Day 1 Flashcards Preview

Anti- HTN & Chronic HF > Day 1 > Flashcards

Flashcards in Day 1 Deck (45):
1

Epidemiology

Affects 76.4 million Americans
1 in 3 adults has HTN
Lifetime risk is 90%

2

Risk Factors for HTN

Cigarette smoking
Obesity (BMI ≥ 30)
Physical inactivity
Dyslipidemia
Diabetes mellitus
Renal dysfunction
Age: men > 55 years, women > 65 years
family history of premature cardiovascular disease (age: men < 55, women < 65)

3

Etiology for 2 types of HTN

Essential Hypertension:
> 90% of cases
Hereditary component

Secondary Hypertension:
< 10% of cases
Common causes: chronic kidney disease, renovascular disease

4

Total Peripheral Resistance (TPR)

Sum of peripheral resistance in peripheral vasculature (represents DBP)

5

Cardiac Output

Amount of blood pumped out by the ventricles (represent the SBP)

6

Systolic and Diastolic BP

Systolic BP (SBP): Number that represents the cardiac contraction

Diastolic BP (DBP): Number that represents nadir (lowest point)…filling of the heart

7

JNC 8 New BP Goals

Patients older than 60 = less than 150/90
Patients younger than 60= less than 140/ 90
Patients with DM and CKD= less than 140/90

8

Mechanism of Pathogenesis for HTN

Increase Peripheral Resistance:
Functional Vascular Constriction/Structural Vascular Hypertrophy:
Over activity of sympathetic nervous system
Genetic components

Increased cardiac output (CO):
Increased Preload:
Increased fluid volume
Excess sodium intake
Renal sodium retention

Venous Constriction:
Excess RAAS stimulation
Sympathetic nervous system over activity

9

Non-Pharmacological Therapy for HTN

Smoking Cessation
Weight loss in overweight and obese
DASH diet
Dietary sodium reduction
Increased physical activity
limit alcohol intake to no more than 1-2 drinks/day

10

First Line Treatment Approaches for HTN

First line options:
Thiazides, CCB’s, ACE-I, ARB’s (all equal in choice)
Note: not the best choice to use ACE-I or ARB’s in a black patient

DM or chronic kidney disease:
ACE-I or ARB’s
JNC 8 states do not use them together

Cardiac history:
Beta-blocker

11

3 Options for Treating HTN

1st option:
Start with 1 drug and max the dose and then add on a 2nd agent if still not at goal, and then add on a 3rd agent once the 2nd drug is maxed out if pt. still not at goal.

2nd option:
Start with 1 drug and if not at goal add a 2nd drug prior to maxing out the dose on the first. Then max the dose on both drugs and if not at goal add a 3rd agent

3rd option:
Start with 2 drugs from the beginning if the SBP >160 and/or the DBP >100. Max out the drug doses and add on a 3rd agent if needed.

12

Thiazide Diuretics MOA

Drugs: Hydrochlorothiazide (HCTZ), chlorthalidone, metolzaone
MOA: Inhibits sodium reabsorption in the distal tubule.

13

Precautions for Thiazide Diuretics

Caution in sulfa allergic patients
Ineffective in patients with severe renal disease
Avoid in patients taking lithium– may increase serum lithium concentrations
Avoid in patients with GOUT

14

Adverse Effects for Thiazide Diuretics

Orthostatic Hypotension
Electrolyte abnormalities: ↓ K, ↓ Na, ↑ Ca, ↑ uric acid, ↑ glucose
Photosensitivity
Increase urination (initially)

15

Place in Therapy and Dose for Thiazide Diuretics

One of the first line drug classes used to treat HTN
Dose: Typically 25mg (can start at 12.5mg)

16

Loop Diuretics

Drugs:
Furosemide (Lasix™)
Bumetanide (Bumex™)
Torsemide (Demadex™)

Mechanism of action:
Inhibits active transport of sodium, chloride and potassium in thick ascending limb of Loop of Henle, causing excretion of these ions
Collecting duct excretes more water in response

17

Place in Therapy for Loop Diuretics

NOT 1st LINE TREATMENT
CHF (preferred diuretic)
Edema (both peripheral and pulmonary)
HTN

18

Adverse Effects for Loop Diuretics

Electrolytes abnormalities: ↓ K, ↓Na, ↓ Ca, ↓ Mg, ↑ uric acid
Dehydration
Ototoxicity
Increase in SCr

19

Precautions for Loop Diuretics

Caution in sulfa allergic patients
Nephrotoxicity
Avoid in patients with GOUT

20

Potassium Sparing Diuretics---Aldosterone Receptor Blockers MOA

Aldosterone Receptor Blockers:
Spironolactone (Aldactone™)
Eplerenone (Inspra)

Mechanism of Action: Competes with aldosterone, prevents sodium reabsorption and potassium excretion

21

Potassium Sparing Drugs

Triamterene
Amiloride
Mechanism of action: blocks sodium reabsorption and potassium excretion, effect independent of aldosterone

22

Potassium Sparing Diuretics Place in Therapy

Hypertension, often in combination with thiazide
Spironolactone – Class IV heart failure

23

Adverse Effect for Potassium Sparing Diuretics

General: Hyperkalemia (caution in patients with renal failure)
Spironolactone: Gynecomastia, menstrual irregularities
Eplerenone: More selective thus less side effects

24

10 ACE- Inhibitor Drugs

Benazepril (Lotensin)
Captopril (Capoten)
Enalapril (Vasotec)
Fosinopril (Monopril)
Lisinopril (Zestril, Prinivil)
Moexipril (Univasc)
Perindopril (Aceon)
Quinapril (Accupril)
Ramipril (Altace)
Trandolapril (Mavik)

25

MOA of ACE- Inhibitors

Inhibits ACE to block production of AT II
Inhibits breakdown of bradykinin (vasodilator)
Benefit: lowers blood pressure
Disadvantage: inflammatory mediator, probably some common adverse effect of ACE-I
Dilate the efferent arteriole of kidney

26

ACE- Inhibitor Place in Therapy

One of the first line drug classes in HTN
First line option for CKD
Used in CHF

27

What is the Dose and what do you have to monitor with ACE inhibitors

Dose: Often once a day, sometimes twice daily

Monitor:
Serum K+ & SCr within 4 weeks of initiation or dose increase. You will likely see a benign increase in Scr (<30% from baseline)
Angioedemia

28

Adverse Effects of ACE Inhibitors

Cough
Up to 20% of patients
Due to increased bradykinin
Angioedema (rare)
Hyperkalemia: particularly in patients with CKD or DM
Other: Neutropenia, agranulocytosis, proteinuria, glomerulonephritis, acute renal failure

29

Contraindications for ACE inhibitors

Pregnancy category C/D- contraindicated
Angioedema with other ACE-inhibitors
Renal artery stenosis (increased risk of renal toxicity)

30

Drug Interactions for ACE inhibitors

Potassium supplements
Potassium-sparing diuretics
NSAIDs

31

ACE-I Clinical Differences

All can be dosed once daily except captopril
Captopril is dosed twice to three times daily
Most may be dosed more than once a day for efficacy

Enalapril is a prodrug of enalaprilat (only one that is available IV)
Most commonly used ACE-I: lisinopril
Dose is 10-40 mg daily
Captopril absorption decreased by 30-40% when given with food

32

Angiotensin II Receptor Blockers (ARB) 7 Drugs

Candesartan (Atacand)
Eprosartan (Teveten)
Irbesartan (Avapro)
Losartan (Cozaar)
Olmesartan (Benicar)
Telmisartan (Micardis)
Valsartan (Diovan)

33

ARB MOA

Inhibits angiotensin II at its receptor sites
Does NOT inhibit the breakdown of bradykinin

34

ARB Place in Therapy

Place in Therapy:
One of the first line drug classes in HTN
First line option for CKD
Used in CHF
Dose: Often once daily

35

Adverse Effects of ARB

Hypotension/orthostatic hypotension
Angioedema
Hyperkalemia
Dizziness
Cough (only case reports)

36

What needs to be monitored with PT taking ARB's

Potassium
Angioedema

37

Contraindications for ARB's

Pregnancy category C/D- should not be used
“Caution” in pts with renal artery stenosis
ARBs CAN be used in patients who have experienced angioedema when taking an ACE inhibitor- but use caution.

38

Drug indications for ARB's

Potassium supplements
Potassium-sparing diuretics
NSAIDs

39

Renin inhibitor- Aliskiren

First oral agent that directly inhibits renin
Role in treatment of hypertension is unclear as it is a new agent
Can be used as monotherapy or in combination
ADRs are similar to ACE inhibitors; and similar to ACE inhibitors, this drug should not be used in pregnancy

40

MC Beta Blockers

Most common:
Atenolol: once a day
Metoprolol Succinate: Once a day
Metoprolol Tartrate: Twice a day
Sotalol (Betapace)
Class III anti-arrhythmic agent

Dose: Depends on the beta-blocker

41

Beta Blockers Place in Therapy

Place in Therapy: Not a first line
Reserved for patients that have significant cardiac history
Heart failure
Post-MI
High coronary artery disease
CKD

42

MOA for Beta Blockers

Beta-1 receptors; located in heart and beta-2 receptors are located in the lungs
Beta-blockers block beta-1 receptors thus decreasing the effects of epinephrine, and nor-epinephrine which therefore decrease BP and HR

43

Beta Blocker Differences

Cardioselectivity (dose-dependent)
AMEBBA: Atenolol, metoprolol, esmolol, bioprolol, betaxaolol, acebutolol

Mixed α and β blockers
Carvedilol and labetalol

ISA (intrinsic sympathomimetic activity)
CAPP: (Carteolol, acebutolol, penbutolol, and pindolol)

Non-Specific
Nadolol, propranolol, timolol

44

Common Adverse Effects for Beta Blockers

Initial: “Beta-blocker blues”: tired, fatigued, depressed, and their chest might feel “different” due to change in heart beat
Other: Sexual dysfunction, rebound HTN if suddenly discontinued

45

Relative Contraindications for Beta Blockers

Asthma and COPD (bronchospasm)
Diabetes (masks hypoglycemic response except sweating)
Severe peripheral vascular disease (decreased output can worsen symptoms)
Heart block
Severe acute heart failure
Pregnancy category C