Therapeutics of Hypertension 2 Flashcards
ACC/AHA Recommendation for Choice of Initial Medication
For initiation of antihypertensive drug therapy, first line agents include (4)
- thiazide diuretics
- CCBs
- ACE-i or ARBs
ALLHAT
Antihypertensive and Lipid-lowering Treatment to Prevent Heart Attack Trial
- patinets older tha 55 with HTN and 1 addition CV risk factor
- results: ___ > amlodipine and lisinopril-based therapy in preventing stroke, MI, and HF
TAKEAWAYS:
1) ___ should be used-first line.
2) Pts who cannot take a diuretic, consider prescribing a ___ or ___.
3) Most patients with high blood presure need more than 1 drug
- chlorthalidone
- thiazides
- CCB, ACE-i
T or F: All first line medication combinations are acceptable.
FALSE
Preferred
- ACE-i/CCB
- ARB/CCB
- ACE-i/diuretic
- ARB/diuretic
Acceptable
- CCB/diuretic
Patient Specific Factor: Stable Ischemic Heart Disease
First line
- ___ (reduce CV events and anginal symptoms)
- ___ (reduce MI, stroke, and CVD)
___ CCBs can be used if still uncontrolled
- BB
- ACE-i/ARBs
- dihydropyridine
Patient Specific Factor: HF
Reduced ejection fraction
- avoid ___ CCBs due to no clinical benefit/worse outcomes
Preserved ejection fraction
- ___ : fluid overload
- ___ : elevated BP
- ___ : elevated HR
Reduced
- non-dihydropyridine
Preserved
- diuretics
- ACE-i/ARB
- BB
Patient Specific Factor: CKD
CKD 1 or 2 AND ____
- >300 mg/day or > 300 mg/g albumin:creatinine ratio: ___
CKD 3 or higher: ___
Post kideny transplantation: ___ CCBs are preferred due to improved ___ and kidney survival
albuminuria
- ACE-i/ARBs
- ACE-i/ARBs
- dihydropyridine, GFR
Patient Specific Factor: Cerebrovascular Disease
Secondary stroke prevention
- ___
- ___
- or combo of both
Usefulness of initiating antihypertensive treatment for BP < 140/90 is not well established
-ACE-i/ARBs
thiazide
Patient Specific Factor: Diabetes
- ___ first-line classes of antihypertensive agents are useful and effective
- in the presence of albuminuria: ___
- all
- ACE-i/ARBs
albuminuria is greater than 300 mg/day or 300 mg/g albumin:creatinine
Patient Specific Factor: Pregnancy
Preferred agents: ___ , ___ , ___
Contraindicated: ACE-i, ARBs, direct renin inhibitors
- methyldopa
- nifedipine
- labetalol
Patient Specific Factor: Ethnicity and Race
In black adults with HTN (w/wo DM) and WITHOUT HF or CKD
- initial anti-hypertensive treatment should include a ___ or ___
- better data for lowering BP and reducing CV events
- thiazide, CCB
Diuretics
thiazide
- 4 examples
loop
- 3 examples
aldosterone antagonists
- 2 examples
potassium-sparing
- 2 examples
thiazide
- chlorthalidone, HCTZ, indapamide, metolazone
loop
- furosemide, torsemide, bumetanide
aldosterone antagonists
- spironolactone, eplerenone
potassium sparing
- amiloride, triamterene
Diuretics in HTN
initial anti-hypertensive effects
- diuresis = ___ SV = ___ in PVR
chronic anti-hypertensive effects
- SV returns to ___ = ___ in PVR (below pre-treatment levels)
different sub-classes can be combined for additive/synergistic effects
SV = stroke volume
PVR = pulmonary vascular resisitance
- reduced, increase
- normal, decrease
Thiazide Diuretics
Agents: HCTZ, chlorthalidone, indapamide, metolazone
- ___ is the most studied and 1-2x more potent that HCTZ
- ___ for most HTN patients (ALLHAT)
- more effective than ___ diuretics with CrCl > ___ mL/min
- dose in the ___ to avoid nocturnal diuresis
- chlorthalidone
- first line
- loop, 30 mL/min
- morning
Thiazide Diuretics
Adverse effects:
- ___ kalemia
- ___magnesemia
- ___calcemia
- ___uricemia
- ___ glycemia
- ___lipidemia
- ___ dysfuntion
- ___ in TG/cholesterol
Drug interactions
- ___ toxicity with concurrent use
Contraindications
- ___ allergy, ___
AE
- hypokalemia
- hypomagnesemia
- hypercalcemia
- hyperuricemia
- hyperglycemia
- hyperlipidemia
- sexual
- increase
Drug interactions
- Li
Contraindications
- sulfa, anuria
Thiazide Frequency
all thiazides are taken ___ daily
once
Loop diuretics
Agents: furosemide, torsemide, bumetanide, and ethacrynic acid
___ first line for HTN
- preferred in HF for ___ managment
- more effective than thiazide diuretics with CrC < ___ mL/min
___ - ceiling dose response curve
- may need ___ doses with severely ___ renal function or fluid ___
- switching to another loop diuretic or from PO to ___ can help
Dose in the ___ or afternoon to avoid nocturnal diuresis
NOT
- symptom
- 30
High
- higher, reduced, overload
- IV
morning
Loop Diuretics
AE:
- ___ kalemia
- ___ magnesemia
- ___ calcemia
- ___ uricemia
- ___ toxicity
Contraindications: ___ allergy
- hypokalemia
- hypomagnesemia
- hypocalcemia
- hyperuricemia
- ototoxicity
- sulfa
Loop Diuretic frequency
- Furosemide and Bumetanide are taken ___ or ___ daily
- Torsemide is taken ___ daily
- once, daily
- once
Aldosterone Antagonists
Agents: spironolactone and
eplerenone
- ___ is preferred with resistant HTN (PATHWAY-2)
- ___ develops in up to 10% of patients on spironolactone , can switch to eplerenone
- do not initiate aldosterone antagonist with K > ___ mEq/L
- dose in the ___ or ___ to avoid nocturnal diuresis
- Spironolactone
- gynecomastia
- 5
- morning, afternoon
Aldosterone Antagonists
AE:
- ___ kalemia
- ___ natremia
- gynecomastia ( ___ )
Drug interactions
- ACEi-ARBs, renin inhibitors, NSAIDs (increase risk of ___)
Contraindications
Eplerenone
- impaired renal function (CrCL < ___ mL/min or SCr > ___ in males or ___ in females)
- ___ and proteinuria
Both
- concominant use of ___ diuretics
- hyperkalemia
- hyponatremia
- spironolactone
- hyperkalemia
- 50, 2, 1.8
- T2DM
- K sparing
Aldosterone Antagonists Frequency
both spironolactone and eplerenone are taken ___ or ___ daily
- consider holding or reducing dose if K is > ___ mEq/L or SCr increase > ___%
once, twice
- 5.5. 25%
Potassium Sparing Diuretics
Agents: amiloride, triamterene
- minimal ___ effects
- used in combo with ___ to minimize ___
- used with caution in patients with ___ or CKD (GFR < ___ mL/min)
- dose in ___ to avoid nocturnal diuresis
- BP
- thiazide, hypokalemia
- diabetes, 45
- morning
Potassium Sparing Diuretics
AE
- ___kalemia
- ___ uric acid
- ___glycemia
- hyperkalemia
- increased
- hyperglycemia
Potassium Sparing Diuretics Frequency
Amiloride and triamterene are both taken ___ or ___ daily
once, twice
