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Therapeutics > Hypertension > Flashcards

Hypertension Flashcards

1
Q

patient specific factor: stable ischemic heart disease

A

first-line:
-beta-blockers
-ACEi/ARBs

-DHP CCBs can be used if still uncontrolled

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2
Q

patient specific factor: chronic kidney disease

A

-CKD stage 1 or 2 AND albuminuria: ACEi (or ARBs)
-CKD stage 3 or higher: ACEi (or ARBs)
-post kidney transplantation: DHP CCBs

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3
Q

preferred HTN agents for pregnancy

A

methyldopa
nifedipine
labetalol

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4
Q

contraindicated HTN agents for pregnancy

A

ACEi
ARBs
direct renin inhibitors

*thiazides

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5
Q

patient specific factor: black patients

A

thiazide or CCB (if no HF or CKD)

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6
Q

when should you dose thiazide diuretics?

A

morning, to avoid nocturnal diuresis

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7
Q

do not initiate aldosterone antagonist with K+ > _______ mEq/L

A

> 5 mEq/L

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8
Q

when should you dose aldosterone antagonists?

A

morning/afternoon, to avoid nocturnal diuresis

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9
Q

adverse effects of aldosterone antagonists

A

hyperkalemia
hyponatremia
gynecomastia (spironolactone)

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9
Q

when should you dose ACE inhibitors and ARBs?

A

PM, ensure BP dipping overnight

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10
Q

drug interactions of aldosterone antagonists

A

ACEi
ARBs
Renin inhibitors
NSAIDS

because they all increase risk of hyperkalemia

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10
Q

three contraindications for both ACEi and ARBs

A
  1. pregnancy
  2. concomitant use of aliskiren in patients with DM
  3. history of angioedema due to ACEi or ARB
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10
Q

what two HTN drug classes are often preferred over other first-line agents in the presence of other comorbidities?

A

ACEi/ARBs

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11
Q

what type of CCB is a more potent vasodilator: dihydropyridines or non-DHPs?

A

dihydropyridines

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12
Q

DHP CCB drug interactions

A

-grapefruit juice
-CYP3A4 inducers/inhibitors

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13
Q

two patient populations with additional benefit from non-dihydropyridine CCBs:

A
  1. supraventricular tachyarrhythmias (Afib)
  2. Pts w/ angina that cannot tolerate BBs
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14
Q

drugs interactions of non-DHP CCBs:

A
  1. grapefruit juice
  2. beta blockers (increases risk of heart block)
  3. CYP3A4 substrates
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15
Q

what is a dose-dependent side effect of dihydropyridine CCBs?

A

peripheral edema

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16
Q

What CCB would be used in the setting of heart failure?

A

amlodipine

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17
Q

When would a beta blocker be first line for HTN?

A

if a compelling indication is present i.e. heart failure or CAD

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18
Q

Patients with these specific comorbidities may benefit from using a beta blocker:

A

tachyarrhythmias
tremors
migraines
thyrotoxicosis

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19
Q

beta blockers decrease _______ ________

A

cardiac output

(because decrease in heart rate and force of contraction)

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20
Q

Three beta blockers with intrinsic sympathomimetic activity (ISA)

A

acebutolol
penbutolol
pindolol

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21
Q

beta blockers with mixed alpha/beta effects

A

carvedilol
labetalol

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22
Q

beta blockers can mask S/Sx of _______________

A

hypoglycemia
(i.e. rapid heartbeat and tremors)

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23
Q

minoxidil is _____ potent than hydralazine

A

more

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24
Q

a patient must be taking these two antihypertensive agents in order to start hydralazine or minoxidil

A
  1. diuretic
  2. beta blocker

*for minoxidil: maximum therapeutic doses of diuretic and two other antihypertensives should be used before this drug is added

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25
Q

what is one side effect unique to hydralazine?

A

lupus-like syndrome/rash

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26
Q

what is one side effect unique to minoxidil?

A

hair growth

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27
Q

Boxed warning for minoxidil

A

-may cause pericarditis and pericardial effusion that may progress to tamponade

-may increase oxygen demand and exacerbate angina pectoris

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28
Q

alpha-1 blockers are associated with ____________ ___________

A

orthostatic hypotension

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29
Q

central alpha-2 agonists are last line due to ________ ___________

A

adverse effects

i.e. CNS depression, dizziness, fatigue, anticholinergic effects, bradycardia

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30
Q

Oral -> Transdermal Patch clonidine regimen:

A

Day 1: place patch, 100% of oral dose
Day 2: 50% of oral dose
Day 3: 25% of oral dose
Day 4: Patch ONLY

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31
Q

Patch -> Oral clonidine regimen:

A

start oral clonidine no sooner than 8 hours after patch removal

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32
Q

Monitoring parameters: ACEi/ARBs

A

BUN/SCr
Potassium

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33
Q

Monitoring parameters: CCBs

A

Heart rate
(just for non-DHP CCBs)

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34
Q

Monitoring parameters: Aldosterone antagonists

A

BUN/SCr
Potassium

35
Q

Monitoring parameters: Diuretics

A

BUN/SCr
Electrolytes: K, Mg, Na
Uric acid (thiazides)

36
Q

Monitoring parameters: beta blockers

A

Heart rate

37
Q

Considerations before diagnosing resistant HTN

A
  1. nighttime dosing for one antihypertensive, other than diuretics
  2. assess adherence
  3. assess diet, exercise, smoking cessation
  4. rule out white coat HTN
  5. D/c interfering substances (i.e. ibuprofen)
38
Q

Define resistant HTN

A

failure to attain goal BP while adherent to at least 3 agents at maximum dose, including a diuretic, or when 4+ agents are needed

39
Q

Risk factors for resistant HTN

A

older age
obesity
CKD
diabetes
African American

40
Q

Management of resistant HTN: STEP 1

A

-maximize lifestyle interventions
-optimize 3-drug regimen (ACEi/ARB, CCB, and diuretic)

41
Q

Management of resistant HTN: STEP 2

A

substitute optimized thiazide-like diuretic (chlorthalidone, indapamide)
*d/c HCTZ

42
Q

Management of resistant HTN: STEP 3

A

Add mineralocorticoid receptor antagonist – spironolactone preferred
(eplerenone if pt develops gynecomastia with spir.)

43
Q

Management of resistant HTN: STEP 4

A

ASSESS HR FIRST

-add BB if HR > 70 bpm
-central alpha-2 agonist (clonidine patch or guanfacine) if BB is contraindicated or if HR < 70 bpm

44
Q

Management of resistant HTN: STEPS 5 + 6

A

*must be on diuretic and BB to move on to these steps

step 5: add hydralazine
step 6: substitute hydralazine for minoxidil

45
Q

Hypertensive emergency: BP goal at Hour 1

A

reduce BP by max of 25%

46
Q

Hypertensive emergency: BP goal at Hours 2 - 6

A

Reduce BP < 160/110

47
Q

Hypertensive emergency: BP goal at Hours 6 - 48

A

Reduce BP to goal

48
Q

what allergy is contraindicated with clevidipine IV?

A

soy and egg

49
Q

nicardipine IV has a _______ onset and _______duration of action than clevidipine

A

slower
longer

50
Q

what are the 3 vasodilators used for hypertensive emergencies?

A
  1. nitroglycerin
  2. sodium nitroprusside
  3. hydralazine
51
Q

which vasodilator (IV) is not titratable?

A

hydralazine

52
Q

what class of drugs interacts with nitrates and should not be taken together?

A

PDE-5 inhibitors (sildenafil, tadalafil, etc)

53
Q

what two beta blockers are used IV for hypertensive emergency?

A

labetalol and esmolol

54
Q

labetalol decreases 1) ? and 2) ?

A

heart rate and blood pressure

55
Q

why is esmolol used as an adjuct for BP reduction and not monotherapy?

A

it’s only used to decrease heart rate during crisis

56
Q

which hypertensive crisis drugs should be avoided with acute kidney injuries?

A

use caution with sodium nitroprusside
avoid enalaprilat

57
Q

pulmonary hypertension is defined as a mean pulmonary artery pressure (MPAP) > ________ at rest

A

> 20 mmHg

58
Q

what is the gold standard for diagnosis of pulmonary arterial hypertension (PAH)?

A

right heart catheterization (used to measure pressure in heart and lungs)

59
Q

what are 5 negative predictors of PAH?

A
  1. advanced functional class
  2. poor exercise capacity
  3. high right atrial pressure
  4. right ventricular dysfunction
  5. low cardiac output
60
Q

In PAH, the left heart becomes _________ and the right heart becomes ______________

A

left = smaller
right = larger

61
Q

what are the four components of endothelial dysfunction in the progression of PAH?

A
  1. decreased nitric oxide synthase
  2. decreased prostacyclin production
  3. increased thromboxane production
  4. increased endothelin 1 production

= VASOCONSTRICTION

62
Q

Guideline recommendation for treatment naive FC II and low-risk FC III – COMBINATION THERAPY
(not candidates for CCBs)

A

ambrisentan and tadalafil

63
Q

Guideline recommendation for treatment naive FC II and low-risk FC III – MONOTHERAPY
(not candidates for CCBs)

A

endothelin receptor antagonist (ERA)
OR
riociguat
OR
PDE-5 inhibitor

64
Q

What are the three therapeutic pathways targeted for treatment of PAH?

A

1) Nitric oxide pathway
2) Endothelin pathway
3) Prostacyclin pathway

65
Q

What are the drugs associated with the nitric oxide pathway?

A

PDE-5 inhibitors: sildenafil, tadalafil
soluble guanylate cyclase stimulator: riociguat

66
Q

What are the drugs associated with the endothelin pathway?

A

endothelin receptor antagonists (ERAs): bosentan, ambrisentan, macitentan

67
Q

What are the drugs associated with the prostacyclin pathway? Which functional class are these drugs reserved for?

A

prostacyclins:
epoprostenol (IV)
iloprost (inhaled)
***treprostinil (IV, SQ, inh, oral)

IP prostacyclin receptor agonist:
selexipag

these are reserved for high risk FC III and FC IV

68
Q

sildenafil is dosed ____x daily while tadalafil is dosed _______x daily

A

sildenafil = three
tadalafil = once

69
Q

Which ERA may cause LFT abnormalities?

A

Bosentan (Tracleer)

70
Q

Which ERA may cause peripheral edema?

A

Ambrisentan (Letairis)

71
Q

Ambrisentan is selective for _________ (ETa or ETb)

A

ETa receptors

72
Q

How long after starting an ERA is improvement likely seen?

A

8-10 weeks

73
Q

PDE-5 inhibitors should not be used in combination with these two drugs:

A
  1. riociguat
  2. nitrates
74
Q

What did the AMBITION trial prove?

A

Ambrisentan + tadalafil were more effective than monotherapy and is now used as first-line

75
Q

Guideline recommendation for high risk FC III and FC IV who are candidates for parenteral prostanoids

A

First-line: SC treprostinil
IV treprostinil, IV epoprostenol

76
Q

Guideline recommendation for high risk FC III and FC IV who are NOT candidates for parenteral prostanoids

A

Inhaled prostanoid + ERA + PDE-5i (or riociguat in place of PDE-5i)

77
Q

What adverse effects do all prostacyclins have in common?

A

inhibition of platelet aggregation
thrombocytopenia (more w/ epo)
hypotension
headache
flushing

78
Q

What side effects are more common with inhaled prostacyclins?

A

gastric effects - N/V/D

79
Q

IV prostacyclins ________ be co-infused with other fluids

A

CANNOT

80
Q

What are two adjunct therapies that may be used during PAH treatment?

A
  1. anticoagulation (typically not with prostacyclins)
  2. diuretics to maintain euvolemia
81
Q

Which PAH drugs can cause birth defects and are listed in REMS?

A

ERAs (i.e. bosentan, ambrisentan)
riociguat

82
Q

Elevated BP classification:

A

120-129
AND
< 80

83
Q

HTN Stage 1 classification:

A

130-139
OR
80-89

84
Q

HTN Stage 2 classification:

A

> 140
OR
90

85
Q

ACC/AHA treatment strategy:
Elevated BP:

A

Non-pharm treatment
Reassess in 3-6 months

86
Q

ACC/AHA treatment strategy:
Stage 1 HTN and ASCVD > 10% or a specific comorbidity:

A

Non-pharm Tx and 1 medication
Reassess in 1 month

87
Q

ACC/AHA treatment strategy:
Stage 2 HTN:

A

Non-pharm Tx and 2 medications
Reassess in 1 month

88
Q

HTN patients at goal should have a follow-up every ___ - ___ months

A

3-6 months

Therapeutics (18 decks)

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