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81 Cards in this Set
- Front
- Back
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BP varies with:
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Temperature
time of day meals activity posture emotions stressors (white coat) |
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Follow up recommendations
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Normal HTN: 2 yrs
Pre-HTN: 1 year Stage 1: confirm w/in 2 months Stage 2: evaluate or refer to source of care w/in one month, if >180/110 evaluate/treat immediately |
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HTN Evaluation Components
Med History |
Duration/Classification of HTN
Pt history of CVD FH Sx suggesting causes of HTN Lifestyle factors Current and previous meds |
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HTN Eval Components: PE
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BP readings, 2 or more
Verification in contralateral arm Ht, wt, waist circumference Funduscopic exam Exam of neck, heart, lungs, abdomen, extremities neurological assessment |
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HTN Eval Components: Routine Lab tests
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determine presence of Target Organ Damage and other risk factors
Specific Causes of HTN Urinalysis, complete blood count, blood chem (K, Na, Ca, Scr, Hematocrit, fasting glucose) FLP 12 lead ECG |
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HTN Eval Components: Optional tests
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microalbuminuria
24 hr urinary protein Serum Ca Serum uric acid Fasting triglycerides LDL Glycosylated hemoglobin TSH Plasma renin activity/urinary sodium determination limited echocardiography ultrasonography measurement of ankle/arm index |
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Identifiable causes of HTN
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Sleep apnea
drug induced CKD Primary aldosteronism renovascular disease Chronic steroid therapy Cushing's syndrome pheochromocytoma coarctation of aorta thyroid or parathyroid disease, esp hyperthyroid |
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Target Organ Damage
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Heart: CAD, LVH, CHF
Cerebrovascular: transient ischemic attack, stroke Peripheral: claudication, aneurysm Renal: Scr >1.5, proteinuria, Retinopathy: exudates, papilledema |
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JNC7 Guideliens
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Pre-HTN: no drug, lifestyle changes
Stage 1: thiazide for most, consider ACE-I, ARB, BB, CBB or combo, drugs for compelling indications Stage 2: Two drug combo for most: thiazide + ACEI, ARB, BB, CBB, w/compelling indication other drugs as needed |
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Lifestyle Modifications
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Weight reduction
DASH Dietary sodium reduction physical activity moderation of alcohol consumption tobacco cessation |
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Goals for HTN managment
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reduce morbidity and mortality by least intrusive means possible
Achieve and maintain goal BP Controlling other CV risk factors Preserve QoL: cost effective, least intrusive |
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Goal BP
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<140/90
<130/80 for pts with Diabetes or CKD |
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Pharmacological Treatment Benefits
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Decrease CV mortality and morbidity
protects against stroke, coronary events, heart failure, progression of renal disease, progression to more severe HTN, all cause mortality |
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ACCELERATE Study
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New school of thought: combo therapies provide faster sustained BP reductions with fewer AE
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Follow Up on HTN therapy
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1-2 months after initiating
Certain meds may require earlier monitoring diuretics, ACEI and ARBS Recognize high risk pts need high dose or combo |
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Drugs to use with Prior MI
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ACEI
BB Aldosterone Antagonist |
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Drugs to use with High Risk Coronary Disease
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Going to be on one of each:
Diuretic, BB, ACE-I, CCB |
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Drugs to use with Diabetes
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1. AceI or ARB
2. CCB 3. Diuretic 4. BB |
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Drugs to use with CKD
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ARB or ACEI
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Drugs to use with prior stroke
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Diuretic and ACE/ARB
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Drugs to use with Heart Failure
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ACE or ARB
BB Aldosterone Blocker Diuretics (loop, used for Sx) |
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Angina comorbid
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BB, CBB
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Atrial tachycardia and fibrillation comorbid
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BB
Non dihydro CBB ACE and ARB |
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Cyclosporine induced HTN comorbid
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CBB
Thiazide? |
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Dyslipidemia comorbid
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alpha blockers
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Prostatism comorbid
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alpha blockers
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Essential tremor comorbid
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non cardioselective BB
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Hyperthyroidism comorbid
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BB
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Migraine comorbid
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Non cardioselective BB (propranolol)
Non-dihydro CBB |
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Osteoporosis Comorbid
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Thiazides
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Perioperative HTN comorbid
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BB (slow HR)
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Caution in bronchospastic disease
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BB
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Caution in Depression
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BB, reserpine
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Caution in dyslipidemia
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BB
diuretics |
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Caution in Diabetes
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BB
high dose diuretics |
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Caution in Gout
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diuretics
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Caution in Heart Failure
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BB (except carvedilol, metoprolol, bisoprolol)
CBB (except amlodipine, felodipine) |
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Diuretic pharmacotherapy issues
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high dietary Na+ can reverse benefits
NSAIDs can antagonize effects Effects on electrolytes, cholesterol, glucose: monitor K+, creatinine |
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SHEP study
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Systolic Hypertension in the Elderly Program:
Goal BP reached by 65-72% of active tx group vs 32-40 of placebo (using chlorthalidone) |
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Doses in Diuretics
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use less than 25 mg
low dose diabetes, gout, hyperlipidemia DONT use when GFR < 30 |
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Diuretics Drug Interactions
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Cholestyramine: reduced HCTZ absorption
Lithium: increased [Li] NSAIDS: reduced diuresis Digoxin: increased risk toxicity Sulfonylureas: reduced sulfonylurea efficacy Cyclophosphamide, fluorouracil, methotrexate: myelosuppression |
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Beta Blockers Non selectives
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ISA-: propranolol, timolol, nadolol
ISA+: pindolol, carteolol, penbutolol |
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Beta Blockers Selective
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ISA-: atenolol, metoprolol, bisoprolol, betaxolol
ISA+: acebutolol |
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Liver metabolized BB
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propranolol
metoprolol labetolol some acebutolol |
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Kidney metabolized BB
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atenolol
nadolol |
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Advantages of BB
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Decrease CAD morality
Decrease mortality post MI (avoid ISA+) Decrease M&M in CHF(metoprolol, bisoprolol, carvedilol) no lab monitoring |
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Disadvantages of BB
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mask hypoclycemia in diabetes (sweat)
Increase lipids Dont use in asthma/COPD Caution in CHF Angina with ISA+ Sexual dysfunction Decreased exercise capacity Rebound HTN |
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BB SE
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bradycardia, tiredness, cold extremtities
sweating |
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Questions about Atenolol and BB
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less effective than others in reducing stroke
maybe because its only dosed 1 time daily Authors argue: BB should not be first line or the second drug added to diuretic |
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BB Drug Interactions
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Cimetidine: decreased metab of metoprolol, labetolol, propranolol
Amiodarone: hypotension, bradycardia Ritonavir: increased [metoprolol] Digoxin: AV nodal block 2D6 inhibitors: SSRI's, increased [metoprolol] St John's Wort: decreased BB effectivness Diltiazem, Verapamil: increased bradycardia, hypotension, AV conduction abnormalitiles |
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ACE-I Pharmacotherapy issues
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Decrease mortality in CHF
Decrease progression of DM nephropathy Decrease progression of CKD decrease mortality from CV causes, MI, stroke |
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ACE-I drug interactions
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Don't use salt substitutes
Careful with K+ supplements, K+ sparing diuretics, spironolactone |
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Advantages of ACE-I
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Neutral on lipids
DM nephropathy--renal protective Improve surivival in Heart Failure |
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Disadvantages of ACE-I
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cough in 10%
Contraindicated in pregnancy and bilateral RAS |
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Monitoring ACE-I
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Scr, K+
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ACE-I SE
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rash
angioedema hyperkalemia renal failure if bilateral RAS dry cough |
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ARB Advantages
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no lipid or glucose changes
useful in combo |
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ARB SE
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dizziness,
cough but less than ACE angioedema Hyperkalemia |
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CCB non dihydros
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diltiazem
verapamil Decreased contractility, HR, AV node conduction |
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CCB dihydros
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amlodipine, nifedipine, felodipine
much less decrease in contractility, slight increase in HR, no effect on AV node |
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INSIGHT and NORDIL Studies
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Showed decrease mortality in HTN similar to conventional drugs, (with CCBs)
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Which CCB may increase mortality?
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nifedipine primarily (short acting CCB) increase risk of MI
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CCB Advantages
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Increase response in elderly for systolic HTN
effective in CAD, decreases angina (esp non dihdryos) neutral lipids and glucose |
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CCB disadvantages
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Increase MI with short acting agents
Caution in HF, use amlodipine or felodipine |
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CCB SE
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constipation, bradycardia, AV block, CHF (verapamil, diltiazem)
edema, dizziness, HA, tachycardia (esp dihydros) gingival hyperplasia (esp nifedipine) Edema angioedema |
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Alpha 1 antagonists
Advantages |
positive impact on lipids
improve BPH Sx |
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Alpha 1 antagonist disadvantages
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first dose hypotension
not recommended as initial monotherapy diuretics superior immediately to decrease CV events |
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Alpha 1 antagonist SE
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HA
fatigue drowsiness weakness vivid dreams |
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Central alpha 2 agonists
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Clonidine and methyldopa
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Alpha 2 agonists advantages
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neutral on lipids
clonidine patch Methyldopa--pregnancy |
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Alpha 2 agonists disadvantages
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Rebound HTN
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alpha 2 agonist SE
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CNS: sedation, decreased alertness, depression
Dry mouth, bradycardia, sodium and fluid retention (monitor) |
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Renin Inhibitors
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Aliskirien
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Renin inhibitors AE
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GI
cough rash hyperuricemia gout kidney stones |
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Renin inhibitor Advantages
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well tolerated
no dose reduction in elderly, hepatic impairment or mild-mod renal impairment Safe in combo with ARB, CCB, thiazide--unless diabetic Reduced rash, cough, angioedema compared to ACE and ARB |
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Direct vasodilators
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hydralazine, minoxidil
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Direct vasodilators disadvantages
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reflex symptathetic activation: leads to increased HR, increased CO, renin release
Increased angina in pts with CAD |
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direct vasodilators SE
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hypertrichosis (minoxidil)
lupus like syndrome (hydralazine) dermatitis, drug fever, peripheral neuropathy, hepatitis, HA |
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Postganglionic sympathetic inhibitors
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guanethedine, guanadrel
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postganglionic sympathetic inhibitors disadvantages
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ortho hypo
syncope impotence, diarrhea, weight gain |
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Reserpine
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cheap, efficacious
sedation, depression, Na/fluid retention, diarrhea, depression |
