Hypertension Flashcards
What are the 1st line anti-hypertensive agents?
ACEis, ARBs, CCBs and thiazides for most patients with no compelling indication for a specific antihypertensive drug class.
*beta-blocker is not appropriate for 1st line
How to determine the number of anti-hypertensive agents to start implementing drug therapy?
Stage 1 hypertension: 1 medication as initial therapy
Stage 2 hypertension: 2 medications as initial therapy
What are the differences between hypertensive urgency and hypertensive emergency?
hypertensive urgency/ hypertensive emergency:
symptoms: No or minimal/ Yes
acute target organ damage/ complication: No/ Yes
BP reduction rate: hours to days/ minutes to hours
evaluation for secondary hypertension: Yes/ Yes
What is hypertensive emergencies?
- A severe elevation of BP associated with new or progressive end organ damage/ complication such as acute heart failure, dissecting aneurysm, acute coronary syndromes, hypertensive encephalopathy, subarachnoid hemorrhage and acute renal failure.
- All these patients should be admitted.
- The BP needs to be reduced rapidly.
- It is suggested that the BP be reduced by 25% depending on clinical scenario over 3 to 12 hours but not lower than 160/90 mmHg.
- Best achieved with parenteral drug.
What is hypertensive urgency?
- A severe increase in BP which is not associated with acute end organ damage/ complication,
- and these include patients with grade III or IV retinal changes (also known as accelerated and malignant hypertension respectively),
- These patients may need admission.
- BP measurement should be repeated after 30 minutes of bed rest.
- Initial treatment should aim for about 25% reduction in BP over 24 hours but not lower than 160/90 mmHg. (Level III).
- Oral drugs proven to be effective (captopril 12.5 mg, nifedipine 10 mg, labetalol 200 mg).
- Combination therapy is often necessary.
What is the aim of management of severe hypertension?
to reduce BP in a controlled, predictable, and safe manner, to avoid provoking or aggravating acute coronary syndrome, cerebral or renal ischemia
What are the common causes of severe hypertension?
- parenchymal renal disease- CKD
- endocrine- pheochromocytoma
- drugs- NSAIDS/ COX-2 inhibitors
- pregnancy related- preeclampsia
What are the 3 categories of severe hypertension?
- asymptomatic severe hypertension
- hypertensive urgencies
- hypertensive emergencies
- 2 and 3 are also referred to as hypertensive crises
What are the common precipitating factors?
- lack of family care physician
- no regular health checks
- age- elderly
- subtherapeutic management
- non-adherence to medication
Examples of patient presentations of severe HPT.
- incidental finding in an asymptomatic non-previously diagnosed patient
- non-specific symptoms like headache, dizziness, lethargy
- symptoms and signs of acute target organ damage.
- acute heart failure
- acute coronary syndromes
- acute renal failure
- dissecting aneurysm
- hypertensive encephalopathy
- stroke
What is severe hypertension?
Severe hypertension is defined as persistent elevated SBP > 180 mmHg and/or DBP > 110 mmHg
List 3 monitoring parameters for HPT pts.
- Have the patient return in 4 weeks to assess efficacy
- May have patient follow-up sooner if BP particularly worrisome
- If there is an inadequate response from the first agent (and adherence verified) and no compelling indication exists, initiate therapy with a drug from a different class
Give 3 considerations within specific patient populations.
- Patients with ischemic heart disease
- Potent vasodilators may cause reflex tachycardia, thereby increasing myocardial oxygen demand (eg. hydralazine, minoxidil, DHP CCB)
- Can attenuate this by also using an atrioventricular nodal depressant (eg. DHP CCB or beta blocker) - elderly patients
- Caution with antihypertensive agents and orthostatic hypotension
- Initiate with low dose and titrate slowly - pregnant women
- Methyldopa and hydralazine are recommended if a new therapy is initiated
- Most anti-hypertensives (except for ACEis and ARBs) can be safely continued in pregnancy.
Give example of considerations with specific antihypertensive agents.
- BETA-BLOCKER
-Caution with asthma, severe chronic obstructive pulmonary disease
(especially higher doses) because of pulmonary β-receptor blockade
-Increased risk of developing diabetes, use caution in patients at high risk of diabetes mellitus
- May mask some signs of hypoglycemia in patients with diabetes mellitus
- May cause depression - THIAZIDES
- May worsen gout by increasing serum uric acid
- Increased risk of developing diabetes, use caution in patients at high risk of diabetes mellitus
- May assist in the management of osteoporosis by preventing urine calcium loss - ANGIOTENSIN-CONVERTING ENZYME INHIBITORS (ACEi) and ARBs
- Contraindicated in pregnancy
- Contraindicated with bilateral renal artery stenosis
- Monitor K closely, especially if renal insufficiency exists or another K-sparing drug is in use.
- The presence of diabetic nephropathy should influence the choice of ACE inhibitor versus ARB. - ALISKIREN
- A direct renin antagonist
Explain drug treatment strategy for HPT and AF.
- initial therapy- (dual combination) (ACEi/ ARB + beta blocker or non-DHP CCB or beta blocker + CCB)
- step 2- (triple combination) (ACEi/ ARB + beta blocker + DHP CCB/ diuretic or beta blocker + DHP CCB + diuretic)
* non DHP CCB: verapamil or diltiazem)