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OU Module Cardio Spring 2018 > Therapeutics of Hypertension > Flashcards

Therapeutics of Hypertension Flashcards

1
Q

blood pressure goals for patients based on the 2017 ACC/AHA Hypertension Guidelines

A

< 130/80 mm Hg

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2
Q

Identify which patients are exceptions to the blood pressure goal for most patients.

A

Elderly patients: Range of recommendations: < 130/80 up to ≤ 150/90

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3
Q

Which labs can impact the treatment of hypertension?

A
  • UA

- Blood chemistries

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4
Q

What does a UA assess in determining hypertension treatment?

A

assess presence of albumin (kidney function), a sign of nephropathy

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5
Q

What is measured in blood chemistries tests?

A
  • potassium
  • SCr
  • sodium
  • thyroid panel
  • glucose
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6
Q

What does potassium levels determine?

A

Provides information about potential secondary causes

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7
Q

What does SCr levels determine?

A

Provides information about potential secondary causes

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8
Q

What does sodium levels determine?

A

Provides information about potential secondary causes

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9
Q

Why do you need a thyroid panel when determining hypertension treatment?

A

Patients with a dysfunctional thyroid may have blood pressure alterations

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10
Q

Why do you need a glucose test when determining hypertension treatment?

A

It helps provide information of overall cardiovascular risk

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11
Q

What constitutes a physical exam (with respect to HTN treatment)?

A
  • BP must be an ACCURATE measurement
  • Height, weight, body mass index (BMI)
  • Pulse
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12
Q

Why is a physical exam important when determining HTN treatment?

A

Physical exam signs of heart failure or neurologic deficits can indicate presence of important co-morbidities or target organ damage.

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13
Q

Why is an EKG important when assessing treatment for HTN?

A
  • Can provide information about cardiovascular disease.

- Can also provide information about anti-hypertensive medication safety.

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14
Q

normal BP

A
  • systolic: <120

- diastolic: <80

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15
Q

elevated BP

A
  • systolic: 120-129

- diastolic: <80

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16
Q

Stage 1 HTN

A
  • systolic: 130-139

- diastolic: 80-89

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17
Q

Stage 2 HTN

A
  • systolic: ≥140

- diastolic: ≥90

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18
Q

Isolated systolic hypertension

A

systolic BP is ≥ 130 mm Hg and diastolic BP is ≤ 80 mm Hg

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19
Q

White coat hypertension

A

BP is elevated in provider’s office, but at home, BP is “normal”

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20
Q

Masked hypertension

A

defined as BP that is normal in the provider’s office, but is elevated in other settings

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21
Q

Labile hypertension

A

not well defined, but generally refers to those patients whose BP fluctuates between low BP and high BP

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22
Q

Orthostatic hypertension

A

Blood pressure is high when lying or sitting, but drops when the patient stands

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23
Q

Hypertension crisis

A

Systolic BP > 180 mm Hg or diastolic BP > 120 mm Hg; Includes hypertensive urgency and hypertensive emergency

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24
Q

impact of BP by the DASH diet

A

decrease in systolic BP of ~ 11 mm Hg

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25
Q

impact of BP by reducing salt intake

A

decrease in systolic BP of 5-6 mm Hg

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26
Q

impact of BP by losing weight

A

Expect 1 mmHg reduction in systolic BP per 1 kg weight loss.

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27
Q

impact of BP by implementing regular physical activity

A

decrease in systolic BP of 4-8 mm Hg

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28
Q

adverse effects of ACEI

A
  • 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.
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29
Q

adverse effects of ARBS

A
  • Less cough and angioedema than ACEI
  • Hyperkalema
  • Renal dysfunction
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30
Q

adverse effects of BB

A
  • Bradycardia
  • Bronchospasm /can worsen asthma
  • Decreased exercise tolerance.
  • Fatigue
  • Sexual dysfunction
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31
Q

adverse effects of thiazides

A
  • 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!).
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32
Q

adverse effects of thiazide-like diuretics

A
  • 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!).
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33
Q

adverse effects of loop diuretics

A
  • Hypokalemia
  • Hypomagnesemia
  • Renal dysfunction
  • Hyperuricemia
  • Hypocalcemia (opposite of thiazides!)
  • Hyponatremia (less than thiazides, however)
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34
Q

adverse effects of potassium-sparing diuretics

A
  • Hyperkalemia
  • Hyponatremia
  • Renal dysfunction
  • Gynecomastia
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35
Q

adverse effects of Non-Dihydropyridine CCBs

A
  • Bradycardia

- Verapamil - constipation

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36
Q

adverse effects of Dihydropyridine CCBs

A
  • Peripheral edema

- Flushing and headache

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37
Q

adverse effects of alpha-1 blockers

A

Postural hypotension (BP drops w/ standing)

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38
Q

adverse effects of central alpha1-agonist

A
  • Drowsiness

- Dry mouth

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39
Q

adverse effects of direct vasodilator

A
  • 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
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40
Q

Ramipril

A
  • Altace
  • 2.5-10 mg daily
  • QD - BID
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41
Q

Enalapril

A
  • Vasotec
  • 10-40 mg
  • QD - BID
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42
Q

Losartan

A
  • Cozaar
  • 50-100 mg
  • QD - BID
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43
Q

Valsartan

A
  • Diovan
  • 80-320 mg
  • QD
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44
Q

Metoprolol succinate

A
  • Toprol XL
  • 25-200 mg
  • QD
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45
Q

Metoprolol tartrate

A
  • Lopressor
  • 100-400 mg
  • BID
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46
Q

Carvedilol

A
  • Coreg / Coreg CR
  • 6.25-50 mg / 10-80 mg
  • BID / QD
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47
Q

Chlorthalidone

A
  • Hygroton
  • 12.5-25 mg
  • QD
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48
Q

Hydrochlorothiazide

A
  • Microzide
  • 12.5-50 mg
  • QD
49
Q

Indapamide

A
  • Lozol
  • 1.25-2.5 mg
  • QD
50
Q

Furosemide

A
  • Lasix
  • 20-80 mg
  • BID
51
Q

Spironolactone

A
  • Aldactone
  • 25-50 mg
  • QD
52
Q

Diltiazem SR

A
  • Cardizem / Cartia / Tiazac
  • 120-480 mg
  • QD
53
Q

Verapamil SR

A
  • Calan / Isoptin / Verelan
  • 180-480 mg
  • QD
54
Q

Amlodipine

A
  • Norvasc
  • 2.5-10 mg
  • QD
55
Q

Doxazosin

A
  • Cardura
  • 1-8 mg
  • QD
56
Q

Clonidine

A
  • Catapres
  • Tab: 0.1-.8 mg QD-BID
  • Patch: 0.1-0.3 mg weekly
57
Q

Hydralazine

A
  • Apresoline
  • 20-100 mg
  • BID-QID
  • less side effects than Minoxidil
58
Q

Minoxidil

A
  • Loniten
  • 10-40 mg
  • QD-BID
59
Q

ACEI

A
  • Lisinopril
  • Ramipril
  • Enalapril
60
Q

ARBs

A
  • Losartan

- Valsartan

61
Q

BB

A
  • Metoprolol succinate
  • Metoprolol tartrate
  • Carvedilol
62
Q

Thiazide diuretics

A
  • Chlorthalidone

- Hydrochlorothiazide

63
Q

Thiazide-like diuretic

A

Indapamide

64
Q

Loop diuretics

A

Furosemide

65
Q

Potassium-sparing diuretics

A

Spironolactone

66
Q

Non-Dihydropyridine CCBs

A
  • Diltiazem SR

- Verapamil SR

67
Q

Dihydropyridine CCBs

A

Amlodipine

68
Q

α-1 Blockers

A

Doxazosin

69
Q

Central α2 agonist

A

Clonidine

70
Q

Direct Vasodilator

A
  • Hydralazine

- Minoxidil

71
Q

How should you monitor BP when starting / adjusting an anti-hypertensive medication?

A

BP should generally be monitored within 2-4 weeks of starting or adjusting antihypertensive medication

72
Q

using ACEI’s

A
  • 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.
73
Q

using ARBs

A
  • 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.
74
Q

using beta-blockers

A
  • 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
75
Q

What are the cardioselective beta blockers?

A
  • bisoprolol
  • atenolol
  • metoprolol
  • acebutalol
  • nebivolol
76
Q

Which beta blockers have vasodilating activity?

A
  • carvedilol
  • nebivolol
  • labetalol
77
Q

Which beta blocker is renally and which is hepatically eliminated?

A
  • renal: atenolol

- hepatic: metoprolol, carvedilol, propranolol

78
Q

What is the most and least lipophillic beta blocker?

A
  • most: propranolol
  • least: atenolol
  • highly lipophilic agents can cross the blood brain barrier better and may cause more CNS side effects
79
Q

using thiazide diuretics

A
  • 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)
80
Q

using loop diuretics

A
  • 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
81
Q

using Potassium-sparing diuretics

A
  • 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
82
Q

using Non-dihydropyridine CCBs

A
  • 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
83
Q

using Dihydropyridine CCBs

A
  • 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
84
Q

using α-1 Blockers

A
  • 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
85
Q

Why should you avoid α-1 Blockers as monotherapy?

A

increase prevalence of development of heart failure

86
Q

Why should you dose α-1 Blockers at bedtime?

A

to minimize risk of postural hypotension

87
Q

using Central α-2 agonists

A
  • avoid abrupt discontinuation
  • May need to use with diuretic to control fluid retention
  • Patch is generally better tolerated than tablet
88
Q

using Direct Arterial Vasodilators

A

Generally used as one of the last additions

89
Q

What are the Fab 4?

A
  • Thiazide diuretics
  • ACEI
  • ARBs
  • Calcium channel blockers
90
Q

What are the factors that contribute to high risk of CV event?

A
  • 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
91
Q

How do you follow up on BP?

A
  • Monthly for those not at their BP goal.

- Weekly for those with dangerously elevated BP (hypertensive crisis level).

92
Q

treating Black patients

A
  • 1st line: CCB or thiazide diuretic

- 2nd line: ARB or ACEI

93
Q

treating White (non-black) patients < 60 years old

A
  • 1st line: ARB or ACEI

- 2nd line: CCB or thiazide diuretic

94
Q

treating White (non-black) patients > 60 years old

A
  • 1st line: CCB or thiazide diuretic (indapamine)

- 2nd line: ARB or ACEI

95
Q

treating pts with HTN and DM

A
  • 1st line: ARB or ACEI

- 2nd line: CCB or thiazide diuretic

96
Q

treating pts with HTN and CKD

A
  • 1st line: ARB or ACEI

- 2nd line: CCB or thiazide diuretic

97
Q

treating pts with HTN and clinical CAD

A
  • 1st line: BB with ARB or ACEI

- 2nd line: CCB or thiazide diuretic

98
Q

treating pts with HTN and stroke history

A
  • 1st line: ARB or ACEI

- 2nd line: CCB or thiazide diuretic

99
Q

treating pts with HTN and heart failure

A

ACEI or ARB + BB + loop diuretic + AA regardless of BP. DHP CCB if needed for additional BP control.

100
Q

Why should ACEI and ARBs be avoided to use together?

A

can lead to hyperkalemia and renal dysfunction

101
Q

Lotrel

A

amlodipine + benazepril

102
Q

Exforge

A

valsartan + amlodipine

103
Q

Zestoretic

A

Lisinopril + hydrochlorothiazide

104
Q

Hyzaar

A

losartan + hydrochlorothiazide

105
Q

Edarbyclor

A

azilsartan + chlorthalidone

106
Q

Tribenzor

A

olmesartan + amlodipine + hydrochlorothiazide

107
Q

Ziac

A

bisoprolol + hydrochlorothiazide

108
Q

define resistant HTN

A
  • 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”.
109
Q

What are the recommended therapies for pregnant women?

A
  • Labetelol

- Methyldopa

110
Q

What are the therapies contraindicated for pregnant women?

A
  • ACEI
  • ARB
  • Direct renin inhibitors
111
Q

symptoms of target organ damage during hypertensive emergency

A
  • 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)
112
Q

What is the BP for hypertensive crisis and why?

A
  • BP greater than 180/120

- the risk of stroke at this level become exponentially higher

113
Q

Chest pain could indicate which TOD?

A

Acute coronary syndrome (ex: myocardial infarction)

114
Q

increased SOB could indicate which TOD?

A

Acute fluid retention in the lungs (which could be acute heart failure); could also indicate myocardial infarction

115
Q

FAST symptoms could indicate which TOD?

A
  • stroke
  • encephalopathy
  • intracranial hemorrhage
116
Q

How do you manage hypertensive urgency?

A
  • 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
117
Q

How do you manage hypertensive emergency?

A
  • 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
118
Q

What are the parenteral agents used to treat hypertensive emergency?

A
  • Clevidipine
  • fenoldopam
  • esmolol
  • enalaprilat
  • nitroprusside
119
Q

How does the bladder affect BP?

A
  • A full bladder can increase systolic BP around 20 – 30 mmHg
  • Have patient empty their bladder before checking their BP

OU Module Cardio Spring 2018 (16 decks)

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