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Cardio Exam 1 > Treatment of HTN 2 > Flashcards

Treatment of HTN 2 Flashcards

1
Q

ACEI can cause what when initiated?

A

Elevated SCr but this is normal

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2
Q

ACEI indication

A

DM, CKD, HF, Stroke, CHD

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3
Q

ACEI Adverse Effects

A 
Dry cough
Angioedema (blacks and smokers)
HYPOtension
Renal dysfunction
HYPERkalemia
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4
Q

Management of Dry Cough

A

Continue if it isn’t annoying
Switch to a different ACEI
Switch to an ARB

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5
Q

What causes the Cough?

A

Increase in bradykinin

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6
Q

ACEI Contraindications

A

Pregnancy
Bilateral Renal artery stenosis
Concurrent NSAID use

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7
Q

Why NSAIDs?

A

Decrease the GFR bc they inhibit PG synthesis which dilates the afferent arteries –> block that then you will have constriction at the afferent
Overall vasoconstriction occurs

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8
Q

ACEI Clinical Pearls

A

Decrease or stabilize albumiuria
Chronic renal insuf: start low and go slow
Monitor renal function and potassium
Limit salt intake

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9
Q

ARB Adverse Effects

A

Angioedema (blacks and smokers)
HYPOtension
Renal dysfunction
HYPERkalemia

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10
Q

ARB Containdications

A

Pregnancy
Bilateral Renal artery stenosis
Concurrent NSAID use

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11
Q

ARB Clinical Pearls

A 
No cough and dreased risk for angioedema
Similar outcomes as ACEI
Renal data available in DM and CKD
More expensive
Not to be in combo with another RAAS inhibitor
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12
Q

Dihydropyridines

A

Potent peripheral vasodilatory effects
Weak Negative inotropic effects (NOT amlodipine)
No effect on conduction (dromotropic)

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13
Q

Dihydropyridines adverse effects

A

Baroreceptor-mediated reflex tachycardia

Pedal edema

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14
Q

Non-Dihydropyridines

A

Verapamil

Diltiazem

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15
Q

Non-Dihydropyridines MOA

A 
Decrease chronotropic
Slow AV conduction (negative dromotropic effects)
Decreased inotropic effects (esp verap)
Weak peripheral vasodilatory effect
Coronary vasodilators
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16
Q

Non-Dihydropyridines Useful for?

A

Supreventrivcular tachyarrhythmias

Afib

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17
Q

Non-Dihydropyridines Adverse Effects

A

Bradycardia

Heart block

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18
Q

CCB Clinical Pearls

A

May use DHP + Non-DHP together
Constipation (verap)
Caution in combo with beta-blocker + Non-DHP (cause bradycardia)
Avoid short-acting DHP –> potent vasodilators –> lower BP really quickly
Watch for drug interactions (esp Non-DHP)

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19
Q

Beta Blockers place in therapy

A 
1st line along with thiazides with MI, HF, angina
High renin-hypertensives
Arrhthmias
Migraine headaches
Tremors
Anxiety
Thyrotoxicosis
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20
Q

Beta blockers are less effective?

A

In black pts

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21
Q

Beta blockers MOA

A

block B1 receptors in the heart and decrease inotropic and chronotropic in the heart
Also block beta receptors in the kidney and decrease renin release

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22
Q

Beta Blocker Adverse Effects

A

B1 blockade: bradycardia, 2nd or 3rd degree heart block, acute HF
B2 blockade: bronchospasm, cold extremities, Raynaud’s, Increased blood glucose and lipids, Mask hypoglycemia
Fatigue, depression and sexual dysfunction

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23
Q

Beta-Blocker Clinical Pearls

A

All lower BP to a similar extent
Cardio selective is dose dependent and varies
Use selective agents in those with COPD or asthma
Do not abruptly withdraw
Use with extreme caution if also on non-DHP

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24
Q

Direct Renin Inhibitor

A

Aliskiren (Tekturna)

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25
Aliskiren MOA
RAAS Inhibitor: inhibits the release of renin so there is no Ang II made
26
Renin normally does what?
Elevates BP via angiotensinogen to Ang I and Ang I to Ang II via ACE
27
Aliskiren Clinical Pearls
Equally as effective as ACEI or ARB Do not use with another RAS inhibitor No hard data
28
Alpha 2 Blockers MOA
Block receptors on blood vessels which causes vasodilation in the periphery
29
Alpha 2 Blockers drugs
Doxazosin (Cardura) Prazosin (Minipress) Terazosin (Hytrin)
30
Alpha 2 Blocker Clinical Pearls
Useful in men with benign prostate hyperplasia Take 1st dose at bedtime May cause Na and H20 retention
31
How do Alpha 2 Blockers cause Na and H20 retention?
Body wants to stay at homeostasis and you are causing vasodilation so the kidney would increase RAAS and cause the body to keep Na and H20
32
Central Alpha 2 Agonists MOA
Receptors in the brain and decrease sympathetic outflow and some PS receptors
33
Central Alpha 2 Agonists Clinical effects
Decrease sympathetic tone and increased parasympathetic activity which leads to a decrease in HR, CO, PVR, plasma renin, and baroreceptors reflexes
34
Central Alpha 2 Agonists Adverse Effects
Sedation and dry mouth CNS effects (depression, dizziness, orthostatic HYPOtension) Anticholinergic effects with clonidine Na and H20 Retention
35
Central Alpha 2 Agonists Clinical Pearls
Avoid in elderly | Do not abruptly withdraw
36
Methyldopa special properties?
Should be given with diuretics | May cause hepatitis or hemolytic anemia
37
Reserpine MOA
Depleting NE from sympathetic nerve terminals and block transport into storage granules
38
Reserpine Adverse Effects
Significant Na/H20 retention | May increase nasal stuffiness, gastric acid secretion, diarrhea and bradycardia secondary to increased PS activity
39
Reserpine Clinical Pearls
Use with diuretic | Very inexpensive
40
Direct Arterial Vasodilators
Hydralazine and Minoxidil
41
Direct Arterial Vasodilators MOA
Direct arteriolar SM relaxations | Increase sympathetic outflow, increase HR/CO and renin release which decreases HYPOtensive effects
42
Direct Arterial Vasodilators Adverse Effects
Na/H2O Retention Reflex tachycardia Drug-induced lupus (hydra) Hirsutism (mino)
43
Direct Arterial Vasodilators Clinical Pearls
Use with beta blocker and diuretic Monotherapy can precipitate angina in CAD pts Reserved for difficult to control HTN
44
Synergistic BP Lowering Combos
RAAS inhibitor + Diuretic | CCB + RAAS Inhibitor
45
Additive BP Lowering Combos
BB + diuretic BB + DHP NonDHP + DHP
46
Elderly HTN due to?
Lead pipe syndromes: BP increases Systolic may be elevated and diastolic may be low because the veins cannot recoil like it is supposed to (lead pipe syndrome)
47
Elderly Treatment
Thiazides + ACEI and DHP | Start low and go slow
48
Avoid what is elderly?
Central acting agents and alpha blockers
49
Pregnancy HTN Drugs
``` Methyldopa Labetolol Beta-blocker CCB Diuretic ```
50
Methyldopa in Pregnancy?
Preferred and safe
51
Labetolol in pregnancy?
Increasing preference | Improved tolerability
52
Beta-blockers in pregnancy?
Generally safe
53
CCB in pregnancy
Limited data
54
Diuretics in pregnancy
Safe at low doses and not first line
55
Management of Hypertensive Emergency
Obtain stat labs including CBC, UA, CMP, EKG, cardiac enzymes, imaging and echo ADMIT TO ICU Gentle hydration with NS to restore fluid and sodium
56
Hypertensive Emergency BP goals
Lower mean arterial BP by 20-25% in 1 hour DBP 10-15% over 30-60 min After stabilizations, lower to 160/110 in 2-6 hours
57
Nitroprusside is used for?
HTN emergencies except MI and renal impairment
58
Nitroglycerin is used for?
Adjunct in ischemia or acute pulmonary edema
59
Labetalol is DOC for?
Hyperadrenergic activity, aortic dissections, acute MI, stroke, eclampsia
60
Labetalol is contraindicated in?
COPD, HF, Heart block
61
Enalaprilat is DOC in?
HF
62
Enalaprilat is contraindicated in?
MI, eclampsia, bilateral RAS
63
Esmolol is used in?
Aute MI, aortic dissection and pre/post-op | Not with BB, bradycardic, or HF
64
Hydralazine is contraindicated in
HF, MI, aortic dissection
65
Hydralazine is DOC in?
Eclampsia
66
Phentolamine is DOC in?
Sympathetic crisis, catecholamine toxicity clonidine withdrawal and MAOI interactions
67
Nicardipine is used in?
Hypertensive emergencies except acute HF, and coronary ischemia
68
Clevidipine
Hypertensive emergencies
69
Follow up and monitoring with HTN drugs
``` Progressive target organ damage Reevaluate in 2-4 weeks Once stable, monitor 6-12 months Monitor ADE Lab test ```
70
When do side effects typically show face?
2-4 weeks after starting a new agent or increasing dose
71
Diuretics require what lab tests?
BP, BUN/SCr, Electrolytes (K, Mg, Na)
72
Aldosterone antagonists require what lab tests?
BP, BUN/SCr, K
73
Beta-Blockers require what lab tests?
BP, HR
74
ACEI/ARB/Renin Inhibitors require what lab tests?
BP, BUN/SCr, K
75
CCBs require what lab tests?
BP, HR
76
Define Resistant HTN
BP above goal despite adherence to treatment with full doses of at least 3 agents, one of which is a diuretic
77
Rule out what before diagnosis of Resistant HTN?
Non-aderence DASH diet Other meds Other diseases
78
Additional studies?
Recheck BP Repeated home BP ECHO Consider secondary cause
79
Resistant HTN treatment
``` Synergistic or additive combos Change to a loop Add spironolactone Combine alpha and beta blockers Centrally acting agents ```

Cardio Exam 1 (7 decks)

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