HTN Flashcards
(215 cards)
1
Q
Correct BP technique
A
- Automated electronic device > sphygmomanometer
- Take 2 readings 1-2 minutes apart
- Measure BP in both arms @ initial visit
2
Q
__% of cases of ischemic HD & CVA are attributable for HTN
A
50
3
Q
What is the new BP goal?
A
130/80
4
Q
Even though some do well with a new goal of 130/80, what else do we need to consider when establishing BP goals?
A
Tailor to the PATIENT
e.g. pt. with orthostatic hypotension -> goal of <140/90 more appropriate
5
Q
Treatment for normal BP (120/80)
A
Maintain health lifestyle habits
6
Q
Treatment for elevated BP (120-129/<80)
A
Lifestyle changes + check for meds that can raise BP
7
Q
Treatment for Stage 1 HTN (130-139/80-89)
A
- Lifestyle changes alone if ASCVD risk is <10%
- BP meds for pts. with CV disease, DM, CKD, or ASCVD >10%
8
Q
Treatment for Stage 2 HTN (>140/90)
A
Lifestyle changes + BP meds
9
Q
Who do we suggest home BP monitoring for?
A
ALL pt. (esp. if you suspect white coat HTN, resistant HTN)
10
Q
What do you do if you use an automatic BP monitor in the office and get a high/unusual BP read?
A
Verify with manual check (esp. before changing med!)
11
Q
How do anti-HTN agents compare to each other?
A
They are roughly equally effective
12
Q
Black pt. respond less to what meds?
A
ACEI, ARBs, BB
13
Q
Preferred anti-HTN meds (combos)
A
- ACEI or ARB + thiazide
- ACEI or ARB + DHP-CCB
14
Q
Meds that induce HTN
A
- OCPS
- Stimulants
- Transplant meds (cyclosporine)
- EPO
- Corticosteroids
- NSAIDs
- Sympathomimetics
- Neuropsychiatrics
15
Q
25% of pts stop anti-HTN within _____
A
6mo
16
Q
What can cut nonadherence?
A
- Identifying ADRs & switching therapy
- Eval cost
- Explain importance of mgmt
- Get pts engaged
- Advise pt to engage automatic refill program
17
Q
What is chronotherapy?
A
Taking >1 BP med at night
18
Q
In what patients should chronotherapy should be recommended?
A
Pt. w/ morning BP rise OR pt. whose BP dose NOT dip @ night like it should
19
Q
Chronotherapy has what additional benefit?
A
Lowers CV risk
20
Q
What is the best predictor of BP control?
A
Med adherence
21
Q
Mannitol formulations
A
IV, urogenic solution
22
Q
Mannitol MOA
A
Nonabsorbable polysaccharide that acts as an osmotic diuretic (“sugar that pulls water in”); inhibits Na+ and H2O reabsorption
23
Q
Mannitol site of action
A
Proximal tubule and loop of Henle
24
Q
Mannitol clinical indications
A
- Decreased ICP ass. w/ cerebral edema
- GU irrigate in TURP or other transurethral procedure
25
What do we monitor in a pt. on mannitol?
- Daily I&O
- Renal fcn & electrolytes
- Serum & urine osmolality
26
Mannitol ADRs
- Fluid & electrolye imbalance
| - Dehydration/hypovolemia secondary to rapid diuresis
27
Drug interactions of ALL anti-HTN meds
Anti-HTN & vasodilators (e.g. nitrates, PDE5 inhibitors)
28
Acetazolamide formulations
PO, IV
29
Acetazolamide MOA
Reversible inhibition of carbonic anhydrase -> ↓ H+ secretion at renal tubule & ↑ renal excretion of Na+, K+, HCO3, & H2O
30
Acetazolamide site of action
Proximal tubule and loop of Henle
31
Acetazolamide clinical indications
Acute mountain sickness (prevention or sx relief)
| - ↓ blood pH stimulates extra breathing = higher blood [O2]
32
Loop diuretic drugs
- Furosemide
- Torsemide
- Bumetanide
- Ethacrynic acid
33
Which loop diuretic does not contain a sulfa group?
Ethacrynic acid
34
Loop diuretic MOA
Inhibit Na+/K+-ATPase
35
Loop diuretic site of action
Thick segment (ascending limb) of the loop of Henle
36
Loop diuretic clinical indication
- Acute pulmonary edema & other edematous states
| - Acute hypercalcemia
37
What do we monitor in a pt. on a loop?
- BMP
- Ca+, Mg+
- Daily wts
38
Why are loops better than thiazides for treatment of HF?
Loops cause more Na+ secretion which results in a profound diuretic effect
39
Starting dose for loops
20-40mg qAM (titrate to lowest dose that achieves fluid balance)
40
Which do we do first for loops: increase the dose or add a second dose?
INCREASE the dose! ("double the dose until the urine flows")
- Titrate to 80mg qAM; if more needed add 80mg in the afternoon
41
If additional diuresis/sx relief is needed for a pt. on a loop, what drugs can we add to the treatment regimen?
Aldosterone agonist - spironolactone! (esp. for HFrEF of GFR >30)
Thiazide for persistent sx
42
Loops work better than thiazides for a GFR of what
<30
43
Which loop causes the most ototoxicity?
Ethacrynic acid
44
Drug interactions w/ loops
- NSAIDs (antagonize diuretic effect via Na+ retention)
- Anti-arrhythmics (QT!)
- Lithium toxicity
- Antagonizes gout (urate absorption) & DM medications (hypoK+)
45
Loop ADRs
- Volume depletion
- HypoK+, hypoMg
- HypoNa+
- Hyperuricemia
- SNHL ("ringing")
- Hyperglycemia
- Rash (r/t sulfa cross-reactivity?)
46
Thiazide drugs
- HCTZ
- Chlorthalidone
- Metolazone
- Indapamide
- Chlorothiazide
47
Which thiazide is the only available IV? (all others tablets)
Chlorothiazide
48
Thiazide MOA
Inhibit Na+/K+-ATPase
49
Thiazide site of action
Distal convoluted tubule
50
Chlorthalidone vs. HCTZ
Chlorthalidone...
- 2x as potent
- Longer DOA
- 25mg more effective than 50mg of HCTZ in decreasing BP at night
- Extensive partitioning into RBCs (creates a "depot")
- ADRs equivalent
51
Which do we use more: Chlorthalidone vs. HCTZ?
HCTZ in most fixed-dose combinations
52
Thiazide indication
HTN
53
When do we dose thiazides?
In the AM
54
What do we monitor in a patient on a thiazide?
- BMP
| - Ca+, Mg+
55
Every thiazide beside what drug is less effective when CrCl <30mL/min?
Metolazone
56
How does thiazide effect Ca++?
```
Enhances reabsorption (improves hypercalciuria/kidney stones, may benefit osteoporosis)
*opposite of loops
```
57
Thiazides have the potential to unmask what types of conditions?
Conditions that increase Ca+ (e.g. hyperPTH, CA, sarcoid, PHEOS)
*thaizides do not traditionally cause hypercalcemia
58
What drug can be used with loop diuretics for synergy in refractory edematous states?
Metolazone
59
Drug interactions w/ thiazides
- NSAIDs (antagonize diuretic effect via Na+ retention)
- Anti-arrhythmics (QT!)
- Lithium toxicity
- Antagonizes gout (urate absorption) & DM medications (hypoK+)
60
Thiazide ADRs
- Volume depletion
- HypoK+, hypoMg (@ risk for metabolic acidosis w/ higher doses)
- HypoNa+
- Hyperuricemia
- Hyperglycemia
- Rash (r/t sulfa cross-reactivity?)
- Hyperlipidemia
61
K+ sparing diuretic drugs
- Spironolactone
- Eplerenone
- Amiloride
- Triamterene
62
Spironolactone & eplerenone MOA
Anti-aldosterone drug
| - Antagonizes mineralocorticoid receptors -> ↓ transcription of gene for Na+/K+-ATPase
63
Amiloride & triamterene MOA
Inhibit Na+/K+-ATPase
64
K+ sparing diuretic site of action
Collecting tubule
65
Which K+ sparing diuretic is the only available as a solution? (all others tablets)
Spironolactone
66
Spironolactone & eplerenone clinical indication
- Mineral corticoid excess (primary OR secondary - CHF, cirrhosis, nephrotic syndrome)
- Acne vulgaris
- Hirsutism
67
Amiloride & triamterene clinical indication
Generally used with other diuretics to prevent or correct hypokalemia
- Overall weak diuretic effect
- Falling out of favor d/t addition of ACEI/ARB to diuretics
68
Do NOT use K+ sparing diuretics for K+ >____ or eGFR
5.5; 30
69
What do we monitor in a patient on a K+ sparing diuretic?
K+ & BUN/Cr (baseline, 1wk, monthly for 3mo, quarterly for 1yr, then q6mo)
70
Drug interactions with K+ sparing diuretics
- K+ supplements/salt substitutes
| - Drugs that retain K+ (BB, TMP-SMX, NSAIDs, ACEI/ARBs)
71
K+ sparing diuretics ADRs
Hyperkalemia
72
Spironolactone ADRs
- TERATOGEN
- Painful gynecomastia
- Amenorrhea
- ED
- ↓ libido
73
Triamterene ADRs
Nephrotoxin: crystalluria & cast formation => stones or AKI
74
Use of 2 diuretic drugs acting at a different nephron sites may......
Have a synergistic effect
75
ACEI drugs end in "___"
pril
76
What drug is the only true QD ACEI?
Lisinopril (half life = 12hrs)
77
Which ACEI is a prodrug?
Enalapril
78
ACE is a kininase, if it's inhibited what increases?
Bradykinin
79
What are the implications of ↑ bradykinin
Cough (bad)
| Release of endothelial NO = vasodilation (good)
80
ACEI MOA
Vasodilate efferent arteriole -> ↓ glomerular pressure
81
ACEI clinical indications
- HTN (esp. w/ LVH)
- HF with systolic dysfcn
- CKD (both DM & non-DM)
- Post-AMI (which resulted in ↓ systolic fcn)
82
What population is less sensitive to ACEI monotherapy?
AA
83
ACEI have synergy with what other drug
Diuretics
84
Are ACEI & ARBs good or bad for the kidneys
Renal protectors!
85
At what GFR are ACEI not recommended
There is NO absolute GFR when ACEIs can't be used
| - The lower the GFR, the greater the need for neph consultation
86
What do we monitor in a patient on a ACEI?
- BUN/Cr
| - K+
87
Drug interactions with ACEI
Other meds that cause hyperkalemia (BB, TMP-SMX, NSAIDs, ACEI/ARBs)
88
Precautions/contraindications w/ ACEI
- Pt. w/ hereditary or idiopathic angioedema
| - Bilateral RAS or stenotic lesion to solitary kidney
89
ACEI ADRs
- Cough
- TERATOGEN
- Decrease intrarenal perfusion = renal fcn decline (CHECK SCr!!! Increase of <30% acceptable)
- Hyperkalemia
- Angioedema
90
What do we do if a pt. on an ACEI/ARB has a SCr increase of <30% and K+ <5.5?
Repeat lab in 2-3 weeks
91
What do we do if a pt. on an ACEI/ARB has a SCr increase 30% to <50% and K+ <5.5?
Cut dose in half and recheck every 5-7 days until stable
| - D/C if persists after 4 weeks
92
Why is there less of a chance of angioedema with ARBs c/t ACEI?
ARBs don't directly inhibit bradykinin
93
Can we use an ARB if a pt. has MILD angioedema (tongue & face swelling) with an ACEI?
Yes
94
Can we use an ARB if a pt. has SEVERE angioedema (airway obstruction, respiratory sx) with an ACEI?
Consider another treatment
95
How long should we wait after stopping an ACEI and starting an ARB for a pt. that experienced angioedema?
>4 wks
96
ARB drugs end in "___"
sartan
97
The generic products of which ARB drug are possibly carcinogenic?
Valsartan
| - CA risk is low, but some are being pulled from the market
98
ARB MOA
Impairs binding of angiotensin II to AT1 receptors -> interferes with RAAS
99
ARB clinical indications
GENERALLY THE SAME AS ACEI
- HTN (esp. w/ LVH)
- HF with systolic dysfcn
- CKD (both DM & non-DM)
- Post-AMI (which resulted in ↓ systolic fcn)
100
Which ARB has the best data?
Losartan
101
Losartan has what additional clinical indication
Used for gout prevention d/t uricosuric activity
102
What do we monitor in a patient on a ARB?
- BUN/Cr
| - K+
103
Losartan is a substrate of CYP____ & ____
2C9, 3A4 (however, minimally metabolized)
104
What other drugs do we want to avoid with ARBs?
Drugs that retain K+
105
ARB ADRs
- TERATOGEN
- Decrease intrarenal perfusion = renal fcn decline (CHECK SCr!!! Increase of <30% acceptable)
- Hyperkalemia
- Angioedema (less risk c/t ACEI)
106
Which ARB is associated with sprue-like enteropathy?
Olmesartan (don't use anyway, limited data)
107
Which drug is a renin inhibitor?
Aliskiren
108
Aliskiren MOA
Binds catalytic site of renin -> inhibits entire RAAS system
109
Do we use aliskiren?
No
110
Does it ever make sense to combine an ACEI with an ARB OR aliskiren with an ACEI or ARB?
Rarely
111
Alpha-adrenergic antagonists (alpha blockers) end in "___"
zosin
112
Which alpha blockers are long acting (QD)?
Terazosin, doxazosin
113
Which alpha blockers are short acting (BID-TID)?
Prazosin
114
Alpha blocker MOA
Highly selective a1 receptor antagonist -> decrease arterial psi by dilating vessels
115
Why is it important to combine an alpha blocker with a diuretic
Alpha blockers commonly cause fluid retention
116
Clinical indications of alpha blockers
- HTN
- BPH
- "Medical expulsive therapy" for ureteral stones
- PTSD, distressing dreams (prazosin)
117
Are alpha blockers more likely to cause tachycardia or frequent postural hypotension?
Postural hypotension
118
Doxazosin is a substrate of CYP___
3A4
119
Although this is an interaction with ALL HTN drugs, the combination of alpha blockers and ________ is CONTRAINDICATED
Vasodilators (e.g. nitrates, PDE5 inhibitors)
120
What other drug type should we avoid using concomitantly with alpha blockers and what are the implications of this interaction?
Decongestants
| - Acute urinary retention (d/t increased tone in bladder neck)
121
Alpha blocker ADRs
- Postural hypotension (COMMON)
- Drowsiness/fatigue
- Nasal congestion/rhinitis
- Retrograde ejaculation
- Floppy-iris syndrome
122
How do we mitigate the postural hypotension/dizziness that is commonly experienced with the first few doses of alpha blockers?
Give 1st few doses @ bedtime
123
Beta blockers end in "___"
lol
124
Non-selective beta blocker (B1) drugs
- Propranolol
- Nadolol
- Timolol
125
Selective beta blocker (B1) drugs
- Metoprolol
126
Are non-selective BB or selective BB more associated with bronchospasm? And are, therefore, use more cautiously in pt. with what conditions?
Non-selective!
| - Caution in pt. w/ asthma, COPD, raynaud's
127
What BB has the best clinical data in treating pt. post-AMI, w/ HF, w/ Afib?
Metoprolol
128
What is metoprolol tartrate
IR product (dosed BID-TID)
129
What is metoprolol succinate
ER product (dose QD)
130
Examples of BB with vasodilatory effects (CHF > HTN)
- Non-selective: carvedilol, labetalol
| - Selective: nebivolol
131
Examples of BB with intrinsic sympathomimetic activity (ISA)
- Non-selective: pindolol
| - Selective: acebutolol
132
What is the physiologic significance of drugs with intrinsic sympathomimetic activity (ISA)
These agents have partial agonist activity = decrease BP w/ less decrease in HR
133
BB MOA
Competitive inhibitors of catecholamines at beta receptors
134
Where are B1 receptors located?
Heart muscle (increase HR, contractility, AV conduction)
135
Where are B2 receptors located?
Heart muscle, but more prominent in bronchial & peripheral vascular smooth muscle (vasodilation, bronchodilation)
136
Clinical use of BB
- HTN (esp. if additional indication (below))
- Stable/unstable angina
- Post-AMI
- Systolic HF/HFrEF
- Certain arrhythmias (Afib)
- Perioperative
137
Other clinical indications for BB
- Proliferating infantile hemangiomas (propranolol)
- Migraines
- Essential tremors
- Symptomatic mgmt of pheos/hyperthyroid
138
What population is less sensitive to BB monotherapy?
AA
139
What must we do when d/c BB therapy?
TAPER (1-3wks)
| - Could lead to accelerated angina, AMI, death
140
What pt. population should we avoid giving BB? Clue: adolescent w/ CP in the ED
Cocaine-induced CP or AMI
141
Are BB more or less effective in preventing CV events, such as CVA, c/t ACEI, ARBs, CCB?
Less
142
What are some positive implications of long-term use of BB in pt. w/ HF?
- Reduce hospital admission
- Improve sx
- Improve QOL
- Improve survival
143
What BB do pt. w/ HF get?
Carvedilol
144
If a pt. w/ HF has symptomatic hypotension or ventricular arrhythmias, what BB should they be on instead of carvedilol?
Metoprolol succinate
145
In what populations do we avoid use of BB?
- Asthma, COPD?
- Pt. w/ 2nd or 3rd degree heart block
- Pt. w/ SSS
- Pt. w/ bradycardia (<50bpm)
146
Which 3 beta blockers are CYP2D6 substrates?
Metoprolol, propanolol, carvedilol
147
BB blunt the effects of what neurotransmitter
Epinephrine
148
BB are used cautiously with other drugs that depress myocardial fcn or pacemaker activity, such as.....
- CCB
| - Antiarrhythmics
149
BB ADRs
- Bradycardia
- HyperK+
- Fatigue/exercise intolerance
- ED
- Floppy-iris syndrome
- Bronchospasm (non-selectives >)
- Mask/delay recovery from hypoglycemia (non-selectives >)
150
CCB end in "_____"
dipine
151
Short-acting DHP-CCBs
Nifedipine
152
Longer-acting DHP-CCBs
Felodipine, isradipine, nicardipine, nisoldipine
153
Long-acting DHP-CCBs
Amlodipine
154
Non-DHP-CCBs
Verapamil, diltiazem
155
CCB MOA
Inhibit L-type Ca+ channels -> no intracellular influx of Ca+
156
DHP-CCBs affects what MOST: vasodilation OR cardiac contractility/conduction?
Vasodilation
157
Non- DHP-CCBs affects what MOST: vasodilation OR cardiac contractility/conduction?
Cardiac contractility/conduction ( - ionotropic effect by suppressing sinus node activity & AV conduction)
158
DHP-CCBs clinical indications
- HTN
- Angina
- Raynaud's
159
Non-DHP-CCBs
- Cardiac arrhythmias (SVT, Afib)
| - Cluster HA prophylaxis (verapamil)
160
The IR formulation of what drug has increase CV mortality, esp. in CAD pts.?
Nifedipine
161
Precautions/contraindications to use of CCB
- Pt. w/ 2nd & 3rd degree AV block
- Pt. w/ SSS
- Pt. w/ bradycardia (<50bpm)
- HF pt.
162
Which 4 drugs are substrates of CYP3A4?
Nifedipine, amlodipine, diltiazem, verapamil
163
Interaction between amlodipine and what ABX may lead to hypotension, edema, bradycardia, AKI (d/t reduced perfusion)
Clarithromycin
164
What if we NEED clarithromycin and a pt. is on amplodipine?
Hold amlodipine or lower dose
165
Use non-DHP-CCBs cautiously with what other drugs?
BB and digoxin
166
DHP-CCBs class ADRs
- HA, dizziness, flushing, peripheral edema, reflex tachycardia
- Dyspepsia
167
Non-DHP-CCBs class ADRs
HA, dizziness, flushing, peripheral edema
168
Special ADR: nifedipine > amlodipine
Gingival hyperplasia
169
Special ADR: verapamil
Constipation
170
Central acting alpha-adrenergic agonists
Clonidine & methyldopa
171
What formulation is clonidine available in
Transdermal
172
Alpha agonist MOA
Stimulate a2 receptors in brainstem -> decrease sympathetic outflow from CNS -> decrease PVR, renal vascular resistance, HR, BP
173
Alpha agonist clinical indications
HTN
174
Clonidine ADRs (mostly PO)
- Dry mouth, sedation
| - Abrupt withdrawal (nervousness, tachy, HA, sweating) may lead to HTN crisis
175
How do we decrease incidence of HTN crisis r/t clonidine?
TAPER (1-2 wks)
176
Methyldopa ADR
- Overt sedation
- Lactation (both M&F)
- + Coomb/s test
177
Direct vasodilator drugs
Hydralazine
| Minoxidil
178
Direct vasodilator MOA
Exact mech NOT well understood: relaxes arterial smooth muscle -> decrease PVR
- Hydralazine alters Ca+ metabolism
- Minoxidil opens ADP-sensitive K+ channels
179
Hydralazine clinical indications
- HTN
- Preeclampsia/eclampsia
- HF (blacks; add isosorbide dinitrate)
180
Minoxidil clinical indications
- HTN
| - Alopecia
181
Direct vasodilators are given with what two drug classes to minimize reflex tachycadia/CO
BB or central acting
182
Direct vasodilators are given with what drug class to avoid Na+ & H2O retention
Diuretic
183
Hydralazine ADR
Lupus-like rxn
184
What drugs should we use in a hypertensive pt. of child-bearing age?
Nifedipine or labetalol
185
How do we define gestational hypertension (GHTN)
Women with normal prior BP that has a BP of >140/90 after 20 wks gestation
186
Fetal complications of GHTN
IUGR, preterm, LBW, NICU stay, death
187
Maternal complications of GHTN
Preeclampsia/eclampsia, AKI, pulmonary edema, C-section, placental abruption, CVA, death
188
How do we monitor a pt. with GHTN?
Weekly in-office checks & labs
189
S/sx of preeclampsia
Vision changes, severe HA, abd pain, worsening edema
190
What is preeclampsia
BP >140/90 + proteinuria
191
What does the data say about treating mild-moderate GHTN?
No evidence that it improves outcomes
192
If we were to treat GHTN, what drugs would be used?
- Labetalol (C)
- Nifedipine (C)
- Methyldopa (B) -> last resort!
193
Screening for HTN in peds pt.
Annually for kids ≥3
OR
At each visit for kids @ high risk (obesity, DM, taking meds that may increase BP)
194
What is a reasonable goal you can set for a peds pt. regarding weight loss
5-10% wt. loss per year OR not gaining wt. as they grow
195
Drugs for pediatric HTN
ACEI or ARB (esp. w/ kidney dz or DM) or DHP-CCB (esp. young girls)
196
Define resistant HTN
Uncontrolled HTN with ≥3 BP meds (including diuretic)
| - Many pt. fit this definition, but are poorly adherent or have inadequate tx regimens
197
How do we manage resistant HTN
1. Assess for pseudoresistance
2. Assess for factors that could contribute (meds, increase Na+ intake)
3. Optimize PB med (#1 chlorthalidone)
4. Screen for secondary causes of HTN (OSA, pheo, hyperthyroid)
198
Define HTN urgency
>180/>110 WITHOUT end organ damage
199
S/sx of HTN urgency
- Severe HA
- SOB
- Epistaxis
- Severe anxiety
200
How do we manage HTN urgency
FOCUS ON THE PT, NOT THE SPECIFIC BP LEVEL
- Immediate tx may cause harm!!!
- If asymptomatic -> urgent f/u & gradual reduction
201
Define HTN emergency
>180/>120 WITH end organ damage
202
S/sx of HTN emergency
Stroke, LOC/memory loss, ocular & renal dysfcn, aortic dissection, angina/MI, pulmonary edema
203
How do we manage HTN emergency
Admit to ICU (IV BP meds given)
204
Treatment of choice: nonblack <60
ACE or ARB
205
Treatment of choice: nonblack >60
ACE or ARB, CCB, thiazide
206
Treatment of choice: black pt.
CCB or thiazide
207
Treatment of choice: black pt. w/ CKD
ACE or ARB
208
Treatment of choice: nonblack pt. w/ CKD
ACE or ARB
209
Treatment of choice: black pt. w/ DM
CCB or thiazide
210
Treatment of choice: nonblack pt. w/ DM
ACE or ARB
211
Treatment of choice: pt. w/ CAD
ACE or ARB + BB
212
Treatment of choice: pt. w/ HF
ACE or ARB + BB + spironolactone
213
Treatment of choice: pt. w/ CVA hx
ACE or ARB
214
When baseline BP is >___/___ above goal, adding a 2nd drug to tx regimen is recommended
>20/10
215
Which is generally more effective? Adding a 2nd drug with a different mechanism OR increasing the dose of the 1st drug?
Adding 2nd drug w/ diff MOA
