HTN tx Flashcards
1
Q
ALLHAT takeaways
A
-thiazides first line
-then CCB or ACE if cant take those
-most pt need more than one
2
Q
First line HTN tx
A
-thiazide dieurtics
-if pt cant consider CCB or ACEi
-most pt gonna need combo
3
Q
First line tx
A
- thiazides
-CCBs
-ACE/ARBs
4
Q
Preferred combo therapy options
A
-ACEi/CCB
-ARB/CCB
-ACEi/diuretic
-ARB/diuretic
-honorable mention: CCB/diuretic
5
Q
Patient specific factors
A
-stable ischemic heart disease
-Heart failure
-CKD
-Cerebrovascular Disease
-Diabetes
-Pregnancy
-Race
6
Q
Stable Ischemic Heart Disease tx considerations
A
-Beta blockers to reduce CV events and anginal symptoms
-ACEi/ARBs to reduce MI, stroke, CVD
-Dihydropyridine CCBs if still uncontrolled
7
Q
Heart failure tx considerations
A
-reduced ejection fraction (HFrEF guidelines)
-Preserved ejection fraction (HFpEF) guidelines
8
Q
Reduced ejection HF tx guidelines
A
-ANRI + BB + mineralcorticoid antagonist + SGLT2 inhibitor
-may add loop for persistant fluid etc
-AVOID CCBs bc no clinical benefit/worse outcomes
9
Q
Preserved ejection fraction (HFpEF) tx guidelines
A
-SGLT2 inhibitor
-may add loop for fluid
-may add mineralcorticoid antagonist or ARNI/ARB in some
10
Q
When to add to HFrEF tx
A
-loop for fluid
-hydralazine + isosorbide if black pt still symptomatic
-ivabradine if resting HR over 70 on max BB
-Vericiguat (IV diuretic) for worsening HF in high risk
11
Q
When to add to HFpEF tx
A
-loop for fluid
-MRA for all women* or men w EF <55-60% and fluid
-ARNI for women* and men w LVEF, ARB if intolerant/cost
-women all EFs, men w EF < 55-60%
12
Q
CKD tx considerations
A
-stage 1 or 2 AND albuminuria OR stage 3+ give ACEi or ARB
-post kidney transplant give dihydropyridine CCBs due to improved GFR and kidney survival, reduces graft loss, maintains GFR (ACEi = anemia, hyperkalemia, lower GFR)
13
Q
Cerebrovascular Disease tx considerations
A
-Secondary stroke prevention
-ACEi/ARB
-thiazide
-combo
-initiating tx for BP <140/90 usefullness unknown
14
Q
Diabetes considerations
A
-all first-line
-ACEi or ARBs if albuminuria
15
Q
Pregnancy considerations
A
-methyldopa
-nifedipine
-llabetalol
-AVOID: ACEi/ARBs and direct renin inhibitors
16
Q
Race tx considerations
A
-black adults w/o HF or CKD, including diabetes, tx w thiazide diuretic or CCB
-better data for lowering BP
17
Q
Stable Ischemic HD tx
A
-ACEi/ARB + BB
-add CCB if not controlled
18
Q
CKD tx
A
-ACEi/ARB
-if stage 1+2 AND albuminuria
-or if stage 3+
19
Q
Renal transplant tx
A
-CCB over ACEi
20
Q
Secondary stroke prevention tx
A
-thiazide
-ACE/ARB
-combo
-only start if BP >/= 140/90
21
Q
Diabetes tx
A
-any firstline
-ACE/ARB if albuminuria
22
Q
Afib tx
A
-ARB for prevention
23
Q
Aortic disease tx
A
-BB for survival
24
Q
Black pt tx
A
-thiazide or CCB
-unless HF or CKD
25
Pregnancy tx
-methyldopa
-nifedipine
-labetolol
26
Albuminuria
>/= 300mg/day or >/= 300mg/g allbumin-to creatinine ratio
-use ACEi or ARB
27
Tx options
-diuretics
-Angiotensin inhibitors
-Calcium Channel Blockers
-Beta Blockers
-Direct Arterial Vasodilators
-A1 blockers
-Central a-2 AGONISTs
28
Diuretic anti-HTN effects
-initial: diuresis = reduce stroke volume = inc PVR
-chronic: stroke volume returns to normal = dec PVR below pretreatment levels
29
Diuretic classes for HTN
-thiazide
-loop
-aldosterone antagonists (MRAs)
-Potassium-Sparing
30
Thiazide Diuretic agents + dosing
-Chlorhtalidone 12.5-100mg
-Hydrochlorothiazide (HCTZ) 12.5-50mg
-Indapamide 1.25-5mg
-Metolazone 2.5-5mg
-all once daily
31
Thiazide diuretics
-first line
-more effective than loop if CrCl > 30 mL/min
-dose in morning to avoid night piss
-chlorothalidone most studied and more potent than HCTZ
32
Thiazide diuretic adverse events
-HYPOkalemia/magnesemia
-HYPERcalcemia/uricemia/glycemia/lipidemia
-sexual dysfunction
-inc TGs and cholesterol
33
Thiazide interactions
-lithium toxicity
34
Thiazide contraindications
-sulfa allergy
-anuria
35
Loop diuretic agents + dosing
-furosemide 20-80mg qd or BID
-Torsemide 2.5-10mg qd
-Bumetanide 0.5-2mg qd or BID
36
Loop diuretics for HTN tx
-NOT first line for HTN
-preferred in HF for sx management
-more effective than thiazide at CrCl < 30 ml/min
-high-ceiling, may need higher doses w reduced renal function or fluid overload, switch to another loop or form PO to IV
-dose in morning but some have BID dosing?
37
Loop diuretics adverse effects + contraindications
-HYPOkalemia/magnesemia/calcemia
-HYPERuricemia
-ototoxicity
-AVOID if sulfa allergy
38
Aldosterone Antagonists (MRAs) agents + dosing
-Spironolactone 12.5-100mg
-Eplerenone 50-100mg
-qd or BID (dose in morning or afternoon)
-hold/reduce dose if potassium>5.5 or SCr inc > 25%
39
Aldosterone Antagonists (MRAs)
-spironolactone preffered w RESISTANT HTN
-switch to eplerenone if gynecomastia (10%)
-do NOT initiate if potassium >5
40
Aldosterone antagonist (MRA) concerns adverse effects
-HYPERkalemia
-HYPOnatremia
-gynecomastia (spirinolactone)
41
Aldosterone Antagonist interactions + Contraindications
-ACE/ARBs/renin inhibitors/NSAIDs inc risk of HYPERkalmeia
-AVOID eplerenone in impaired renal function (CrCl<50ml/min or SCr >2 (males) or 1.8 (female)), T2DM, proteinuria
-AVOID potassium sparing diuretics
42
Potassium-Sparing Diuretic Agents + dosing
-amiloride 5-10mg
-triamterene 50-100mg
-qd or BID
43
Potassium-Sparing diuretics
-minimal BP effects, use in combo w thiazide to minimize hypokalemia
-caution in pt w diabetes or CKD (GFR<45ml/min)
-dose in the morning to avoid nocturnal diuresis
44
Potassium-sparing diuretic adverse effects
-HYPERkalemia
-inc uric acid
-HYPERglycemia
-caution in DM and CKD
45
Diuretic monitoring
-electrolytes and renal function 3-4 weeks after initiation
-only loop and MRA
46
Diuretic clinical pearls
-do not give a tbedtime
-thiazides first-line for most
-Spirinolactone is first-line for resistant HTN
-watch sulfa allergy
-check CrCl
-monitor potassium and electrolytes
47
Angiotensin Inhibitors
-Angiotensin converting enzyme inhibitors (ACEi)
-Angiotensin II receptor Blockers (ARBs)
-Renin inhibitors
48
Angiotensin Converting Enzyme Inhibitors (ACEi) mech
-inhibits angiotensin I to II conversion
-vasodilation
-reduced PVR
-inc diuresis
49
ACEi benefits
-good for pt w h/o:
-DM w proteinuria
-post MI
-CKD
-good option for PM dosing to ensure BP dipping overnight
50
ACEi agents + dosing
-BenazePRIL 10-40mg qd or BID
-Captopril 12.5-150mg BID or TID
-Enalapril 5-40mg qd or BID
-Fosinopril 10-40mg qd
-Lisinopril 10-40mg qd
-Moexipril 7.5-30mg qd or BID
-Perindopril 4-16mg qd
-Quinapril 10-80mg qd or BID
-Ramipril 2.5-10mg qd or BID
-Trandolapril 1-4mg qd
51
ACEi adverse effects (pril)
-angioedema
-cough up to 20%
-HYPERkalemia
-acute renal failure w severe bilateral renal artery stenosis
52
ACEi contraindications (pril)
-h/o angioedema on ACEi
-use of aliskiren in pt w DM
-pregnancy/breastfeeding
53
Angiotensin II Receptor Blockers (ARBs)
-binds target to block angiotensin II blockers
-vasodilation
-reduce PVR
-inc diuresis
54
ARBs
-first line tx option
-back up if ACEi not tolerated
-(doesnt block bradykinin breakdown = less cough)
-(can use w h/o angioedema from ACEi)
-good for PM dosing
55
ARB agents + doising
-Azilsartan 40-80mg
-Candesartan 8-32mg
-Irbesartan 150-300mg
-Lostartan 50-100mg qd or BID!
-Omlesartan 20-40mg
-Telmisartan 20-80mg
-Valsartan 80-320mg
-all qd
-losartan qd or bid
56
ARB adverse effects
-angioedema
-HYPERkalemia
-acute renal failure w severe bilateral renal artery stenosis
57
ARB contraindications
-h/o angioedema on ARB
-use of aliskren in DM
-pregnany/breastfeeding
58
ACEi/ARB monitoring
-Potassium and renal function 1-2 weeks after initiation in elderly
-3-4 weeks in low risk or potassium <4.5
-check at 3-4 weeks only needed is elevated SCr or potassium at 1-2 weeks
-consider holding/reducing dose if potassium >5.5 or SCr inc >30%
59
Direct Renin Inhibitors
-aliskiren 150-300mg qd
-not first line (expensive and not better than ACE/ARB)
-less cough than ACEi
-avoid in pregnancy
-dont use w ACEi or ARB in DM
60
Direct renin inhibitor monitoring (aliskren)
-Postassium
-BUN
-SCr
61
Aliskiren (renin inhibitor) adverse effects
-diarrhea
-musculoskeletal effects (CK increase
-dizziness
-HA
-HYPERkalemia
-renal insufficiency/ARF
-orthostatic hypotension
62
Angiotensin Inhibitor clinical pearls
-discuss contraceptive methods in younger women
-do not combine drug classes
-assess hyperkalemic risk (CKD, meds, etc)
-educate on dietay potassium (bananas, seasining)
ACEi/ARBs preferred over other first-line agents in presnce of other compelling indications
63
Calcium Channel Blockers (CCB)
-inhibit influx of calcium across cardiac and smooth muscle cell membranes = coronary and peripheral vasodilation
-firstline
64
CCB subclasses
-Dihydropyridines (more vasodilation)
-Nondihydropyridines (more negative ionotropic effects)
-overall similar effect on BP
65
Dihydropyridine CCB agents + dosing
-Amlodipine 2.5-10mg qd
-Felodipine 5-20mg qd
-Isradipine 2.5-20mg BID
-Isradipine SR 5-20mg qd
-Nicradipine SR 30mg-120mg BID
-Nifedipine LA 30-120mg qd
-Nisoldipine 10-40mg qd
-Amlodipine and felodipine no ionotropic effects
66
Dihydropyridine CCBs
-additional benefit in pt w Reynaud's and elederly pt w isolated systolic HTN
-more potent vasodilators than nondihydropyridine CCBs
-vasodilation = baroreceptor mediated tachycardia
-no effect on AV node conduction
-avoid short-acting (IR nifedipine/nicardipine)
67
Dihyropyridine CCB adverse effects (-dipines)
-reflec tachycardia
-flushing
-dizziness
-headache
-peripheral edema (dose related)
-gingival hyperplasia
68
Dihyrdopyridine CCB warnings (-dipines)
-inc risk of angina/MI pt w obstructive coronary disease due to reflex tachycardia
69
Dihydropyridine (-dipine) CCB interactions
-grapefruit juice
-CYP3A4 enzyme inducers/inhibitors
70
Nondihydropyridine CCB agents
-Diltiazem ER 120-180mg start max 360-540mg qd or BID
-Verapamil ER 100-180mg start max 400-480mg qd or BID
-diff formulations w diff dosing
71
Nondihydropyridine CCBs
-good for AFib
-good for pt w agina that cant take BB
-slows AV node conductino and decreases HR = NEG ionotropic effects
-extended release prefferred
72
Nondihydropyridine CCBs adverse effects
-bradycardia
-headache
-dizziness
-AV node block
-systolic HF
-gingival hyperplasia
-constipation (worse in verapamil > diltiazem)
73
Nondihydopyridine CCB interactions
-use of BB (inc risk of heart block)
-grapefruit juice
-CYP3A4 enzyme inducers/inhibitors
74
Nondihydropyridine CCB contraindications
-heart block
-left ventricular dysfunction
75
CCB clinical pearls
-no routine lab monitoring required
-check for drug interactions
-CCBs first line HTN
-peripheral edema dose-dependent
-ER preffered
-nondihydropyridine CCB formulations are NOT interchangable
-if CCB is needed in setting of HF, choose amlodipine
76
CCB to use in heart failure
-amlodipine
77
Cardioselective Beta Blocker agents + dosing
-Atenolol 25-100mg
-Betaxolol 5-20mg
-Bisoprolol 2.5-20mg
-Metoprolol Tartrate 50-450mg BID
-Metopolol succinate 25-400mg
-Nebivolol 5-40mg
-all qd except metoprolol tartrate BID
-Nebivolol is nitric oxide induced vasodilation
78
Nonselevtive Beta Blocker agents + dosing
-Nadolol 40-320mg
-Propranolol IR 40-640mg BID
-Propranolol LA 80-640mg
-avoid in bronchospastic airway disease
79
Intrinsic sympathomimetic activity (ISA) Beta blocker agents + dosing
-Acebutolol 100-800mg BID
-Penbutolol 10-40mg qd
-Pindolol 5-60mg BID
-AVOID in HF and IHD
80
Mixed a/B Beta blocker agents + dosing
-Carvedilol 6.25-50mg BID
-Labetalol 100-800mg BID
81
Beta blockers
-not firstline unless HF or CAD
-pt populations w extra benefit: tachyarrythmias, tremors, migraines, thyrotoxicosis
-dec HR + force of contraction = decrease CO
-avoid abrupt cessation
82
BB subclasses
-cardioselective
-nonselective
-intrinsic sympathomimetic activity (ISA)
-mixed
83
Beta blocker adverse effects
-bronchospasm
-bradycardia
-fatigue
-exercise intolerance
-depression
-can mask s/sx of hypoglycemia
84
BB contraindications
-second or third degree heart block
-decompensated HF
-post-MI (ISA BBs only)
-severe bradycardia
-sick sinus syndrome
84
Direct Arterial Vasodilator agents + dosing
-Hydralazine 40-300mg BID-QID
-Minoxidil 5-100mg qd-TID
-minoxidil more potent
84
Beta blocker use caution in pt with:
-Peripheral artery disease (carvedilol preferred)
-reactive ariway disease (use selective BBs)
85
Direct Arterial Vasodilators
-last-line
-reserved for pt w special indications or very difficult to control BP (severe CKD/hemodialysis)
-minoxidil more potent
-combo w diuretic and BB
86
Direct arterial vasodilator. adverse effects
-palpitations
-tachycardia
-chest pain
-GI effects
-Headache
-hematologic dyscrasias
-hepatotoxicity
-lupus-like syndrome/rash (hydralazine)
-fluid retention
-hair growth (minoxidil)
87
Minoxidil box warning
-may cause pericarditis and pericardial effusion that may progress to tamponade
-may inc oxygen demand and exacerbate angina pectoris
-max therapeutic doses of diuretic and 2 other anti-HTN should be used before adding this drug
-should be given w diuretic to minimize fluid gain AND a beta blocker
88
Direct arterial vasodialtors caution with
-CVA
-Renal impairment
-CAD
-liver disease
-Systemic Lupus Erythematosus (SLE)
-CAD listed as contraindication for hydralazine
89
a-1 blocker agents
-doxazosin
-prazosin
-terazosin
90
a-1 blockers
-never first-line
-second-line for pt w concomitant BPH
-associated w orthostatic HYPOtension esp in elderly
91
Central a-2 agonist agents
-clonidine (PO or patch)
-methyldopa 250-500mg BID
-gunafacine 0.5-2mg qd
92
Central a-2 agonists
-last-line due to adverse effects
-avoid abrupt cessation due to rebound HTN
-methyldopa in pregnancy
93
Central a-2 agonist adverse effects
-CNS depression
-Dizziness/fatigue
-anticholinergic effects
-bradycardia
-reflex tachycardia
-fluid retention
94
Clonidine dosing (central a-2)
-PO: 0.1-0.2mg BID-TID (max 2.4mg/day)
-Patch: 0.1-0.3mg/24 hours (weekly and lower risk of rebound HTN)
95
Clonidine clinical pearls
-SLOW titrating: half dose q2-3 days, wean BB several days prior to clonidine wean if applicable
-Oral to transdermal: over lap oral regimen 3-4 days
-Patch to oral: start oral no sooner than 8 hours after patch removal
96
Oral to patch clonidine
-day 1: patch + 100% dose
-day 2: admin 50%
-day 3: 25%
-day 4: patch only
97
Monitoring summary
-ACEi/ARBs: BUN/SCr, potassium
-CCBs: HR (non-dihysropyridine)
-Aldosterone ANTAgonists: BUN/SCr, potassium
-Other diuretics: BUN/SCr, electrolytes (K, Mg, Na), uric acid (thiazides))
-BB:HR
98
What if patient is NOT at goal
-consider nighttime dosing of one anti-HTN rx
-assess adherance
-educate on lifestyle mods
-rule out white coat HTN
-d/c interfering substances
-Pt may have resistant HTN
99
Resistant HTN
-failure to attain goal BP while adherent to regimen of 3+ meds at max dose (including diuretic) or when 4+ agents needed
-estimated 17% of HTN pt
-risk: age, obesity, CKD, DM, black
-rule out secondary causes of HTN
100
Stepwide management of resistant HTN
1. max lifestyle interventions and optimize 3-drug regimen (ACEi/ARB, CCB, diuretic)
2. Sub optimized thiazide diuretic (chlorthalidone/indapamide)
3. Add MRA (spirinolactone, eplerenone)
4. Add BB if HR > 70 BPM, consider a-2 (clonidine patch or guanfacine at bedtime if BB contraindicated and/or HR < 70 bpm *diltiazem
5. Add hydralazine
6. Sub minoxidil for hydralazine
101
De-escalating theraoy
-comorbidities that would impact drug choice?
-1st line vs 2nd line
-adverse effects
-can we stop abruptly
