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AGPCNP Board Prep > Ch12: HTN, HLD, CHF > Flashcards

Ch12: HTN, HLD, CHF Flashcards

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1
Q

(3) components of BP

A
  • heart rate
  • stroke volume
  • peripheral vascular resistance
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2
Q

as we age, what happens to CO and PVR

A

cardiac output goes down (decrease in HR and SV)

PVR goes up

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3
Q

(4) primary target organs damaged with uncontrolled HTN

A
  • brain
  • cardiovascular system
  • kidneys
  • eyes
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4
Q

target organ damage from HTN: brain (2)

A

stroke, vascular (multi-infarct) dementia

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5
Q

target organ damage from HTN: cardiovascular system (4)

A
  • atherosclerosis
  • myocardial infarction
  • left ventricular hypertrophy
  • heart failure
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6
Q

1 cause of kidney failure in the US

A

hypertensive nephropathy

3x more common than diabetic nephropathy, the second cause

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7
Q

target organ damage from HTN: kidneys

A
  • hypertensive nephropathy

- renal failure

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8
Q

target organ damage from HTN: eyes

A
  • hypertensive retinopathy

- risk for blindness

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9
Q

Grade 1 & 2 hypertensive retinopathy (LOW GRADE)

A
  • narrowing of the terminal arteriolar branches (grade 1) or severe local constriction (grade 2)
  • no vision change or permanent findings
  • reversible when HTN is treated
  • common in long-standing poorly-controlled HTN
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10
Q

Grade 3 hypertensive retinopathy (HIGH GRADE)

A
  • preceding signs (constriction of the aterioles) now with flame-shaped hemorrhages
  • DBP is usually 110 or greater, HTN emergency
  • potential for visual change and permanent findings
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11
Q

Grade 4 hypertensive retinopathy (HIGH GRADE)

A
  • preceding signs (constriction of the aterioles, flame hemorrhages) now with papilledema
  • DBP is usually 130 or greater, HTN emergency
  • potential for visual changes (black spots in visual fields) and permanent findings
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12
Q

papilledema is a sign of….

A

increased intracranial pressure

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13
Q

JNC8 vs. AHA/ACC guidelines for blood pressure control goals

A

JNC8 = <140/<90 for nearly everyone

AHA/ACC = <130/<80 for nearly everyone

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14
Q

per ACC/AHA and JNC, what are the (4) first-line medication classes for HTN treatment

A
  • thiazide diuretic
  • calcium channel blocker
  • ACE inhibitor
  • ARB
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15
Q

per ACC/AHA and JNC, what are the (2) best choices for first-line medication class in treatment of HTN in Black adults

A
  • thiazide diuretic

- calcium channel blocker

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16
Q

Per JNC8, what is the (2) best choices for medication class in treatment of HTN in adult with CKD

A
  • ACE inhibitor

- ARB

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17
Q

Initial labs and diagnostics needed for someone with new diagnosis of HTN to facilitate CVD risk profiling, establish a baseline for medication use, and to screen for secondary causes of HTN:

A
  • fasting blood glucose
  • CBC
  • lipids
  • BMP (electrolytes, serum creatinine, eGFR)
  • TSH
  • urinalysis
  • electrocardiogram (ECG – looking for chamber enlargement)
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18
Q

optimal dietary sodium restriction in HTN

A

optimal <1500 mg/day

alternatively, can reduce from current amount by at least 1000mg/day and remove the salt shaker off the table

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19
Q

optimal potassium intake in HTN

A

aim for 3500-5000 mg/day (not supplementation, but total through diet rich in potassium)

adequate potassium can reduce BP!

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20
Q

preferred anti-hypertensive for postmenopausal females with risk for osteoporosis

A

thiazide diuretics (e.g., HCTZ, chlorthalidone)

calcium-sparing diuretics = lower observed rate of fractures in folks who are long-term thiazide diuretic users

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21
Q

HTN diuretic =______

CHF diuretic = _______

A

HTN = thiazides

CHF = loops

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22
Q

thiazide diuretics deplete vs. spare which electrolytes

A

deplete sodium (Na+), potassium (K+) and magnesium (Mg++)

spare calcium (Ca+)

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23
Q

diuretic use and eGFR: thiazides, loops

A

thiazide diuretics preferred for HTN when eGFR >30, however they become ineffective when eGFR <30

once eGFR <30, loop diuretics remain effective

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24
Q

medication class: HCTZ

A

thiazide diuretic

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25
medication class: chlorthalidone
thiazide diuretic
26
medication class: furosemide (Lasix)
loop diuretic
27
medication class: torsemide (Demadex)
loop diuretic
28
which is more potent: HCTZ vs. chlorthalidone
chlorthalidone
29
medication class: lisinopril (Prinivil, Zestril)
ACE inhibitor
30
medication class: enalapril (Vasotec)
ACE inhibitor
31
medication class: losartan (Cozaar)
angiotensin receptor blocker (ARB)
32
medication class: telmisartan (Micardis)
angiotensin receptor blocker (ARB)
33
MOA: thiazide diuretics for HTN .... 1. HR 2. SV 3. PVR
reduce peripheral vascular resistance
34
MOA: ACE inhibitors for HTN... 1. HR 2. SV 3. PVR
reduce peripheral vascular resistance
35
MOA: ARBs for HTN.... 1. HR 2. SV 3. PVR
reduce peripheral vascular resistance
36
ACE inhibitors and ARBs increase risk for which electrolyte abnormality
hyperkalemia (spare potassium)
37
priority medication in someone with HTN and comorbid T2DM
ACE inhibitors or ARB
38
angioedema risk in folks using ACE inhibitors
<1% of general population risk factors = Black, Latinx, history of NSAID allergy
39
risk factors for angioedema with ACE inhibitor use (3)
- NSAID allergy (most potent risk factor) - Black - Latinx
40
risk factors for hyperkalemia for someone on an ACE or ARB (4)
- inadequate fluid intake (dehydrated) - over-diuresis (dehydrated) - renal impairment - concurrent use of aldosterone antagonist (aka potassium-sparing diuretic)
41
medication class: amlodipine (Norvasc)
dihydropyridine calcium channel blocker
42
medication class: diltiazem (Cardiazem)
non-dihydropyridine calcium channel blocker
43
MOA: CCBs for HTN.... 1. HR 2. SV 3. PVR
reduce peripheral vascular resistance | peripheral vasodilators
44
edema is more common in [DHP vs. non DHP] calcium channel blockers, avoid use in heart failure or CKD
dihydropyridines (e.g., amlodipine) d/t potent peripheral vasodilators
45
most potent class of antihypertensives, per Fitzgerald
calcium channel blockers
46
edema in CCBs is dependent on.....
dose (use lower doses)
47
which antihypertensive medications are not a good choice for someone with CHF, CKD, or liver impairment
DHP CCBs because they cause edema s/t potent peripheral vasodilation
48
medication class: atenolol (Tenoretic)
beta blocker
49
medication class: metoprolol (Lopressor)
beta blocker
50
MOA: beta blockers for HTN.... 1. HR 2. SV 3. PVR
lowers HR and SV
51
medication class: propanolol (Inderal)
beta blocker
52
medication class: spironolactone (Aldactone)
aldosterone antagonist / potassium-sparing diuretic
53
medication class: eplerenone (Inspra)
aldosterone antagonist / potassium-sparing diuretic
54
(1) cardio-selective beta blocker
metoprolol
55
(2) non-cardioselevtive beta blockers
propanolol | nadolol
56
avoid ______ [cardiac med] in folks with lower airway disease
non-cardioselective beta blockers (e.g., propanolol, nadolol)
57
beta blockers and lower airway disease?
avoid beta blockers that are non-cardioselective cardioselective beta blockers are usually ok in COPD or asthma
58
priority electrolyte abnormality risk with aldosterone antagonists
hyperkalemia particularly if used with an ACE or ARB
59
which cardiac medication class can cause gynecomastia with long-term use
aldosterone antagonists / potassium-sparing diuretics (e.g., spironolactone)
60
why are beta blockers not first line for HTN?
not that effective
61
why are aldosterone antagonists not first line for HTN?
very effective, but lots of side effects: - hyperkalemia - volume depletion/excessive diuresis - gynecomastia
62
after starting someone on a new HTN medication, when should they come back for fup?
1 month takes 1 mo to see full benefit of that dose of therapy
63
which common cold medication should be avoided in someone with HTN?
pseudoephedrine (Sudafed) s/t vasoconstrictive effects
64
true or false: friends don't let friends lower BP in clinic with short-acting meds like clonidine
TRUE! don't want to drop the BP too quickly and risk poor perfusion to the brain in hypertensive urgency, no indication for immediate in-office BP reduction with short-acting antihypertensive agents such as clonidine, hydralazine, nitroglycerin, etc.
65
hypertensive urgency, aka....
asymptomatic elevated blood pressure
66
hypertensive urgency and emergency are both defined by blood pressure higher than....
>180/>120
67
difference between hypertensive urgency and emergency
BP >180/>120 in both however, urgency is asymptomatic emergency includes symptoms or evidence of impending end organ damage such as visual changes, shortness of breath, grade 3 or 4 retinopathy, S3, tachycardia, distended neck veins (signs of CHF), pulmonary edema
68
intervention for outpatient generalist NP in hypertensive urgency
restart or intensify standard antihypertensive therapy NO indication for referral to ED NO indication for immediate in-office BP reduction with short-acting antihypertensives
69
intervention for outpatient generalist NP in hypertensive emergency
immediate transfer to the ED or ICU admission for careful BP reduction via parenteral medications
70
risks of hypertensive emergency
- intracerebral hemorrhage - hypertensive encephalopathy - acute ischemic stroke - acute MI - unstable angina pectoris - dissecting aortic aneurysm - acute renal failure - eclampsia
71
lipid profile can be drawn fasting or non-fasting. however, if triglycerides are >_______, repeat in fasting state
TG >400 mg/dL
72
which antihypertensive medication should you prioritize in someone with evidence of LVH
ACE or ARB
73
why does she love carvedilol specifically
- beta blocker - also has alpha blockade - insulin sensitizing
74
components of a lipid panel for screening
- total cholesterol - LDL cholesterol - HDL cholesterol - triglycerides
75
which part of the lipid profile is most affected by fasting vs. non-fasting
triglycerides
76
dietary change to reduce lipids
- increase fiber (10-25 g/day) and plant sterols/stanols (2g/day) - decrease saturated fats (<7% of total calories) - avoid trans fats entirely - increase intake of omega-3 fatty acids (e.g., oily fish 2x weekly, flaxseeds, supplement)
77
High vs. Mod vs. Low intensity statin therapy reduces LDL by.....
``` High = 1/2 (50%) Mod = 1/3 (30-50%) Low = 1/4 (<30%) ```
78
there is no clinical indication for ____ intensity statin therapy as first line for anything
low
79
who should you be cautious in using a high intensity statin therapy (6)
- adverse effects - age >75yo - CKD - frailty - multiple comorbidities - concurrent use of a fibrate THESE ARE THE FOLKS MOST LIKLEY TO DEVELOP RHABDO
80
(2) high intensity statin therapy regimens
- atorvastatin 40-80mg | - rosuvastatin 20-40mg
81
(5) moderate intensity statin therapy regimens
- atorvastatin 10-20mg - rosuvastatin 5-10mg - simvastatin 20-40mg - pravastatin 40-80mg - lovastatin 40mg
82
(2) medications no longer recommended for dyslipidemia
- niacin | - resins (e.g., cholestyramine)
83
medication class: simvastatin (Zocor)
HMG-CoA reductase inhibitor
84
medication class: atorvastatin (Lipitor)
HMG-CoA reductase inhibitor
85
medication class: rosuvastatin (Crestor)
HMG-CoA reductase inhibitor
86
medication class: pravastatin (Pravachol)
HMG-CoA reductase inhibitor
87
expected effect of HMG-CoA reductase inhibitors on cholesterol
- significant reduction in LDL, as much as 50% or more - minor increase in HDL - minor decrease in TG
88
check this lab prior to starting a statin for HLD to establish a baseline (don't need to routinely follow)
liver enzymes (AST/ALT)
89
only (3) statins that are CYP 450 3A4 substrates
simvastatin, atorvastatin, lovastatin
90
priority side effects of HMG-CoA reductase inhibitors
rhabdomyolosis, myositis rare, but most often noted with higher statin doses and risk factors (e.g., frail elderly)
91
medication class: ezetimibe (Zetia)
selective cholesterol absorption inhibitor only drug in its class! oral tablet
92
effect of ezetimibe (Zetia) on cholesterol
- modest reduction in LDL up to 20% | - minor increase in HDL
93
side effects of ezetimibe (Zetia)
very well-tolerated! few side effects works at the level of intestinal lumen alone, not really systemic-acting
94
medication class: alirocumab (Praulent)
PCSK9 (proprotein convertase subtilisin/kexin type 9) SC injection only, VERY expensive
95
medication class: evolocumab (Repatha)
PCSK9 | proprotein convertase subtilisin/kexin type 9
96
effect of PCSK9s on cholesterol
- significant reduction in LDL of 60% or more in folks already on a statin therapy
97
who is a possible candidate for PCSK9s? (2)
- add on to statin therapy in someone with familial hypercholesterolemia - clinical ASCVD when goal LDL cannot be met on other therapies
98
effect of omega-3 fatty acids on cholesterol
- up to 30% reduction in TG - minor increase in HDL - no significant effect on LDL this is only at the 4g dose
99
prescription strength omega-3 fatty acids
4g/day supplement
100
side effects of omega-3 fatty acid supplements
- increased risk of bleeding s/t modest antiplatelet effects - GI upset - "fishy" taste (this can be minimized by freezing the capsules, taking with food, and avoiding hot beverages after taking)
101
modest increased risk of bleeding with this dyslipidemia medication
omega-3 fatty acid supplements
102
medication class: fenofibrate (Tricor)
fibric acid derivatives (fibrates)
103
medication class: fenofibric acid (Triplipix)
fibric acid derivatives (fibrates)
104
effect of fibrates on cholesterol
- significant increase in HDL by 20% - significant reduction in TG by up to 50% - minor reduction in LDL
105
side effects of fibrates
myopathy, including rhabdomyolysis, particularly if taken with a statin
106
which two cholesterol medications should not be taken together d/t risk for rhabdo
statins + fibrates
107
(5) priority medication classes in the treatment of dyslipidemia
- HMG-CoA reductase inhibitors (statins) - selective cholesterol absorption inhibitor (ezetimibe) - PCSK9s (-mab) - omega-3 fatty acids - fibrates
108
best cholesterol medications for LDL (3)
- PCSK9s (60% or more reduction if already on statin) - statins (up to 50% or more reduction) - ezetimibe (up to 20% reduction)
109
best cholesterol medications for HDL (1)
- fibrates (up to 20% increase)
110
best cholesterol medications for triglycerides (2)
- omega-3 fatty acids (up to 30% reduction) | - fibrates (up to 50% reduction)
111
anyone with an LDL of _____, recommend high intensity statin therapy regardless of ASCVD score or presence of other risk factors
LDL >190 mg/dL
112
anyone with _______ comorbidity, recommend at least moderate intensity statin therapy regardless of presence of cholesterol levels, ASCVD score, or presence of other risk factors
T2DM and ages 40-75yo
113
low risk on ASCVD calculator %
<5%
114
borderline risk on ASCVD calculator %
5% - 7.5%
115
intermediate risk on ASCVD calculator %
7.5% - <20%
116
high risk on ASCVD calculator %
20% or higher
117
low risk on ASCVD calculator, recommend....
healthy lifestyle
118
borderline risk on ASCVD calculator, recommend....
healthy lifestyle consider moderate intensity statin
119
intermediate risk on ASCVD calculator, recommend....
healthy lifestyle moderate intensity statin
120
high risk on ASCVD calculator, recommend....
healthy lifestyle high intensity statin
121
if risk-decision-making is ever uncertain in dyslipidemia, can consider measuring....
coronary artery calcium (CAC) scoring
122
interpretation of CAC scoring results
0 = low risk, don't need to consider a statin unless they also have diabetes, family history of premature CHD, or smoke cigarettes 1 or higher = favors statin therapy, especially after age 55 100+ or 75% percentile = definitively recommends statin therapy
123
normal range triglycerides
<150 mg/dL
124
mildly elevated triglycerides range
150-199 mg/dL
125
moderately elevated triglycerides range
200-999 mg/dL
126
severely elevated triglycerides range
1000-1999 mg/dL
127
very severely elevated triglycerides range
2000 or higher mg/dL | risk for acute pancreatitis!
128
how high are triglycerides before risk factor for acute pancreatitis
>1000-2000 mg/dL
129
common causes of high trigylcerides
- lifestyles = high carb diet, excess alcohol, sedentary, obesity - T2DM, especially with poor glycemic control - untreated hypothyroidism - some medications (2nd gen antipsychotics, systemic corticosteroids, systemic estrogen, systemic retinoids)
130
recommended treatment for Triglycerides 199-499 mg/dL
statin therapy, lifestyle
131
recommended treatment for Triglycerides 500 mg/dL or higher
lifestyle, statins, consider omega-3 fatty acids or fibrates
132
at what level do you start to consider adding omega-3 fatty acids or fibrates to statin therapy for someone with elevated TG
TG 500 mg/dL or higher
133
lab test that can be used evaluate myositis in someone on statin therapy
serum creatinine kinase (CK)
134
INR goal in someone on warfarin therapy for a fib
2.0 - 3.0
135
why do almost all antibiotics increase risk of bleeding in someone on warfarin?
because warfarin is antagonized by vitamin K vitamin K is produced by the gut microflora all antibiotics disrupt the gut microflora
136
for any patient on warfarin, be concerned for increased risk of bleeding if on these other meds:
- all antibiotics (altered gut microflora reduces vitamin K) - all NSAIDs (antiplatelet effect) - gingko biloba (antiplatelet effect)
137
warfarin + St. Johns Wort
St Johns Wort is a CYP450 inducer will increase metabolism of warfarin decrease efficacy of warfarin lowers INR, risk for clots
138
warfarin + antibiotics
increased risk for bleeding | altered gut microflora > decreased vitamin K synthesis > increased warfarin effect
139
warfarin + NSAIDs
increased risk for bleeding (NSAID antiplatelet effect)
140
warfarin + gingko biloba
increased risk for bleeding (antiplatelet effect)
141
(3) triad of symptoms in heart failure
- dyspnea - fatigue - edema
142
possible physical exam findings suggestive of CHF
- tachycardia - increased JVP - displaced apex - S3 heart sound - heart murmur - pulmonary crackles - dependent edema
143
PMH history suggestive of possible CHF
- previous MI or ACE inhibitor use - HTN - angina - valvular disease or rheumatic heart disease - palpitations
144
possible etiologies of CHF (6)
- LV dysfunction (systolic or diastolic) - valvular disease - congenital heart disease - pericardial disease - endocardial disease - rhythm/conduction disturbance
145
ACC/AHA Stage A heart failure in primary care
Stage A = high risk for HF, but without structural heart disease or symptoms of HF e.g., someone with HTN, DM, obesity, metabolic syndrome, family history goals of therapy are to prevent ASCVD and LV abnormalities via heart healthy lifestyle, ACEI/ARB, statins prn can be managed in outpatient primary care NP generalist
146
ACC/AHA Stage B heart failure in primary care
Stage B = evidence of structural heart disease but without signs or symptoms of CHF e.g., patients with a previous MI, LVH, low EF, asymptomatic valvular disease goals of therapy include preventing HF symptoms and preventing further cardiac remodeling treatment includes ACI/ARB, beta blockers, statins ICD, revascularization surgery, or valvular surgery as appropriate thus, should be co-managed with a specialist (cardiologist)
147
LVH and reduced EF are both examples of....
cardiac remodeling (problematic)
148
(3) primary care medications for Stage A and B heart failure
- ACE/ARBs - statins - beta blockers (minimize risk of sudden cardiac death)
149
role of beta blockers in Stage B heart failure
minimize risk of sudden cardiac death (a risk in LVH)
150
ICD in heart failure is used to prevent....
sudden cardiac death

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