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Flashcards in Hypertension Deck (101):

What is the leading global risk factor for death and disability? (CHEP)

  • Hypertension


How common is hypertension in Canada? (CHEP)

  • Affects 1 in 4 (23%) Canadian adults


What benefit can treating hypertension have on the risk of stroke and CVD?

  • Reduces stroke by 1/3 and CVD by 15%
  • Treating HTN and cholesterol can reduce CVD by almost half


What are 11 risk factors for hypertension?

  • Demographics
    • Age >55
    • Male
    • Southeast Asian, African, First Nations
  • Lifestyle
    • Sedentary
    • Poor diet
    • Obesity
    • Smoking
    • Excessive alcohol
    • Stress
  • Personal medical history
    • Dysglycemia
  • Family medical history
    • CAD <55 in men, <65 in women


In patients presenting with hypertension, what are non-modifiable and modifiable cardiac risk factors that should be asked about? (CHEP)

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In patients presenting with hypertension, what are 5 organ systems that should be asked about to assess for end organ damage?

  • Brain – recent TIA/stroke, intracerebral hemorrhage, aneurysmal sub-arachnoid hemorrhage, dementia (vascular, mixed vascular and Alzheimer’s)
  • Eyes – visual blurring (hypertensive retinopathy)
  • Heart – prior MI/angina, CHF, LVH, CP, SOB
  • Kidney – asymptomatic (CKD)
  • Peripheral Arterial Disease - claudication


What are 8 secondary causes of hypertension and associated signs or symptoms?

  • OSA – snores, AM headaches, non-refreshing sleep
  • RAS – asymptomatic, CAD risks
  • Renal insufficiency – CKD, diabetes, or recent strep infection
  • Pheochromocytoma – paroxysmal sweating and headache and palpitations
  • Hyperaldosteronism – weight loss, low energy
  • Cushings – weight gain
  • Hyperthyroidism – weight loss, tremor, heat intolerance, diarrhea, light menses
  • Medications


What are 12 exogenous substances that can induce/aggravate hypertension? (CHEP)

  • NSAIDs
  • Steroids
  • OCP/HRT/Testosterone
  • Decongestants
  • Calcineurin inhibitors – cyclosporine, tacrolimus
  • EPO
  • Midodrine
  • Licorice root
  • Stimulants/cocaine
  • Salt
  • Alcohol


What are 3 important considerations when performing a physical exam on a patient with hypertension?

  • Signs of end organ damage
  • Secondary causes of hypertension
  • Metabolic syndrome


What are 4 organ systems that should be evaluated for end organ damage on physical exam in patients with hypertension?

  • Brain – neurologic exam, carotid bruits, dementia
  • Eyes – retinal hemorrhage
  • Heart – loud S2, precordial heave
  • Peripheral vascular – poor pulses, AAA


What are signs on physical exam that could be associated with 7 different secondary causes of hypertension?

  • OSA – wide neck, micronathia
  • RAS – abdominal bruits
  • Renal insufficiency - asymptomatic
  • Pheochromocytoma – flank mass, tachycardia
  • Hyperaldosteronism – flank mass
  • Cushings – central obesity, hirsutism, easy bruising, striae
  • Hyperthyroidism – tachycardia, goiter, ophthalmoplegia, hyperreflexia


How is metabolic syndrome diagnosed?

≥3 measures to make the diagnosis of metabolic syndrome

Waist Circumference

≥102 cm (Men) / ≥88 cm (Women)


≥1.7 mmol/L


<1.0 mmol/L (Men) / <1.3 mmol/L (Women)


SBP ≥130 mm Hg and/or DBP ≥85 mm Hg


≥5.6 mmol/L


What are 4 different scenarios in which BP can be measured?

  • Office
    • Non-AOBP
    • AOBP
  • Home
  • Ambulatory


What is the preferred method of measuring in-office blood pressure? (CHEP)

  • Automatic office BP (AOBP)
    • Taken WITHOUT patient-health provider interaction
    • Using a FULLY-automatic device


What are the advantages of AOBP over the non-AOBP approach for diagnosing hypertension? (CHEP)

  • Eliminates the risk of conversation during readings
  • Reduces the risk of the white coat effect
  • Facilitates multiple measurements with each clinical encounter (and automatically calculates the mean)
  • Closely approximate mean awake ambulatory BP levels
  • Consistent from visit to visit
  • Are not significantly altered by the setting (e.g. ambulatory BP monitoring unit, office waiting room, physician’s examination room, pharmacy)
  • Predict the presence of end-organ damage (carotid intima-media thickness, left ventricular mass index, microalbuminuria) and incidence cardiovascular events


How should BP be measured in the office with non-AOBP?

  • Bladder width ~40% of arm circumference
  • Patient resting for 5 minutes, legs not crossed
  • Cuff 3 cm above antecubital fossa, bladder over brachial artery
  • First reading by palpation to evaluate for systolic gap
    • Elevate to 30 mmHg above cessation of radial pulse
    • Slow deflation of the cuff by 2 mmHg each heartbeat
  • No conversation
  • First reading disregarded, average second 2 readings


How should the mean BP be measured in the office with non-AOBP? (CHEP)

  • First reading discarded
  • Latter readings averaged


How should BP be measured for home BP measurement? (CHEP)

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How should BP be measured for ambulatory BP monitoring? (CHEP)

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How should postural hypotension be assessed? (CHEP)

  • Check after 2 minutes of standing (with arm supported)


What levels are considered to be elevated for BP in the 4 measuring scenarios? (CHEP)

  • Non-AOBP
    • High = SBP ≥140 mmHg or DBP ≥90 mmHg
    • High-Normal = SBP 130-139 mmHg or DBP 85-89 mmHg
  • AOBP
    • High = SBP ≥135 mmHg or DBP ≥85 mmHg
  • Ambulatory
    • Mean awake SBP ≥135 mmHg or DBP ≥85 mmHg
    • Mean 24-hour SBP ≥130 mmHg or DBP ≥80 mmHg
  • Home
    • High = SBP ≥135 mmHg or DBP ≥85 mmHg


How can hypertension be diagnosed? (CHEP)

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What are examples of hypertensive urgencies or emergencies? (CHEP)

  • Urgency: Asymptomatic diastolic BP ≥130 mmHg
  • Emergency: Severe elevation of BP in the setting of any of:
    • Hypertensive encephalopathy
    • Acute aortic dissection
    • Acute left ventricular failure
    • Acute coronary syndrome
    • Acute kidney injury
    • Intracranial hemorrhage
    • Acute ischemic stroke
    • Pre-eclampsia/eclampsia
    • Catecholamine-associated hypertension


What BP levels can lead to the diagnosis of hypertension on visit 1? (CHEP)

  • Mean non-AOBP or AOBP SBP ≥180 mmHg and/or DBP ≥110 mmHg


If the visit 1 mean non-AOBP SBP is 140-179 mmHg and/or DBP is 90-109 mmHg or the mean AOBP SBP is 135-179 mmHg and/or DBP is 85-109 mmHg, what should be done? (CHEP)

  • Out-of-office BP measurements


What is the recommended out-of-office BP measurement? (CHEP)

  • Ambulatory BP monitoring


When is home BP monitoring recommended? (CHEP)

  • Ambulatory BP monitoring not tolerated, not readily available, or because of patient preference


What should be done if the office BP measurement is high and the mean home BP is <135/85 mmHg? (CHEP)

  • Repeat home monitoring to confirm home BP is < 135/85 mmHg OR
  • Perform 24-hour ambulatory BP monitoring
  • If repeat is not high, then diagnose white coat hypertension


If the out-of-office measurement is not performed after visit 1, how can hypertension be diagnosed on subsequent visits? (CHEP)

  • Visit 2
    • Mean office BP measurement (averaged across all visits) is SBP ≥140 mmHg or DBP ≥90 mmHg
    • Macrovascular target organ damage, diabetes mellitus, or CKD (eGFR <60)
  • Visit 3
    • Mean office BP measurement (averaged across all visits) is SBP ≥160 mmHg or DBP ≥100 mmHg
  • Visit 5
    • Mean office BP measurement (averaged across all visits) is SBP ≥140 mmHg or DBP ≥90 mmHg


How often should patients on antihypertensive drug treatment be seen? (CHEP)

  • Monthly or every 2 months until readings on 2 consecutive visits are below their target
  • Every 3 to 6 months once at target


What should be done in all patients diagnosed with hypertension? (CHEP)

  • Global cardiovascular risk
    • Use terms such as “cardiovascular age”, “vascular age”, or “heart age”
    • SCORE risk calculator


What routine laboratory tests should be performed for the investigation of all patients with hypertension? (CHEP)

  • Urinalysis
  • Blood chemistry (potassium, sodium and creatinine)
  • Fasting blood glucose and/or glycated hemoglobin
  • Lipid panel (fasting or non-fasting)
  • ECG


How much variation is seen between fasting and non-fasting lipid levels? (CHEP)

  • TC <2%
  • HDL <2%
  • LDL <10%
  • TG 20%


What are two pathophysiologic causes of hypertension that should be investigated in patients newly diagnosed with hypertension? (CHEP)

  • Renovascular hypertension
  • Endocrine hypertension


Which patients with hypertension should be investigated for renovascular hypertension? (CHEP)

  • ≥2 of the following clinical clues:
    • Sudden onset or worsening of hypertension and age >55 or <30 years
    • Presence of an abdominal bruit
    • Hypertension resistant to ≥3 drugs
    • Increase in serum creatinine level ≥30% associated with the use of an ACEi or ARB
    • Other atherosclerotic vascular disease, particularly in patients who smoke or have dyslipidemia
    • Recurrent pulmonary edema associated with hypertensive surges


What are 4 tests that can be done to screen for renal vascular disease? (CHEP)

  • Captopril-enhanced radioisotope renal scan
  • Doppler sonography
  • MR angiography
  • CT angiography (if normal renal function)


Which patients with hypertension should be investigated for hyperaldosteronism? (CHEP)

  • Hypertensive patients with unexplained spontaneous hypokalemia (K <3.5 mmol/L) or marked diuretic-induced hypokalemia (K <3.0 mmol/L)
  • Patients with hypertension refractory to treatment with ≥3 drugs
  • Hypertensive patients found to have an incidental adrenal adenoma


What screening tests should be done for hyperaldosteronism? (CHEP)

  • Plasma aldosterone and renin
  • Collected in the morning after the patient has been ambulatory for at least 2 hours
  • Agents that markedly affect the results (aldosterone antagonists, potassium sparing and wasting diuretics) should be withdrawn at least 4-6 weeks prior


How should the diagnosis of primary hyperaldosteronism be made? (CHEP)

  • Saline loading tests
  • Plasma aldosterone to PRA ratio
  • Captopril suppression test
    • Administer 25-50 mg captopril PO after the patient has been sitting or standing for 1 hour
    • While seated, renin and plasma aldosterone levels should be measured at time zero and 1-2 hours after ingestion


How should the abnormality be localized in patients diagnosed with primary hyperaldosteronism? (CHEP)

  • Adrenal CT or MRI


What is recommended in patients with primary hyperaldosteronism and a definite adrenal mass who are eligible for surgery? (CHEP)

  • Adrenal venous sampling to assess for lateralization of aldosterone hypersecretion


What are 5 situations in which patients with hypertension should be considered for screening for pheochromocytoma or paraganglioma? (CHEP)

  • Paroxysmal, unexplained, labile, and/or severe (BP ≥180/110 mmHg) sustained hypertension refractory to usual antihypertensive therapy
  • Patients with hypertension and multiple symptoms suggestive of catecholamine excess (e.g. headaches, palpitations, sweating, panic attacks, and pallor)
  • Patients with hypertension triggered by Beta-blockers, MAOIs, micturition, changes in abdominal pressure, surgery, or anesthesia
  • Patients with an incidentally discovered adrenal mass
  • Patients with predisposition to hereditary causes (e.g. MEN2A or 2B, NF1, VHL)


How can pheochromocytomas be diagnosed? (CHEP)

  • 24-hr urinary total metanephrines and catecholamines
    • Concomitant 24-hr urinary creatinine to confirm accurate collection
  • Plasma free metanephrines and free normetanephrines
  • Urinary VMA measurements should NOT be used for screening


How should localization of pheochromocytomas or paragangliomas be performed in patients with positive biochemical screening tests? (CHEP)

  • MRI (preferable)
  • CT (if MRI unavailable)
  • Iodine I-131 meta-iodobenzylguanidine scintigraphy


In which patients should home BP monitoring be considered? (CHEP)

  • Diabetes
  • CKD
  • Suspected nonadherence
  • Demonstrated white coat effect
  • BP controlled in the office but not at home (masked hypertension)


What type of home BP monitoring devices should patients be advised to purchase? (CHEP)

  • Met standards of either:
    • Association for the Advancement of Medical Instrumentation
    • British Hypertension Society protocol
    • International Protocol for validation of automated BP measuring devices


What home BP values should be considered elevated and associated with an increased overall mortality risk? (CHEP)

  • SBP ≥135 mmHg or DBP ≥85 mmHg


In which patients should ambulatory BP monitoring be considered? (CHEP)

  • Office-induced increase in BP is suspected in treated patients with:
    • BP that is not below target despite receiving appropriate chronic antihypertensive therapy
    • Symptoms suggestive of hypotension
    • Fluctuating office BP readings


What home BP values should be considered elevated and associated with an increased overall mortality risk? (CHEP)

  • Mean awake SBP ≥135 mmHg or DBP ≥85 mmHg
  • Mean 24-hour SBP ≥130 mmHg or DBP ≥80 mmHg


In which patients with hypertension is echocardiography recommended? (CHEP)

  • Hypertensive patients suspected to have left ventricular dysfunction or CAD
    • Assess left ventricular mass and systolic and diastolic left ventricular function


What are 7 health behavior management recommendations that can be made for patients with hypertension? (CHEP)

  • Physical exercise
    • 30-60 minutes of moderate-intensity dynamic exercise 4-7 days per week
  • Weight reduction
  • Alcohol consumption
    • Limit alcohol to 2 or less drinks per day, and <15 drinks per week for men and <10 drinks per week for women
  • DASH diet
  • Reduce sodium intake to <2000 mg per day
  • Increase potassium intake
  • Stress management



Weight loss

BMI <25 kg/m2

Alcohol restriction

< 2 drinks/day

Salt & DASH diet

Salt <2000mg/day, fruits, vegetables, whole grains, plant protein, low-fat

Physical activity

30-60 minutes 4-7 days/week

Smoking cessation

Smoke free environment

Waist circumference

Men <102 cm             Women <88 cm

Stress Management

CBT and relaxation therapy


What is the evidence for a reduced salt diet (or sodium restriction) in reducing mortality from CVD? (TFP)

  • Controversial
  • Cochrane review of 7 RCTs found no difference for outcomes in normotensive and hypertensive patients
    • Subsequent reanalysis combining normotensive and hypertensive patients resulted in significant reduction in CVD (RR 0.80, NNT = 48)
    • Average baseline sodium ~3900 mg reduced to ~3000 mg per day


What are 4 risk factors for hyperkalemia in patients with hypertension? (CHEP)

  • RAAS
  • Other drugs that can cause hyperkalemia (e.g. TMP-SMX, amiloride, triamterene)
  • CKD (eGFR <60)
  • Baseline serum K >4.5 mmol/L


What are the indications for drug therapy in adults with hypertension without compelling indications for specific agents? (CHEP)

  • Average SBP ≥160 mmHg or DBP ≥100 mmHg in patients withOUT macrovascular target organ damage or other cardiovascular risk factors
  • Average DBP ≥90 mmHg in the presence of macrovascular target organ damage or other independent cardiovascular risk factors
  • Average SBP ≥140 mmHg in the presence of macrovascular target organ damage


What is the SBP threshold for initiating antihypertensive therapy in the elderly (aged ≥80 years) who do not have diabetes or target organ damage? (CHEP)

  • SBP ≥160 mmHg


What are 6 possible reasons for poor response to therapy? (CHEP)

  • Poor adherence
  • Associated conditions
    • Obesity
    • Tobacco
    • Alcohol
    • OSA
    • Chronic pain
  • Drug interactions
    • NSAIDs, OCP, steroids, decongestants, cocaine, amphetamines, EPO, cyclosporine, licorice, OTC dietary supplements, antidepressants
  • Suboptimal treatment regimens
    • Dosage too low
    • Inappropriate combinations of antihypertensive agents
  • Volume overload
    • Excessive salt intake
    • Renal sodium retention
  • Secondary hypertension


What time of day for taking antihypertensive drugs may provide improved CVD outcomes? (TFP)

  • Bedtime
    • Single RCT with many limitations (poorly described randomization and allocation of patients, lack of blinding, no correction for multiple analysis, higher CVD events than expected
    • NNT = 67 for mortality
    • NNT = 9 for total CVD events


What is first-line and second-line therapy for individuals with diastolic and/or systolic hypertension? (CHEP)

  • First-line
    • Thiazide/thiazide-like diuretic (Grade A)
    • Beta-blocker (in patients younger than 60 years) (Grade B)
    • ACEi (in nonblack patients) (Grade B)
    • Long-acting CCB (Grade B)
    • ARB (Grade B)
  • Second-line
    • Thiazide + ACEi/ARB/Beta-blocker
    • CCB + ACEi/ARB/Beta-blocker
      • Caution with nondihydropyridine CCB

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What adverse effect needs to be avoided in patients treated with thiazide/thiazide-like diuretic monotherapy? (CHEP)

  • Hypokalemia


In which patients would combination therapy using 2 first-line agents for hypertension be considered as initial treatment? (CHEP)

  • SBP is 20 mmHg greater than target OR
  • DBP is 10 mmHg greater than target


What is first-line and second-line therapy for individuals with isolated systolic hypertension? (CHEP)

  • First-line
    • Thiazide/thiazide-like diuretic (Grade A)
    • Long-acting CCB (Grade A)
    • ARB (Grade B)
  • Second-line
    • Combination of first-line

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What is the best 4th-line therapy for patients with resistant hypertension? (TFP)

  • Spironolactone provides largest BP reduction (10/4 mmHg)
    • Compared to bisoprolol and doxazosin
  • NNT = 3 for spironolactone
  • Potassium rises on average 0.4 mmol/L
  • 2% stop due to hyperkalemia (≥5.5 mmol/L)


In which patients with hypertension is statin therapy recommended? (CHEP)

  • ≥3 cardiovascular risk factors
  • Established atherosclerotic disease


What are 4 clinical indications to define high-risk patients that could be candidates for intensive hypertension management? (CHEP)

  • Clinical or subclinical cardiovascular disease
  • CKD (nondiabetic, eGFR 20 to 59)
  • Estimated 10-year global cardiovascular risk ≥ 15%
  • Age ≥75 years


In which high-risk patients could intensive management (target SBP ≤120 mmHg) be considered? (CHEP)

  • Aged ≥50 years
  • SBP ≥130 mmHg


In which patients would intensive blood pressure-lowering be contraindicated? (CHEP)

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What is the evidence for intensive blood-pressure lowering in high risk patients? (CHEP/TFP)

  • SPRINT trial randomized 9631 individuals at high risk for CVD (withOUT diabetes or previous stroke) to intensive treatment (target SBP <120 mmHG) or standard control (target SBP <140 mmHg)
  • CVD risk ~20% over 10 years
  • Trial terminated after 3.26 years
  • Attained BP 136/76 vs 121/68
  • Average patient on 2.8 vs 1.8 medications
  • Primary outcome (composite of MI, ACS, stroke, acute decompensated HF, death from cardiovascular cause) was lower with intensive treatment than standard (1.65% vs 2.19% per year, RRR 25%, NNT=61)
  • Death: RRR 27%, NNT=90
  • Individuals with normal kidney function at baseline – intensive treatment increased risk of renal deterioration (NNH = 56, HR 3.49)
  • Serious adverse events similar in both groups


What are the treatment goals for hypertension in patients not receiving intensive treatment? (CHEP)

  • SBP < 140 mmHg and DBP <90 mmHg
  • Very elderly (80+ years) SBP <150 mmHg


What is the evidence of a target BP <150/80 mmHg in the elderly (≥80 years of age)? (TFP)

  • HYVET study
    • Large RCT of 3,845 patients, mean follow-up 2.1 years, 60% female, mean age 83.5, BP >160 systolic
    • Placebo or Indapamide +/- Perindopril
    • Target BP <150/80 mmHg
    • NNT = 47 (10% vs 12%) for mortality
    • NNT = 34 (7% vs 10%) for CVD
    • NNT = 35 (1.1% vs 3%) for heart failure


What is first-line and second-line therapy for individuals with CAD? (CHEP)

  • First-line
    • ACEi or ARB (Grade A)
  • Second-line
    • ACEi + dihydropyridine CCB (preferred over ACEi +  thiazide)

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What is first-line therapy for individuals with hypertension and stable angina (but without previous heart failure, myocardial infarction, or CABG)? (CHEP)

  • First-line
    • Beta-blocker or CCB


What is first-line and second-line therapy for individuals with hypertension who have had a recent MI? (CHEP)

  • First-line
    • ACEi + Beta-blocker
      • ARB instead of ACEi if intolerance
      • CCB instead of Beta-blocker if contraindicated or not effective
        • NOT nondihydropyridine CCBs if heart failure

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What is first-line and second-line therapy for individuals with heart failure (EF <40%)? (CHEP)

  • First-line
    • ACEi + Beta-blockers
      • ARB instead of ACEi if intolerance
      • Hydralazine + Isosorbide dinitrate if ACEi and ARB contraindicated or not tolerated
  • Second-line
    • Aldosterone antagonists (recent cardiovascular hospitalization, acute MI, elevated BNP or NYHA class II-IV symptoms)
    • ACEi + ARB (careful monitoring for hypotension, hyperkalemia and CKD)

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What is first-line and second-line therapy for individuals with stroke 72 hours after onset? (CHEP)

  • First-line
    • ACEi and Thiazides/thiazide-like diuretics

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What is first-line and second-line therapy for individuals with left ventricular hypertrophy? (CHEP)

  • First-line
    • ACEi
    • ARBs
    • Long-acting CCBs
    • Thiazide/thiazide-like diuretics

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What is first-line and second-line therapy for individuals with nondiabetic CKD? (CHEP)

  • First-line
    • ACEi
      • ARB instead of ACEi if intolerance
  • Second-line
    • Thiazide/thiazide-like diuretics
    • Loop diuretics (if volume overload)

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What is first-line and second-line therapy for individuals with diabetes? (CHEP)

  • First-line
    • ACEi or ARB
  • Second-line
    • Dihydropyridine CCB (preferred over thiazides)

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What are the rational first-line drug choices for each indication of hypertension?

Rational First-Line Drug Choices








Diastolic +/- systolic HTN







Isolated systolic HTN







DM (without complication)




2nd line




DM (with CAD or CKD)







CKD with proteinuria (non-DM)





Loop for volume






2nd DHP











CHF (EF <40%)



2nd DHP

*@Aldo antag


If can’t use ACE








A. Fib





















Essential Tremor




























*Grade 1 Evidence

@ recent CAD hospitalization, acute MI, elevated BNP or NYHA class II-IV – caution K


What are the absolute and relative contraindications to ACEi and ARBs?

  • Absolute
    • Hypersensitivity
  • Relative
    • RAS
    • Pregnancy
    • Angioedema


What are known AE associated with ACEi or ARBs?

  • Cough
  • Angioedema
  • Dizzy
  • HYPERkalemia
    • Caution with diuretics, lithium and NSAIDs


What should be monitored in patients on ACEi or ARBs?

  • Cr
  • Lytes


Which beta-blockers are cardio-selective, non-cardio-selective, and which are mixed alpha and beta?

  • Cardio-selective (MAB) – Metoprolol, Atenolol, Bisoprolol
  • Non-cardio-selective – Propranolol
  • Mixed Alpha and Beta – Carvedilol and Labetolol


What are the absolute and relative contraindications to beta-blockers?

  • Absolute
    • Sinus bradycardia
    • >2nd degree heart block
    • Acute CHF
    • Pheochromocytoma
  • Relative
    • Peripheral arterial disease
    • Asthma/COPD
    • Hyperthyroidism
    • Concurrent non-dihydropyridine CCB or Digoxin


What are 5 known AEs associated with beta-blockers?

  • Fatigue, insomnia, vivid dreams
  • Masked hypoglycemia – no adrenergic symptoms
  • Bronchospasm
  • Mixed have more orthostatic hypotension
  • AV block


What should be monitored in patients on Beta-blockers?

  • HR
  • BP


Which CCBs are dihydropyridines and which are non-dihydropyridines?

  • Dihydropyridine – Amlodipine, Felodipine, Nifedipine
  • Non-dihydropyridine – Diltiazem, Verapamil
    • More cardiac effect


What are the absolute and relative contraindications to CCBs?

  • Absolute
    • Hypersensitivity
    • Non-dihydropyridine
      • Acute CHF
      • >2nd degree heart block
  • Relative
    • Concurrent BB or digoxin
    • Dihydropyridine with CHF


What are 4 known AEs associated with CCBs?

  • Dizzy, flushing, headaches
  • Peripheral edema
  • Dihydropyridine – reflex tachycardia
  • Non-dihydropyridine – AV block


What should be monitored in patients on CCBs?

  • LFTs


What are 4 types of diuretics and examples of each?

  • Thiazides – HCTZ, indapamide, chlorthalidone, metolazone
  • Loop diuretics – furosemide, bumetanide, ethacrynic acid
  • Potassium-sparing – amiloride, triamterene
  • Aldosterone antagonists - spironolactone


What are the absolute and relative contraindications to diuretics?

  • Absolute
    • Anuria
    • Hyperkalemia – K spare and Spironolactone
  • Relative
    • Gout – Thiazides
    • Sulfa allergy – Thiazides and Loop
    • Electrolyte abnormalities


What are 4 known AEs associated with diuretics?

  • Thiazides and Loop
    • Hypokalemia
    • Hyponatremia
    • Low Ca, Mg
    • Increased uric acid – thiazide
  • K sparing and Spironolactone
    • Hyperkalemia


What should be monitored in patients on diuretics?

  • Cr
  • Lytes


How does hydralazine work and how is it dosed?

  • Direct vasodilator
  • 10 mg QID, increasing qweek by 10-25 mg/dose to max 300 mg/day


What are the absolute and relative contraindications to hydralazine?

  • Absolute
    • Hypersensitivity
    • Rheumatic heart disease
  • Relative
    • Volume overload
    • CAD – reflex tachycardia
    • Pulmonary hypertension


What are 4 known AEs associated with hydralazine?

  • Orthostatic hypotension
  • Palpitations
  • Angina
  • Peripheral edema


What should be monitored in patients on hydralazine?

  • BP


Which ACEi and ARBs are true 24h duration?

  • Perindopril
  • Trandolapril
  • Irbesartan


Which beta-blocker has the worst evidence for a benefit? (TFP)

  • Atenolol
  • Multiple meta-analyses (one Cochrane) have compared beta-blockers to other antihypertensives
    • NNH=461 for stroke, no difference in MI or death
    • Atenolol
      • NNH=130 for stroke
      • NNH=140 for death
  • 2006 meta-analysis stratifying by age subgroup
    • <60 years: no significant difference
    • ≥60 years: increased risk


Which thiazide/thiazide-like diuretics have the best evidence? (TFP)

  • Chlorthalidone >>> HCTZ
    • Chlorthalidone 25 mg vs HCTZ 50 mg provided superior BP reduction overall (12 vs 7 mmHg on 24-hr monitor) and at nighttime (13 vs 6 mmHg)
    • Large trials using chlorthalidone (ALLHAT and SHEP) have demonstrated cardiovascular improvements whereas HCTZ evidence is less robust
    • Chlorthalidone has longer half-life than HCTZ (50-60h vs 9-10h)
  • Indapamide also has good evidence for reduction in cardiovascular endpoints as first or second-line antihypertensives


What % of thiazide users and ACEi/ARB users experience electrolyte disturbances? What is the evidence for monitoring electrolytes in these patients? (TFP)

  • Thiazides
    • 4% Hyponatremia (Na <130 mmol/L)
    • 4% Hypokalemia (K <3.2 mmol/L)
  • ACEi/ARB
    • 4% Hyperkalemia (K >5.4 mmol/L)
  • Limited evidence for checking in the first 2-4 weeks after starting, and again after increasing doses of these agents, and at least annually thereafter