Tuesday HTN highlights

Question 1

NEVER EVER put a patient on an _______ and ________ together or direct renin antagonist (i.e. only one med that affects angiotensin-aldosterone system)

Answer 1

ACEi and ARB

Question 2

Acc/AHA 2017 HTN guidelines:
1) What should you Rx the general black population?
2) What abt the general non-black population?

Answer 2

1) Thiazides and CCB
2) Thiazides, CCB, & ACEi or ARB

Question 3

Acc/AHA 2017 HTN guidelines:
1) What should you Rx any patient with CKD?
2) What should you do if the pt’s BP isn’t at the goal after 1 month?
3) What should you NOT use together?

Answer 3

1) Tx should incl. ACEi or ARB
2) Up-titrate or add Rx
3) ACEi and ARBs

Question 4

What are 2 key parts of the DASH diet?

Answer 4

1) Eating vegetables, fruits, and whole grains
2) Limiting foods that are high in saturated fat, such as fatty meats, full-fat dairy products, and tropical oils such as coconut, palm kernel, and palm oils

Question 5

Do not use an ______ & _________ together in same patient

Answer 5

ACEi; ARB
(don’t give to pregnant patients either)

Question 6

AHA/ACC guidelines: patients with an initial BP of 130/80 mm Hg or higher and a high cardiovascular risk should be treated initially with what?

Answer 6

lifestyle modifications AND pharmacotherapy

Question 7

What is contraindicated in gout?

Answer 7

Thiazide diuretic (causes decreased excretion of uric acid)

Question 8

In patients 18 and older with ______, treatment should include ACEi or ARB

Answer 8

CKD

Question 9

Calcium channel blockers: List, define, and give and example of the 2 primary groups

Answer 9

1) Dihydropyridines: vasodilators with little to no negative effect on cardiac contractility (inotropic) or AV nodal conduction (chronotropic)
-Amlodipine
2) Non-dihydropyridine: less effective vasodilators and more affect to slow the AV node (negative chronotropic) and decrease contractility (negative inotropic)
-Verapamil > diltiazem

Question 10

Give 4 examples of dihydropyridines (Ca+ channel blockers)

Answer 10

1) Amlodipine
2) Felodipine
3) Nicardipine
4) Nifedipine

Question 11

Give 2 examples of non-dihydropyridines (Ca+ channel blockers)

Answer 11

1) Verapamil
2) DiltiazemER

Question 12

Dihydropyridines: List the doses Amlodipine comes in

Answer 12

2.5, 5.0, or 10 mg daily

Question 13

Differentiate between verapamil and diltiazem

Answer 13

Verapamil has a stronger effect on HR

Question 14

HTN & Ischemic heart disease:
AHA guidelines recommend ____________ and/or ACEi for HTN in patients with stable ischemic heart disease – angina, HF, Previous MI, tachyarrhythmias, migraine HA

Answer 14

B-blockers

Question 15

You should avoid what 3 things in pregnancy bc they’re teratogenic?

Answer 15

ACEi and ARBs, & aldosterone receptor antagonists

Question 16

1) Define resistant HTN
2) What is the most common cause of resistant HTN?
3) What 2 things should you check/ look for?

Answer 16

1) Persistent HTN despite 3 or more drugs
2) Poor compliance w/ lifestyle and Rx
3) Exogenous substances + secondary HTN

Question 17

List the 5 steps of HTN evaluation

Answer 17

1) Is it real?
2) Address Life-style and compliance with current Rx – are they trying?
3) Consider secondary causes
4) Optimal regimen
5) Adjunctive therapy

Question 18

Spironolactone (potential fourth drug) is potassium sparing and a ______________ ____________

Answer 18

aldosterone antagonist

Question 19

What can cause a tolerance to thiazides or “braking” effect?

Answer 19

Restrict salt intake

Question 20

ACEi and ARB relatively contraindicated in __________ vascular disease

Answer 20

Renal

Question 21

Renal vascular disease: Angioplasty is tx of choice for __________________ dysplasia

Answer 21

fibromuscular

Question 22

Rx induced renal function decline with use of any antihypertensive: Which are most likely to do this?

Answer 22

ACEi and ArB’s

Question 23

What is generally the ULN (physiologic) of increase in creatinine when starting an Rx?

Answer 23

up to 30%

Question 24

A hypertensive ________________ with severely elevated BP is often acute

Answer 24

emergency

Question 25

What BP is defined as severe asymptomatic HTN?

Answer 25

>180/110

Question 26

What is a common example of end-organ damage?

Answer 26

Papillary edema

Question 27

What are 2 types of severe HTN (HTN crisis)

Answer 27

1) Hypertensive emergency 2) Severe asymptomatic HTN

Question 28

Differentiate between a hypertensive emergency and severe asymptomatic HTN (3 main differences)

Answer 28

1) HTN emergency: requires hospitalization, often acute, incl. end-organ damage 2) Severe asymptomatic HTN: outpatient mgmt, usually chronic, no end-organ damage

Question 29

Sx of severe HTN: What 6 Sx are considered mild and NOT acute target organ injury?

Answer 29

1) Mild Headache 2) Lightheadedness 3) Nausea 4) Palpitations [or new/ changed chest pain] 5) Epistaxis 6) Anxiety

Question 30

Sx of severe HTN: Patients with chest pain should receive appropriate evaluation for what?

Answer 30

Chest pain, not severe asymptomatic hypertension

Question 31

What does GDMT stand for?

Answer 31

Guideline directed medical therapy

Question 32

1) What is the short term risk of severe asymptomatic HTN (HTN urgency)? 2) Where is it managed? 3) BP control is best achieved with GDMT with what?

Answer 32

1) Short term risk is low 2) Outpatient 3) Gradual lowering of BP over several days to weeks using PO medications [in an outpatient setting]

Question 33

American College of ER physicians ____________ recommend routine labs in HTN urgency (severe asymptomatic HTN)

Answer 33

does not

Question 34

Serious adverse events related to severe asymptomatic HTN (death, ARF, CV events, ruptured AA) are ____________, even with delayed follow up

Answer 34

rare (one study < 1%)

Question 35

What is not a primary neurologic issue?

Answer 35

Syncope

Question 36

List the 5 steps you should take if BP is not controlled

Answer 36

1) Alter thiazide to chlorthalidone or indapamide 2) Add spironolactone or eplerenone 3) Add B-blocker. Alternative is alpha-blocker or diltiazem Qday. 4) Add hydralazine (3x/day). Add isosorbide if HFrEF 5) Substitute minoxidil. Involve specialist if not effective.

Question 37

Differentiate between neurogenic and non-neurogenic orthostatic hypotension

Answer 37

1) Neurogenic = baroreflex dysfunction 2) Nonneurogenic = external factors (e.g. medications) inhibiting normal compensatory physiologic function

Question 38

Give the criteria for Dx of orthostatic hypotension

Answer 38

Drop of 20 mm Hg or more SBP or drop of 10 mm Hg or more DBP

Question 39

What is especially important in treating elderly pts with orthostatic hypotension?

Answer 39

Medication review