HTN - Thumar Flashcards
(77 cards)
1
Q
at what BP do you initiate txt for pts ≥60 y/o (w/o CKD or DM)?
A
BP ≥ 150/90mmHg
2
Q
at what BP do you initiate txt for pts < 60 y/o (w/o CKD or DM)?
A
BP ≥ 140/90mmHg
3
Q
at what BP do you initiate txt for pts ≥ 18 y/o w/CKD?
A
BP ≥ 140/90mmHg
4
Q
at what BP do you initiate txt for pts ≥ 18 y/o w/DM?
A
BP ≥ 140/90mmHg
5
Q
what is the BP goal for pts ≥60 y/o (w/o CKD or DM)?
A
< 150/90mmHg
6
Q
what is the BP goal for pts < 60 y/o (w/o CKD or DM)?
A
BP < 140/90mmHg
7
Q
what is the BP goal for pts ≥ 18 y/o w/CKD?
A
BP < 140/90mmHg
8
Q
what is the BP goal for pts ≥ 18 y/o w/DM?
A
BP < 140/90mmHg
9
Q
are beta-blockers still first-line for HTN?
A
no!
10
Q
chlorthalidone vs amlodipine vs lisinopril
A
No clear difference b/w single agent regarding fatal CAD and nonfatal MI
Chlorthalidone may be preferable (thiazide diuretic) -HCTZ largely used in US – drug cost, availability, assumption of class effect among thiazides
Chlorthalidone used more in elderly population
11
Q
hierarchy for HTN txt
A
CKD > race > co-morbidities
12
Q
If pt has CKD (+/- DM, regardless of race), what meds do you treat HTN with?
A
ACEI or ARB
13
Q
Black population (+/- DM; w/o CKD), what meds do you treat HTN with?
A
Thiazide or CCB
14
Q
General population (non-block; +/- DM; w/o CKD), what meds do you treat HTN with?
A
Thiazide or CCB or ACEI or ARB
15
Q
what do ACEI & ARBs treat and what are they shown to delay?
A
ACEI & ARBs treat <b>HTN</b> and are shown to <b>delay the progression of CKD</b>
16
Q
what are the CrCl qualifications for Thiazides?
A
Less effective/ineffective in GFR < 30
-if Cr <30, they have CKD -> use ACEI or ARB
17
Q
what is the definition of CKD?
A
abnormalities of kidney structure (GFR) or function, present for > 3 months, with implications for health
18
Q
what is CKD classified by?
A
CKD is classified based on cause, GFR category, and albuminuria category
19
Q
how many stages of CKD are there?
A
5 stages
20
Q
at what stage is end stage renal dysfunction?
A
stage 5
higher the stage = more severe CKD
21
Q
what are CKD stage 1-2?
A
GFR > 60 ml/min for > 3 months plus one or more markers of kidney damage <b>(albuminuria)</b>
22
Q
what are CKD stage 3-5?
A
GFR < 60 ml/min for > 3 months
<b><i>-Don’t need to have measure of albuminuria for stage 2-5</i></b>
23
Q
what should be considered obtaining for all pts with HTN and/or DM?
A
consider obtaining baseline and yearly albumin assessment for all pts with HTN and/or DM
(both HTN and DM are linked to CKD progression)
24
Q
what is a common lab to order for HTN and/or DM patients?
A
“albumin-creatinine ratio”; “ACR”
- “microalbumin/urine creatinine ratio”
- **NOT serum creatinine
25
what is a normal ACR? (albumin-creatinine ratio)
normal < 30mg/g
26
what is a moderate increase (previously "microalbuminuria") in ACR? if have DM at increased risk of?
30-300mg/g
If have DM, at increased risk of nephropathy, retinopathy, neuropathy
27
what is a severe increase (previously "macroalbuminuria") in ACR? if have DM at increased risk of?
>300mg/g
If have DM, at increased risk of MI, stroke
28
what medications can be used to decrease albuminuria in pt with CKD? why would you be on an ACEI or ARB w/out HTN? secondary effect of ACEI or ARB w/out HTN?
ACEIs or ARBs
- Can have CKD w/out HTN and be on an ACEI or an ARB b/c ACEI/ARB are helping the CKD
- Secondary effect may be BP lowering that you might not even want
29
what other medications besides ACEIs or ARBs also decrease albuminuria?
SGLT-2's (specifically empagaflozin)
- Can delay CKD progression in DM patients
- Great txt option for patient with angioedema & has DM
Liraglutide delays CKD progression
30
what medication is a great option to delay CKD and for pts with angioedema & has DM?
SGLT-2's (specifically empagaflozin)
31
why don't ACEIs or ARBs work well for AA's? What txt approach is preferable for them?
- Low plasma renin activity and increased sodium/fluid loading (high-volume HTN)
- Means vasodilation & diuretics are preferable txt approach
32
what is the black population w/HTN particularly responsive to?
Black population with HTN particularly responsive to sodium restriction and diuresis
33
what meds have better efficacy as monotherapy for Blacks w/HTN? what are these meds most effective in improving? what have some studies shown about ACEIs as mono therapy in Blacks w/HTN?
- Thiazide diuretics and CCBs have better efficacy as monotherapy
- Most effective in improving cerebrovascular, heart failure, and combined CV outcomes
- Some studies have shown an increase in stroke risk with ACEIs in this populations (as monotherapy)
34
when can you consider starting with dual therapy for HTN?
Can consider starting with dual therapy if BP is >20/>10mHg above goal at diagnosis
Both SBP & DBP need to be above goal by >20/>10
35
if BP goal isn't reached within one month of initiating txt, what can you do?
Increase/maximize dose of the initial drug OR
- Add a second agent from a different class (Thiazide-type, ACEI/ARB, CCB)
- (regardless of race; no longer “mono”therapy)
36
what should you monitor for patients?
monitor labs as appropriate for chosen meds -> get CMP
37
what should you recommend to your patient to keep?
a BP diary
38
what else should you consider with your patient when treating their HTN?
- Consider dietary/lifestyle interventions as appropriate
- Respect cultural sensitivities, lifestyles, and beliefs
- Smoking cessation has a huge impact on HTN -> decreases BP
39
in the accomplish study, what did they show?
* *Benazepril/amlodipine >> benazepril/HCTZ
- Significantly less CV mortality
- ACEI plus CCB showed superiority versus ACEI plus thiazide
-These were also single pills (increased adherence and less cost)
40
what did the accomplish study suggest that you should consider when treating HTN?
Consider ACEI + CCB over ACEI + thiazide
41
if goal BP is not achieved with 2 agents, what can you do?
Add a third recommended agent; maximize doses
- Avoid using ACEI and ARB in combination
- Too potent hyperkalemic effect and too much impact on kidney injury
42
if goal BP can't be reached using a 3rd drug, what can you consider doing?
- Ensure dose optimization and proper BP measurement techniques; consider secondary HTN work-up
- Consider aldosterone-antagonist, beta-blocker, alpha-blocker, etc. due to resistant HTN
- Consider referral to a HTN specialist
43
what is a big barrier to HTN management?
COMPLIANCE!!!
| -need to confirm that pts are picking up/taking their meds
44
what meds are for primary prevention of HTN based on ASCVD risk profile?
anti-platelets; statins
45
what are is age cutoffs range for elderly?
60-80 years or older
46
when treating elderly for HTN, what meds showed favorable data?
low-dose thiazide diuretics
| some data for DHP CCBs & ACEIs
47
what must you consider for elderly when treating their HTN?
consider fall risk; hypo perfusion if BP goes too low
48
what meds is there a limited role of in younger/women of child-bearing age?
ACEIs/ARBs; also statins
| -unless contraception is in place and monitoring
49
what should all women of child-bearing age be taking?
MVI + folic acid
50
what are first-line HTN meds for pregnancy? second line?
first line = methyldopa; labetalol
second line = nifedipine (non-DHP); verapamil
-alternative -> clonidine
51
role of what in pts with post-MI, HF, stroke?
BBs, anti-platelets, statins, anticoags
52
what about treating HTN in osteoporosis pts?
MONITOR Ca
- Thiazides -> increase Ca in blood (hypercalcemia)
- Diuretics have volume depleting
- Loops cause hypocalcemia (doesn't mean you shouldn't use loop b/c if have HF will need a loop)
53
what HTN meds have sulfa component?
Thiazides and loops
54
if have sulfa anaphylaxis allergy what should you do?
stay away from thiazides and loops
| -use K-sparing diuretics or Ethycrinic acid
55
what do all diuretics do to uric acid levels and gout?
all diuretics can cause hyperuricemia (increase uric acid levels)
56
what about treating BPH & HTN?
alpha-1 blockers dual benefit for lowering BP & BPH
57
what are the 7 simple tips to get an accurate BP reading?
1. Support arm at heart level
- Unsupported adds 10mmHg
2. Put cuff on bare arm
- Cuff over clothing adds 10-40mmHg
3. Don’t have a conversation
- Talking adds 10-15mmHg
4. Empty bladder first
- Full bladder adds 10-15mmHg
5. Support back
- Unsupported back adds 5-10mmHg
6. Keep legs uncrossed
- Crossed legs add 2-8mmHg
7. Support feet
- Unsupported feet add 5-10mmHg
58
considerations for treatment-resistant pts?
COMPLIANCE!! Dose-optimiation!!
Combination agents
- consider costs, available doses, and dosing
- reduce pill burden and increase adherence
"Chronotherapeutics"
59
how do you improve a pts adherence to HTN medication?
- Assess patient understanding of disease and treatments
- Use adherence aids such as charts or pill boxes
- Link medication use with daily activities
- Provide multi-disciplinary support
- Recognize socio-behavioral issues
- Simplify medication regimens
60
what is chronotherapeutics?
consider administering one BP med at night (change one BP med that's taken in the morning to taking it in the evening)
- better 24hr control; possibly less dizziness
- do not use diuretic in evening (b/c will make you pee a lot)
61
what does recent data suggest about nighttime elevated BP?
that nighttime elevated BP correlates more closely with CV than does daytime BP
62
what is there a concern for with chronotherapeutics?
loss of adherence & nocturnal hypotension
63
what lifestyle modifications are there for HTN?
- weight reducing (BMI index of 18.5-24.9 should be maintained)
- Adopt DASH eating plan
- Dietary sodium reduction
- Physical activity
- Moderation of alcohol consumption (no more than 2 drinks/day in men & no more than 1 drink/day in women)
64
what is resistant HTN?
Blood pressure that remains above goal despite the concurrent use of 3 antihypertensive agents of different classes at optimal doses
65
what is a common secondary cause of resistant HTN?
pseudoresistance, which can be due to several situations:
- faulty BP measurement technique
- white coat HTN; aggravation
- NON-ADHERENCE!!! (MOST COMMON CAUSE)
66
what are common causes of secondary causes of resistant HTN?
-Obstructive sleep apnea
-Primary aldosteronism
-Advanced CKD
-Renal artery stenosis
-Volume overload
-Excess alcohol intake
-Obesity
-Medications*
67
what are uncommon causes of secondary causes of resistant HTN?
- Pheochromocytoma
- Cushing’s disease
- Hyperparathyroidism
- Intracranial tumor
68
what drugs can induce HTN?
NSAIDs; COX-2 inhibitors; vasoconstrictors; stimulations; cocaine; other illicit drugs
sympathomimetics (decongestants, diet pills)
OCPs
Cyclosporine; tacrolimus; steroids
erythropoietin
natural licorice; herbals (ephedra, bitter orange)
69
do updated guidelines recommend specific agents for pts with resistant HTN (already on 3 meds)?
NO!!!
70
what other diuretics can you consider adding on to regimen for pt with resistant HTN?
K-sparing diuretics
| -spironolactone (dear SBP 5-20mmHg, decr DBP 5-10mmHg & improve left ventricular size)
71
what must you monitor K-sparing diuretics for?
monitor potassium b/c cause hyperkalemia
- also consider impact of other medications on K
- if pt has hyperkalemia at dx of HTN, may not be able to start K-sparing diuretic
72
what is the dosing for spironolactone, eplerenone, amiloride?
spironolactone: 12.5-50mg daily
eplerenone: 50mg BID
amiloride: 2.5-10mg daily
73
if pt does not have BB as part of their regiment, when should you consider their use?
if resting HR >80bpm
74
which beta-blockers should you consider using for resistant HTN?
carvedilol/labetalol
-don't have strong BP reducing effect
75
when should BBs already be a part of a pts regimen?
if they have CHF or CVD
76
when can alpha-1 blockers be considered for resistant HTN?
if pt has low HR and/or BPH
77
what meds that are not commonly used to treat HTN due to adverse effect profile can be useful in resistant HTN?
clonidine, hydralazine, etc.
