpha-2 Agonists
-because of adverse effects
205
True or False: Central Alpha-2 Agonists need to be titrated
True
-avoid abrupt cessation due to rebound hypertension
206
What 3 drug classes need to be titrated?
-ACEi (when starting)
-Beta blockers (when stopping)
-Central Alpha-2 Agonists (when stopping)
207
Which central alpha-2 agonist is preferred in pregnancy?
methyldopa
208
What two dosage forms does clonidine come in?
PO
Patch
209
What are some reasons why we would use the patch form of clonidine and not the PO form?
-Lower risk of rebound hypertension with patch
-Improved adherence with patch
210
How do we titrate patients off of clonidine?
-Slow wean (half dose every 2-3 days)
-Concomitant beta blocker prescribed
-Wean BB several days prior to clonidine wean
211
When changing from oral clonidine to the patch form, how many days of overlap should there be with the oral regimen?
3-4 days
(takes time for patch to begin working)
212
What is the titration schedule when switching from oral clonidine to the patch form?
Day 1: Place Patch, Give 100% of oral dose
Day 2: Give 50% of oral dose
Day 3: Give 25% of oral dose
Day 4: Patch only
213
When switching from the patch form of clonidine to oral, how long after removing the patch should oral clonidine be started?
Do not start oral clonidine sooner than 8 hours after patch removal
After 8 hours, can start oral medication
214
What parameters need to be monitored for ACEi/ARBs?
-BUN
-SCr
-Potassium
*Same as aldosterone antagonists
215
What parameters need to be monitored for CCBs?
Heart rate (non-dihydropyridine)
216
What parameters need to be monitored for Aldosterone Antagonists?
-BUN
-SCr
-Potassium
*Same as ACEi/ARB
217
What parameters need to be monitored for Beta Blockers?
Heart rate
*same as CCB
218
What should be done if a patient on antihypertensives is not at goal?
-Consider nighttime dosing of one antihypertensive (not diuretics)
-Assess adherence
-Educate on diet, exercise, and smoking cessation
-Rule out white coat hypertension
-Discontinue interfering substances
*Patient may have resistant hypertension*
219
What is resistant HTN?
Failure to attain goal BP while:
-Adherent to at least 3 agents at max dose (including a diuretic)
OR
-When 4 or more agents are needed
220
What is the estimated % of patients with resistant hypertension?
17%
221
What does it mean by resistant HTN is a "disease of exclusion"?
Must rule out secondary causes of HTN (nonadherence, whitecoat HTN, etc.) before diagnosing
222
What is Step 1 for resistant HTN treatment?
-Maximize lifestyle interventions
-Optimize 3-drug regimen (ACEi/ARB, CCB, and diuretic)
223
What is Step 2 for resistant HTN treatment?
Substitute optimized thiazide-like diuretic
(Chlorthalidone or Indapamide)
224
What is Step 3 for resistant HTN treatment?
Add mineralocorticoid receptor antagonist
(*Spironolactone* or Eplerenone)
225
What is Step 4 for resistant HTN treatment?
Add beta blocker IF heart rate >70 bpm
If BB contraindicated or heart rate <70 bpm: use a central alpha-2 agonist (clonidine patch or guanfacine at bedtime)
*diltiazem is contraindication to BB and can be used if alpha-2 agonists not tolerated
226
What is Step 5 for resistant HTN treatment?
Add hydralazine
227
What is step 6 for resistant HTN treatment?
Substitute minoxidil for hydralazine
228
What things should we keep in mind when de-escalating therapy (removing medications)?
-Presence of comorbidities that would impact drug choice
-First vs Second-line agents
-Which drug has the most potential for adverse effects
-Can we stop abruptly
-*Heart failure trumps hypertension (keep these meds on)
