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
Diuretic Clinical Pearls
- do not give at ___
- ___ are 1st line for most HTN pts
- ___ is 1st line for pts with resistant HTN
- do not use K sparing diuretics as ___ for HTN
- pay attention to ___ allergies
- check ___ when choosing diuretic class
- important to monitor ___
- bedtime
- thiazides
- spironolactone
- monotherapy
- sulfa
- CrCl
- K
Diuretic Monitoring
___ and ___ function should be checked at baseline, ___ - ___ weeks after initiation, and every ___ - ___ months
- additional check at ___ - ___ weeks after initiation only for ___ diuretics and ___ antagonists
electrolyte, renal, 1-2, 6-12
- 3-4, loop, aldosterone
Summary of Patient Specific Factors
Stable ischemic heart disease
ACE-i/ARB and BB first, then CCB can be added if still not controlled
Summary of Patient Specific Factors
HFrEF
- ACE-i/ARB/ARNI
- mineralocorticoid receptor antagonists
- diuretics
- BB
all first line
Summary of Patient Specific Factors
HFpEF
First line: diuretics (if symptomatic)
if persistent HTN: ACE-i/ARB or BB (if HR elevated)
Summary of Patient Specific Factors
CKD
if albuminuria, ACE-i/ARB first line
Summary of Patient Specific Factors
Renal transplant
CCB first line over ACE-i (reduces graft loss and maintains higher GFR)
ACE-i would result in anemia, hyperkalemia, and lower GFR
Summary of Patient Specific Factors
Secondary stroke prevention
thiazide, ACE-i/ARB, or combo
only need to start os BP is greater than 140/90
Summary of Patient Specific Factors
DM
any first line option
- ACE-i/ARBs if albuminuria
Summary of Patient Specific Factors
AFib
ARB
Summary of Patient Specific Factors
Aortic disease
BB
Summary of Patient Specific Factors
Black patients
thiazide or CCB (unless HF or CKD)
Summary of Patient Specific Factors
pregnancy
methyldopa
nifedipine
labetalol
