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HTN Lecture Flashcards

1
Q

Resistant HTN?

A

PT fails to achieve BP goal despite use of 3 meds (ideally 1 is diuretic)

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2
Q

Isolated HTN?

A

SBP > 140 AND DBP > 90 (widening pulse pressure)

Indicative of arterial stiffness and increased CV risk

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3
Q

Large determinants of SBP? DBP?

A

CO largely determines SBP (SV, HR, venous capacitance)

Total peripheral resistance largely determines DBP

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4
Q

MAP?

A

2/3DBP + 1/3SBP

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5
Q

Cardiac output affected by?

A 
Blood volume (Na, mineralcorticoids, ANP)
Cardiac factors (HR, contractility)
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6
Q

Total peripheral resistance (TPR) affected by?

A

Humoral (Constristrictors: (CATLE) catecholamine, angiotensin 2, thromboxane, leukotrienes, endothelin; Dilators: (PKN) prostaglandins, kinins, NO)

Neural ( alpha, beta adrenergic)

Local factors (ionic/pH/hyhpoxia)

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7
Q

Inhibit Na, Cl reabsorption in the DCT ( = Na, Cl, water elimination)

Over time, volume normalizes but decrease in peripheral reistsance keeps BP lower

A

Thiazide/thiazide like diuretics

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8
Q

Best tolerated med for HTN

Not effective for pts w/ poor KF *****(CrCl < 30 ml/min or SCr > 2.5 mg/dL)

A

Thiazide (hydrochorothiazide)/thiazide like diuretics

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9
Q

Non-thiazides?

A

Metolazone (**use for when KF < 30)

Indapamide

Chlorothalidone

MIC the “thigh guy”

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10
Q

Thiazides most effective when combined with?

A

ACEI or ARB

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11
Q

Inhibit conversion of angiotensin 1 to angiotensin 2, causing?

A

ACEI

Reduces:

vascular smooth muscle constriction

aldosterone synthesis/release

Na reabsorption (thus increasing excretion)

HR

ADH release

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12
Q

ACEI also increases availability of?

A

Bradykinin, which is a vasodilator

ACE itself is responsible for breakdown of bradykinin

BUT bradykinin is involved in production of prostacyclin/NO (a humoral dilator)

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13
Q

Despite bradykinin’s vasodilator effects, it also has some negative effects…?

A

angioedema/dry cough (adverse effects of ACEI)

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14
Q

ACEI reduced efficacy in what pop?

A

African-Americans (however, effective when combined with CCBs/diuretics)

Those with renal insufficiency

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15
Q

Considerations/Adverse events for ACEI?

A

taste disturbances

hyperkalemia

increase in BUN (up to 20% acceptable)

Renal artery stenosis

SHOULD MONITOR K, SCr, BUN @ baseline, 2 weeks

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16
Q

Mixing ACEI w/ what can increase rsk of arrythmias/deaht?

A

K-sparing diuretics/K supps

Increase in SK levels -> arrhythmias

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17
Q

Drug induced acute injury death?

A

RENAL TRIFECTA

Diuretics (concentrate blood urine)

ACEI/ARB (dilates afferent arteriole)

NSAIDS (inhibits prostaglandins/bradykinins -> constriction of afferent renal arteriole)

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18
Q

ACEI end in?

Only IV only ACEI?

A

-pril

Enalaprilat

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19
Q

ARBs act on what receptor?

A

Antagonize angiotensin2 at the AT1 receptor (which predominates in the vasculature) thus prevents vasoconstriction

Allows blocks aldosterone secretio (reducing salt/water retention)

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20
Q

ARBs/ACEIs are similar, except?

A

ARBs are generally more expensive (which is why they’re reserved for those who can’t tolerate ACEIs)

However, ARBs don’t significantly affect bradykinin (no cough/angioedema

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21
Q

Considerations/Adverse events for ARBs?

A

hyperkalemia

increase in SCr/BUN (up to 20% acceptable)

Renal artery stenosis

Caution w/ K-sparing diuretics/K supps (Increase in SK levels -> arrhythmias)

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22
Q

ARBs end in?

A

-sartan

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23
Q

Both ACEIs/ARBs?

A

Cat D (pregnancy)

Renal stenosis

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24
Q

Directly inhibits renin (thus reducing Angiotensin 1,2 and aldosterone)

A

Aliskiren

(not routinely combined w/ ACEI/ARBs)

ADE: diarrhea, cough/angioedema, hyperkalemia, incraesed BUN/SCr

Hypersensitivity to sulfonamide

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25
Alpha1 adrenergic blocking agents?
Rarely used as 1st step for HTN HTN monotherapy is discouraged BUT can use for BPH & HTN (or can be used in resistant HTN w/ other meds)
26
Uroselective Alpha1A antagonists?
Used for BPH ONLY not HTN Tamsulosin Silodosin
27
Alpha1 antagonists?
Terazosin Doxazosin Prazosin (***Not for BPH, BUT for PTSD)
28
Alpha1 antagonists adverse effects?
Orthostatic HOTN Reflex tachycardia -> angina Edema (prazosin esp.) which may require a diuretic
29
A2 agonists
Reduction in sympathetic outflow Best used with agents that have other MOA (diueretics, ACEI)
30
Can be combined with other meds for tough HTN Also for ADHD, Tourette's Offlabel = etoh w/drawal, mania, restless legs, smoking cessation
Clonidine | caution with olds and abrupt w/drawal
31
First line for pregnanc HTN? Requires TID/QID?
Methyldopa
32
B blockers for HTN?
antagonizes B1 receptors causing decreased CO, also reduces renin secretion
33
B blockers for hyperthyroidism?
propranol/esmolol
34
post-MI DOC?
B blocker Also beneficial in: ``` Angina (reduce myocardial Oxygen) CHF MI (DOC) Glaucoma Pheochromocytoma ```
35
"Cardioselective" (B1) blockers have less effect on?
Asthma/diabetes
36
Beta blocker w/ ISA?
Good option for pts who need beta blocker but can't handle bradycardia ***AVOID USE POST-MI
37
ISA Beta blockers?
Acebutolol Pindolol Penbutolol
38
Beta blockers that cross the BBB well (i.e., high lipid solubility)? Resulting in?
Propranolol Bisoprolol Drowsiness, confusion, nightmares, depression
39
Precautions w/ Beta blockers?
DM: ***** mask symptoms of hypoglycemia Asthma: non-cardioselectives can make bronchoconstriction worse Can disrupt lipid metabolism Decreased libido
40
Beta blockers combined with non-dihydropyridine CCBs may produce?
bradycardia | NonDHP CCB = verapmil, diltiazem
41
Mainly used in pts w/ HF and HTN mixed Alpha1-nonspecific Beta blocker
Carvedilol | take w/ food, only tabs
42
mixed Alpha1-nonspecific Beta blocker 2nd line agent for pregnancy (offlabel) SEVERE HTN
Labetalol
43
B1 selective antagonists?
``` Betaxolol Bisoprolol Atenolol Acebutolol (ISA) Metoprolol ```
44
Non-selective antagonist (beta1,2)
Propanolol Nadolol Timolol Pindolol (ISA) Penbutolol (ISA)
45
blocks transport of catecholamines, resulting in depletion and impairment of sympathetic function adjunctive therapy with other HTN meds
Central monoamine-depleting agent Reserpine
46
Blocks inward movement of calcium through L channels of ARTERIAL smooth muscle and CARDIAC cells of coronary system (obvs a CCB)... what two categories?
Dihydropyridines (DHPs) [end in -pine] Non-DHPs [more selective for myocardium & neg inotrope]
47
Preferred in pts w/ fast HRs and those who have A Fib who can't tolerate beta blockers
Non DHP CCBs Verapamil Diltiazem
48
***least selective CCB (so effects on both cardiac/vascular smooth muscle) Angina, SVTs, Tachyarrhythmias, ***migraines/cluster HAs
verapamil (non-DHP)
49
CCB w/ less pronounced neg inotropic effects significant effects on both cardiac/arterial smooth muscle SVTs/tachyarrhythmias
Diltiazem (non-DHP CCB)
50
More efficacious in HTN of African AMerican population?
CCB
51
Caution in HF?
CCB Amlodipine has increased risk of HF vs diuretic
52
adverse effects... HOTN -> peripheral edema High dose -> excessive vasodilation & reflex tachy Gingival enlargement (which particular drug?)
Dihydropyridines (CCBs) big gums = Nifedipine
53
Verapamil/diltiazem can increase presence of what drug?
digoxin
54
Verapamil/diltiazem may increase negative inotropic effects of beta blockers -> bracycardia BUT....
Dihydropyridines can be combined with beta DHPs end in -pine
55
Directly relax smooth muscle in arteries (decreases vasc resistance/BP) Increases renin concentration, so you need a diuertic to reduce Na/H20 May precipitaet angina/MI/cardiac failure
DIrect arterial vasodilators LAME (4th line) Effective when combined with diueretics, betas, sympatholytics
56
Reserved for severe HTN or pts who fail triple therapy HTN emergency Pregnancy HTN (cat C) Combined with nitrates to treat both hTN/HF in African Americans
Hydralazine (DIrect arterial vasodilator) | can cause lupus erythematosis-like syndrome
57
Can use if hydralazine isn't effective Hypertrichosis
Minoxidl (DIrect arterial vasodilator)
58
What stages warrant drug tx?
Stage 1, 2 HTN
59
BP of 120-129.... therapy?
Nonpharmacologic reassess in 3-6 mos
60
Stage 1 HTN (130-139/80-89)... What's a decision point?
ASCVD risk... if >10 (use a BP-lowering med) If risk <10, use a non-pharmacologic approach
61
Stage 2 HTN (140/90)?
BP-lowering meds regardless of ASCVD risk
62
Stage 1 HTN... single drug?
Upon initiation of tx, A single HTN is reasonable in adults with stage 1 w/ dosage titration/addition of other agents
63
Stage 2 HTN... tx?
2 first line agents of different classes is rec'd
64
In black adults w/ HTN but w/o HF/CKD (including those w/ DM) initial HTN tx should be?
thiazide-type diuretic or CCB
65
Pregnancy HTN tx?
methyldopa Labetalol Nifedipine
66
DM & HTN?
All first line drugs are useful/effective ACEI/ARBs may be considered in presence of albuminuria
67
Adults w/ stroke & prior TIA?
NOT A CCB
68
Albuminura >300 mg/d (creatinine >300)?
Start w/ an ACEI If less than 300, usual "first-line"
69
HTN urgency vs emergency?
Urgency > 180 but no indication of end organ damage Emergency > 180 w/ EVIDENCE OF END ORGAN DAMAGE (ssx - stroke, LOC, crushing chest pn, eye/kdiney damage, unstable angina, pulm edema, eclampsia)
70
African American w/ HTN (w/w/o DM) but w/o HF or CKD.... first line med?
thiazide type or CCB
71
Oral or IV in HTN urgency?
Oral
72
HTN urgency... timelines?
Slow... over 24-48 hrs (reduce MAP by no more than 25%)
73
HTN urgency mgmt? (3x drugs...)
Clonidine Captopril (use this over clonidine if pt has HF) Labetalol (consider if pregnant)
74
HTN emergency... similar to HTN urgency, you should only reduce MAP by 25% in first hour UNLESS?
Pt has compelling condition (aortic dissection, preeclampsia/eclampsia, pheochromocytoma crisis), wherein you should reduce to 140 or 120 (aortic dissection) IV is preferred
75
Vasodilators for HTN emergency?
Sodium Nitroprusside (DOC, except CKD, hepatic fx, aortic dissection) Nitroglycerin (preferred in pts w/ pulmonary congestion) Hydralazine Fenoldopam (dope agonist)
76
ACEI for HTN Emer?
Enalaprilat (only IV ACEI as well, hint)
77
CCB for HTN emer?
Nicardipine (strong cerebral effects, consider w/ intracerebral hemorrhage/stroke) Clevidipine
78
Adrenergic inhibitors for HTN emer?
Esmolol Labetalol
79
HTN emergency and Useful in severe tachy, increased CO, severe post op HTN BUT Avoid in pts w/ decompensated HF, already on a beta, or have brady
esmolol
80
Useful in HTN urgency/emer Doesn't cause reflex tachy, so preferred in CAD, acute dissection, end stage renal disease, acute intracerebral hemorrhage, acute ischemic stroke (doesn't reduce cerebral blood flow), MI
labetalol
81
Adverse... Cyanide toxicity, methemoglobinemia CI in renal/hep fx Caution in increased ICP
Sodium nitroprusside
82
Adverse... tachyphylaxis methemglobinemia Increased ICP (Caution)
Nitroglycerin
83
Adverse... Reflex tachy Caution in angina/MI, incerased ICP, aortic dissection
hydralazine
84
Adverse... Long half life.... CI = pregnancy, renal artery stenosis, angioedema
Enalaprilat (ACEI)
85
HTN emer agent... caution in Angina/MI, acute HF
Nicardipine (CCB)
86
HTN Emer agents... Caution in acute HF, asthma, heart block (hint they're both adrenergic inhibitors)
esmolol (beta blocker) labetalol (beta blocker)

Pharm 2 (5 decks)

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