Pharmacotherapy of HTN Flashcards Preview

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Flashcards in Pharmacotherapy of HTN Deck (42):
1

Epidemiology of HTN 

1/3 adults in US have HTN 

About 70% of people with MI, CVA, or heart failure have BP >140/90

2

Normal BP

<120/80

3

Pre-HTN 

120-139/80-89

4

Stage 1 HTN

140-159/90-99

5

Stage 2 HTN 

>160/100

6

CVD risk doubles with what increase in BP?

20/10

7

Evaluation of elevated BP

  1. Asses lifestyle and identify other CV RFs or concomitant disorders
  2. Reveal identifiable causes of high BP (primary vs secondary HTN)
  3. Asses the presence or absence of target organ damage

8

JNC 7 Major Cardiovascular Disease RFs

HTN 

Tobacco Use

Obesity 

Physical inactivity 

DM 

Dyslipidemia 

Microalbuminuria 

Age (55/65)

FHx of premature CVD (MI/sudden death)-- 55/65

9

Definable causes of HTN 

(secondary HTN)

Sleep apnea

Chronic kidney disease

Primary aldosteronism 

Renovascular disease

Chronic steroid therapy/Cushings syndrome

Pheochromocytoma

Coarctation of the aorta

Thyroid or parathyroid disease

10

Medications that can cause HTN

NSAIDs

Corticosteroids 

Oral contraceptives 

Cocaine, amphetamines 

Sympathomimetics 

Erythropoieten 

Licorice 

11

Target Organ Damage 

Heart: LV hypertrophy, angina or prior MI, prior coronary revascularization, heart failure

Brain: stroke/TIA

Nephropathy

Peripheral artery disease 

Retinopathy

12

Goal of HTN therapy

Reduce CVD and renal morbidity and mortality 

Achieve SBP goal 

13

Blood pressure goals for uncomplicated HTN 

<140/90

14

Blood pressure goals if also have DM, renal disease, CAD, CAD equivalents, Framingham score >10%, or left ventricular heart failure

<130/80

15

The Big 5: Lifestyle Modifications to Manage HTN 

  1. Weight reduction 
  2. DASH diet
  3. Decrease Sodium intake
  4. Physical activity 
  5. Moderation of alcohol consumption 

16

Pharm treatment decreases the risk of what? 

clearly decreases the incidence of cardiovascular morbidity and mortality 

Dec BP by 5-6 leads to 42% dec in stroke and 14% in CHD

17

Potential additive favorable and unfavorable effects of thiazide diuretics

Useful in slowing osteoporosis 

Should be used cautiously with history of gout or hyponatremia 

18

Potential additive favorable and unfavorable effects of BBs

Useful in treating atrial tachyarrhythmias/fib, migraine, essential tremor, perioperative HTN 

Avoid in pts with asthma, reactive airways disease, or second/third degree heart block 

 

19

Potential additive favorable and unfavorable effects of CCBs 

Useful in Raynuad's syndrome and certain arrhythmias 

 

20

Potential additive unfavorable effects of  ACEI

Do not use in women who are pregnant or may become pregnant 

Do not use if hx of angioedema 

21

Preferred Combos of synergistic antihypertensives 

ACEI + thiazide 

ACEI + DHP CCB

ARB + thiazide 

ARB + DHP CCB

22

NOT preferred combos of antihypertensives 

ACEI + ARB 

BB + ACEI or ARB 

BB + NDHP CCB 

BB + Central acting 

23

Follow up in pts being treated for HTN

Patients should return of f/u and adjustment of meds until goal is reached: 

  • Check BP 2-4 weeks after start or change in dose, assess response after 4-6wks 
  • More frequent visits for stage 2 or if comorbid conditions 

After BP at goal, f/u at 3-6 month intervals 

Serum potassium and creatinine montitored 1-2times/year 

May come in more frequently if other comorbid conditions

24

Monitoring of pts being treated for HTN 

  • Diuretics 
  • Aldosterone antagonists
  • ACEI
  • ARBs
  • CCB
  • BB

Diuretics

  • K, Mg, UA, Cr, Na, BG

Aldosterone antagonists, ACEI, ARBs

  • Cr, K 

CCB, BB

  • HR

 

25

Antihypertensive Therapy Adherence Issues

One in four will take taking med withing 6 months. To improve this: 

  1. Educate pts why its import to control BP 
  2. Identify problems with drug tolerance as early as possible 
  3. Address increased urination with diuretics; use low doses and advise that limiting salt will help decrease urination and improve thiazide efficiency 
  4. Use generics or combo products to dec cost

26

If patient is not responding to treatment, check causes of resistant HTN 

Improper BP measurement

Volume overload

  • Excessive sodium intake
  • Volume retention from kidney disease 
  • Inadequate diuretic therapy 

Medication 

  • Nonadherence 
  • Inadequate doses
  • Drug interactoins

Associated conditions

  • Obesity, excess EtOH intake
  • Secondary HTN 

27

HTN Urgency

DBP > 130mmHg but no target organ damage 

Can use oral agents

Reduce DBP to 100 mmHg within 24hrs

28

HTN Emergency 

DBP > 130mmHg and target organ damage present

Goal: reduce DBP to 110mmHg in 30 minutes, then to 100 within 12-24 hrs

Requies IV drug therapy: nitropusside, nicardipine, fenoldopam, nitroglycerin, enaliprilat, hydralazine, diazoxide 

29

What is the inital drug of choice for most patients, either alone or in combination? 

Thiazide diuretics

30

Classes of diuretics 

Thiazides

Potassium sparing

Loop 

31

Thiazide Diuretics 

Chorthalidone (Thalidone)

Work at distal tubule to 

  • Inc Na excresion 
  • Dec plasma volume and CO

Adverse Effects 

  • Hypokalemia and hypomagnesemia 
  • Hyperuricemia 
  • Hyperglycemia 

Effective in renal insufficiency, unless really severe (SCr)

32

Potassium Sparing Diuretics 

Spironolactone 

Weak diuretic effects at collecting duct

Used with thiazides because will offset hypokalemia by conserving potassium 

If used with ACEI may cause hyperkalemia 

May cause gynecomastia because aldosterone antagonist

33

Loop Diuretics 

Furosemide 

More potent diuretic effect at loop of Henle to

  • Inc Na excretion 
  • Dec plasma volume 

More effective than thiazide in pts with significant heart failure or renal insufficiency 

Greater risk for hypokalemia, hypomagnesemia, overdiuresis, and metabolic alkalosis 

34

ACE Inhibitors 

Lisinopril (Prinivil, Zestril)

Mechanism of Action 

  • By inhibiting ACE, they...
  • Block formation of Angiotensin II (powerful vasoconstrictor) 
  • Dec Aldosterone (dec Na retention)
  • Inc Bradykinin (vasodilator) 

May cause hyperkalemia (especially with potassium sparing diuretic). Consider stopping diuretic to avoid excessive hypotension. 

Adverse effects: 

  • cough, hypotension, rash, angioedema, and acute renal failure in pts with bilateral renal artery stenosis 
  • Do not use in pregnant women

35

Angiotensin II Receptor Blockers (ARB)

Losartan 

By blocking the angiotensin II receptor, they 

  • cause vasodilation
  • Dec aldosterone (dec Na retention)

Adverse effects: Same as ACEI, except no cough or rash (hypotension, angioedema, acute renal failure)

Use in pts who cannot tolerate ACEI 

36

Direct Renin Inhibitors 

Aliskiren 

By directly inhibiting renin, they lead to 

  • Vasodilation
  • Dec aldosterone (dec Na retention)

Adverse effects: 

  • Diarrhea 
  • Cough, angioedema 
  • Do not use in pregnancy 

ESPENSIVE 

37

Calcium Channel Blockers 

Class effects

 

Block intracellular influx of calcium therby causing vascular smooth muscle relaxation or vasodilation 

Adverse side effects: 

  • headache
  • dizziness
  • peripheral (ankle) edema
  • eczema in elderly
  • Do not use in pts with HF because dec's contractile force of heart 

38

Calcium Channel Blockers--Dihydropyridine class

Amlodipine 

Contractility (-)

Peripheral Vasodilation (+++) Strong

May cause tachycardia--because heart compensating for fluid accumulating in LE

39

Calcium Channel Blockers--Non-dihydropyridine Class

Diltiazem and Verapamil

Diltiazem

  • Contractility (- -)
  • Peripheral Vasodilation (++)

Verapamil 

  • Contractility (- - -)
  • Peripheral Vasodilation (++)
  • May increase digoxin levels significantly,
  • May cause constipation 

Both slow down HR, so use caution in pts with bradycardia, heart block, or sinus node disease

40

Beta Blockers 

Class adverse effects and comments

Beta 2 blockade may aggrave asthma

CI in patients with bradycardia, heart block, and sinus node disease due to decreased HR

Caution use in pts with uncontrolled HF 

May cause: 

  • fatigue 
  • bradycardia
  • aggrevate PVD
  • masks signs of hypoglycemia 
  • insomnia, nightmares

Do not stop abruptly in pts with IHD

41

Beta Blockers Classes and MOA

Non-Selective (Propranolol)

Cardioselective (Atenolol, Metoprolol)

Mixed alpha-beta (Labetalol)

Intrinsic Sympathomimetic Activity (ISA) (Acebutolol)

Non-Selective (Propranolol)--beta 1 and 2

  • Block beta 1 in heart to...
  • Dec HR and CO, therefore dec BP 
  • Also dec plasma renin activity

Cardioselective (Atenolol, Metoprolol)

  • Same as non-selective

Mixed alpha-beta (Labetalol)

  • Same as beta blocker with additional alpha blocking effects (vasodilation)

Intrinsic Sympathomimetic Activity (ISA) (Acebutolol)

  • Same, but only indicated for HTN 
  • Does not confer cardioprotective effects

42

Second line agents for HTN 

Centrally Acting alpha-2 Agonists 

Peripherally-acting Adrenergic Antagonists 

Direct Vasodilators 

alpha-1 Receptor Blockers