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Hypertension Dr. Higsmith Flashcards

Dr. Higsmith EXAM II (60 cards)

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1
Q

Signs for secondary HTN

A

-Onset age < 30y
-Abrupt onset
-excessive hypokalemia
-drug-resistant HTN
-palpitation, headaches, sweating
-severe vascular disease

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2
Q

Diseases - Secondary Causes of HTN

A

-Obstructive sleep apnea (25-50%)
-Primary aldosteronism (8-20%)
-Renovascular disease (5-35%)
-Renal parenchymal disease (1-2%)

Rare:
Thyroid disease. Cushing’s syndrome, pheochromocytoma, Coarctation of aorta

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3
Q

Drugs - Secondary Causes of HTN

A

-Corticosteroids - Prednisone, methylprednisolone
-NSAIDs
-Sympathomimetics/stimulants - Amphetamine salts, caffeine
Hormones - Estradiol, conjugated estrogens, testosterone, contraceptives
-Decongestants: Pseudoephedrine
-Antidepressants: venlafaxine, duloxetine, bupropion, MAOIs
-Erythropoiesis stimulating agents: Erythropoietin, darbepoetin
-Immunosuppressants: Cyclosporine, tacrolimus
-Illicit substances: Cocaine, methamphetamine, anabolic steroids

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4
Q

Lifestyle - Secondary Causes of HTN

A

-Inactivity, high salt diet, obesity, alcohol, smoking

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5
Q

Mean arterial pressure (MAP)

A

average pressure in the arteries during one cardiac cycle
-2/3 of the cycle is spent in diastole
-1/3 is spent is systole

MAP = (1/3 * SBP) + (2/3 * DBP)

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6
Q

Pulse pressure

A

difference between SBP and DBP

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7
Q

White coat HTN

A

-affects 15-20% of patients
-BP is higher in clinic than at home
-minimal increase in CV risk
-may lead to overtreatment

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8
Q

Masked HTN

A

-BP higher at home than in clinic
-Undertreatment of HTN
-increased CV risk, similar to sustained HTN

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9
Q

ACC/AHA 2017 Guidelines - BP

A

Normal: <120/<80
Elevated: 120-129 / <80
Stage 1: 130-139 / 80-90
Stage 2: >140 / >90

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10
Q

Initiate therapy - ACC/AHA 2017

A

Clinical ASCVD: >130 / >80 (Stage 1)
10y risk >10%: >130 / >80 (Stage 1)
10 y risk <10%: >140 / >90 (Stage 2)
Elderly (over 65): SBP >130

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11
Q

Initiate therapy - JNC 8 2014

A

-Age over 60: >150/90
-Age under 60: >140/90
Diabetes w/o CKD: >140/90
-CKD w/o Diabetes: >140/90

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12
Q

Treatment: Patient with Stage 1 HTN

A

BP: >130-139/80-89
No ASCVD or 10y risk is <10%: Nonpharmacologic therapy -> Reasses in 3-6 months

ASCVD or 10y risk is >10%: Non-pharm therapy + Medication -> Reasses in 1 mo

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13
Q

Treatment: Patient with Stage 2 HTN

A

BP: >140/>90
Nonpahrm therapy + Medication
-> Reassess in 1 mo

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14
Q

When to consider treatment based on JNC 8 guidelines?

A

Age over 60 (>150/90) or under 60 (>140/90)
-check CKD and diabetes

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15
Q

BP Goals: JNC 8 vs ACC/AHA

A

-depends on the Comorbid disease and age
-Goal by JNC 8:
< 140/90 for comorbidites
<150/90 if over 60y

-Goal by ACC/AHA:
< 130/80 for comorbidites
SBP <130/90 for elderly over 65

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16
Q

Goals for elderly

A

JNC 8: <150/90
ACC/AHA: SBO <130

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17
Q

Which non-pharmacologic intervention has the biggest impact?

A

Weight loss: 5-20 mmHg reduction in SBP for every 10kg

-Exercise: 90-150 min/wk –> 5-9 mmHg SBP decrease
-Limit alcohol: no more than 2 drinks for men and 1 drink for women per day - reduction in 2-4 mmHg SBP

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18
Q

SBP reduction for diet

A

-DASH diet: 8-14 mmHg SBP reduction
-reduce salt: 5-6 mmHg SBP reduction

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19
Q

Evidence for ACEi/ARBs

A

-Hypertension
-Heart failure
-Primary prevention of CAD
-Secondary prevention of CAD (post-MI), diabetes
-Primary prevention of nephropathy -> diabetes

-less effective in preventing CVA (stroke) than other BP meds

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20
Q

ADE of ACEi/ARB

A

-Increase in SCr: Vasodilation of efferent arteriole -> lower GFR -> more SCr in the blood
-Hyperkalemia
-Angioedema (bradykinin)
-cough (ACEi)

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21
Q

Direct Renin inhibitor

A

Aliskiren (Tekturna)
-no benefit or outcomes data
-not recommended!

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22
Q

Evidence for diuretics

A

-increased SCr/BUN
-increase in Ca2+
-decrease in K+, Na, Mg

-Hypotension due to volume depletion
-possible worsening of gout, DM, lipids

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23
Q

What is the most effective diuretic to treat HTN?

A

Thiazides
-Chlorthalidone over HCTZ
-Twice as potent
-reduced HF in African Americans (better than CCB)

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24
Q

Which diuretic is effective in removing fluid?

A

Loops
-used for HTN when caused by edema
-consider loops for HTN when GFR is <30-50 ml/min

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25
When are K+-sparing diuretics considered?
-Spironolactone, Eplerenone -in combination with K+ wasting diuretics (loops, thiazides) -good for the treatment of resistant HTN -add on drug: reducing CV morbidity reducing mortality in HFrEF
26
ADE of Aldosterone Antagonist
-Spironolactone, Eplerenone -gynecomastia -amenorrhea -erectile dysfunction -electrolyte abnormalities
27
Calcium Channel blocker: DHP
DHP: Amlodipine (Norvasc), Felodipine (Plendil), Nifedipine (Adalat) -Peripheral: Relaxation of arterial smooth muscle -> decreasing peripheral resistance
28
Calcium Channel blocker: Non-DHP
Verapamin (Calan), Diltiazem (Cardizem) -Central: -> Vasodilator of coronary vessels -> increases blood flow -> depresses AV node conduction -> decreasing HR
29
When to consider CCB
-Angina -may be more effective in isolated systolic HTN (often elderly) -Afib rate control (non-DHP)
30
ADE of CCB
-avoid short-acting CCBs -DHP-HA: flushing, peripheral edema (due to vasodilation -> more blood -> hydrostatic pressure pushing fluid into tissue) -Non-DHP: bradycardia AV block potential benefit in Raynaud’s Disease migraine prophylaxis (verapamil) arrhythmias (non-DHPs)
31
Selectivity of ß-blockers
Cardioselective: Metoprolol, Nebivolol, Bisoprolol, Atenolol Mixed-selective: carvedilol, labetalol Non-selective: propranolol, nadolol
32
ADE of ß-blockers
-Rebound HTN (taper) -orthostatic hypotension -mask hypoglycemia
33
When to consider ß-blockers?
-treatment of resistant HTN (also Spironolactone) - 1st and 2nd line didn't work -compelling indication (HFreF, Ischemic heart disease, HFpEF after ACEi/ARB) other compelling indications: tachyarrhythmias, CHF, migraine, tremor, portal HTN, thyrotoxicosis
34
Which ß-blocker should be used in heart failure?
-Metoprolol succinate (long-acting, Toprol XL) -Carvedilol (mixed-selective) -Bisoprolol (Cardioselective) -if respiratory issues use cardioselective (BEAM)
35
Other drugs for HTN - Alpha-2-agonists
clonidine, guanfacine, and methyldopa -Alpha-2-agonists: when activated -> RELAXATION (in the CNS - blocking sympathetic tone) -Rebound HTN, tremor, agitation, nervousness, headache -Methyldopa for pregnancy -Clonidine for treatment-resistant HTN
36
Alpha-1-blocker and direct vasodilator
-prazosin, terazosin, doxazosin -Used most commonly if concomitant BPH -direct arterial vasodilator: - hydralazine and minoxidil -> may cause edema and water retention
37
When is monotherapy or a two-drug therapy recommended?
Monotherapy: Stage 1 HTN with ASCVD, CKD, diabetes OR 10y risk over 10% -use ACEi/ARB, CCB, or thiazide Two-drug: Stage 2 HTN WITHOUT compelling indication and >20/10 mmHg away from goal BP
38
Treatment HFrEF or Ischemic heart disease
HFrEF: Betablocker (BEAM) OR ACEi/ARB, if edema use diuretic Ischemic heart disease: Betablocker then add ACEi/ARB, if angina use CCB add on: Spironolactone HFpEF: ACEi/ARB then add Betablocker, if edema use diuretic add on: Spironolactone
39
Treatment compelling indication Diabetes
ACEi/ARB CCB Thiazide if albuminuria: only ACEi or ARB
40
Treatment CKD
ACEi or ARB
41
Treatment secondary stroke prevention
Thiazide Thiazide with ACEi
42
Which drug should be avoided in Gout?
Diuretics, thiazides -being poorly hydrated increases the risk of gout
43
Which drug should be avoided in asthma and heart failure?
-ß-blocker for patients with asthma -CCB (diltiazem, verapamil) for heart failure, A-V block, LV dysfunction
44
Which drug to avoid in pregnancy?
-ACEi, ARBs -aslo in hyperkalemia -renal artery stenosis (blockage of the renal artery)
45
When to avoid ARBs?
-pregnancy -hyperkalemia -renal artery stenosis
46
When should spironolactone or eplerenone be avoided?
-Acute or severe renal failure (GFR 30-50) -> use loops -Hyperkalemia
47
Which drug to avoid in tachyarrhythmia?
CCB (DHP): bc they cause a drop in BP -> causing reflex tachycardia -also avoid in heart failure (non-DHP and DHP)
48
Which drugs to use in two-drug therapy?
ACEi or ARB with thiazide ACEi or ARB with CCB Thiazide with CCB -in Stage 2 HTN without compelling indication and >20/10 away from goal
49
ACEi Dosing
Enalapril: 5mg -> 20mg (1-2x daily) Lisinopril: 10mg -> 40mg (1x daily)
50
ARB Dosing
Losartan: 50mg -> 100mg (1-2 daily) Valsartan: 40-80mg -> 160-320mg (1x daily)
51
ß-blocker dosing
Metoprolol: 50mg -100mg (1-2 daily)
52
CCB dosing
Amlodipine: 2.5mg -> 10mg (1 daily) Diltiazem ER: 120-180mg -> 360 mg (1 daily)
53
Thiazide Dosing
Chlorthalidone: 12.5 mg -> 12.5 - 25mg (1 daily)
54
Special Population: Pregnant
-Estrogen increases BP -> contraceptives, Premarin (dose-dependent increase) -bed rest -initiate txt: >140/90 -Methyldopa (Alpha-2-agonist), Labetalol, clonidine in the third trimester -diuretics may cause electrolyte abnormalities -ACEi/ARB are category X
55
Special Population: Elderly
-often isolated systolic hypertension (ISH) -Chlorthalidone reduces stroke and CV events but consider physiological changes (electrolyte changes, renal function, risk of falling)
56
Special Population: Diabetes
1st line: ACEi/ARBs - for renal benefit 2nd line: CCB or thiazide BB masks hypotension
57
Special Population: CHF (congestive heart failure)
-ACEi or ARB + neprilysin inhibitor (Entresto) -BB: metoprolol succ, carvedilol, bisoprolol) -Aldoblocker & diuretic preferred
58
Special Population: African American
-CCB and thiazides are more effective -ACEi/ARBs are still a great choice for HTN and diabetes
59
Special Population: CKD
ACEi/ARB consider loop if GFR <30-50
60
Drugs for treatment-resistant HTN
-Spironolactone -ß-blocker -clonidine

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