Treating Hypertension

Question 1

A single elevated blood pressure reading . . .

Answer 1

. . . does not establish a diagnosis of HTN

Question 2

Nonpharmacologic treatments for HTN

Answer 2

• Weight Loss
• Exercise
• Diet (lower sodium intake, increase potassium intake, decrease alcohol consumption)
• Smoking cessation
• Relaxation therapy

Question 3

Pharmacologic management of blood pressure tree diagram

Answer 3

Question 4

___ are the most commonly perscribed diuretics.

Answer 4

Thiazides are the most commonly perscribed diuretics.

Question 5

Adverse thiazide side effects

Answer 5

• Increased blood glucose, TAG, and LDL
• Hypokalemia
• Hyperuricemia
• Decreased sexual function

Question 6

Doxazosin

Answer 6

α₁-antagonist

Question 7

ACE inhibitor mechanisms

Answer 7

1. Decreased angiotensin II direct vasoconstriction
2. Decreased sodium and water retention
3. Increased circulating bradykinin (vasodilation)

Question 8

ACE inhibitor side effects

Answer 8

• Dry cough
• Hyperkalemia
• Azotemia (high levels of nitrogen-containing metabolites)

Question 9

Angiotensin II receptor blockers

Answer 9

Inhibit vasoconstriction and aldosterone selection by directly antagonizing the AT1 receptors. Usually much better tolerated than ACE inhibitors, and do not have cough as a side effect.

Question 10

Current recommendations for limiting salt intake in hypertensive patients

Answer 10

<6 g of sodium chloride per day

This is less than 1/3 the average American’s daily salt consumption

Question 11

Centrally acting α₂-adrenergic agonists

Answer 11

Ex, methyldopa and clonidine

Reduce sympathetic outflow to the heart, blood vessels, and kidneys

Rarely used owing to their high frequency of side effects (e.g., dry mouth, sedation)

Question 12

Direct renin inhibitor

Answer 12

Aliskiren

Newest class of antihypertensives. reduces levels of angiotensin I and angiotensin II by binding to the proteolytic site of renin, thus inhibiting cleavage of angiotensinogen.

Side effects and long-term effects still unknown.

Question 13

Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure recommendations for treating HTN

Answer 13

• Start with thiazide diurectics as the first line treatment for uncomplicated HTN
• In patients with concurrent heart failure, diabetes, or LV dysfunction following myocardial infarction, consider starting with an ACE inhibitor
• In a patient with CAD, a β-blocker is most appropriate

Question 14

Why is combination drug therapy so frequent in treating HTN?

Answer 14

The effects of one drug, acting at one physiologic control point, can be defeated by natural compensatory mechanisms.

For example, the drop in renal perfusion by a direct vasodilator can activate the renin–angiotensin system, prompting the kidney to retain more volume, thereby blunting the antihypertensive benefit. A direct vasodilator is often paired with a low-dose diuretic to avoid the undesired volume expansion effect.

Question 15

Effects of pregnancy on blood pressure

Answer 15

BP usually declines during the first trimester of pregnancy and then slowly rises.

Question 16

Preeclampsia

Answer 16

A dangerous form of hypertension with proteinuria that has the potential to result in serious adverse consequences for a pregnant mother (stroke, HF) and fetus (small for gestational age, premature birth)

Most effective risk reduction is with beta blockers and calcium channel blockers.

Question 17

Many commonly used antihypertensives, such as ___, are contraindicated for pregnancy

Answer 17

Many commonly used antihypertensives, such as ACE inhibitors, angiotensin receptor blockers, and direct renin inhibitors, are contraindicated for pregnancy

Question 18

What drugs are indicated for treatment of hypertensive pregnant women?

Answer 18

• Beta blockers (labetalol)
• Calcium channel blockers (nifedipine)
• Centrally acting alpha2 agonists (methyldopa)
• Alpha1 blockers (hydralazine)

Question 19

Factoring racial trends into treating blood pressure

Answer 19

In general, whites appear to respond better to beta-blockers and ACE inhibitors whereas blacks appear to respond better to diuretics and calcium channel blockers.

You should know these, BUT, do not let them guide clinical decisions. HTN is a patient-tailored approach and this is a sweeping generalization that is not particularly nuanced.

Question 20

Most hypertensive patients need ____ for adequate blood pressure control

Answer 20

Most hypertensive patients need 2 to 4 drugs for adequate blood pressure control

Question 21

Thiazides: Mechanism, When to use, Side effects

Answer 21

Hydrochlorothiazide and Chlorthalidone

Mechanism: Blocks Na+ and H2O reabsorption at distal convoluted tubule

When to use: 1st line anti-HTN medication, Can use with loop diuretics to increase diuresis in volume overload

Side effects: HYPOKALEMIA, Volume depletion, Metabolic alkalosis, Hypercalcemia, Hyperuricemia/Gout

Question 22

Loop diuretics: Mechanism, When to use, Side effects

Answer 22

Furosemide and Torsemide

Mechanism: Blocks Na+ and H2O reabsorption at ascending loop of Henle

When to use: Congestive heart failure, Edema/volume overload, hyperkalemia

Side effects: HYPOKALEMIA, Volume depletion, Metabolic alkalosis, Ototoxicity

Question 23

K+ sparing diuretics: Mechanism, When to use, Side effects

Answer 23

Spironolactone

Mechanism: Mineralocorticoid receptor blocker, indirectly blocks Na+ and H2O reabsorption at collecting duct

When to use: Management of refractory edema in CHF and cirrhosis, Reduction of K+ loss from other diuretic therapy, Attenuation of cardiac remodeling in heart failure

Side effects: HYPERKALEMIA, Gynecomastia