Hypertension Flashcards Preview

Primary Care > Hypertension > Flashcards

Flashcards in Hypertension Deck (101):
1

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

  • Hypertension

2

How common is hypertension in Canada? (CHEP)

  • Affects 1 in 4 (23%) Canadian adults

3

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

4

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

5

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

A image thumb
6

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

7

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

8

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

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

9

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

10

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

11

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

12

How is metabolic syndrome diagnosed?

≥3 measures to make the diagnosis of metabolic syndrome

Waist Circumference

≥102 cm (Men) / ≥88 cm (Women)

TG

≥1.7 mmol/L

HDL

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

BP

SBP ≥130 mm Hg and/or DBP ≥85 mm Hg

FPG

≥5.6 mmol/L

13

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

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

14

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

15

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

16

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

17

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

  • First reading discarded
  • Latter readings averaged

18

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

A image thumb
19

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

A image thumb
20

How should postural hypotension be assessed? (CHEP)

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

21

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

22

How can hypertension be diagnosed? (CHEP)

A image thumb
23

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

24

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

25

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

26

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

  • Ambulatory BP monitoring

27

When is home BP monitoring recommended? (CHEP)

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

28

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

29

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

30

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

31

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

32

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

33

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

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

34

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

  • Renovascular hypertension
  • Endocrine hypertension

35

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

36

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)

37

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

38

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

39

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

40

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

  • Adrenal CT or MRI

41

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

42

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)

43

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

44

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

45

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)

46

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

47

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

  • SBP ≥135 mmHg or DBP ≥85 mmHg

48

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

49

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

50

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

51

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

Intervention

Target

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

52

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

53

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

54

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

55

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

56

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

57

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

58

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

A image thumb
59

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

  • Hypokalemia

60

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

61

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

A image thumb
62

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)

63

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

  • ≥3 cardiovascular risk factors
  • Established atherosclerotic disease

64

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

65

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

  • Aged ≥50 years
  • SBP ≥130 mmHg

66

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

A image thumb
67

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

68

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

69

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

70

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)

A image thumb
71

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

72

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

A image thumb
73

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)

A image thumb
74

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

A image thumb
75

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

A image thumb
76

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)

A image thumb
77

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)

A image thumb
78

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

Rational First-Line Drug Choices

Indication

ACE/ARB

BB

CCB

Diuretic

Alpha

Hydralazine

Diastolic +/- systolic HTN

non-black

<60years

Yes

*Thiazide

 

 

Isolated systolic HTN

Yes

 

*DHP

*Thiazide

 

 

DM (without complication)

*Yes

 

*DHP

2nd line

*Thiazide

 

 

DM (with CAD or CKD)

*Yes

 

 

 

 

 

CKD with proteinuria (non-DM)

*Yes

 

 

Thiazide

Loop for volume

 

 

Angina/CAD

*Yes

Yes

2nd DHP

 

 

 

Post-MI

 

 

 

 

 

 

CHF (EF <40%)

*Yes

*Yes

2nd DHP

*@Aldo antag

 

If can’t use ACE

LVH

Yes

 

Yes

Thiazide

 

Never

A. Fib

 

Yes

Non-DHP

 

 

 

Post-Stroke

Yes

 

 

Yes

 

 

Migraines

 

Yes

Non-DHP

 

 

 

Essential Tremor

 

Non-cardio

 

 

 

 

BPH

 

 

 

 

Yes

 

Raynaud’s

 

 

DHP

 

 

 

Hyperthyroid

 

Yes

 

 

 

 

*Grade 1 Evidence

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

79

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

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

80

What are known AE associated with ACEi or ARBs?

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

81

What should be monitored in patients on ACEi or ARBs?

  • Cr
  • Lytes

82

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

83

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

84

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

85

What should be monitored in patients on Beta-blockers?

  • HR
  • BP

86

Which CCBs are dihydropyridines and which are non-dihydropyridines?

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

87

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

88

What are 4 known AEs associated with CCBs?

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

89

What should be monitored in patients on CCBs?

  • LFTs

90

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

91

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

92

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

93

What should be monitored in patients on diuretics?

  • Cr
  • Lytes

94

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

95

What are the absolute and relative contraindications to hydralazine?

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

96

What are 4 known AEs associated with hydralazine?

  • Orthostatic hypotension
  • Palpitations
  • Angina
  • Peripheral edema

97

What should be monitored in patients on hydralazine?

  • BP

98

Which ACEi and ARBs are true 24h duration?

  • Perindopril
  • Trandolapril
  • Irbesartan

99

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

100

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

101

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