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104 Cards in this Set
- Front
- Back
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Primary HTN
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-90% of cases
-aka Essential HTN -Not due to identifiable causes -can't be cured |
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Secondary HTN
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-10%
-due to another identifiable cause |
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Goals of HTN Therapy
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-Reduce morbidity/mortality
-Prevent CCD and TOD modify other cardiovasc. risk factors |
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What are the BP goals?
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general <140/90
Diabetic, CRI <130/80 |
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Non-Pharm Therapies
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weight reduction
salt restriction smoking cessation alcohol restriction (1 oz. for males and .5 oz. for females) exercise (30-45 min, 3-4xweek adequate intake of K, Mg, Ca low fat, low cholesterol diet |
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NL BP classification
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SBP <120 and DBP <80
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Tx for NL BP
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encourage lifestyle modification, no HTN meds
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Pre-HTN classification
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SBP 120-139 or DBP 80-89
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Tx for Pre-HTN
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lifestyle modification, no HTN meds
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Stage I HTN classification
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SBP 140-159 or DBP 90-99
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Tx for Stage I HTN
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lifestyle modification, Thiazide diuretic for most, consider ACE, ARB, BB, CCB
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Stage II HTN classification
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SBP >160 or DBP >100
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Tx for Stage II HTN
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lifestyle modification, 2 drug combo with thiazide diuretic for most, plus ACE, ARB, BB, CCB
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What are compelling indications for HTN? Tx for any classification with compelling indications
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CRI or DM
diuretics, ACE, ARB, BB, CCB as needed |
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If pt. is not at goal BP and has had no response or troublesome side effects, what is the next step
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substitute another drug from a different class
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If pt. is not at goal BP and has had inadequate response, but tolerated the drugs well, what is the next step
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add a 2nd agent for different class (diuretic is not already used)
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If either of these pt. are still not at goal BP, what is the next step
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continue optimizing dosages or adding agents from other classes until BP is achieved
or may need to refer to a HTN specialist |
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when is Tx initiated with 2 drugs
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BP >20/10mmHg above the goal
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Uncomplicated HTN
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thiazide diuretic for most pt., except ACE-I in white males (ALLHAT trial)
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Tx in the elderly
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-more sensitive than younger pt.
-req. lower intial and maintenance doses -more gradual and longer intervals btwn dose adjustments or addition -presence of orthostasis -impaired renal and hepatic fxn -decr. beta-adrenergic fxn |
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What is the principle Tx in Caucasians and why?
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BB and ACE-I because high-renin system
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What is the principle Tx in AA pt. and why
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diuretics and CCB because low-renin system
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T/F Pre-menopausal women are at same risk for HTN as males
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False--they are at lower risk because the presence of endogenous estrogen has a protective risk, but post-menopausal women are at equal risk compared to men
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Estimates of Compliance
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-daily or 2x a day
-combination products to simplify regimes -avoid agents with potential for rebound HTN (clonidine) |
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which is the most cost-effective anti-HTN drug
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diuretic
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Diuretics initial MOA
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initially decr. plasma volume (SV), which will decr. CO and thus decr. BP
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Diuretics MOA after continued use
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decr. peripheral vascular resistance, thereby decr. BP
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What are the 3 types of diuretics
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Thiazide, loop, and potassium sparing
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Thiazide efficacy
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-AA > whites
-very effective in elderly -synergy with ACE, ARB, BB -useful in pt. w/ uncomplicated HTN, ISH, osteoporosis (retains Ca) |
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Thiazide Adverse Reactions
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Electrolyte disturbance
Hyperuricemia hyperglycemia photosensitivity impotence, dehydration, dizziness, nausea, polyuria |
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If pt. is not at goal BP and has had inadequate response, but tolerated the drugs well, what is the next step
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add a 2nd agent for different class (diuretic is not already used)
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If either of these pt. are still not at goal BP, what is the next step
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continue optimizing dosages or adding agents from other classes until BP is achieved
or may need to refer to a HTN specialist |
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when is Tx initiated with 2 drugs
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BP >20/10mmHg above the goal
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Uncomplicated HTN
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thiazide diuretic for most pt., except ACE-I in white males (ALLHAT trial)
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Tx in the elderly
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-more sensitive than younger pt.
-req. lower intial and maintenance doses -more gradual and longer intervals btwn dose adjustments or addition -presence of orthostasis -impaired renal and hepatic fxn -decr. beta-adrenergic fxn |
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What is the principle Tx in Caucasians and why?
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BB and ACE-I because high-renin system
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What is the principle Tx in AA pt. and why
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diuretics and CCB because low-renin system
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T/F Pre-menopausal women are at same risk for HTN as males
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False--they are at lower risk because the presence of endogenous estrogen has a protective risk, but post-menopausal women are at equal risk compared to men
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Estimates of Compliance
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-daily or 2x a day
-combination products to simplify regimes -avoid agents with potential for rebound HTN (clonidine) |
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which is the most cost-effective anti-HTN drug
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diuretic
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Diuretics initial MOA
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initially decr. plasma volume (SV), which will decr. CO and thus decr. BP
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Diuretics MOA after continued use
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decr. peripheral vascular resistance, thereby decr. BP
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What are the 3 types of diuretics
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Thiazide, loop, and potassium sparing
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Thiazide efficacy
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-AA > whites
-very effective in elderly -synergy with ACE, ARB, BB -useful in pt. w/ uncomplicated HTN, ISH, osteoporosis (retains Ca) |
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Thiazide Adverse Reactions
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Electrolyte disturbance
Hyperuricemia hyperglycemia photosensitivity impotence, dehydration, dizziness, nausea, polyuria |
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Loop efficacy
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-weak anti-HTN
-maybe useful in pt. with renal insufficiency -useful in pt. with CHF |
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Loop adverse effects
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similar side effects as Thiazide, except decr. Ca and lipid and glucose abn. not as severe
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Potassium Sparing Efficacy
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-often not effective for HTN
-used in combo with thiazide to decr. incidence of hypokalemia |
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What drugs are the exception to the rule of not using K sparing and when?
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-spironolactone--used in severe CHF
-Eplerenone--used in severe CHF and post-MI |
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K sparing adverse effects
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incr. K
spironolactone--gynecomastia |
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What side effect do all diuretics potentially have
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increase Scr and BUN
may cause gout attack |
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Diuretic drug interactions
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-ACE-I: precipitous fall in BP, renal insufficiency
-K sparing diuretics + ACE/ARB: increases risk of hyperkalemia |
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Beta Blockers MOA
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-decr. HR and CO
-block renin release and decrease plasma volume |
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Beta Blockers Efficacy
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-young > elderly
-good in combo w/ diuretic (the alpha-blocker) -smoking may decr. efficacy -useful in pt. w/ concomitant A-tachy, AFib, angina, migraine, throtoxicosis, peri-operative HTN, s/p MI, benign essential tremor, CHF |
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BB precautions/Side effects
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-bronchospasm in pt. w/ asthma or COPD
-Bradycardia, AV block -fatigue, decr. exercise tolerance, depression -incr. TG, decr. HDL -hyperglycemia -erectile dysfunction |
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In diabetics, what are the precautions/side effects for using BB
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-blunts natural response to hypoglycemia
-masks symptoms of hypoglycemia |
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What peripheral vascular precautions/side effects exist for BB
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-acts at the B2 receptors of arterioles causing vasoconstriction
-this can: may worsen Raynaud's dz may worsen intermittent claudication |
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BB drug interactions w/ decongestants
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antagonize the effects of BB; can raise BP
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BB drug interactions w/ Verapamil/dilitazem
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risk of significant bradycardia, AV block
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BB drug interactions w/ NSAIDs and COX-2 inhibitors
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blunt antihypertensive effects
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BB drug interactions w/ thyroid hormones
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antagonistic effect
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BB drug interactions w/ Digoxin/Digitoxin
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incr. risk for bradycardia
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what can abrupt discontinuation of BB cause
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-rebound HTN
in pt. w/ CAD, may produce unstable angina, MI , or even death -need to taper over 14 days |
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BB Contraindications
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-asthma, COPD
-avoid labetalol in liver dz -2nd/3rd degree heart block -sick sinus syndrome -? PVD -do not start in pt. with acute heart failue |
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alpha-1, beta blockers
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similar to other BB, but also has alpha-blockade which produces more orthostasis
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Example of alpha-1, beta blockers
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-Labetalol--inidicated in pregnancy
-Carvedilol--indicated in heart failure |
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alpha-1 blockers
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-reduces vasc. resistance from sympathetic activation--decr. PVR
-vasodilation--induces smooth msc. relaxation, no reflex tachy |
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alpha-1 blockers efficacy
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-improves lipid profile
-useful in pt. w/ BPH, hyperlipidemia -tolerance may occur over time |
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alpha-1 blockers precautions/side effects
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-1st dose syncope, orthostasis (esp. in elderly)
-h/a -dizziness |
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alpha-1 blockers dosing compliance
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start low and titrate slowly to avoid orthostasis
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alpha-1 blocker drugs
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Doxazosin
Terazosin Prazosin |
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alpha-1 blockers pt. education
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-take at bedtime in supine position
-avoid driving for 12-24 hrs. after any change in meds -change positions slowly |
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ACE-I/ARB efficacy
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-less effective as monotherapy in AA
-good in combo -effective in mild-severe HTN -lipid neutral -beneficial effects on glucose/insulin sensitivity -useful in CHF, DM, s/p MI< high coronary dz risk, renal insufficiency |
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ACE-I/ARB precautions/side effects
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-cough (less w/ ARB)
-renal--incr. Scr, BUN, hyperkalemia -CI in bilat. renal a. stenosis -angioedema -hypotension -metallic taste -fetal death (CI in pregnancy) |
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ACE-I/ARB drug interactions
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-ACE-I: precip. fall in BP
-NSAIDs/ASA/COX-2: inhibit anti-HTN effects of ACE-I -K sparing drugs: incr. risk of hyperkalemia -lithium: incr. risk for toxicity |
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Calcium Channel Blockers
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-decreases PVR
-different effects on HR, contractility, AV-nodal contraction |
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2 types of CCB
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1. nondihydropyridine
2. dihydropyridine |
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non-dihydropyridine drugs
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verapamil and diltiazem
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dihydropyridine (DHP) drugs
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amlodipine
felodipine isradipine nifedipine nisoldipine |
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CCB efficacy
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-AA > whites
-mild-severe HTN -DHP--useful in ISH, angina -non-DHP--useful in diastolic dysfxn, migraine, angina, a-tachy, Afib, DM w/ proteinuria |
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CCB contraindications
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systolic heart failure or heart block: verapamil and diltiazem
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Central Adrenergic Inhibitors MOA
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-stim. central postsynaptic alpha-2 receptors in the brain
-decr. sympathetic activity to periphery, decr. plasma NE, decr. PVR -suppress plasma renin activity |
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Central Adrenergic Inhibitors drugs
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clonidine
methyldopa guanfacine guanabenz |
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Central Adrenergic Inhibitors Efficacy
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-very potent, not 1st line Tx
-use w/ diuretic sec. to Na/fluid retention -best not to use w. preipheral alpha-1 blockers |
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Clonidine
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rapid onset,good for HTN urgency
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Methyldopa
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drug of choice in pregnancy
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Central Adrenergic Inhibitors Precautions/Side Effects
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withdrawal syndrome (rebound HTN)
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Central Adrenergic Inhibitors Drug Interactions
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abrupt discontinuation of clonidine can cause life-threatening HTN crisis
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Direct Vasodilators
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-decr. PVR (afterload)
-reflex tachycardia -Na and water retention -direct smooth msc. relaxation and dilation of arterioles |
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Direct Vasodilators drugs
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Hydralazine
Minoxidil |
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Direct Vasodilators Efficacy
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-decr. DBP > SBP
-not as monotherapy, not 1st line -very useful in resistant HTN |
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Hydralazine
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good for pt. w/ systolic HF
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Minoxidil
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-more potent than hydralazine
-useful for pt. w/ renal insufficiency who are refractory to all other Tx |
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Direct Vasodilators precautions/side effects
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-lupus-like syndrome
-hypotension -reflex tachycardia (need BB) -edema (need diuretic) |
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Minoxidil side effects
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-hair growth
-precipitate angina in pt. w/ CAD |
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Useful drug combinations
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BB + diuretic
ACE + diuretic ARB + diuretic CCB + ACE |
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Pre-clampsia
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-presents after 20wks.
-HTN >140/90 w/ proteinuria, hyperuricemia, coag abn. -can be fatal for mother and fetus |
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Tx for pre-clampsia
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-delivery, bed rest, activity restriction
-IV hydralazine or IV labetalol -Nifedipine IR oral has been used, but not FDA approved |
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HTN urgency
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-benefit from reducing BP w/in 24-48 hrs.
-DBP >120mmHg w/ min. to no TOD, usually asymptomatic -not life-threatening |
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TX for HTN urgency
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-Avoid nifedipine and other CCB (short-acting)
-use fast acting drug ORAL agents -Captopril -Clonidine -Labetalol -Prazosin |
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HTN emergency
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-DBP >120 mmHg and symptomatic
-life-threatening |
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Drug-induced caused of HTN emergency
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-MAO-I and tyramine interactions
-overdose w/ phenyclidine, cocaine, LSD (ilicit drugs) |
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Tx goals
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-immediate BP reduction to a safe value to prevent/limit TOD and death
- decr. MAP by 20-25% w/in 2 hrs., then goal of 160/100mmHg -avoid rapid reduction in BP bc can cause ischemic damage |
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Tx for HTN emergency
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IV route:
-Na nitroprusside -Nicardipine -Labetalol -Fenoldopam -Nitroglycerine (acute MI) -Hydralazine (pregnancy) -Diazoxide (obsolete) |
