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Fall 2020: Therapeutics 2 > Therapeutics of Hypertension > Flashcards

Therapeutics of Hypertension Flashcards

1
Q

Define essential hypertension.

A

Elevated blood pressure with an unknown etiology.

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2
Q

Define secondary hypertension.

A

Elevated arterial blood pressure due to concurrent medical conditions or medications (definable cause).

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3
Q

Define isolated systolic hypertension.

A

Systolic blood pressure values are elevated and diastolic blood pressure values are not.

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4
Q

Define resistant hypertension.

A

Failure to attain goal blood pressure while adherent to a regimen that includes at least 3 agents at maximum dose (including a diuretic) or when 4 or more agents are needed.

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5
Q

Define orthostatic hypotension.

A

A systolic blood pressure decrease of ≥20 mmHg, a diastolic blood pressure decrease of ≥10 mmHg within 3 minutes of positional change, and/or increase in heart rate >20 BPM

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6
Q

What 5 factors contribute to essential hypertension pathophysiology?

A
  • Humoral abnormalities
  • Neuronal mechanisms
  • Vascular endothelial mechanisms
  • Peripheral autoregulation defects
  • Electrolyte disturbances
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7
Q

How do you calculate blood pressure?

A

CO x TPR

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8
Q

How do you calculate cardiac output?

A

CO = SV x HR

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9
Q

List some examples of modifiable hypertension risk factors.

A
  • High sodium intake
  • Obesity
  • Low potassium intake
  • Excess alcohol intake
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10
Q

List some examples of non-modifiable hypertension risk factors.

A
  • Age
  • Ethnicity
  • Genetic predisposition
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11
Q

Who is more at risk for developing hypertension in the <55 age group: males or females?

A

Males

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12
Q

Who is more at risk for developing hypertension in the 55-64 age group: males or females?

A

Females (slightly)

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13
Q

Who is more at risk for developing hypertension in the >64 age group: males or females?

A

Females

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14
Q

List some possible causes of secondary hypertension.

A
  • Chronic kidney disease
  • Renovascular disease
  • Primary aldosteronism
  • Obstructive sleep apnea
  • Drug-induced
  • Food/substances (sodium, ethanol)
  • Pheochromocytoma
  • Cushing’s syndrome/chronic steroid use
  • Thyroid or parathyroid disease
  • Aortic coarctation
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15
Q

List some examples of substances that can increase blood pressure.

A
  • Illicit drugs (cocaine, ecstasy)
  • Caffeine
  • Nicotine
  • Decongestants (pseudoephedrine, phenylephrine)
  • Amphetamines (methylphenidate, dextroamphetamine, amphetamine)
  • Antidepressants (MAO-Is, SNRIs, TCAs)
  • Atypical antipsychotics (clozapine, olanzapine)
  • Immunosuppressants (cyclosporine)
  • Oral contraceptives (estrogens, androgens, progesterone)
  • NSAIDs
  • Systemic steroids (methylprednisolone, prednisone, prednisolone, dexamethasone)
  • Oncology agents (angiogenesis inhibitors, tyrosine kinase inhibitors)
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16
Q

How do you conduct an in-office blood pressure reading?

A

Take two readings 5 minutes apart and sitting in a chair; confirm elevated readings in an opposite arm

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17
Q

When would ambulatory blood pressure monitoring (ABPM) be indicated?

A

For the evaluation of white-coat hypertension, masked hypertension, and nighttime blood pressure dipping.

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18
Q

When is home blood pressure monitoring (HBPM) indicated?

A

For the evaluation of white-coat and masked hypertension, response to therapy, and to (possibly) improve adherence.

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19
Q

What is the range for normal blood pressure?

A

<120/80

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20
Q

What is the range for elevated blood pressure?

A

120-129 and <80

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21
Q

What is the range for Stage 1 hypertension?

A

130-139 OR 80-89

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22
Q

What is the range for Stage 2 hypertension?

A

≥140 OR ≥90

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23
Q

According to the ACC/AHA, what blood pressure management strategy should be initiated in patients with elevated (120-129/<80) blood pressure?

A

Non-pharmacologic treatment, then reassess in 3-6 months

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24
Q

According to the ACC/AHA, what blood pressure strategies should be initiated in patients with Stage 1 hypertension (130-139/80-89) and an ASCVD risk of ≥10% or a specific comorbidity?

A

Initiate non-pharmacologic treatment AND medication, reassess in 1 month

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25
Q

According to the ACC/AHA, what blood pressure strategies should be initiated in patients with Stage 1 hypertension (130-139/80-89) and without an ASCVD risk of ≥10% or a specific comorbidity?

A

Initiate non-pharmacologic treatment, reassess in 3-6 months

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26
Q

According to the ACC/AHA, what blood pressure management strategies should be utilized in patients with Stage 2 hypertenion (≥140/90)?

A

Initiate non-pharmacologic treatment AND 2 medications, reassess in 1 month

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27
Q

How often should follow-ups take place for hypertension patients at goal?

A

Every 3-6 months

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28
Q

What is the ACC/AHA blood pressure threshold for treatment initiation in patients with clinical CVD or a 10-year ASCVD ≥10%?

A

≥130/80

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29
Q

What is the ACC/AHA blood pressure threshold for treatment initiation in patients with no clinical CVD and a 10-year ASCVD <10%?

A

≥140/90

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30
Q

What is the ACC/AHA blood pressure threshold for treatment initiation in non-institutionalized, ambulatory, community-living adults 65 and older?

A
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31
Q

Which specific comorbidity has a blood pressure threshold for treatment initiation of ≥140/90?

A

Secondary stroke prevention

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32
Q

What is the most commonly-used blood pressure goal according to the ACC/AHA?

A

<130/80

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33
Q

What is the ADA-accepted blood pressure goal for patients without CVD and an ASCVD <15%?

A

<140/90

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34
Q

What is the ADA-accepted blood pressure goal for patients with CVD or an ASCVD ≥15%?

A

<130/80

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35
Q

What is the KDIGO-accepted blood pressure goal for patients without albuminuria?

A

<140/90

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36
Q

What is the KDIGO-accepted blood pressure goal for patients with albuminuria (>30 mg/24 hours)?

A

<130/80

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37
Q

Explain the SPRINT trial.

A

Involved partipants without diabetes/prior stroke, and demonstrated that 2.8 medications are needed on average to approach blood pressure goals (<120 mmHg) in an intensive group.

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38
Q

Explain the ACCORD trial.

A

In participants with T2DM age 40-79 with CVD or multiple risk factors, there was no benefit in primary composite outcome despite meeting blood pressure goals.

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39
Q

List some non-pharmacologic treatment options for hypertension/elevated blood pressure.

A
  • Weight loss
  • DASH diet
  • Decreased sodium intake (<1500 mg/day or 1000 mg reduction per day)
  • Enhanced potassium intake (3500-5000 mg/day)
  • Physical activity
  • Moderation in alcohol intake
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40
Q

What foods should be limited in the DASH diet?

A
  • High saturated fat foods (fatty meats, full-fat dairy, tropical oils)
  • Sugar-sweetened beverages and sweets
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41
Q

What are the four classes of first-line agents for antihypertensive therapy?

A
  1. Thiazide diuretics
  2. Calcium channel blockers
  3. ACE inhibitors
  4. ARBs
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42
Q

Explain the ALLHAT trial.

A

Patients >55 with HTN and 1 additional CV risk factor were randomized to 4 different drugs

  • Thiazides are first-line
  • Chlorthalidone was better than amlodipine and lisinopril-based therapy in preventing stroke, heart attacks, and heart failure
  • Patients who cannot take a diuretic should be prescribed a calcium channel blocker or ACE inhibitor
  • Most patients with high blood pressure need more than 1 drug
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43
Q

What are the three first-line treatments that can be used in patients with stable ischemic heart disease?

A
  • Beta blockers
  • ACE inhibitors
  • ARBs
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44
Q

If first-line treatments have already been initiated for hypertension with stable ischemic heart disease and blood pressure goals still aren’t being met, what medication class can be considered?

A

Dihydropyridine calcium channel blockers

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45
Q

What medication class should be avoided in patients with heart failure with reduced ejection fraction?

A

Non-dihydropyridine calcium channel blockers

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46
Q

What drug class should be first-line in heart failure patients with preserved ejection fraction and fluid overload?

A

Diuretics

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47
Q

What two drug classes should be first-line for patients with heart failure and preserved ejection fraction with elevated blood pressure?

A

ACE inhibitors and ARBs

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48
Q

What drug class is first-line for patients with heart failure with preserved ejection fraction and elevated heart rate?

A

Beta blockers

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49
Q

What medication classes are first-line for hypertension patients with CKD stage 1/2 AND albuminuria?

A

ACE inhibitors or ARBs

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50
Q

What medication classes are first-line for patients with hypertension and CKD Stage 3 or higher?

A

ACE inhibitors or ARBs

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51
Q

What medication class is first-line in hypertension patients who are post-kidney transplant?

A

Dihydropyridine calcium channel blockers

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52
Q

What three medication classes are first-line in hypertension patients requiring secondary stroke prevention (cerebrovascular disease)?

A
  • Thiazide diuretics
  • ACE inhibitors
  • ARBs
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53
Q

What medication classes are first-line in hypertension patients with diabetes?

A

All first-line classes are useful and effective

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54
Q

What medication classes are first-line in hypertension patients with diabetets in the presence of albuminuria?

A
  • ACE inhibitors
  • ARBs
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55
Q

What three agents are preferred in pregnant hypertensive patients?

A
  • Methyldopa
  • Nifedipine
  • Labetalol
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56
Q

What three medication classes are contraindicated in pregnant hypertensive patients?

A
  • ACE inhibitors
  • ARBs
  • Direct renin inhibitors
57
Q

What medication classes are first-line in black adults with hypertension but without HF or CKD?

A
  • Thiazide diuretics
  • Calcium channel blockers
58
Q

List the four thiazide diuretics.

A
  • Chlorthalidone
  • Hydrochlorothiazide
  • Indapamide
  • Metolazane
59
Q

List the four loop diuretics.

A
  • Furosemide
  • Torsemide
  • Bumetanide
  • Ethacrynic acid
60
Q

List the two aldosterone antagonist diuretics.

A
  • Spironolactone
  • Eplerenone
61
Q

List the two potassium-sparing diuretics.

A
  • Amiloride
  • Triamterene
62
Q

Explain the initial antihypertensive effects of diuretics.

A
  1. Diuresis
  2. Reduced stroke volume
  3. Increase in PVR
63
Q

Explain the chronic antihypertensive effects of diuretics.

A
  1. Stroke volume returns to normal
  2. Decrease in PVR (below pretreatment)
64
Q

Which thiazide diuretic is most potent?

A

Chlorthalidone

65
Q

Which trial determined that thiazide diuretics are first-line for most hypertension patients?

A

ALLHAT

66
Q

When are thiazidide diuretics more effective than loop diuretics in hypertensive patients?

A

When CrCl >30 ml/min

67
Q

How should thiazide diuretics be administered (frequency and time of day)?

A

Once daily in the morning to avoid nocturnal diuresis

68
Q

What adverse effects are associated with thiazide diuretics?

A
  • Hypokalemia
  • Hypomagnesemia
  • Hypercalcemia
  • Hyperuricemia
  • Hyperglycemia
  • Hyperlipidemia
  • Sexual dysfunction
  • Increase in TGs/cholesterol
69
Q

What drug class interacts with thiazide diuretics?

A

Lithium (toxicity with concurrent use)

70
Q

What are the two contraindications for thiazide diuretics?

A
  • Sulfa allergy
  • Anuria
71
Q

When are loop diuretics more effective than thiazides?

A
  • Heart failure symptom management
  • CrCl <30 ml/min
72
Q

What can help with the high-ceiling dose response curve in loop diuretics?

A
  • May need higher doses with severely reduced renal function/fluid overload
  • Switch to another loop diuretic
  • Switch from PO to IV
73
Q

How should loop diuretics be administered (frequency and time of day)?

A

Once or twice daily in the morning/afternoon to avoid nocturnal diuresis.

74
Q

What adverse effects are associated with loop diuretics?

A
  • Hypokalemia
  • Hypomagnesemia
  • Hypocalcemia
  • Hyperuricemia
  • Ototoxicity
75
Q

When are loop diuretics contraindicated?

A

Sulta allergy

76
Q

What trial demonstrated that spironolactone is preferred with resistant hypertension?

A

PATHWAY-2

77
Q

How should aldosterone antagonists be administered (frequency and time of day)?

A

Once or twice daily in the morning/afternoon to avoid noctural diuresis

78
Q

When should you consider holding/reducing aldosterone antagonist doses?

A
  • Potassium >5.5 mEq/L
  • SCr increase >25%
79
Q

What adverse effects are associated with aldosterone antagonists?

A
  • Gynecomastia (spironolactone only)
  • Hyperkalemia
  • Hyponatremia
80
Q

When is eplerenone contraindicated?

A
  • Impaired renal function (CrCl <50 or SCr >2 (male) or >1.8 (female))
  • T2DM and proteinuria
  • Concomitant use of potassium sparing diuretics
81
Q

When is spironolactone contraindicated?

A

Concomitant use of potassium-sparing diuretics

82
Q

Since potassium-sparing diuretics have minimal effect on blood pressure alone, how are they commonly used?

A

In combination with thiazides to minimize hypokalemia

83
Q

How should potassium-sparing diuretics be administered?

A

Once or twice daily in the morning to avoid nocturnal diuresis

84
Q

When should caution be used with potassium-sparing diuretics?

A
  • Diabetics
  • CKD (GFR <45 ml/min)
  • Gout
85
Q

What adverse effects are associated with potassium-sparing diuretics?

A
  • Hyperkalemia
  • Increased uric acid
  • Hyperglycemia
86
Q

When should electrolytes and renal function be monitored in patients taking thiazide and potassium-sparing diuretics?

A
  • Baseline
  • 1-2 weeks after initiation
  • Every 6-12 months
87
Q

When should electrolytes and renal function be monitored in patients taking loop diuretics and aldosterone antagonists?

A
  • Baseline
  • 1-2 weeks after initiation
  • 3-4 weeks after initiation
  • Every 6-12 months
88
Q

How do ACE inhibitors work?

A

Inhibit conversion of angiotensin I to angiotensin II

89
Q

How do angiotensin II receptor blockers (ARBs) work?

A

Block the effects of angiotensin II by binding to target receptors

90
Q

How do renin inhibitors work?

A

Inhibit the conversion of angiotensinogen to angiotensin I

91
Q

ACE inhibitors are drugs with what suffix?

A

“-pril”

92
Q

ACE inhibitors have additional benefit in patients with a history of what?

A
  • Diabetes with proteinuria
  • Heart failure
  • Post-MI
  • CKD
93
Q

Why are ACE inhibitors a good option for PM dosing?

A

To ensure blood pressure dipping overnight

94
Q

How do ACE inhibitors provide antihypertensive effects?

A
  • Vasodilation
  • Reduced PVR
  • Increased diuresis
95
Q

What is the only ACE inhibitor that is dosed 2-3 times daily?

A

Captopril

96
Q

All ACE inhibitors (except for captopril) are dosed at what frequency?

A

Minimum once daily

97
Q

What adverse effects are associated with ACE inhibitors?

A
  • Angioedema
  • Cough
  • Hyperkalemia
  • Acute renal failure with severe bilateral renal artery stenosis
98
Q

When are ACE inhibitors contraindicated?

A
  • History of angioedema on an ACE inhibitor
  • Concomitant use of aliskiren in patients with diabetes
  • Pregnancy/breastfeeding
99
Q

ARB drugs have what suffix?

A

“-sartan”

100
Q

Why is there a smaller risk of cough with ARBs?

A

They don’t block bradykinin breakdown

101
Q

Why are ARBs a good option for PM dosing?

A

To ensure blood pressure dipping overnight

102
Q

Explain the antihypertensive effect of ARBs.

A
  • Vasodilation
  • Reduced PVR
  • Increased diuresis
103
Q

How are ARBs administered (frequency and time of day)?

A

Once to twice daily at bedtime

104
Q

What adverse effects are associated with ARBs?

A
  • Angioedema (less than ACEi)
  • Hyperkalemia
  • Acute renal failure/severe bilateral renal artery stenosis
105
Q

When are ARBs contraindicated?

A
  • History of angioedema on an ARB
  • Concomitant use of aliskiren in patients with diabetes
  • Pregnancy/breastfeeding
106
Q

What drug is a direct renin inhibitor?

A

Aliskiren

107
Q

When is aliskiren contraindicated?

A
  • Concomitant use with an ACEi/ARB in diabetes patients
  • Pregnancy
108
Q

How is aliskiren administered?

A

Once daily

109
Q

What three categories should be monitored in patients taking aliskiren?

A
  • Potassium
  • BUN
  • SCr

(same as ACEi/ARBs)

110
Q

What adverse effects are associated with aliskiren?

A
  • Diarrhea
  • Musculoskeletal effects (CK increase)
  • Dizziness
  • Headache
  • Hyperkalemia
  • Renal insufficiency (ARF)
  • Orthostatic hypotension
111
Q

How do calcium channel blockers work?

A

They cause coronary and peripheral vasodilation by inhibiting calcium influx across cardiac and smooth muscle cell membranes

112
Q

What class of calcium channel blockers causes more vasodilation?

A

Dihydropyridines

113
Q

What class of calcium channel blockers causes more inotropic effects?

A

Non-dihydropyridines

114
Q

Dihydropyridine CCBs have what suffix?

A

“-pine”

115
Q

Which two dihydropyridine CCBs have no negative inotropic effects?

A

Amlodipine and felodipine

116
Q

Dihydropyridine CCBs have additional benefit in which patient populations?

A
  • Reynaud’s syndrome
  • Elderly patients with isolated systolic hypertension
117
Q

What can result given that dihydropyridine CCBs are more potent vasodilators?

A

Baroreceptor-mediated tachycardia

118
Q

Which type of dihydropyridine CCBs are preferred in treating hypertension?

A

Long-acting dihydropyridines

119
Q

How are dihydropyridine CCBs administered?

A

Once or twice daily

(Twice = isradipine and nicardipine DR)

120
Q

What adverse effects are associated with dihydropyridine CCBs?

A
  • Peripheral edema (dose-related)
  • Reflex tachycardia
  • Flushing
  • Dizziness
  • Headache
  • Gingival hyperplasia
121
Q

What warning is associated with dihydropyridine CCBs?

A

Increased risk of angina/MI in patients with obstructive coronary disease due to reflex tachycardia (for short-acting, immediate release)

122
Q

What do dihydropyridine CCBs interact with?

A
  • Grapefruit juice
  • CYP3A4 inducers/inhibitors (i.e. statins)
123
Q

What are the two non-dihydropyridine CCBs?

A

Diltiazem and verapamil

124
Q

Non-dihydropyridine CCBs are shown to have additional benefit in which patient populations?

A
  • Supraventricular tachyarrhythmias (atrial fibrilation)
  • Angina patients who can’t tolerate beta blockers
125
Q

Explain the antihypertensive effect of non-dihydopyridine CCBs.

A

Slows AV node conduction and decreases heart rate (negative inotopic effects)

126
Q

How are non-dihydropyridine CCBs administered?

A

Once or twice daily

127
Q

What adverse effects are associated with non-dihydropyridine CCBs?

A
  • Bradycardia
  • Headache
  • Dizziness
  • AV node block
  • Systolic heart failure
  • Gingival hyperplasia
  • Constipation (verapamil > diltiazem)
128
Q

What drug interactions exist with non-dihydropyridine CCBs?

A
  • Concomitant use of beta blockers (increased risk of heart block)
  • Grapefruit juice
  • CYP3A4 inducers/inhibitors
129
Q

When are non-dihydropyridine CCBs contraindicated?

A
  • Heart block
  • Left ventricular dysfunction
130
Q

Which calcium channel blocker should be used in heart failure patients?

A

Amlodipine

131
Q

List the cardioselective beta blockers.

A
  • Atenolol
  • Betaxolol
  • Bisoprolol
  • Metoprolol tartrate
  • Metoprolol succinate
  • Nebivolol
132
Q

List the nonselective beta blockers.

A
  • Nadolol
  • Propranolol IR
  • Propranolol LA
133
Q

When should nonselective beta blockers be avoided?

A

In bronchospastic airway disease

134
Q

List the intrinsic sympathomimetic activity beta blockers.

A
  • Acebutolol
  • Penbutolol
  • Pindolol
135
Q

When should intrinsic sympathomimetic activity beta blockers be avoided?

A

Heart failure and IHD.

136
Q

List the mixed alpha/beta blockers.

A
  • Carvedilol
  • Labetalol
137
Q

What are the two compelling indications that would make beta blockers first-line for hypertension?

A

Heart failure and CAD

138
Q

Beta blockers are shown to have additional benefit in which patient populations?

A
  • Tachyarrhythmias
  • Tremors
  • Migraines
  • Thyrotoxicosis

Fall 2020: Therapeutics 2 (11 decks)

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