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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
Q

Aliskiren MOA

A

RAAS Inhibitor: inhibits the release of renin so there is no Ang II made

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26
Q

Renin normally does what?

A

Elevates BP via angiotensinogen to Ang I and Ang I to Ang II via ACE

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27
Q

Aliskiren Clinical Pearls

A

Equally as effective as ACEI or ARB
Do not use with another RAS inhibitor
No hard data

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28
Q

Alpha 2 Blockers MOA

A

Block receptors on blood vessels which causes vasodilation in the periphery

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29
Q

Alpha 2 Blockers drugs

A

Doxazosin (Cardura)
Prazosin (Minipress)
Terazosin (Hytrin)

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30
Q

Alpha 2 Blocker Clinical Pearls

A

Useful in men with benign prostate hyperplasia
Take 1st dose at bedtime
May cause Na and H20 retention

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31
Q

How do Alpha 2 Blockers cause Na and H20 retention?

A

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

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32
Q

Central Alpha 2 Agonists MOA

A

Receptors in the brain and decrease sympathetic outflow and some PS receptors

33
Q

Central Alpha 2 Agonists Clinical effects

A

Decrease sympathetic tone and increased parasympathetic activity which leads to a decrease in HR, CO, PVR, plasma renin, and baroreceptors reflexes

34
Q

Central Alpha 2 Agonists Adverse Effects

A

Sedation and dry mouth
CNS effects (depression, dizziness, orthostatic HYPOtension)
Anticholinergic effects with clonidine
Na and H20 Retention

35
Q

Central Alpha 2 Agonists Clinical Pearls

A

Avoid in elderly

Do not abruptly withdraw

36
Q

Methyldopa special properties?

A

Should be given with diuretics

May cause hepatitis or hemolytic anemia

37
Q

Reserpine MOA

A

Depleting NE from sympathetic nerve terminals and block transport into storage granules

38
Q

Reserpine Adverse Effects

A

Significant Na/H20 retention

May increase nasal stuffiness, gastric acid secretion, diarrhea and bradycardia secondary to increased PS activity

39
Q

Reserpine Clinical Pearls

A

Use with diuretic

Very inexpensive

40
Q

Direct Arterial Vasodilators

A

Hydralazine and Minoxidil

41
Q

Direct Arterial Vasodilators MOA

A

Direct arteriolar SM relaxations

Increase sympathetic outflow, increase HR/CO and renin release which decreases HYPOtensive effects

42
Q

Direct Arterial Vasodilators Adverse Effects

A

Na/H2O Retention
Reflex tachycardia
Drug-induced lupus (hydra)
Hirsutism (mino)

43
Q

Direct Arterial Vasodilators Clinical Pearls

A

Use with beta blocker and diuretic
Monotherapy can precipitate angina in CAD pts
Reserved for difficult to control HTN

44
Q

Synergistic BP Lowering Combos

A

RAAS inhibitor + Diuretic

CCB + RAAS Inhibitor

45
Q

Additive BP Lowering Combos

A

BB + diuretic
BB + DHP
NonDHP + DHP

46
Q

Elderly HTN due to?

A

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
Q

Elderly Treatment

A

Thiazides + ACEI and DHP

Start low and go slow

48
Q

Avoid what is elderly?

A

Central acting agents and alpha blockers

49
Q

Pregnancy HTN Drugs

A 
Methyldopa
Labetolol
Beta-blocker
CCB
Diuretic
50
Q

Methyldopa in Pregnancy?

A

Preferred and safe

51
Q

Labetolol in pregnancy?

A

Increasing preference

Improved tolerability

52
Q

Beta-blockers in pregnancy?

A

Generally safe

53
Q

CCB in pregnancy

A

Limited data

54
Q

Diuretics in pregnancy

A

Safe at low doses and not first line

55
Q

Management of Hypertensive Emergency

A

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
Q

Hypertensive Emergency BP goals

A

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
Q

Nitroprusside is used for?

A

HTN emergencies except MI and renal impairment

58
Q

Nitroglycerin is used for?

A

Adjunct in ischemia or acute pulmonary edema

59
Q

Labetalol is DOC for?

A

Hyperadrenergic activity, aortic dissections, acute MI, stroke, eclampsia

60
Q

Labetalol is contraindicated in?

A

COPD, HF, Heart block

61
Q

Enalaprilat is DOC in?

A

HF

62
Q

Enalaprilat is contraindicated in?

A

MI, eclampsia, bilateral RAS

63
Q

Esmolol is used in?

A

Aute MI, aortic dissection and pre/post-op

Not with BB, bradycardic, or HF

64
Q

Hydralazine is contraindicated in

A

HF, MI, aortic dissection

65
Q

Hydralazine is DOC in?

A

Eclampsia

66
Q

Phentolamine is DOC in?

A

Sympathetic crisis, catecholamine toxicity clonidine withdrawal and MAOI interactions

67
Q

Nicardipine is used in?

A

Hypertensive emergencies except acute HF, and coronary ischemia

68
Q

Clevidipine

A

Hypertensive emergencies

69
Q

Follow up and monitoring with HTN drugs

A 
Progressive target organ damage
Reevaluate in 2-4 weeks
Once stable, monitor 6-12 months
Monitor ADE
Lab test
70
Q

When do side effects typically show face?

A

2-4 weeks after starting a new agent or increasing dose

71
Q

Diuretics require what lab tests?

A

BP, BUN/SCr, Electrolytes (K, Mg, Na)

72
Q

Aldosterone antagonists require what lab tests?

A

BP, BUN/SCr, K

73
Q

Beta-Blockers require what lab tests?

A

BP, HR

74
Q

ACEI/ARB/Renin Inhibitors require what lab tests?

A

BP, BUN/SCr, K

75
Q

CCBs require what lab tests?

A

BP, HR

76
Q

Define Resistant HTN

A

BP above goal despite adherence to treatment with full doses of at least 3 agents, one of which is a diuretic

77
Q

Rule out what before diagnosis of Resistant HTN?

A

Non-aderence
DASH diet
Other meds
Other diseases

78
Q

Additional studies?

A

Recheck BP
Repeated home BP
ECHO
Consider secondary cause

79
Q

Resistant HTN treatment

A 
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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