Therapy of Hypertension Flashcards
1
Q
What are the non-drug causes of secondary hypertension?
A
1) Chronic kidney disease
2) Cushing’s syndrome
3) Coarctation of the aorta
4) Obstructive sleep apnea
5) Primary hyperparathyroidism
6) Pheochromocytoma
7) Primary aldosteronism
8) Renovascular disease.
9) Thyroid disease (both hypo- and hyper-thyroidism)
2
Q
Which drugs can cause secondary hypertension? !!!
A
1) Amphetamines
2) Antivascular endothelial growth factor agents.
3) Corticosteroids
4) Calcineurin inhibitors
5) Decongestants
6) Ergot alkaloids
7) Erythropoiesis-stimulating agents
8) Estrogen-containing oral contraceptives
9) NSAIDs
10) β-blocker withdrawal
11) Tyramine-containing foods
12) Street drugs
13) Alcohol
14) Licorice
3
Q
Which drugs are anti-vascular endothelial growth factors?
A
1) Bevacizumab
2) Ranibizumab
3) Aflibercept
4
Q
Which drugs are Calcineurin inhibitors?
A
1) Cyclosporine
2) Tacrolimus
5
Q
Which drugs are decongestants?
A
1) Pseudoephedrine
2) Phenylephrine
6
Q
Which drugs are Ergot alkaloids?
A
1) Bromocriptine
2) Methysergide
3) Dihydroergotamine
7
Q
Which drugs are Erythropoiesis-stimulating agents?
A
1) Erythropoietin
2) Darbepoetin
8
Q
What is the first step in management of secondary hypertension?
A
Removing the offending agent or treating/correcting the underlying co-morbid condition
9
Q
Hypertensive crises (>180/>120) are categorized into:
A
1) Hypertensive emergency
2) Hypertensive urgency
10
Q
What is a hypertensive emergency?
A
Extreme BP elevations that are accompanied by acute or progressing end-organ damage
11
Q
What is a hypertensive urgency?
A
Extreme BP elevations without acute or progressing end-organ injury
12
Q
The specific selection of antihypertensive drug therapy should be based on:
A
Evidence demonstrating CV event reduction
13
Q
According to JNC8, the BP goal for ages ≥ 60 years is:
A
< 150/90
14
Q
According to JNC8, the BP goal for ages < 60 years is:
A
< 140/90
15
Q
Treating patients to lower BP goals may lead to:
A
1) Hypotension
2) Syncope
3) Electrolyte abnormalities
4) Acute kidney injury or failure
16
Q
What is the main reason for poor BP control rates?
A
“Clinical Inertia”
17
Q
What is “Clinical Inertia”?
A
A clinic visit at which NO therapeutic move was made to lower BP in a patient with uncontrolled hypertension
18
Q
After the diagnosis of hypertension, most patients should be placed on:
A
Both life-style modifications and drug therapy
19
Q
After the diagnosis of pre-hypertension, most patients should be placed on:
A
Life-style modifications
20
Q
The choice of initial antihypertensive drug therapy depends on:
A
1) Degree of BP elevation
2) Presence of compelling indication
21
Q
Most patients with stage 1 hypertension should be initially treated with a first-line drug or the combination of two, which are:
A
Monotherapy:
1) ACEi
2) ARB
3) CCB
4) Thiazide diuretic
Two-drug combination:
ACEi or ARB + CCB or thiazide diuretic.
22
Q
For patients with stage 2 hypertension, combination drug therapy is recommended, using preferably two first-line antihypertensive drugs, such as:
A
1) ACEi or ARB + CCB
2) ACEi or ARB + thiazide
23
Q
Life-style modifications should never be used as:
A
A replacement for antihypertensive drug therapy
24
Q
Which lifestyle modifications should pre-hypertensive and hypertensive patients follow?
A
1) Gradual weight loss
2) Diet
3) Reduced salt intake
4) Aerobic physical activity
5) Moderation of alcohol intake
6) Smoking cessation
7) Control of diabetes and dyslipidemia
25
Maximum sodium intake should be:
2400 mg/day
26
Why are the first-line drugs chosen?
Because of evidence demonstrating cardiovascular event reduction
27
β-Blocker therapy should be reserved to either:
1) Treat a specific compelling indication
OR
2) Used in combination with one or more of the first-line antihypertensive agents for patients without a compelling indication
28
When can β-blockers be used as first-line antihypertensive agents?
When an ACEi, ARB, CCB, or thiazide can NOT be used as the first-line agent.
29
Alternative antihypertensive drug classes may be used in select patients after first-line agents, such as:
1) Loop diuretics
2) Potassium sparing diuretics
3) β-blockers
4) α1-blockers
5) Central α2-agonists
6) Direct renin inhibitors
7) Direct arterial vasodilator (hydralazine)
30
What drug therapy is used for patients with compelling indications?
Drug combination
31
Systolic heart failure is associated with:
Decreased cardiac output
32
Which antihypertensives are indicated in heart failure with reduced ejection fraction?
1) Low dose ACEi or ARB
+
2) Diuretic therapy
+
3) Low dose β-blocker (Bisoprolol, Carvedilol, or Metoprolol)
±
4) Aldosterone receptor antagonist
33
Why low dose ACEi/ARBs in heart failure with reduced ejection fraction?
Heart failure induces a compensatory high-renin condition = profound first-dose effect and possible orthostatic hypotension.
34
Which drug relieves edema in heart failure with reduced ejection fraction?
Diuretics
35
____ are often needed, especially for patients with more advanced heart failure and/or CKD.
Loop diuretics
36
Which β-blockers are the only ones proven to be beneficial in heart failure with reduced ejection fraction?
1) Bisoprolol
2) Carvedilol
3) Sustained-release Metoprolol
37
The addition of an aldosterone antagonist (spironolactone or eplerenone) in heart failure with reduced ejection fraction can reduce:
Cardiovascular morbidity and mortality
38
What are the first choices to decrease cardiac adrenergic stimulation post-MI?
1) β-Blockers (without intrinsic sympathomimetic activity)
2) ACEi or ARB
39
Why are β-Blockers and ACEi or ARB the first choice post-MI?
They reduce the risk of a subsequent MI or sudden cardiac death
40
ACEi treatment post-MI:
1) Improves cardiac remodeling and function
2) Reduces cardiovascular events
41
What should be used first post-MI: β-Blockers or ACEi/ARBs?
β-blockers
42
What are the most common hypertension-associated complications?
1) Chronic stable angina
2) Acute coronary syndrome (unstable angina and acute MI)
43
___ is a standard of care for treating hypertension-associated complications.
β-Blocker therapy
44
β-Blocker therapy is the first-line therapy in chronic stable angina and have the ability to:
Reduce BP and improve ischemic symptoms by decreasing myocardial oxygen consumption and demand.
45
Which drugs are alternatives to β-blockers in hypertension-associated complications?
Long-acting CCBs
46
What are the long-acting CCBs?
The Non-dihydropyridines:
1) Diltiazem
2) Verapamil
47
____ are considered as add-on therapy in chronic stable angina for patients with ischemic symptoms.
Dihydropyridine CCBs
48
Thiazides can be added to the therapy of Coronary Artery Disease to:
1) Provide additional BP lowering
2) Further reduce cardiovascular risk
49
Do thiazides provide anti-ischemic effects?
NO
50
___ have been shown to reduce CV events in patients with diabetes.
ACEi/ARB
51
ACEi/ARBs provide ___ due to vasodilation in the efferent arteriole.
Nephro-protection
52
___ are the most appropriate add-on agents for BP control for patients with diabetes.
CCBs
53
ACEi/ARBs provide nephro-protection due to:
Vasodilation in the efferent arteriole
54
What problems do diabetic patients face when using β-Blockers?
1) Masking hypoglycemia signs & symptoms
2) Delay in hypoglycemia recovery time
3) Acutely elevated BP due to
vasoconstriction during hypoglycemia recovery
55
Which physiologic function still occurs during a hypoglycemic episode despite β-blocker therapy?
Sweating
56
Which type of β-blockers are used in diabetic patients?
Selective
57
How do ACEi/ARBs slow the progression of CKD in diabetics and nondiabetics?
By reducing intraglomerular
pressure
58
Patients may experience ____ when given an ACEi or ARB.
1) A rapid and profound drop in BP
2) Acute kidney failure
59
Patients may experience a rapid and profound drop in BP or acute kidney failure when given an ACEi or ARB, especially in patients with:
1) Bilateral renal artery stenosis
2) A solitary functioning kidney with stenosis
60
How can you minimize the risk of CKD when taking ACEi/ARBs?
Start with low dose and monitor serum creatinine soon after starting the drug.
61
Which drugs are given to reduce the risk of Ischemic strokes and transient ischemic attacks in hypertensive patients?
1) Thiazides
2) Combined with an ACEi or an ARB
AFTER patient stabilization
62
Which drugs should be avoided in hypertensive patients with reactive airway disease (asthma or COPD) due to a fear of
inducing bronchospasm?
1) Nonselective β-Blockers
2) ACEis or ARBs
63
Which drug can be used in hypertensive patients with reactive airway disease (asthma or COPD)?
β-blocker with α1-blocking properties (Carvedilol)
64
Alternative drug treatments for hypertension include:
1) Direct renin inhibitors
2) α-blockers
3) Central α2-agonists
4) Adrenergic inhibitors
5) Direct arterial vasodilators
65
Why aren't the alternative drug treatments for hypertension used much?
1) They do NOT reduce morbidity and mortality in hypertension
2) They have poor tolerability and adverse effects
66
When do we use alternative drug treatments for hypertension?
1) Resistant hypertension
2) Add-on therapy with multiple other first-line antihypertensive agents
67
Hypertension may present as ___ in the elderly.
Isolated systolic hypertension
68
Which population is at high risk for hypertension-associated complications?
The elderly
69
Which antihypertensives reduce cardiovascular morbidity and mortality in the elderly?
1) Thiazides
2) Long-acting dihydropyridine CCBs
70
Elderly patients are more sensitive to ____ than younger patients = orthostatic hypotension = ↑ falls
1) Volume depletion
2) Sympathetic inhibition
71
Which drugs should be avoided in the elderly because they are frequently associated with dizziness and orthostatic hypotension?
1) Centrally acting agents
2) α1-blockers
72
To minimize risks in the elderly, dosage should be:
Titrated over a longer period of time
73
Standard SBP goals of ___ should be considered for elderly patients, who tolerate therapy.
<140 mmHg
74
Which patients are at risk for orthostatic hypotension?
1) Older patients
Those with:
2) Isolated systolic hypertension
3) Long-standing diabetes
4) Severe volume depletion
5) Baroreflex dysfunction
6) Autonomic insufficiency
7) On concomitant venodilators (α-blockers, mixed α-/β-blockers, nitrates).
75
Hypertensive children often have/are:
1) Family history of high BP
2) Overweight
76
What is the most common cause of secondary hypertension in children?
Kidney disease (Pyelonephritis, Glomerulonephritis)
77
What, other than kidney disease, can cause secondary hypertension in children?
Coarctation of the aorta
78
___ is the cornerstone of hypertension therapy in children.
Weight loss
79
Which antihypertensive drugs can be used in children?
1) ACEi
2) ARB
3) β-blocker
4) CCB
5) Thiazide
80
Ongoing monitoring, in all patients treated with antihypertensive drugs, is required to assess:
1) The desired effects of antihypertensive therapy (BP goal)
2) Drug adverse effects
3) Disease progression
81
What should you monitor when giving Aldosterone antagonists?
1) BP
2) BUN/serum creatinine
3) Serum potassium
82
What should you monitor when giving ACEis & ARBs?
1) BP
2) BUN/serum creatinine
3) Serum potassium
83
What should you monitor when giving Calcium channel
blockers?
1) BP
2) Heart rate
84
What should you monitor when giving Thiazides?
1) BP
2) BUN/serum creatinine
3) Serum electrolytes (potassium, magnesium, sodium)
4) Uric acid
5) Glucose
85
What should you monitor when giving β-Blockers?
1) BP
2) Heart rate
86
Only __ of patients with newly diagnosed hypertension are continuing treatment at 1 year.
50%
87
Identification of nonadherence should be followed up with:
Appropriate patient education, counseling, and intervention.
88
___ are preferred in most patients to improve adherence.
Once-daily regimens
89
When is resistant hypertension diagnosed?
Failure to achieve goal BP with the use of three or more antihypertensive drugs
90
Pseudo-resistance should also be ruled out by:
Assuring adherence with prescribed therapy.
91
What are the causes of resistant hypertension?
1) Improper BP measurement
2) Volume overload
3) Drug-induced (2◦)
4) Other causes:
a) Nonadherence
b) Inadequate antihypertensive doses
5) Associated conditions:
a) Obesity
b) Excess alcohol intake
c) Obstructive sleep apnea
92
What can cause volume overload?
1) Excess sodium intake
2) Volume retention from kidney disease
3) Inadequate diuretic therapy
93
A common error with hypertensive urgency is:
Aggressive antihypertensive therapy
94
Hypertensive urgencies are ideally managed by:
Adjusting maintenance therapy
95
How can you adjust the maintenance therapy in hypertensive urgencies?
1) Adding a new antihypertensive
2) Increasing the dose of a present medication
= Gradual BP reduction
96
Should we attempt very rapid reductions in BP to goal values?
NO
97
What are the risks of reducing BP too rapidly in hypertensive urgencies?
1) Cerebrovascular accidents
2) MI
3) Acute renal failure
98
Hypertensive urgency requires BP reductions with oral antihypertensive agents to stage 1 (130-139/80-89) over a period of:
Several hours to days
99
All patients with hypertensive urgency should be reevaluated within, and NOT later than:
7 days (preferably after 1 to 3 days)
100
Which antihypertensives can be given during hypertensive urgency?
Short-acting oral antihypertensives:
1) Captopril
2) Clonidine
3) Labetalol
101
Oral or sublingual immediate-release ___ is dangerous and should never be used for hypertensive urgencies due to risk of causing severe adverse events (MI, stroke)
Nifedipine
102
Oral or sublingual immediate-release nifedipine is dangerous and should never be used for hypertensive urgencies due to risk of causing:
Severe adverse events (MI, stroke)
103
Hypertensive emergencies require____ to limit new or progressing end-organ damage.
Immediate BP reduction
104
Hypertensive emergencies require ___ therapy initially.
Parenteral
105
Do NOT lower BP to ___ mmHg in hypertensive emergencies.
˂ 140/90
106
The initial target in hypertensive emergencies is:
A reduction in MAP of up to 25% within minutes to hours
107
When the patient is stable, DBP in hypertensive emergencies can be reduced to:
100-110 mmHg within the next 2-6 hours
108
Precipitous drops in BP in hypertensive emergencies may lead to:
End-organ ischemia or infarction
109
If hypertensive emergency patients tolerate the BP reduction well, additional gradual reductions toward goal BP values can be attempted after 24 to 48 hours EXCEPT FOR WHICH PATIENTS?
Those with an acute ischemic stroke where maintaining an elevated BP is needed for a longer period of time
110
A persistent BP >185/110 mmHg is a contraindication to:
Intravenous thrombolytic therapy
111
If BP >220/120 mmHg, a reasonable goal would be to lower BP by approximately __ during the first 24 hours after onset of stroke.
15%
112
Which drug is ideal for the management of hypertensive emergency in the presence of
myocardial ischemia?
IV nitroglycerin
112
Which drug was the first choice in the past?
Sodium nitroprusside
113
IV nitroglycerin is associated with ___ when used over 24 to 48 hours and can cause severe headache.
Tolerance
114
Which drug is ideal for the management of hypertensive emergency in the presence of
renal insufficiency?
Fenoldopam
115
What is Fenoldopam?
Dopamine D1-receptor agonist
116
__ and __ provide arterial vasodilation and can treat cardiac ischemia similar to nitroglycerin, and may provide more predictable reductions in BP.
1) Nicardipine
2) Clevidipine
117
Adverse effects of Sodium nitroprusside?
1) Nausea
2) Vomiting
3) Muscle twitching
4) Sweating
5) Thiocyanate and cyanide intoxication
118
Special indications for Sodium nitroprusside?
Most hypertensive emergencies except if renal function is impaired
119
Use Sodium nitroprusside with caution in:
1) High intracranial pressure
2) Azotemia
3) Chronic kidney disease
120
Adverse effects of Nitroglycerin?
1) Headache
2) Vomiting
3) Methemoglobinemia
4) Tolerance with prolonged use
121
Special indications for Nitroglycerin?
Coronary ischemia
122
Adverse effects of Clevidipine?
1) Headache
2) Nausea
3) Tachycardia
4) Hypertriglyceridemia
123
Special indications for Clevidipine?
Most hypertensive emergencies
except acute heart failure
124
Use Clevidipine with caution in:
Coronary ischemia
125
Contraindications for Clevidipine?
1) Soy or egg allergy
2) Defective lipid metabolism
3) Severe aortic stenosis
126
Adverse effects of Nicardipine?
1) Tachycardia
2) Headache
3) Flushing
4) Local phlebitis
127
Special indications for Nicardipine?
Most hypertensive emergencies except acute heart failure
128
Use Nicardipine with caution in:
Coronary ischemia
129
Adverse effects of Enalaprilat?
1) Precipitous fall in pressure in high-renin states
2) Variable response
130
Special indications for Enalaprilat?
Acute left ventricular failure
131
Avoid Enalaprilat in:
1) Acute myocardial infarction
2) Eclampsia
132
Adverse effects of Esmolol?
1) Hypotension
2) Nausea
3) Asthma
4) First-degree heart block
5) Heart failure
133
Special indications for Esmolol?
1) Aortic dissection
2) Perioperative
134
Avoid Esmolol in patients that are:
1) Already on β-blockers
2) Bradycardic
3) Decompensated heart failure
135
Adverse effects of Fenoldopam?
1) Tachycardia
2) Headache
3) Nausea
4) Flushing
136
Special indications for Fenoldopam?
Most hypertensive emergencies
137
Use Fenoldopam with caution in:
Glaucoma
138
Adverse effects of Hydralazine?
1) Tachycardia
2) Flushing
3) Headache
4) Vomiting
5) Aggravation of angina
139
Special indications for Hydralazine?
Eclampsia
140
Adverse effects of Labetalol?
1) Vomiting
2) Scalp tingling
3) Bronchoconstriction
4) Dizziness
5) Nausea
6) Heart block
7) Orthostatic hypotension
141
Special indications for Labetalol?
Most hypertensive emergencies except acute heart failure or heart block
