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Kelly Olynyk Hypertension Flashcards

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1
Q

ALLHAT key takeaways

A

-Thiazide diuretics should be first-line
-For patients who cannot take a diuretic, consider prescribing a calcium channel blocker or ACE inhibitor
-Most patients with high blood pressure need more than one drug

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2
Q

ACC/AHA recommendation for choice of initial medication for treatment of HTN

A

For initiation of antihypertensive drug therapy, first-line agents include thiazide diuretics, CCBs, and ACE inhibitors or ARBs

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3
Q

What are the options for combination therapy for HTN

A

-ACEi/CCB
-ARB/CCB
-ACEi/diuretic
-ARB/diuretic
-CCB/diuretic

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4
Q

First-line treatment for stable ischemic heart disease

A

-Beta blockers (reduce CV events and anginal symptoms)
-ACEi/ARBs (reduce MI, stroke, and CVD)
-Dihydropyridine CCBs can be used if still uncontrolled

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5
Q

How to treat heart failure with reduced ejection fraction

A

Avoid non-dihydropyridine CCBs due to no clinical benefit/worse outcomes in patients with HF

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6
Q

How to treat heart failure with preserved ejection fraction

A

-Diuretics: fluid overloaded
-ACEi/ARB: elevated BP
-Beta blockers: elevated heart rate

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7
Q

Which HTN treatment is preferred in patients with CKD stage 1 or 2 AND albuminuria?

A

ACEi (or ARBs) (ACE is better)

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8
Q

Which HTN treatment is preferred in patients with CKD stage 3 or higher?

A

ACEi (or ARBs)

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9
Q

What HTN treatment is preferred in patients post-kidney transplantation?

A

Dihydropyridine CCBs are preferred due to improved GFR and kidney survival

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10
Q

Which medications are used for secondary stroke prevention?

A

-ACEi/ARBs
-Thiazide diuretics
-Combination of above
-Only initiate treatment if BP is over 140/90

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11
Q

What medications should be used for patients with diabetes and albuminuria?

A

ACEi or ARBs

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12
Q

What HTN medications are preferred for pregnant patients?

A

-Methyldopa
-Nifedipine
-Labetalol

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13
Q

What HTN medications are contraindicated for pregnant patients?

A

-ACEi
-ARBs
-Direct renin inhibitors

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14
Q

What HTN medications should be used in black adults without HF or CKD?

A

Thiazide diuretic or CCB

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15
Q

Initial effects of anti-hypertensives

A

Diuresis -> reduced stroke volume -> increase in PVR

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16
Q

Chronic anti-hypertensive effects

A

Stroke volume returns to normal -> decrease in PVR (below pretreatment levels)

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17
Q

Which thiazide diuretic is the most potent and most studied?

A

Chlorthalidone

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18
Q

When are thiazide diuretics more effective than loop diuretics?

A

When the CrCl >30 mL/min

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19
Q

When should diuretics be dosed?

A

In the morning or morning and afternoon to avoid nocturnal diuresis

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20
Q

How often are thiazide diuretics dosed?

A

Once daily in the morning

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21
Q

Adverse effects associated with thiazide diuretics

A

-Hypokalemia
-Hypomagnesemia
-Hypercalcemia
-Hyperuricemia
-Hyperglycemia
-Hyperlipidemia
-Sexual dysfunction
-Increase in triglycerides/cholesterol

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22
Q

Drugs that interact with thiazide diuretics

A

Lithium toxicity with concurrent use

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23
Q

Contraindications to thiazide diuretics

A

-Sulfa allergy
-Anuria

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24
Q

When are loop diuretics preferred?

A

-Heart failure for symptom management
-More effective than thiazide diuretics with CrCl <30 mL/min

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25
When should loop diuretics be dosed?
In the morning and the afternoon
26
How often should loop diuretics be taken?
Twice daily
27
Adverse effects to loop diuretics
-Hypokalemia -Hypomagnesemia -Hypocalcemia -Hyperuricemia -Ototoxicity
28
Contraindications to loop diuretics
Sulfa allergy
29
Which aldosterone antagonist is preferred with resistant HTN?
Spironolactone
30
When should aldosterone antagonists not be initiated?
With potassium >5mEq/L
31
When should aldosterone antagonists be dosed?
In the morning or morning and afternoon to avoid nocturnal diuresis
32
What are the aldosterone antagonists?
-Spironolactone -Eplerenone
33
When should aldosterone antagonists be held or reduced?
If potassium >5.5 mEq/L
34
Adverse effects of aldosterone antagonists
-Hyperkalemia -Hyponatremia -Gynecomastia
35
What drugs used with aldosterone antagonists increases potassium levels?
-ACEi -ARBs -Renin inhibitors -NSAIDs
36
What are the contraindications for eplerenone?
-Impaired renal function (CrCl <50 mL/min or SCr >2 for males and SCr >1.8 for females) -T2DM and proteinuria -Concomitant use of potassium-sparing diuretics
37
What are the contraindications for spironolactone?
-Concomitant use of potassium sparing diuretics
38
What are the potassium-sparing diuretics?
-Amiloride -Triamterene
39
Why are potassium-sparing diuretics used in combination?
They are used with a thiazide to minimize hypokalemia and because potassium-sparing diuretics by themselves do not effect BP much
40
Which patient populations must potassium-sparing diuretics be used in caution with?
Diabetes or CKD (GFR < 45 ml/min)
41
When are potassium-sparing diuretics given?
In the morning or afternoon to avoid nocturnal diuresis
42
How often are potassium-sparing diuretics given?
1 or 2 times a day
43
Adverse effects of potassium-sparing diuretics
-Hyperkalemia -Increased uric acid -Hyperglycemia
44
Diuretics clinical pearls
-Do not give at bedtime -Thiazides are first-line for most HTN patients -Spironolactone is first-line for patients with resistant HTN -Do not use potassium-sparing diuretics as monotherapy for HTN -Pay attention to patient allergies -Check CrCl when choosing the diuretic class -Important to monitor potassium and other electrolytes
45
What is the mechanism of action of angiotensin-converting enzyme inhibitors?
Inhibits the conversion for angiotensin 1 to angiotensin 2
46
What is the mechanism of action of angiotensin 2 receptor blockers?
Block effects of angiotensin 2 by binding to target receptors
47
What is the mechanism of action of renin inhibitors?
Inhibits conversion of angiotensinogen to angiotensin 1
48
What are the first line treatment options for HTN?
-ACEi -ARBs -Thiazide diuretics -Calcium Channel blockers
49
What other conditions do ACEIs provide additional benefit to?
-Diabetes with proteinuria -Heart failure -Post MI -Chronic kidney disease
50
When should ACEis and ARBs be taken?
At night to ensure "BP dipping" overnight
51
What are examples of ACEis?
-Benazepril -Captopril -Enalapril -Fosinopril -Lisinopril -Moexipril -Perindopril -Quinapril -Ramipril -Trandolapril
52
ACEi adverse effects
-Angioedema -Cough (up to 20%) -Hyperkalemia -Acute renal failure with severe bilateral renal artery stenosis
53
ACEi contraindications
-History of angioedema on an ACEi -Concomitant use of aliskiren in patients with DM -Pregnancy/breastfeeding
54
Why are ARBs used as back-up to ACEis?
-It does not block bradykinin breakdown so there is less of a cough -It can be used if the patient has a history of angioedema with ACEi
55
How often should benazepril be taken?
once or twice daily
56
How often should captopril be taken?
two or three times daily
57
How often should enalapril be taken?
once or twice daily
58
How often should fosinopril be taken?
once daily
59
How often should lisinopril be taken?
once daily
60
How often should moexipril be taken?
once or twice daily
61
How often should perindopril be taken?
once daily
62
How often should quinapril be taken?
once or twice daily
63
How often should ramipril be taken?
once or twice daily
64
How often should trandolapril be taken?
once daily
65
What are the ARBs?
-Azilsartan -Candesartan -Eprosartan -Irbesartan -Losartan -Olmesartan -Telmisartan -Valsartan
66
How often should candesartan be taken?
once daily
66
How often should azilsartan be taken?
once daily
67
How often should eprosartan be taken?
once or twice daily
68
How often should irbesartan be taken?
once daily
69
How often should losartan be taken?
once or twice daily
70
How often should olmesartan be taken?
once daily
71
How often should telmisartan be taken?
once daily
72
How often should valsartan be taken?
once daily
73
ARB adverse effects
-Angioedema -Hyperkalemia -Acute renal failure with severe bilateral renal artery stenosis
74
ARB contraindications
-History of angioedema -Concomitant use of aliskiren in patients with diabetes -Pregnancy/breastfeeding
75
When should ACEi/ARBs be held?
If potassium is greater than 5.5 mEq/L or if SCr increases by 30%
76
What are the direct renin inhibitors?
Aliskiren
77
Why is aliskiren not first line for HTN?
It is very expensive and typically is not better than ACEi/ARBs
78
What is aliskiren contraindicated in?
-Pregnancy -Concomitant use with an ACEi or ARB in patients with diabetes
79
Adverse effects of direct renin inhibitors
-Diarrhea -Musculoskeletal effects -Dizziness -Headache -Hyperkalemia -Renal insufficiency/ARF -Orthostatic hypotension
80
How often should aliskiren be taken?
once daily
81
Angiotensin inhibitors clinical pearls
-Discuss contraceptive methods with women of childbearing age -Do not combine drug classes due to risk of adverse effects -Assess patients risk of hyperkalemia (CKD, other medications, etc) -Educate patient on dietary sources of potassium -ACEi/ARBs often preferred over other first-line agents in the presence of other compelling indications
82
What is the mechanism of action of calcium channel blockers?
Inhibits the influx of calcium across cardiac and smooth muscle cell membranes leading to coronary and peripheral vasodilation
83
Subclasses of calcium channel blockers
-Dihydropyridines - more vasodilation -Nondihydropyridines - more negative inotropic effects -Overall similar effect on BP
84
Patient populations that benefit from the use of dihydropyridines
-Reynauds syndrome -Elderly patients with isolated systolic HTN
85
Which dihydropyridines should be avoided?
Short-acting (IR nifedipine/nicardipine)
86
What are the dihydropyridines?
-Amlodipine -Felodipine -Isradipine -Isradipine SR -Nicardipine SR -Nifedipine LA -Nisoldipine
87
How often should amlodipine be taken?
once daily
88
How often should felodipine be taken?
once daily
89
How often should isradipine be taken?
twice daily
90
How often should isradipine SR be taken?
Once daily
91
How often should nicardipine SR be taken?
twice daily
92
How often should nifedipine LA be taken?
once daily
93
How often should nisoldipine be taken?
once daily
94
Adverse effects of dihydropyridines
-Reflex tachycardia -Flushing -Dizziness -Headache -Peripheral edema -Gingival hyperplasia
95
Warnings for dihydropyridines
Increased risk of angina/MI in patients with obstructive coronary disease due to reflex tachycardia
96
What do dihydropyridines interact with?
-Grapefruit juice -CYP3A4 enzyme inducers/inhibitors
97
Which patient populations see additional benefits from nondihydropyridines?
-Supraventricular tachyarrhythmias -Patients with angina who can not tolerate a beta blocker
98
What is the mechanism of action of nondihydropyridines?
Slows AV node conduction and decreases heart rate leading to negative ionotropic effects
99
Which nondihydropyridines are preferred?
Extended-release formulations
100
What are the nondihydropyridines?
-Diltiazem ER -Verapamil ER
101
How often should the nondihydropyridines be taken?
once or twice daily
102
Adverse effects of nondihydropyridines
-Bradycardia -Headache -Dizziness -AV node block -Systolic heart failure -Gingival hyperplasia -Constipation
103
Interactions with nondihydropyridines
-Concomitant use of beta blockers (increases risk of heart block) -Grapefruit juice -CYP3A4 enzyme inducers/inhibitors (3A4 substrates)
104
Contraindications of nondihydropyridines
-Heart block -Left ventricular dysfunction
105
CCB clinical pearls
-No routine laboratory monitoring required -Check for drug interactions -CCBs are first line for HTN -Peripheral edema is dose-dependent -Extended release formulations are preferred -Nondihydropyridine CCB formulations are not interchangeable -If a CCB is needed in the setting of heart failure choose amlodipine
106
When are beta blockers a first line treatment for HTN?
When there is a compelling indication present such as heart failure and CAD
107
Which patient populations have additional benefits when using beta blockers?
-Tachyarrhythmias -Tremors -Migraines -Thyrotoxicosis
108
Mechanism of action of beta blockers
Decreases heart rate and force of contraction leading to a decrease in cardiac output
109
What are some warnings associated with beta blockers?
-Avoid abrupt discontinuation -Can mask signs/symptoms of hypoglycemia
110
What are the cardioselective beta blockers?
-Atenolol -Betaxolol -Bisoprolol -Metoprolol tartrate -Metoprolol succinate -Nebivolol
111
How often should atenolol be taken?
once daily
112
How often should betaxolol be taken?
once daily
113
How often should bisoprolol be taken?
once daily
114
How often should metoprolol tartrate be taken?
twice daily
115
How often should metoprolol succinate be taken?
once daily
116
How often should nebivolol be taken?
once daily
117
What are the nonselective beta blockers?
-Nadolol -Propranolol IR -Propranolol LA
118
How often should nadolol be taken?
once daily
119
How often should propranolol IR be taken?
twice daily
120
How often should propranolol LA be taken?
once daily
121
What are the beta blockers with intrinsic sympathomimetic activity?
-Acebutolol -Penbutolol -Pindolol
122
How often should acebutolol be taken?
twice daily
123
How often should penbutolol be taken?
once daily
124
How often should pindolol be taken?
twice daily
125
Which cardioselective beta blocker induces vasodilation using nitric oxide?
Nebivolol
126
When should nonselective beta blockers be avoided?
In bronchospastic airway disease
127
When should beta blockers with intrinsic sympathomimetic activity be avoided?
In heart failure and IHD
128
What are the mixed alpha/beta blockers?
-Carvedilol -Labetalol
129
How often should carvedilol be taken?
twice daily
130
How often should labetalol be taken?
twice daily
131
Adverse effects of beta blockers
-Bronchospasm -Bradycardia -Fatigue -Exercise intolerance -Depression
132
When should beta blockers be used with caution?
In patients with peripheral artery disease and reactive airway disease
133
Beta blocker contraindications
-Second or third degree heart block -Decompensated heart failure -Post-MI (ISA BBs only) -Severe bradycardia -Sick sinus syndrome
134
What are the direct arterial vasodilators?
-Hydralazine -Minoxidil
135
When are direct arterial vasodilators used?
For patients with special indications or very difficult to control BP (i.e. severe CKD or hemodialtsis)
136
Which direct arterial vasodilator is the most potent?
Minoxidil
137
Which other medications must be used along with direct arterial vasodilators?
Diuretic and beta blocker needed
138
How often should hydralazine be taken?
2 to 4 times daily
139
How often should minoxidil be taken?
1 to 3 times daily
140
Adverse effects associated with direct arterial vasodilators
-Palpitations -Tachycardia -Chest pain -GI side effects -Headache -Hematologic dyscrasias -Hepatotoxicity -Lupus-like syndrome/rash (hydralazine) -Fluid retention -Hair growth (minoxidil)
141
Boxed warning for minoxidil
-May cause pericarditis and pericardial effusion that may progress to tamponade -May increase oxygen demand and exacerbate angina pectoris -Maximum therapeutic doses of diuretic and two other antihypertensives should be used before this drug is ever added. Should be given with a diuretic to minimize fluid gain and a beta blocker
142
Which patient populations should direct arterial vasodilators be used with caution in?
-CVA -Renal impairment -CAD -Liver disease -SLE -Stroke
143
What are the alpha-1 blockers?
-Doxazosin -Prazosin -Terazosin
144
When are alpha-1 blockers second-line treatment?
In patients with concomitant BPH
145
What is a common side effect of alpha-1 blockers?
Orthostatic hypotension (especially in the elderly)
146
What are the central alpha-2 agonists?
-Clonidine -Methyldopa -Guanfacine
147
What are the adverse effects associated with alpha-2 agonists?
-CNS depression -Dizziness -Fatigue -Anticholinergic effects -Bradycardia -Reflex tachycardia -Fluid retention
148
Why should you avoid abrupt cessation of alpha-2 agonists?
Rebound hypertension
149
How to titrate off clonidine
-Slow wean - half dose every 2-3 days -Concomitant beta blockers prescribed -Wean BB several days prior to clonidine wean
150
How do you transfer from oral clonidine to a transdermal patch?
Overlap oral regimen for 3-4 days
151
How do you transfer from patch to oral clonidine?
Consider starting oral clonidine no sooner than 8 hours after patch removal
152
Monitoring parameters for ACEi/ARBs
-BUN/SCr -Potassium
153
Monitoring parameters for CCBs
Heart rate (non-dihydropyridine)
154
Monitoring parameters for aldosterone antagonists
-BUN/SCr -Potassium
155
Monitoring parameters for other diuretics
-BUN/SCr -Electrolytes -Uric acid (thiazides)
156
Monitoring parameters for beta blockers
Heart rate
157
What should you do if patient is not at goal?
-Consider nighttime dosing of one antihypertensive -Assess adherence -Educate on diet, exercise, and smoking cessation -Rule out white coat hypertension -Discontinue interfering substances -Patient may have resistant hypertension
158
What is resistant hypertension?
Failure to attain goal BP while adherent to a regimen that includes at least 3 agents at maximum dose or when 4 or more agents are needed
159
Risk factors for resistant hypertension
-Older age -Obesity -CKD -Diabetes -African American
160
Step 1 of the AHA step-wise guidance for the management of resistant HTN
-Maximize lifestyle interventions -Optimize 3-drug regimen (ACEi or ARB, CCB, and diuretic)
161
Step 2 of the AHA step-wise guidance for the management of resistant HTN
-Substitute optimized thiazide-like diuretic (chlorthalidone, indapamide)
162
Step 3 of the AHA step-wise guidance for the management of resistant HTN
-Add mineralocorticoid receptor antagonist (spironolactone, eplerenone)
163
Results of the PATHWAY-2 trial
Spironolactone is better than placebo/doxazosin/bisoprolol as add-on therapy in resistant hypertension
164
Step 4 of the AHA step-wise guidance for the management of resistant HTN
-Add BB if heart rate is greater than 70 -Consider central alpha-2 agonist (clonidine patch or guanfacine at bedtime) if BB contraindicated and/or heart rate is less than 70 bpm
165
Step 5 of the AHA step-wise guidance for the management of resistant HTN
-Add hydralazine
166
Step 6 of the AHA step-wise guidance for the management of resistant HTN
-Substitute minoxidil for hydralazine
167
What should be collected about a patient when discussing HTN?
-Patient characteristics -Patient history -Home blood pressure readings -Current medications and prior anti-hypertensive medication use -Objective data: vitals, lab results
168
What should be assessed about a patient when discussing HTN?
-Presence of compelling indications -HTN-related complications -10-year atherosclerotic cardiovascular disease risk (ASCVD) -Current medications that may contribute to or worsen HTN -BP goal -Appropriateness/effectiveness of current HTN regimen -For resistant HTN if taking 3 or more hypertensive medications
169
How should a plan be developed for a patient to treat their HTN?
-Tailored lifestyle modifications -Drug therapy regimen: dose, route, frequency, duration -Monitoring parameters: efficacy, safety, timeframe -Education -Self-monitoring -Referrals to other providers when appropriate
170
How should the plan be implemented for a patient with HTN?
-Provide patient education of treatment plan -Use motivational interviewing to maximize adherence -Schedule a follow-up
171
What should be monitored when following up with a patient with HTN?
-BP goal attainment -Adverse effects -CV events -Development/progression of kidney disease -Adherence

Therapeutics II (33 decks)

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