Treatment of HTN 2 Flashcards
ACEI can cause what when initiated?
Elevated SCr but this is normal
ACEI indication
DM, CKD, HF, Stroke, CHD
ACEI Adverse Effects
Dry cough Angioedema (blacks and smokers) HYPOtension Renal dysfunction HYPERkalemia
Management of Dry Cough
Continue if it isn’t annoying
Switch to a different ACEI
Switch to an ARB
What causes the Cough?
Increase in bradykinin
ACEI Contraindications
Pregnancy
Bilateral Renal artery stenosis
Concurrent NSAID use
Why NSAIDs?
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
ACEI Clinical Pearls
Decrease or stabilize albumiuria
Chronic renal insuf: start low and go slow
Monitor renal function and potassium
Limit salt intake
ARB Adverse Effects
Angioedema (blacks and smokers)
HYPOtension
Renal dysfunction
HYPERkalemia
ARB Containdications
Pregnancy
Bilateral Renal artery stenosis
Concurrent NSAID use
ARB Clinical Pearls
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
Dihydropyridines
Potent peripheral vasodilatory effects
Weak Negative inotropic effects (NOT amlodipine)
No effect on conduction (dromotropic)
Dihydropyridines adverse effects
Baroreceptor-mediated reflex tachycardia
Pedal edema
Non-Dihydropyridines
Verapamil
Diltiazem
Non-Dihydropyridines MOA
Decrease chronotropic Slow AV conduction (negative dromotropic effects) Decreased inotropic effects (esp verap) Weak peripheral vasodilatory effect Coronary vasodilators
Non-Dihydropyridines Useful for?
Supreventrivcular tachyarrhythmias
Afib
Non-Dihydropyridines Adverse Effects
Bradycardia
Heart block
CCB Clinical Pearls
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)
Beta Blockers place in therapy
1st line along with thiazides with MI, HF, angina High renin-hypertensives Arrhthmias Migraine headaches Tremors Anxiety Thyrotoxicosis
Beta blockers are less effective?
In black pts
Beta blockers MOA
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
Beta Blocker Adverse Effects
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
Beta-Blocker Clinical Pearls
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
Direct Renin Inhibitor
Aliskiren (Tekturna)
Aliskiren MOA
RAAS Inhibitor: inhibits the release of renin so there is no Ang II made
Renin normally does what?
Elevates BP via angiotensinogen to Ang I and Ang I to Ang II via ACE
Aliskiren Clinical Pearls
Equally as effective as ACEI or ARB
Do not use with another RAS inhibitor
No hard data
Alpha 2 Blockers MOA
Block receptors on blood vessels which causes vasodilation in the periphery
Alpha 2 Blockers drugs
Doxazosin (Cardura)
Prazosin (Minipress)
Terazosin (Hytrin)
Alpha 2 Blocker Clinical Pearls
Useful in men with benign prostate hyperplasia
Take 1st dose at bedtime
May cause Na and H20 retention
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
Central Alpha 2 Agonists MOA
Receptors in the brain and decrease sympathetic outflow and some PS receptors
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
Central Alpha 2 Agonists Adverse Effects
Sedation and dry mouth
CNS effects (depression, dizziness, orthostatic HYPOtension)
Anticholinergic effects with clonidine
Na and H20 Retention
Central Alpha 2 Agonists Clinical Pearls
Avoid in elderly
Do not abruptly withdraw
Methyldopa special properties?
Should be given with diuretics
May cause hepatitis or hemolytic anemia
Reserpine MOA
Depleting NE from sympathetic nerve terminals and block transport into storage granules
Reserpine Adverse Effects
Significant Na/H20 retention
May increase nasal stuffiness, gastric acid secretion, diarrhea and bradycardia secondary to increased PS activity
Reserpine Clinical Pearls
Use with diuretic
Very inexpensive
Direct Arterial Vasodilators
Hydralazine and Minoxidil
Direct Arterial Vasodilators MOA
Direct arteriolar SM relaxations
Increase sympathetic outflow, increase HR/CO and renin release which decreases HYPOtensive effects
Direct Arterial Vasodilators Adverse Effects
Na/H2O Retention
Reflex tachycardia
Drug-induced lupus (hydra)
Hirsutism (mino)
Direct Arterial Vasodilators Clinical Pearls
Use with beta blocker and diuretic
Monotherapy can precipitate angina in CAD pts
Reserved for difficult to control HTN
Synergistic BP Lowering Combos
RAAS inhibitor + Diuretic
CCB + RAAS Inhibitor
Additive BP Lowering Combos
BB + diuretic
BB + DHP
NonDHP + DHP
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)
Elderly Treatment
Thiazides + ACEI and DHP
Start low and go slow
Avoid what is elderly?
Central acting agents and alpha blockers
Pregnancy HTN Drugs
Methyldopa Labetolol Beta-blocker CCB Diuretic
Methyldopa in Pregnancy?
Preferred and safe
Labetolol in pregnancy?
Increasing preference
Improved tolerability
Beta-blockers in pregnancy?
Generally safe
CCB in pregnancy
Limited data
Diuretics in pregnancy
Safe at low doses and not first line
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
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
Nitroprusside is used for?
HTN emergencies except MI and renal impairment
Nitroglycerin is used for?
Adjunct in ischemia or acute pulmonary edema
Labetalol is DOC for?
Hyperadrenergic activity, aortic dissections, acute MI, stroke, eclampsia
Labetalol is contraindicated in?
COPD, HF, Heart block
Enalaprilat is DOC in?
HF
Enalaprilat is contraindicated in?
MI, eclampsia, bilateral RAS
Esmolol is used in?
Aute MI, aortic dissection and pre/post-op
Not with BB, bradycardic, or HF
Hydralazine is contraindicated in
HF, MI, aortic dissection
Hydralazine is DOC in?
Eclampsia
Phentolamine is DOC in?
Sympathetic crisis, catecholamine toxicity clonidine withdrawal and MAOI interactions
Nicardipine is used in?
Hypertensive emergencies except acute HF, and coronary ischemia
Clevidipine
Hypertensive emergencies
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
When do side effects typically show face?
2-4 weeks after starting a new agent or increasing dose
Diuretics require what lab tests?
BP, BUN/SCr, Electrolytes (K, Mg, Na)
Aldosterone antagonists require what lab tests?
BP, BUN/SCr, K
Beta-Blockers require what lab tests?
BP, HR
ACEI/ARB/Renin Inhibitors require what lab tests?
BP, BUN/SCr, K
CCBs require what lab tests?
BP, HR
Define Resistant HTN
BP above goal despite adherence to treatment with full doses of at least 3 agents, one of which is a diuretic
Rule out what before diagnosis of Resistant HTN?
Non-aderence
DASH diet
Other meds
Other diseases
Additional studies?
Recheck BP
Repeated home BP
ECHO
Consider secondary cause
Resistant HTN treatment
Synergistic or additive combos Change to a loop Add spironolactone Combine alpha and beta blockers Centrally acting agents
