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Cardiology > Pharmacotherapy of HTN > Flashcards

Pharmacotherapy of HTN Flashcards

(42 cards)

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1
Q

Epidemiology of HTN

A

1/3 adults in US have HTN

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

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2
Q

Normal BP

A

<120/80

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3
Q

Pre-HTN

A

120-139/80-89

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4
Q

Stage 1 HTN

A

140-159/90-99

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5
Q

Stage 2 HTN

A

>160/100

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6
Q

CVD risk doubles with what increase in BP?

A

20/10

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7
Q

Evaluation of elevated BP

A
  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
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8
Q

JNC 7 Major Cardiovascular Disease RFs

A

HTN

Tobacco Use

Obesity

Physical inactivity

DM

Dyslipidemia

Microalbuminuria

Age (55/65)

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

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9
Q

Definable causes of HTN

(secondary HTN)

A

Sleep apnea

Chronic kidney disease

Primary aldosteronism

Renovascular disease

Chronic steroid therapy/Cushings syndrome

Pheochromocytoma

Coarctation of the aorta

Thyroid or parathyroid disease

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10
Q

Medications that can cause HTN

A

NSAIDs

Corticosteroids

Oral contraceptives

Cocaine, amphetamines

Sympathomimetics

Erythropoieten

Licorice

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11
Q

Target Organ Damage

A

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

Brain: stroke/TIA

Nephropathy

Peripheral artery disease

Retinopathy

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12
Q

Goal of HTN therapy

A

Reduce CVD and renal morbidity and mortality

Achieve SBP goal

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13
Q

Blood pressure goals for uncomplicated HTN

A

<140/90

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14
Q

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

A

<130/80

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15
Q

The Big 5: Lifestyle Modifications to Manage HTN

A
  1. Weight reduction
  2. DASH diet
  3. Decrease Sodium intake
  4. Physical activity
  5. Moderation of alcohol consumption
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16
Q

Pharm treatment decreases the risk of what?

A

clearly decreases the incidence of cardiovascular morbidity and mortality

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

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17
Q

Potential additive favorable and unfavorable effects of thiazide diuretics

Study These Flashcards
A

Useful in slowing osteoporosis

Should be used cautiously with history of gout or hyponatremia

18
Q

Potential additive favorable and unfavorable effects of BBs

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A

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
Q

Potential additive favorable and unfavorable effects of CCBs

Study These Flashcards
A

Useful in Raynuad’s syndrome and certain arrhythmias

20
Q

Potential additive unfavorable effects of ACEI

Study These Flashcards
A

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

Do not use if hx of angioedema

21
Q

Preferred Combos of synergistic antihypertensives

Study These Flashcards
A

ACEI + thiazide

ACEI + DHP CCB

ARB + thiazide

ARB + DHP CCB

22
Q

NOT preferred combos of antihypertensives

Study These Flashcards
A

ACEI + ARB

BB + ACEI or ARB

BB + NDHP CCB

BB + Central acting

23
Q

Follow up in pts being treated for HTN

Study These Flashcards
A

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
Q

Monitoring of pts being treated for HTN

  • Diuretics
  • Aldosterone antagonists
  • ACEI
  • ARBs
  • CCB
  • BB
Study These Flashcards
A

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

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