Therapeutics of Hypertension Flashcards
blood pressure goals for patients based on the 2017 ACC/AHA Hypertension Guidelines
< 130/80 mm Hg
Identify which patients are exceptions to the blood pressure goal for most patients.
Elderly patients: Range of recommendations: < 130/80 up to ≤ 150/90
Which labs can impact the treatment of hypertension?
- UA
- Blood chemistries
What does a UA assess in determining hypertension treatment?
assess presence of albumin (kidney function), a sign of nephropathy
What is measured in blood chemistries tests?
- potassium
- SCr
- sodium
- thyroid panel
- glucose
What does potassium levels determine?
Provides information about potential secondary causes
What does SCr levels determine?
Provides information about potential secondary causes
What does sodium levels determine?
Provides information about potential secondary causes
Why do you need a thyroid panel when determining hypertension treatment?
Patients with a dysfunctional thyroid may have blood pressure alterations
Why do you need a glucose test when determining hypertension treatment?
It helps provide information of overall cardiovascular risk
What constitutes a physical exam (with respect to HTN treatment)?
- BP must be an ACCURATE measurement
- Height, weight, body mass index (BMI)
- Pulse
Why is a physical exam important when determining HTN treatment?
Physical exam signs of heart failure or neurologic deficits can indicate presence of important co-morbidities or target organ damage.
Why is an EKG important when assessing treatment for HTN?
- Can provide information about cardiovascular disease.
- Can also provide information about anti-hypertensive medication safety.
normal BP
- systolic: <120
- diastolic: <80
elevated BP
- systolic: 120-129
- diastolic: <80
Stage 1 HTN
- systolic: 130-139
- diastolic: 80-89
Stage 2 HTN
- systolic: ≥140
- diastolic: ≥90
Isolated systolic hypertension
systolic BP is ≥ 130 mm Hg and diastolic BP is ≤ 80 mm Hg
White coat hypertension
BP is elevated in provider’s office, but at home, BP is “normal”
Masked hypertension
defined as BP that is normal in the provider’s office, but is elevated in other settings
Labile hypertension
not well defined, but generally refers to those patients whose BP fluctuates between low BP and high BP
Orthostatic hypertension
Blood pressure is high when lying or sitting, but drops when the patient stands
Hypertension crisis
Systolic BP > 180 mm Hg or diastolic BP > 120 mm Hg; Includes hypertensive urgency and hypertensive emergency
impact of BP by the DASH diet
decrease in systolic BP of ~ 11 mm Hg
impact of BP by reducing salt intake
decrease in systolic BP of 5-6 mm Hg
impact of BP by losing weight
Expect 1 mmHg reduction in systolic BP per 1 kg weight loss.
impact of BP by implementing regular physical activity
decrease in systolic BP of 4-8 mm Hg
adverse effects of ACEI
- Cough – in about 30%
- Hyperkalema
- Renal dysfunction, especially in those w/ bilateral renal artery stenosis.
- Angioedema – rare, but more common in black patients; accumulation of bradykinin.
adverse effects of ARBS
- Less cough and angioedema than ACEI
- Hyperkalema
- Renal dysfunction
adverse effects of BB
- Bradycardia
- Bronchospasm /can worsen asthma
- Decreased exercise tolerance.
- Fatigue
- Sexual dysfunction
adverse effects of thiazides
- Hypokalemia
- Hyponatremia - do not give to someone whose sodium is on the lower end
- Hypomagnesemia
- Renal dysfunction (pre-renal azotemia)
- Hyperglycemia
- Increased lipids
- Hyperuricemia
- Hypercalcemia (can be used to help those with osteoporosis!).
adverse effects of thiazide-like diuretics
- Hypokalemia
- Hyponatremia - do not give to someone whose sodium is on the lower end
- Hypomagnesemia
- Renal dysfunction (pre-renal azotemia)
- Hyperglycemia
- Increased lipids
- Hyperuricemia
- Hypercalcemia (can be used to help those with osteoporosis!).
adverse effects of loop diuretics
- Hypokalemia
- Hypomagnesemia
- Renal dysfunction
- Hyperuricemia
- Hypocalcemia (opposite of thiazides!)
- Hyponatremia (less than thiazides, however)
adverse effects of potassium-sparing diuretics
- Hyperkalemia
- Hyponatremia
- Renal dysfunction
- Gynecomastia
adverse effects of Non-Dihydropyridine CCBs
- Bradycardia
- Verapamil - constipation
adverse effects of Dihydropyridine CCBs
- Peripheral edema
- Flushing and headache
adverse effects of alpha-1 blockers
Postural hypotension (BP drops w/ standing)
adverse effects of central alpha1-agonist
- Drowsiness
- Dry mouth
adverse effects of direct vasodilator
- Fluid retention - if you put someone on Minoxidil, be ready to put them on a diuretic as well
- Tachycardia
- Hydralazine – lupus with longer use and/or higher doses
Ramipril
- Altace
- 2.5-10 mg daily
- QD - BID
Enalapril
- Vasotec
- 10-40 mg
- QD - BID
Losartan
- Cozaar
- 50-100 mg
- QD - BID
Valsartan
- Diovan
- 80-320 mg
- QD
Metoprolol succinate
- Toprol XL
- 25-200 mg
- QD
Metoprolol tartrate
- Lopressor
- 100-400 mg
- BID
Carvedilol
- Coreg / Coreg CR
- 6.25-50 mg / 10-80 mg
- BID / QD
Chlorthalidone
- Hygroton
- 12.5-25 mg
- QD
Hydrochlorothiazide
- Microzide
- 12.5-50 mg
- QD
Indapamide
- Lozol
- 1.25-2.5 mg
- QD
Furosemide
- Lasix
- 20-80 mg
- BID
Spironolactone
- Aldactone
- 25-50 mg
- QD
Diltiazem SR
- Cardizem / Cartia / Tiazac
- 120-480 mg
- QD
Verapamil SR
- Calan / Isoptin / Verelan
- 180-480 mg
- QD
Amlodipine
- Norvasc
- 2.5-10 mg
- QD
Doxazosin
- Cardura
- 1-8 mg
- QD
Clonidine
- Catapres
- Tab: 0.1-.8 mg QD-BID
- Patch: 0.1-0.3 mg weekly
Hydralazine
- Apresoline
- 20-100 mg
- BID-QID
- less side effects than Minoxidil
Minoxidil
- Loniten
- 10-40 mg
- QD-BID
ACEI
- Lisinopril
- Ramipril
- Enalapril
ARBs
- Losartan
- Valsartan
BB
- Metoprolol succinate
- Metoprolol tartrate
- Carvedilol
Thiazide diuretics
- Chlorthalidone
- Hydrochlorothiazide
Thiazide-like diuretic
Indapamide
Loop diuretics
Furosemide
Potassium-sparing diuretics
Spironolactone
Non-Dihydropyridine CCBs
- Diltiazem SR
- Verapamil SR
Dihydropyridine CCBs
Amlodipine
α-1 Blockers
Doxazosin
Central α2 agonist
Clonidine
Direct Vasodilator
- Hydralazine
- Minoxidil
How should you monitor BP when starting / adjusting an anti-hypertensive medication?
BP should generally be monitored within 2-4 weeks of starting or adjusting antihypertensive medication
using ACEI’s
- Good in co-morbid DM, coronary heart disease, chronic kidney disease, heart failure.
- Usually well tolerated.
- Check labs within 7-10 days.
• Contraindicated in pregnancy.
using ARBs
- Good in co-morbid DM, coronary heart disease, chronic kidney disease, heart failure.
- Usually well tolerated.
- Check labs within 7-10 days.
• Contraindicated in pregnancy.
using beta-blockers
- Good in patients with co-morbid heart failure, coronary heart disease/post-MI, migraines, tachycardias, essential tremor, portal hypertension, or thyrotoxicosis.
- Unless a patient has one of these co-morbidities, β-blockers are not one of the first line agents
- Do not abruptly stop
- avoid in asthma unless cardioselective
- use in caution with DM pts; can mask hypoglycemia symptoms
- monitor heart rate and breathing
What are the cardioselective beta blockers?
- bisoprolol
- atenolol
- metoprolol
- acebutalol
- nebivolol
Which beta blockers have vasodilating activity?
- carvedilol
- nebivolol
- labetalol
Which beta blocker is renally and which is hepatically eliminated?
- renal: atenolol
- hepatic: metoprolol, carvedilol, propranolol
What is the most and least lipophillic beta blocker?
- most: propranolol
- least: atenolol
- highly lipophilic agents can cross the blood brain barrier better and may cause more CNS side effects
using thiazide diuretics
- more effective in lowering BP than loop diuretics
- Diuretic effect goes away after about 1 week of consistent use
- check labs within 7-10 days
- Good in patients with co-morbid osteoporosis / osteopenia
- Can precipitate gout
- Chlorthalidone is about 1.5 – 2 times more potent for blood pressure lowering than hydrochlorothiazide; it is also more slightly potent at causing hypokalemia
- Significant contraindication: with dofetilide (brand name, Tikosyn)
using loop diuretics
- Most effective for BP when used in patients with GFR < 30 mL/min.
- Has a sulfonamide group, but is generally well tolerated among those patients with a reaction to sulfonamide drugs
- Can precipitate gout
using Potassium-sparing diuretics
- Good choice for patients with “resistant” or “difficult to treat” hypertension
- Excellent option for patient with known or suspected hyperaldosteronism
- Must check labs within 3-7 days
using Non-dihydropyridine CCBs
- Contraindicated in patients with heart failure with a reduced ejection fraction
- slow heart rate and weaken heart contractility
- Good in patients with co-morbid tachycardias
using Dihydropyridine CCBs
- do not slow heart rate
- peripheral edema is local
- safe for all types of heart failures
- Short-acting agents are no longer used as they are excessive at BP lowering
using α-1 Blockers
- Good in patients with co-morbid benign prostatic hypertrophy
- Avoid as monotherapy
- Dose at bedtime
- should avoid this class in patients with an orthostatic pattern to their BP
Why should you avoid α-1 Blockers as monotherapy?
increase prevalence of development of heart failure
Why should you dose α-1 Blockers at bedtime?
to minimize risk of postural hypotension
using Central α-2 agonists
- avoid abrupt discontinuation
- May need to use with diuretic to control fluid retention
- Patch is generally better tolerated than tablet
using Direct Arterial Vasodilators
Generally used as one of the last additions
What are the Fab 4?
- Thiazide diuretics
- ACEI
- ARBs
- Calcium channel blockers
What are the factors that contribute to high risk of CV event?
- Prior CV disease, stroke, or heart failure
- Diabetes
- Chronic Kidney Disease
- Estimated 10-yr CV risk of 10% or higher based on ACC/AHA Risk estimator
How do you follow up on BP?
- Monthly for those not at their BP goal.
- Weekly for those with dangerously elevated BP (hypertensive crisis level).
treating Black patients
- 1st line: CCB or thiazide diuretic
- 2nd line: ARB or ACEI
treating White (non-black) patients < 60 years old
- 1st line: ARB or ACEI
- 2nd line: CCB or thiazide diuretic
treating White (non-black) patients > 60 years old
- 1st line: CCB or thiazide diuretic (indapamine)
- 2nd line: ARB or ACEI
treating pts with HTN and DM
- 1st line: ARB or ACEI
- 2nd line: CCB or thiazide diuretic
treating pts with HTN and CKD
- 1st line: ARB or ACEI
- 2nd line: CCB or thiazide diuretic
treating pts with HTN and clinical CAD
- 1st line: BB with ARB or ACEI
- 2nd line: CCB or thiazide diuretic
treating pts with HTN and stroke history
- 1st line: ARB or ACEI
- 2nd line: CCB or thiazide diuretic
treating pts with HTN and heart failure
ACEI or ARB + BB + loop diuretic + AA regardless of BP. DHP CCB if needed for additional BP control.
Why should ACEI and ARBs be avoided to use together?
can lead to hyperkalemia and renal dysfunction
Lotrel
amlodipine + benazepril
Exforge
valsartan + amlodipine
Zestoretic
Lisinopril + hydrochlorothiazide
Hyzaar
losartan + hydrochlorothiazide
Edarbyclor
azilsartan + chlorthalidone
Tribenzor
olmesartan + amlodipine + hydrochlorothiazide
Ziac
bisoprolol + hydrochlorothiazide
define resistant HTN
- Uncontrolled BP in spite of taking ≥ 3 agents OR
- Controlled BP but is taking ≥ 4 agents
- Ideally one of the agents should be a diuretic when possible before labeling
“resistant”.
What are the recommended therapies for pregnant women?
- Labetelol
- Methyldopa
What are the therapies contraindicated for pregnant women?
- ACEI
- ARB
- Direct renin inhibitors
symptoms of target organ damage during hypertensive emergency
- BP greater than 180/120
- Outencephalopathy (brain swelling type symptoms)
- intracranial hemorrhage (bleeding into the brain)
- acute heart failure
- pulmonary edema
- dissecting aortic aneurysm (bleeding goes into the lining of the arteries)
- acute coronary syndrome (heart attack)
- eclampsia (organ dysfunction during pregnancy)
- papilledema (damage to the eye)
What is the BP for hypertensive crisis and why?
- BP greater than 180/120
- the risk of stroke at this level become exponentially higher
Chest pain could indicate which TOD?
Acute coronary syndrome (ex: myocardial infarction)
increased SOB could indicate which TOD?
Acute fluid retention in the lungs (which could be acute heart failure); could also indicate myocardial infarction
FAST symptoms could indicate which TOD?
- stroke
- encephalopathy
- intracranial hemorrhage
How do you manage hypertensive urgency?
- Optimize chronic therapy.
- Avoid overly aggressive BP reduction (can cause hypotension-related problems).
- Goal: reduce BP to Stage 1 level over period of several hours to several days
- don’t want to normalize BP too fast
How do you manage hypertensive emergency?
- Immediate BP reduction needed to limit progression of TOD.
- Requires parenteral therapy.
- Goal: reduce mean arterial BP (MAP) by no more than 25% within minutes to hours; NOT to obtain BP < 140/90
What are the parenteral agents used to treat hypertensive emergency?
- Clevidipine
- fenoldopam
- esmolol
- enalaprilat
- nitroprusside
How does the bladder affect BP?
- A full bladder can increase systolic BP around 20 – 30 mmHg
- Have patient empty their bladder before checking their BP
