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81 Cards in this Set

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Which 3 antihypertensives do blacks not respond to as well?
ACE
ARB
Beta Blockers
What are compelling reasons for use a an ACE-inhibitor?
- Systolic heart failure
- Post MI
- Proteinuric chronic renal failure
- maybe DM even w/o proteinuria
- maybe high coronary risk w/o past MI
What are contraindications to using an ACE-inhibitor?
angioedema (duh)
pregnancy (duh)
renovascular disease (relative CI)
What are compelling reasons for use of a beta blocker?
- past MI
- Angina
- A fib (rate control)
- A flutter (rate control)
- essential tremor
- hyperthyroidism
- migraine
What are contraindications to using a beta blocker?
- bronchospastic airway disease
- heart block (2nd or 3rd degree)
- depression?
Which antihypertensive should be avoided in a patient who is hyperkalemic?
aldo antagonists
ACE
ARB
Which antihypertensive should be avoided in a patient w/hyponatremia?
thiazide diuretics
Which patients would you probably want to avoid using a diuretic in?
hyponatremic
gout
Would you consider using nondihydropridine or dihydropiridine CCBs in a patient with raynauds?
dihydopyridine CCB
Where do thiazide diuretics act in the nephron?
distal tubule and connecting segment
Name 4 thiazide diuretics
Hydrochlorothiazide
Chlorthalidone
Metolazone
Indapamide
Thiazides interact mainly with which 4 medications?
Digoxin (via hypokalemia)
Lithium (dec excretion)
DM meds (antagonizes)
Gout meds (antagonizes)
Which antihypertensive can enhance calcium reabsorption and what are the effects of that?
Thiazide
- may unmask underlying condition like hyperparathyroidism, CA, sarcoid
- doesn't just cause hypercalcemia itself
- may decrease hypercalcuria(stones)
- may help w/osteoporosis
What are the adverse reactions most commonly associated with thiazides?
- Volume depletion (orthostatic hypotension)
- hypokalemia
- hyponatremia
- hyperuricemia
- hyperlipidemia
- hyperglycemia
- impotence
- rash (sulfa drug)
Which antihypertensive enhances calcium excretion and may be beneficial in treating hypercalcemia from small cell lung CA?
loop
Which 3 medications do loop diuretics antagonize?
dig
lithium
gout meds
Which drugs are associated with sensorineural hearing loss?
Loops (furosemide)
AGs (irreversible)
Vancomycin
Cisplatin
Aspirin (low dose - one time)
Which potassium sparing diuretics work b inhibiting Na influx through ion channels in the luminal membrane?
triamterene and amiloride
Which patient's are at inc risk of hyperkalemia when taking a potassium-sparing diuretic?
- pts w/renal disease
- pt on another drug that dec. renin (beta blocker, NSAIDS)
- pt on another drug that dec angiotensin II (ACE, ARB)
Which hypertension med is a potential nephrotoxin that may lead to crystalluria and cast formation?
triamterene
Which two drugs besides triamterene can precipitate in the kidney?
Indinavir and acyclovir
Which drug may be added to furosemide in a CHF pt who is diabetic w/some kidney problems and can't diurese easily?
metolazone
Where is angiotensin I converted to angiotensin II?
lungs
Which is the only ACE available in IV form?
enalapril
WHich populations of patients are best suited for ACE inhibitors?
HTN especially w/LVH
Systolic heart failure
Chronic renal failure
Post AMI -> systolic dysfunction
What are the CYP interactions of ACE inhibitors?
Lisinopril has none

Enalapril is a substrate of 3A4
ACE inhibitors are synergistic with which meds?
diuretics
Why must you be careful when using an ACE with something like an ARB or triamterene/HCTZ?
they all lead to hyperkalemia - monitor the K
Due to the potential side effect of decreased intrarenal perfusion pressures, which patients must you be careful/or avoid starting an ACE in?
Bilateral RAS
HTN nephrosclerosis
CHF?
CRF (check creat w/in a week)
Polycystic kidneys
How do ARBs work?
They impair binding of angiotensin II to AT1 receptors but do not actually block the receptors
What are the cytochrome interactions of ARBs?
Losartan is a substrate of 2C9 and 3A4
How do alpha blockers work?
the reduce arterial pressure by dilating resistance and capacitance vessels
Which antihypertensive med will likely lead to fluid retention if not given with a diuretic?
alpha blocker (terazosin, doxazosin, prazosin)
Which antihypertensive has higher cardiac mortality with use?
alpha blocker
Which med should not be taken if patient is taking an alpha blocker?
any ED med (phosphodiesterase inhibitors)
Which causes more reflex tachycardia, direct vasodilators or alpha blockers?
direct vasodilators

(but alpha blockers --> postural hypotension . . .esp w/first dose!)
What are two random side effects of alpha blockers besides postural hypotension?
drowsiness/fatigue
and nasal congestion
What does stimulation of beta-1 receptors do?
inc HR
inc contractility
inc AV nodal condution
How do beta blockers work?
competetively inhibit catecholamines at beta receptors
Name the non selective beta blockers
propranolol
nadolol
timolol
Which patients should not recieve a nonselective beta blocker?
asthma
COPD
Raynauds
Name the beta-1 selective beta blockers
metoprolol
atenolol
betaxolol
bisoprolol
What does it mean if a beta blocker has intrinsic sympathomimetic activity?
partial agonist - so they produce slight activation of the receptor as they prevent access of catecholamines to the receptor (dec BP with less bradycardia)
Which beta blockers have ISA?
pindolol
acebutolol
penbutolol
Whatis the only situation you should a beta blocker with ISA be considered?
pt must have bradycardia to consider use
Which beta blockers have some alpha blocking action (and what does this mean)?
Carvedilol
Labetalol

*alpha blocking = vasodilation
Can beta blockers be used in systolic or diastolic dysfunction?
both (but must consider other factors)
What is the difference between lipophilic beta blockers and non-lipophilic beta blockers?
lipophilic agents are largely metabolized by the liver (2D6)

non-lipophilic agents are eliminated unchanged in the urine
Which beta blockers are lipophilic?
propanolol
metoprolol
Which beta blockers are non-liphophilic?
atenolol
Which beta blocker is a sustracte of 2D6 and 2C9
carvedilol
IF pt is on SSRI, or other drugs w/narrow therapeutic windows what is your beta blocker of choice?
atenolol
How do beta blockers mask/delay recovery from hypoglycemia?
blocks epinephrine acting on beta receptors which would normally stimulate glycogenolysis and gluconeogenesis protecting against development of hypoglycemia; epinephrine is also responsible for early warning signs of hypoglycemia (sweating, anxiety, etc)
How do CCBs work?
inhbit L-type Ca channels -> no intracellular Ca influx
-> no Ca to bind to troponin or calmodulin (vascular smooth muscle) --> complex cannot allow actin and myosin to interact/contract
What is the difference between dihydropyridine and non-dihydropyridine CCBs?
dihydros mostly vasodilate vascular smooth muscle (-> dec SVR) but do not affect contractility/conduction like the non-dihydros do
Which drug is a short acting dihydropyridine CCB?
nifedipine
Which drugs are longer-acting dihydropyridines?
amlodipine
felodipine
isradipine
nicardipine
nisoldipine
Which drug is a long-acting dihydropyridine?
amlodipine (most consistent CCB)
What are the dihydros used for? the non-dihydros?
Dihydro- for HTN
nondihydro - for cardiac problems
Name the non-dihydro CCBs.
verapamil
diltiazem
Which CCBs are substrates of 3A4?
amlodipine
verapamil
diltiazem

felodipine
nifedipine
both the non-dihydros and the long-acting dihydro
What are the 3A4 inducers?
Rifampin
Phenytoin
Carbamazepine
St John's Wort
What are the 3A4 inhibitors?
CCBs (nondihydros)
Keto/Itraconazole
Cimetedine
Ritonavir
Grapefruit Juice
Macrolides (except azithro)
What are the 2D6 substrates?
Beta Blockers (not atenolol)
TCAs
Antiarrythmics
SSRIs (will deactivate enzyme also!)
Opiods
If patient is deficient in 2D6 what is the problem with beta blockers (metoprolol and carvedilol)? what about TCAs?
metoprolol dose will build up --> toxicity

TCAs --> anticholinergic effects
What are the side effects of CCBs?
HA, dizziness, flushing, peripheral edema

*reflex tachycardia, gingival hyperplasia

**less likely w/long-acting agents
What drugs causes gingival hyperplasia?
verapamil (all CCBs but mostly this one)
Phenytoin
What is the most common side effect of verapamil?
constipation
Which CCB can cause a lupus like reaction? What other hypertension med can cause a lupus like reaction?
diltiazem

hydralazine
How do central alpha-adrenergic agonists work?
decrease sympathetic outflow from vasopressor centers in the brainstem leading to a decrease in systemic vascular resistance.
Name two cental alpha-adrenergic agents
clonidine
methyldopa
Abrupt withdrawal of this drug may lead to HTN crisis.
Clonidine
This anti-hypertensive drug may cause a positive coombs test.
methyldopa
Name two direct vasodilators
Hydralazine
Minoxidil
Which direct vasodilator may lead to peripheral neuropathy?
hydralazine
Which patients are at most risk of developing a lupus like reaction from taking hydralazine? What is hydralazine?
Slow acetylators (50% of Caucasians and AA)

a direct vasodilator
Which hypertension drug must be given with a beta blocker because of reflex tachycardia and with a loop because of fluid retention?
minoxidil
hirsuitism
Which three beta blockers have been shown to reduce mortality in pts with systolic heart failure?
bisoprolol
carvedilol
S-R metroprolol succinate
Which two ARBs are approved for use in heart failure?
candesartan
valsartan
What therapy might you try in a patient with CHF who is taking a BB and an ACE and is still symptomatic?
combination of a nitrate and hydralazine
In which HF class have aldosterone antagonist been studied/recommended?
NYHA class III and IV