Therapy of Hypertension Flashcards
What are the non-drug causes of secondary hypertension?
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)
Which drugs can cause secondary hypertension? !!!
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
Which drugs are anti-vascular endothelial growth factors?
1) Bevacizumab
2) Ranibizumab
3) Aflibercept
Which drugs are Calcineurin inhibitors?
1) Cyclosporine
2) Tacrolimus
Which drugs are decongestants?
1) Pseudoephedrine
2) Phenylephrine
Which drugs are Ergot alkaloids?
1) Bromocriptine
2) Methysergide
3) Dihydroergotamine
Which drugs are Erythropoiesis-stimulating agents?
1) Erythropoietin
2) Darbepoetin
What is the first step in management of secondary hypertension?
Removing the offending agent or treating/correcting the underlying co-morbid condition
Hypertensive crises (>180/>120) are categorized into:
1) Hypertensive emergency
2) Hypertensive urgency
What is a hypertensive emergency?
Extreme BP elevations that are accompanied by acute or progressing end-organ damage
What is a hypertensive urgency?
Extreme BP elevations without acute or progressing end-organ injury
The specific selection of antihypertensive drug therapy should be based on:
Evidence demonstrating CV event reduction
According to JNC8, the BP goal for ages ≥ 60 years is:
< 150/90
According to JNC8, the BP goal for ages < 60 years is:
< 140/90
Treating patients to lower BP goals may lead to:
1) Hypotension
2) Syncope
3) Electrolyte abnormalities
4) Acute kidney injury or failure
What is the main reason for poor BP control rates?
“Clinical Inertia”
What is “Clinical Inertia”?
A clinic visit at which NO therapeutic move was made to lower BP in a patient with uncontrolled hypertension
After the diagnosis of hypertension, most patients should be placed on:
Both life-style modifications and drug therapy
After the diagnosis of pre-hypertension, most patients should be placed on:
Life-style modifications
The choice of initial antihypertensive drug therapy depends on:
1) Degree of BP elevation
2) Presence of compelling indication
Most patients with stage 1 hypertension should be initially treated with a first-line drug or the combination of two, which are:
Monotherapy:
1) ACEi
2) ARB
3) CCB
4) Thiazide diuretic
Two-drug combination:
ACEi or ARB + CCB or thiazide diuretic.
For patients with stage 2 hypertension, combination drug therapy is recommended, using preferably two first-line antihypertensive drugs, such as:
1) ACEi or ARB + CCB
2) ACEi or ARB + thiazide
Life-style modifications should never be used as:
A replacement for antihypertensive drug therapy
Which lifestyle modifications should pre-hypertensive and hypertensive patients follow?
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
Maximum sodium intake should be:
2400 mg/day
Why are the first-line drugs chosen?
Because of evidence demonstrating cardiovascular event reduction
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
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.
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)
What drug therapy is used for patients with compelling indications?
Drug combination
Systolic heart failure is associated with:
Decreased cardiac output
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
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.
Which drug relieves edema in heart failure with reduced ejection fraction?
Diuretics
____ are often needed, especially for patients with more advanced heart failure and/or CKD.
Loop diuretics
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
The addition of an aldosterone antagonist (spironolactone or eplerenone) in heart failure with reduced ejection fraction can reduce:
Cardiovascular morbidity and mortality
What are the first choices to decrease cardiac adrenergic stimulation post-MI?
1) β-Blockers (without intrinsic sympathomimetic activity)
2) ACEi or ARB
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
ACEi treatment post-MI:
1) Improves cardiac remodeling and function
2) Reduces cardiovascular events
What should be used first post-MI: β-Blockers or ACEi/ARBs?
β-blockers
What are the most common hypertension-associated complications?
1) Chronic stable angina
2) Acute coronary syndrome (unstable angina and acute MI)
___ is a standard of care for treating hypertension-associated complications.
β-Blocker therapy
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.
Which drugs are alternatives to β-blockers in hypertension-associated complications?
Long-acting CCBs
What are the long-acting CCBs?
The Non-dihydropyridines:
1) Diltiazem
2) Verapamil
____ are considered as add-on therapy in chronic stable angina for patients with ischemic symptoms.
Dihydropyridine CCBs
Thiazides can be added to the therapy of Coronary Artery Disease to:
1) Provide additional BP lowering
2) Further reduce cardiovascular risk
Do thiazides provide anti-ischemic effects?
NO
___ have been shown to reduce CV events in patients with diabetes.
ACEi/ARB
ACEi/ARBs provide ___ due to vasodilation in the efferent arteriole.
Nephro-protection
___ are the most appropriate add-on agents for BP control for patients with diabetes.
CCBs
ACEi/ARBs provide nephro-protection due to:
Vasodilation in the efferent arteriole
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
Which physiologic function still occurs during a hypoglycemic episode despite β-blocker therapy?
Sweating
Which type of β-blockers are used in diabetic patients?
Selective
How do ACEi/ARBs slow the progression of CKD in diabetics and nondiabetics?
By reducing intraglomerular
pressure
Patients may experience ____ when given an ACEi or ARB.
1) A rapid and profound drop in BP
2) Acute kidney failure
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
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.
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
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
Which drug can be used in hypertensive patients with reactive airway disease (asthma or COPD)?
β-blocker with α1-blocking properties (Carvedilol)
Alternative drug treatments for hypertension include:
1) Direct renin inhibitors
2) α-blockers
3) Central α2-agonists
4) Adrenergic inhibitors
5) Direct arterial vasodilators
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
When do we use alternative drug treatments for hypertension?
1) Resistant hypertension
2) Add-on therapy with multiple other first-line antihypertensive agents
Hypertension may present as ___ in the elderly.
Isolated systolic hypertension
Which population is at high risk for hypertension-associated complications?
The elderly
Which antihypertensives reduce cardiovascular morbidity and mortality in the elderly?
1) Thiazides
2) Long-acting dihydropyridine CCBs
Elderly patients are more sensitive to ____ than younger patients = orthostatic hypotension = ↑ falls
1) Volume depletion
2) Sympathetic inhibition
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
To minimize risks in the elderly, dosage should be:
Titrated over a longer period of time
Standard SBP goals of ___ should be considered for elderly patients, who tolerate therapy.
<140 mmHg
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).
Hypertensive children often have/are:
1) Family history of high BP
2) Overweight
What is the most common cause of secondary hypertension in children?
Kidney disease (Pyelonephritis, Glomerulonephritis)
What, other than kidney disease, can cause secondary hypertension in children?
Coarctation of the aorta
___ is the cornerstone of hypertension therapy in children.
Weight loss
Which antihypertensive drugs can be used in children?
1) ACEi
2) ARB
3) β-blocker
4) CCB
5) Thiazide
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
What should you monitor when giving Aldosterone antagonists?
1) BP
2) BUN/serum creatinine
3) Serum potassium
What should you monitor when giving ACEis & ARBs?
1) BP
2) BUN/serum creatinine
3) Serum potassium
What should you monitor when giving Calcium channel
blockers?
1) BP
2) Heart rate
What should you monitor when giving Thiazides?
1) BP
2) BUN/serum creatinine
3) Serum electrolytes (potassium, magnesium, sodium)
4) Uric acid
5) Glucose
What should you monitor when giving β-Blockers?
1) BP
2) Heart rate
Only __ of patients with newly diagnosed hypertension are continuing treatment at 1 year.
50%
Identification of nonadherence should be followed up with:
Appropriate patient education, counseling, and intervention.
___ are preferred in most patients to improve adherence.
Once-daily regimens
When is resistant hypertension diagnosed?
Failure to achieve goal BP with the use of three or more antihypertensive drugs
Pseudo-resistance should also be ruled out by:
Assuring adherence with prescribed therapy.
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
What can cause volume overload?
1) Excess sodium intake
2) Volume retention from kidney disease
3) Inadequate diuretic therapy
A common error with hypertensive urgency is:
Aggressive antihypertensive therapy
Hypertensive urgencies are ideally managed by:
Adjusting maintenance therapy
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
Should we attempt very rapid reductions in BP to goal values?
NO
What are the risks of reducing BP too rapidly in hypertensive urgencies?
1) Cerebrovascular accidents
2) MI
3) Acute renal failure
Hypertensive urgency requires BP reductions with oral antihypertensive agents to stage 1 (130-139/80-89) over a period of:
Several hours to days
All patients with hypertensive urgency should be reevaluated within, and NOT later than:
7 days (preferably after 1 to 3 days)
Which antihypertensives can be given during hypertensive urgency?
Short-acting oral antihypertensives:
1) Captopril
2) Clonidine
3) Labetalol
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
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)
Hypertensive emergencies require____ to limit new or progressing end-organ damage.
Immediate BP reduction
Hypertensive emergencies require ___ therapy initially.
Parenteral
Do NOT lower BP to ___ mmHg in hypertensive emergencies.
˂ 140/90
The initial target in hypertensive emergencies is:
A reduction in MAP of up to 25% within minutes to hours
When the patient is stable, DBP in hypertensive emergencies can be reduced to:
100-110 mmHg within the next 2-6 hours
Precipitous drops in BP in hypertensive emergencies may lead to:
End-organ ischemia or infarction
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
A persistent BP >185/110 mmHg is a contraindication to:
Intravenous thrombolytic therapy
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%
Which drug is ideal for the management of hypertensive emergency in the presence of
myocardial ischemia?
IV nitroglycerin
Which drug was the first choice in the past?
Sodium nitroprusside
IV nitroglycerin is associated with ___ when used over 24 to 48 hours and can cause severe headache.
Tolerance
Which drug is ideal for the management of hypertensive emergency in the presence of
renal insufficiency?
Fenoldopam
What is Fenoldopam?
Dopamine D1-receptor agonist
__ and __ provide arterial vasodilation and can treat cardiac ischemia similar to nitroglycerin, and may provide more predictable reductions in BP.
1) Nicardipine
2) Clevidipine
Adverse effects of Sodium nitroprusside?
1) Nausea
2) Vomiting
3) Muscle twitching
4) Sweating
5) Thiocyanate and cyanide intoxication
Special indications for Sodium nitroprusside?
Most hypertensive emergencies except if renal function is impaired
Use Sodium nitroprusside with caution in:
1) High intracranial pressure
2) Azotemia
3) Chronic kidney disease
Adverse effects of Nitroglycerin?
1) Headache
2) Vomiting
3) Methemoglobinemia
4) Tolerance with prolonged use
Special indications for Nitroglycerin?
Coronary ischemia
Adverse effects of Clevidipine?
1) Headache
2) Nausea
3) Tachycardia
4) Hypertriglyceridemia
Special indications for Clevidipine?
Most hypertensive emergencies
except acute heart failure
Use Clevidipine with caution in:
Coronary ischemia
Contraindications for Clevidipine?
1) Soy or egg allergy
2) Defective lipid metabolism
3) Severe aortic stenosis
Adverse effects of Nicardipine?
1) Tachycardia
2) Headache
3) Flushing
4) Local phlebitis
Special indications for Nicardipine?
Most hypertensive emergencies except acute heart failure
Use Nicardipine with caution in:
Coronary ischemia
Adverse effects of Enalaprilat?
1) Precipitous fall in pressure in high-renin states
2) Variable response
Special indications for Enalaprilat?
Acute left ventricular failure
Avoid Enalaprilat in:
1) Acute myocardial infarction
2) Eclampsia
Adverse effects of Esmolol?
1) Hypotension
2) Nausea
3) Asthma
4) First-degree heart block
5) Heart failure
Special indications for Esmolol?
1) Aortic dissection
2) Perioperative
Avoid Esmolol in patients that are:
1) Already on β-blockers
2) Bradycardic
3) Decompensated heart failure
Adverse effects of Fenoldopam?
1) Tachycardia
2) Headache
3) Nausea
4) Flushing
Special indications for Fenoldopam?
Most hypertensive emergencies
Use Fenoldopam with caution in:
Glaucoma
Adverse effects of Hydralazine?
1) Tachycardia
2) Flushing
3) Headache
4) Vomiting
5) Aggravation of angina
Special indications for Hydralazine?
Eclampsia
Adverse effects of Labetalol?
1) Vomiting
2) Scalp tingling
3) Bronchoconstriction
4) Dizziness
5) Nausea
6) Heart block
7) Orthostatic hypotension
Special indications for Labetalol?
Most hypertensive emergencies except acute heart failure or heart block
