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Pharmacology 2 > Hypertension > Flashcards

Hypertension Flashcards

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1
Q

ACE inhibitor means …

A

Angiotensin converting enzyme inhibitor

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2
Q

MOA
ACE inhibitor

A
  • block angiotensin I conversion to angiotensin II
  • inhibit breakdown of bradykinin (contribute to vasodilation)
  • reduce sodium retention
  • reduced aldosterone (hormone that controls sodium and water retension and therefore controls BP)

ACE inhibitors block conversion of angiotensin I to angiotensin II and also inhibit the breakdown of bradykinin. They reduce the effects of angiotensin II-induced vasoconstriction, sodium retention and aldosterone release. They also reduce the effect of angiotensin II on sympathetic nervous activity and growth factors.
## water follows salt … increased salt = increased BP, decreased salt = decreased BP

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3
Q

Indication
ACE inhibitors

A

Hypertension

Chronic heart failure with reduced ejection fraction as part of standard treatment

Diabetic nephropathy

Prevention of progressive renal failure in patients with persistent proteinuria (>1 g daily)

Post MI

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4
Q

Adverse reactions
ACE inhibitors

A
  • hypotension
  • headache
  • dizziness
  • cough (dry / non productive)
  • hyperkalaemia
  • fatigue
  • nausea
  • renal impairment
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5
Q

Practice points

A

*You may feel dizzy when you start taking this medicine. Get up gradually from sitting or lying to minimise this effect; sit or lie down if you become dizzy or light-headed.

Do not take potassium supplements while you are taking this medicine unless your doctor tells you to.*

When starting an ACE inhibitor:
* stop potassium supplements and potassium-sparing diuretics
* in heart failure, consider reducing dose or withholding other diuretics for 24 hours before starting an ACE inhibitor
* review use of NSAIDs (including selective COX‑2 inhibitors)
* start with a low dose
* check renal function and electrolytes before starting an ACE inhibitor and review after 1–2 weeks
* encourage patients to continue ACE inhibitors during the COVID‑19 pandemic as there is no clinical evidence to support stopping treatment

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6
Q

Drug class and indication

Captopril

A

ACE inhibitor
* Hypertension
* Chronic heart failure with reduced ejection fraction as part of standard treatment
* Post MI in patients with left ventricular dysfunction
* Diabetic nephropathy (type 1 diabetes)

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7
Q

Drug Class and indication

Enalapril

A

ACE inhibitor
* Hypertension
* Chronic heart failure with reduced ejection fraction as part of standard treatment
* Asymptomatic left ventricular dysfunction

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8
Q

Drug class and indication

Enalapril with hydrochlorothiazide

A

ACE inhibitor + Thiazide diuretic
* Hypertension

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9
Q

Drug class and indication

Fosinopril

A

ACE inhibitor
* Hypertension
* Chronic heart failure with reduced ejection fraction as part of standard treatment

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10
Q

Drug class and indication

Fosinopril with hydrochlorothiazide

A

ACE inhibitor + Thiazide diuretic
* Hypertension

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11
Q

Drug class and indication

Lisinopril

A

ACE inhibitor
* Hypertension
* Chronic heart failure with reduced ejection fraction as part of standard treatment
* Post MI, acute treatment

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12
Q

Drug class and indication

Perindopril

A

ACE inhibitor
* Hypertension
* Chronic heart failure with reduced ejection fraction as part of standard treatment
* Reduction of risk of MI or cardiac arrest in people with established coronary heart disease without heart failure

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13
Q

Drug class and indication

Perindopril with amlodipine

A

ACE inhibitor + Dihydropyridine Calcium channel blocker
* Hypertension
* Stable coronary heart disease

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14
Q

Drug class and indication

Perindopril with indapamide

A

ACE inhibitor + Thiazide diuretic
* Hypertension

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15
Q

Drug class and indication

Quinapril

A

ACE inhibitor
* Hypertension
* Chronic heart failure with reduced ejection fraction as part of standard treatment

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16
Q

Drug class and indication

Quinapril with hydrochlorothiazide

A

ACE inhibitor + Thiazide diuretic
* hypertension

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17
Q

Drug class and indication

Ramipril

A

ACE inhibitor
* Hypertension
* Post MI
* Prevention of MI, stroke, cardiovascular death in patients >55 years with: cardio risk factors

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18
Q

Drug class and indication

Ramipril with felodipine

A

ACE inhibitor + Dihydropyridine calcium channel blocker
* Hypertension

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19
Q

Drug class and indication

Trandolapril

A

ACE inhibitor
* Hypertension
* Post MI in patients with left ventricular dysfunction

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20
Q

Generic names of ACE inhibitors

A

Captopril
Enalapril
Enalapril with hydrochlorothiazide
Fosinopril
Fosinopril with hydrochlorothiazide
Lisinopril
Perindopril
Perindopril with amlodipine
Perindopril with indapamide
Quinapril
Quinapril with hydrochlorothiazide
Ramipril
Ramipril with felodipine
Trandolapril

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21
Q

Drug interactions
ACE inhibitor

A

Triple threat = ACE inhibitor + NSAID + loop or thiazide diuretic
Lithium + ACE inhibitors
Loop diuretics + ACE inhibitors
NSAIDs + ACE inhibitors NSAIDs (including selective COX‑2 inhibitors) may reduce antihypertensive effect of ACE inhibitor and may increase risk of renal impairment and hyperkalaemia (risk is further increased if a thiazide or loop diuretic is also taken). Avoid combination in the elderly or if renal hypoperfusion or impairment exists; monitor BP, weight, serum creatinine and potassium concentration. Use no more than 100–150 mg aspirin daily.
sartans + ACE inhibitors
Sartans given with ACE inhibitors increase the risk of hypotension, hyperkalaemia and renal impairment without additional benefit; avoid combinations (see Treatment with an ACE inhibitor and a sartan).

Members of this class are captopril, enalapril, fosinopril, lisinopril, perindopril, quinapril, ramipril and trandolapril.

ACE inhibitors can cause potassium retention, which may lead to hyperkalaemia, especially in people with renal impairment or diabetes, or if taken with potassium supplements or with other drugs* that can also cause potassium retention. Avoid combinations if possible or monitor potassium concentration.

Note that aldosterone antagonists are used with ACE inhibitors in patients with heart failure, with routine potassium concentration monitoring.

Monitor potassium concentration if an ACE inhibitor is given with drugs* that can reduce potassium concentration, as hypokalaemia may still occur.

ACE inhibitors also reduce BP; administration with other drugs* that lower BP may result in additional hypotensive effects (which may be intended); avoid combinations or use carefully and monitor BP.

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22
Q

SARTANs a.k.a. …

A

angiotensin receptor agonists (ARA)

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23
Q

MOA
sartans / ARA

A

Competitively block binding of angiotensin II to type 1 angiotensin (AT1) receptors. They reduce angiotensin II-induced vasoconstriction, sodium reabsorption and aldosterone release. They also reduce the effect of angiotensin II on sympathetic nervous activity and growth factors.

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24
Q

Indication
sartans / ARAs

A
  • Hypertension
  • Chronic heart failure with reduced ejection fraction as part of standard treatment in patients unable to tolerate ACE inhibitors
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25
**Adverse effects** sartans
dizziness, headache, hyperkalaemia
26
**Precautions / contradictions** sartans / ARAs
**Peripheral vascular disease or atherosclerosis**—patients may be more likely to have renal artery stenosis. **Volume or sodium depletion**—Monitor combination w/ diuretics (both affect sodium and BP) **Black African or Caribbean descent** **Treatment with drugs that can increase potassium concentration**,
27
**Practice points** sartans / ARAs
* stop K+ and K+ sparing diuretics * review use of NSAIDs * check renal function * used when ACE inhibitors are not tolerated for HTN and chronic heart failure ## Footnote You may feel dizzy when you start taking this medicine. Get up gradually from sitting or lying to minimise this effect; sit or lie down if you become dizzy or light-headed. Do not take potassium supplements while you are taking this medicine unless your doctor tells you to. when starting a sartan: stop potassium supplements and potassium-sparing diuretics in heart failure, consider reducing dose or withholding other diuretics for 24 hours before starting a sartan review use of NSAIDs (including selective COX‑2 inhibitors) start with a low dose check renal function and electrolytes before starting a sartan and review after 1–2 weeks unlike ACE inhibitors, sartans do not inhibit the breakdown of bradykinin and may be useful if an ACE inhibitor is not tolerated because they: cause less cough than ACE inhibitors may be used if there is a history of angioedema caused by an ACE inhibitor (with close monitoring as there is a small risk of recurrence) maximum antihypertensive effect occurs about 4–6 weeks after starting treatment encourage patients to continue sartans during the COVID‑19 pandemic as there is no clinical evidence to support stopping treatment
28
# Drug class and indication Candesartan
**sartan / ARA** * Hypertension * Chronic heart failure with reduced ejection fraction as part of standard treatment in patients unable to tolerate ACE inhibitors
29
# Drug class and indication Candesartan with hydrochlorothiazide
**sartan / ARA + thiazide diuretic** Hypertension
30
# Drug class and indication Eprosartan
**sartan / ARA** Hypertension
31
# Drug class and indication Eprosartan with hydrochlorothiazide
**sartan / ARA + thiazide diuretic** Hypertension
32
# Drug class and indication Irbesartan
**sartan / ARA** * Hypertension * Reduction of renal disease progression in patients with type 2 diabetes, hypertension and microalbuminuria (>30 mg/24 hours) or proteinuria (>900 mg/24 hours)
33
# Drug class and indication Irbesartan with hydrochlorothiazide
**sartan /ARA + thiazide diuretic** Hypertension
34
# Drug class and indication Losartan
**sartan / ARA** * Hypertension * Reduction of renal disease progression in patients with type 2 diabetes, hypertension and proteinuria (urinary albumin to creatinine ratio greater than or equal to 300 mg/g or proteinuria >500 mg per 24 hours)
35
# Drug class and indication Olmesartan
**sartan / ARA** Hypertension
36
# Drug class and indication Olmesartan with amlodipine
**sartan / ARA + Dihydropyridine calcium channel blocker** Hypertension
37
# Drug class and interaction Olmesartan with amlodipine and hydrochlorothiazide
**sartan / ARA + Dihydropyridine calcium channel blocker + thiazide diuretic** Hypertension
38
# Drug class and interaction Olmesartan with hydrochlorothiazide
**sartan / ARA + thiazide diuretic** Hypertension
39
# Drug class and indication Telmisartan
**sartan / ARA** * Hypertension * Prevention of cardiovascular morbidity and mortality in patients with coronary artery disease, peripheral artery disease, high-risk diabetes, previous stroke or TIA
40
# Drug class and indication Telmisartan with amlodipine
**sartan / ARA + Dihydropyridine calcium channel blocker** Hypertension
41
# Drug class and indication Telmisartan with hydrochlorothiazide
**sartan / ARA + thiazide diuretic** Hypertension
42
# Drug class and indication Valsartan
**Sartan / ARA** * Hypertension * Chronic heart failure with reduced ejection fraction as part of standard treatment in patients unable to tolerate ACE inhibitors * Left ventricular failure/dysfunction after MI, when clinically stable
43
# Drug class and indication Valsartan with hydrochlorothiazide
**Sartan / ARA + Thiazide diuretic** Hypertension
44
Generic names of Sartans / ARA
Candesartan Candesartan with hydrochlorothiazide Eprosartan Eprosartan with hydrochlorothiazide Irbesartan Irbesartan with hydrochlorothiazide Losartan Olmesartan Olmesartan with amlodipine Olmesartan with amlodipine and hydrochlorothiazide Olmesartan with hydrochlorothiazide Telmisartan Telmisartan with amlodipine Telmisartan with hydrochlorothiazide Valsartan Valsartan with hydrochlorothiazide
45
**Tripple Whammy**
NSAID + Sartan + ACE | Sounds like satan ate enough said
46
Generic names: Thiazide diuretics and Thiazide-related diuretics
**Thiazide** Hydrochlorothiazide **Thiazide-related** Chlortalidone Indapamide
47
**Indication** Thiazide and related diuretics
* Hypertension * Oedema associated with heart failure or hepatic cirrhosis * Nephrogenic diabetes insipidus
48
**MOA** Thiazide and related diuretics
**Inhibit reabsorption of sodium and chloride** in the proximal (diluting) segment of the distal convoluted tubule, **increased potassium excretion**. When used in recommended low doses for hypertension, thiazides **lower BP mostly by a vasodilator effect.**
49
**Precautions** Thiazide and related diuretics
**Gout**—may be aggravated by diuretic-induced hyperuricaemia **Heart failure with significant oedema**—hyponatraemia may occur, particularly if higher doses are used with a salt-restricted diet and/or potassium-sparing diuretics and excess water intake. **Conditions or drugs that may cause hypokalaemia**—further increases risk of hypokalaemia; monitor potassium concentration. **Conditions or drugs that cause volume depletion**—further increases risk of renal impairment and hypotension (particularly in patients with heart failure); monitor renal function and BP (sitting and standing).
50
**Adverse effects** Thiazide and related diuretics
Effects on electrolytes, blood glucose and lipids are dose-dependent. dizziness, weakness, muscle cramps, polyuria, orthostatic hypotension, electrolyte disturbances (eg hyponatraemia, hypokalaemia, hyperuricaemia, hypochloraemic alkalosis, hypomagnesaemia, hypercalcaemia)
51
**Nursing considerations** Thiazide and related diuretics
You may feel dizzy on standing when taking this medicine. Get up gradually from sitting or lying to minimise this effect; sit or lie down if you become dizzy. most adverse effects are dose-related; start with a low dose and increase slowly **Heart failure** * may be given with loop diuretics to relieve symptoms of fluid retention; seek specialist advice * start with a low dose and adjust according to clinical response; use small, intermittent doses with careful monitoring of renal function, electrolytes, BP and volume status * advise patients to report any dizziness, thirst, or increased fluid loss due to diarrhoea, vomiting or excessive sweating **Diuretic-induced hypokalaemia** * reduce risk by using a low dose * is less likely when also taking an ACE inhibitor, sartan or potassium-sparing diuretic * potassium supplements may be used to treat mild hypokalaemia (each potassium chloride 600 mg tablet contains 8 mmol potassium; daily potassium replacement requirement is around 20–60 mmol (3–8 tablets))
52
**Drug interactions** Thiazide and related diuretics
**ACE inhibitors + thiazide diuretics** = hypotension **sartans + thiazide diuretics** = Hypotension **loop diuretics + thiazide diuretics** = hypokalemia + hypotension **NSAIDs + thiazide diuretics** = reduced renal function ## Footnote Hydrochlorothiazide is a thiazide diuretic; chlortalidone and indapamide are related to the thiazide diuretics and behave in the same way. Thiazide diuretics cause hypotension; administration with other drugs* with this effect may result in additional hypotension. They also cause hypokalaemia; additional potassium loss may occur if they are given with other drugs* that reduce potassium concentration; monitor potassium concentration and give potassium supplements if necessary. See also Prolonged QT interval. High doses of thiazide diuretics can increase blood glucose concentration
53
Two kinds of Calcium channel blockers
Dihydropyridines Non-dihydropyridines
54
**suffix** Dihydropyridines Calcium channel blocker
Pine
55
Generic names of Dihydropyridines Calcium channel blocker
Amlodipine Amlodipine with atorvastatin Amlodipine with valsartan Amlodipine with valsartan and hydrochlorothiazide Clevidipine Felodipine Lercanidipine Lercanidipine with enalapril Nifedipine Nimodipine
56
Generic names of Non-dihydropyridines Calcium channel blockers
Diltiazem Verapamil Trandolapril with verapamil
57
**Indication** Calcium channel blockers
Hypertension Angina
58
**MOA** Calcium channel blockers
Block inward current of calcium into cells in vascular smooth muscle, myocardium and cardiac conducting system via L‑type calcium channels. Act on coronary arteriolar smooth muscle to reduce vascular resistance and myocardial oxygen requirements, relieving angina symptoms. **Dihydropyridines** act mainly on arteriolar smooth muscle to reduce peripheral vascular resistance and BP. They have minimal effect on myocardial cells. **Non-dihydropyridines**: diltiazem and verapamil act on cardiac and arteriolar smooth muscle. They reduce cardiac contractility, heart rate and conduction, with verapamil having the greater effect. Diltiazem has a greater effect on arteriolar smooth muscle than verapamil.
59
**Precautions** Calcium channel blockers
**Myasthenia-like neuromuscular disease**—calcium channel blockers may increase risk of muscle weakness and respiratory depression (most case reports with verapamil). **Peritoneal dialysis**—cloudy peritoneal fluid (with no signs of infection) has been reported, mostly with lercanidipine; it is not clear if this is a class effect.
60
**Adverse effects** Calcium channel blockers
Most listed adverse effects occur with all calcium channel blockers. Adverse effects vary between the calcium channel blockers according to their relative effects on vascular, myocardial and conducting tissue. Dihydropyridines have more pronounced vasodilatory effects than diltiazem and verapamil. Verapamil, and to a lesser extent, diltiazem, reduce cardiac contractility, heart rate and conduction. **Peripheral oedema** Dihydropyridines commonly cause peripheral oedema due to redistribution of extracellular fluid (rather than fluid retention); this does not respond to treatment with diuretics, which may put patient at risk of volume depletion.
61
**Practice points** Calcium channel blockers
vasodilatory adverse effects usually subside with continued treatment (may require dose reduction)
62
# Drug class and indication Amlodipine
**Dihydropyridine Calcium channel blocker** Hypertension Angina
63
# Drug class and indication Amlodipine with atorvastatin
**Dihydropyridine Calcium channel blocker + statin / HMG-CoA reductase inhibitors** Hypertension or angina, in patients with hypercholesterolaemia or multiple cardiovascular risk factors
64
# Drug class and indication Amlodipine with valsartan
**Dihydropyridine Calcium channel blocker + sartan (ARA)** Hypertension | Sartan a.k.a. angiotensin II antagonists and angiotensin receptor antago
65
# Drug class and indication Amlodipine with valsartan and hydrochlorothiazide
**Dihydropyridine Calcium channel blocker + Sartan (ARA / ARB/ angiotensin II receptor blocker + Thiazide diuretic** Hypertension
66
# Drug class and Indication Clevidipine
**Dihydropyridine calcium channel blocker** Hypertension (short-term use when oral treatment not appropriate)
67
# Drug class and indication Felodipine
**Dihydropyridine calcium channel blocker** Hypertension
68
# Drug class and indication Lercanidipine
**Dihydropyridine calcium channel blocker** Hypertension
69
# Drug class and Indication Lercanidipine with enalapril
**Dihydropyridine calcium channel blocker + ACE inhibitor** Hypertension
70
# Drug class and indication Nifedipine
**Dihydropyridine calcium channel blocker** Hypertension Angina
71
# Drug class and indication Diltiazem
**Non-Dihydropyridine calcium channel blocker** Angina Hypertension (controlled release tablet)
72
# Drug class and indication Verapamil
**Non-dihydropyridine calcium channel blocker** SVT AF or atrial flutter (ventricular rate control) Hypertension Angina
73
# Drug class and indication Trandolapril with verapamil
**ACE inhibitor + Non-dihydropyridine calcium channel blocker** Hypertension
74
# Suffix: Beta-blocker
lol
75
# Drug class lol
Beta-blockers
76
**Indication** Beta-blocker
Hypertension Angina Tachyarrhythmias MI Chronic heart failure with reduced ejection fraction as part of standard treatment Prevention of migraine
77
**MOA** Beta-blocker
Competitively **block beta receptors** in heart, peripheral vasculature, bronchi, pancreas, uterus, kidney, brain and liver. **Beta-blockers reduce heart rate, BP and cardiac contractility**; also depress sinus node rate and slow conduction through the atrioventricular (AV) node, and prolong atrial refractory periods.
78
**Precautions / adverse effects** Beta-blockers
**Shock** (cardiogenic and hypovolaemic)—contraindicated. **Hyperthyroidism**—beta-blockers may mask clinical signs, eg tachycardia. **Phaeochromocytoma**—beta-blockers may aggravate hypertension; an alpha-blocker should be given first. **History of anaphylactic reactions**—beta-blockers may reduce the response to usual doses of adrenaline (epinephrine) for anaphylaxis. **Myasthenic symptoms**—may worsen. **CARDIAC**Contraindicated in bradycardia (45–50 beats/minute), second‑ or third-degree AV block, sick sinus syndrome (without pacemaker), severe hypotension or uncontrolled heart failure. **Respiratory** contraindicated in asthma, alpha 1 selective drugs may be used in controlled asthma and COPD | Myasthenic symptoms (muscle weakness)
79
**Adverse effects** Beta-blockers
* bradycardia, * hypotension, * orthostatic hypotension * bronchospasm, * dyspnoea, * fatigue, dizziness * Mask Hypoglycemia ## Footnote Can mask signs of hypoglycemia in diabetics
80
**Counselling / practice points** Beta-blockers
Counselling This medicine **may cause dizziness or tiredness** **Do not stop** taking this medicine suddenly **Practice points** **beta-blockers are not usually recommended first line for uncomplicated essential hypertension**; they are associated with reduced protection against stroke in the elderly **when stopping treatment, reduce dosage gradually
81
# Drug class and indication Atenolol
**Beta-blocker** Hypertension Angina Tachyarrhythmias MI
82
# Drug class and indication Bisoprolol
**Beta-blocker** Chronic heart failure with reduced ejection fraction as part of standard treatment
83
# Drug class and Indication Carvedilol
**Beta-blocker** Hypertension Chronic heart failure with reduced ejection fraction as part of standard treatment
84
# Drug class and indication Labetalol
**Beta-blocker** Hypertension Hypertensive emergency
85
# Drug class and Indication Metoprolol
**Beta-blocker** Hypertension Angina Tachyarrhythmias MI Prevention of migraine Chronic heart failure with reduced ejection fraction as part of standard treatment
86
# Drug class and Indication Nebivolol
**Beta-blocker** Hypertension Chronic heart failure with reduced ejection fraction as part of standard treatment
87
# Drug class and indication Propranolol
**Beta-blocker** Hypertension Angina Tachyarrhythmias Tetralogy of Fallot, seek specialist advice MI Prevention of migraine Essential tremor Phaeochromocytoma (with an alpha-blocker)
88
**Generic drug names** Beta-blockers
Atenolol Bisoprolol Carvedilol Esmolol Labetalol Metoprolol Nebivolol Propranolol Sotalol
89
**Pathophysiology** Hypertension
The pathophysiology of hypertension involves the impairment of renal pressure natriuresis, the feedback system in which high blood pressure induces an increase in sodium and water excretion by the kidney that leads to a reduction of the blood pressure.
90
**Signs and symptoms** Hypertension
* Early morning headache * Nosebleeds * Irregular heart rhythms * Vision changes * Buzzing in ears
91
**Rationale for drug use** Hypertension
Reduce premature cardiovascular morbidity and mortality and microvascular disease affecting the brain, kidneys and retinas
92
**Drug choice** Hypertension
**For uncomplicated hypertension**, unless there is a contraindication or a specific indication for another drug, first consider: * an **ACE inhibitor (or sartan**) or * a **dihydropyridine calcium channel blocker** or * if 65 or older, a thiazide diuretic (low dosage).

Pharmacology 2 (41 decks)

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