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166 Cards in this Set

  • Front
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CBC count
WBC, Hb, Hct, platelet
Normal Hemoglobin values
Male: 13-18 g/dL
Female: 12-16 g/dL
Normal Hematocrit values
Male: 40-54%
Female: 38-47%
MCV (normal value)
80-100 um^3

Hct / RBC count
MCH
26-32 pg
MCHC
32-36%
corrected reticulocyte count
observed Hct/normal Hct
usually 0.5-1.5%
normal adult hemoglobin
A: 97%
A2: 3%
F: <1%
Specific signs for iron deficient anemia
koilonychias, pica, pagophagia, smooth tongue
Specific signs for folate deficient anemia
swollen, red tongue
Specific signs for vitamin B12 deficient anemia
swollen red tongue, icterus, gastric mucosal atrophy and NEUROLOGICAL FINDINGS
Hemolytic anemia
Jaundice
normal WBC
5-10,000/mm^3
normal platelet count
140,000-400,000/mm^3
RDW
red blood cell distribution width

indicates the variability of RBC sizes

normal: 11-15%
Vitamin B12 deficiency neurological findings
numbness and paresthesias
peripheral neuropathy
ataxia: muscular incoordination (stagger, etc)
diminished vibratory sense
gait abnormalities
depressed deep tendon reflexes
psychiatric abnormalities
dementia
Iron deficient lab assays
Serum iron
TIBC
Fe/TIBC MOST IMPORTANT (pregnancy increases this)
serum ferritin (increased by liver disease, inflammatory disease and cancer)
Normal folate
1.8-16ng/mL
Normal Vitamin B12
100-900 pcg/mL
Erythropoietin
0-19mU/mL
Usual oral iron dose
200mg/day elemental iron in 2 or 3 divided doses
Elemental iron in oral iron preparations
ferrous sulfate (20%)
exsiccated ferrous sulfate (30%)
ferrous fumarate (33%)
ferrous gluconate (12%)
polysaccharide iron complex and carbonyl iron (100%)
Counseling points to maximize absorption of iron
1+ hours before meal on empty GI
No tea/milk
Orange juice and Vit.C rich foods
Parenteral products administration of iron
Iron dextran contains 50mg/mL iron and is administered 100 mg IV over 2-5 min.

ALL: Administer daily till dose reaches 1000mg, then reassess and give after 4 weeks if necessary

Premedicate with APAP and diphenhydramine
Adequate response to iron therapy
Hgb and Hct: 1-2 g/dL/2 weeks, then 0.5-1.5 g/dL/wk after

Hemoglobin: >2grams/3 weeks

PRBC: 1 unit increases Hgb by 1g/dL and Hct by 3%
Vitamin B12 anemia lab abnormalities
Dec. Vit. B12
High/normal methylmalonic acid/homocysteine, LDH, bilirubin
Hypersegmented neutrophils
Leukopenia and thrombocytopenia in sever cases
Anti-IF antibodies may be present
schilling test may indicate decreased absorption
oral/sublingual treatment of Vitamin B12 deficient anemia
only for dietary deficiency
1-2 mg po daily for 1-2 weeks, followed by 1 mg po daily/weekly
parenteral treatment of Vitamin B12 deficient anemia
Cyanocobalamin is PREFERRED -- 30mcg/day IM for 5-10 days, then 100-200 mcg/month (usually used as 100-1000mcg/day IM or SQ for 2-3 wks, then monthly.

Hydroxocobalamin is used as same dosage but is retained longer and not more efficacious.

Nascobal (nasal cyanocobalamin gel) 500mcg once a week through one nostril. maintenance therapy AVOID WITHIN 1 HOUR OF DRINKING BEVERAGE.
Monitor response to B12 therapy
Reticulocyte count, hgb,and hct
Check CBC and B12 in 1-2 mths
Homocysteine and methylmalonic acid in 2-3 months
Hypersegmented neutrophils may persist for 2 weeks.
Clinical signs of folate deficient anemia
Elevated MCV, reticulocyte, folic acid level, homocysteine. Rule out B12 deficiency if MMA levels are high!!
ACD causes
IMPAIRED ERYTHROPOIESIS
Infections
Autoimmune disorders
Chronic kidney disease
Malignancy
Organ transplant rejection
Clinical signs of ACD
MCV/MCHC elevated/normal
Erythropoetin decreased/normal
Reticulocyte decreased/normal
Erythroid hypoplasia
Hgb/hct
NCD for coverage of ESAs
Hgb level must be <10g/dL OR
Hct level must be <30%

Solid tumors and hematological malignancies
Epoetin Alfa to treat ACD
Initial dose: 50-150units/kg SQ or IV two or three times weekly
Renal: 50units/kg
AIDS: 100units/kg
Cancer w/ chemo: 150units/kg
Darbepoetin (aranesp-amgen)
ACD
CKD: 0.45 mcg/kg IV/SQ weekly
Malignancy: 2.25mcg/kg

200units epoetin/1 mcg darbepoetin
Mircera (methoxy poly. glycol-epoetin beta; Roche)
ONLY FOR ANEMIA IN CKD

0.6ug/kg once every 2 wks IV/SQ till Hg>11g/dL, then continue at twice the starting dose every month
ESA dosage changes for myelosuppressive chemotherapy
Start if Hgb<10g/dL and Hct<30%
Maintain dose if a mth after starting dose, the Hgb increased >1 but is still <10.
Increase dose by 25% if a mth after starting therapy, the rise is <1 but is still <10.
Decrease dose by 25% if there's a rise of >1g/dL over 2 wks and is >10g/dL.
DISCONTINUE 8 WEEKS AFTER CHEMOTHERAPY ENDS

START IRON SUPPLEMENT AT START OF EPO THERAPY IF FERRITIN <100ng/mL or TIDC <20%
Adequacy of ACD therapy
Increase in Hgb >1 g/dL after 4 weeks of EPO or after 6 weeks with Darbopoetin
Causes of hemolytic anemia
G6PD (inherited) -antimalarials, antibacterials, etc.
Sickle cell disease
Thalassemia
Autoimmune diseases
Hypersplenism
Clinical signs of hemolysis
Peripheral blood smear: spherocytes, RBC fragments
Dec. Hgb and Hct
Inc. Reticulocyte count, bilirubin, LDH
+/- Coomb's test
Dec. haptoglobin
Jaundice and hemoglobinuria
Peak Flow zones
>80% of personal best GOOD (green)
50-80% CAUTION (yellow)
<50% EMERGENCY (red)
Special modifcation for corticosteroidal MDI/Puffer
Use a SPACER! slightly extend neck when inhaling and gargle after each dose.
Special modification for anticholinergic MDI/Puffer
Use CLOSED MOUTH technique and CLOSE EYES
Autohaler
pirbuterol (Maxair)
Diskus
Salmeterol (serevent)
Fluticasone (flovent)
Fluticasone/salmeterol (advair)
Aerolizer
Formoteral (foradil)
Handihaler
Tiotropium (spiriva)
Flexhaler
Budesonide (pulmicort)
Which spacer device does not contain a valve?
Inspirease
Pathophysiology of OAG vs CAG
open-ended: high IOP resulting in optic nerve damage

close-ended: mechanical blockage causing episodes of high IOP
Disease progression of OAG vs CAG
OAG: may not be noticeable in the optic disk or visual fields for years

CAG: high IOP >40mmHg causes opti c nerve damage; Very high IOP >60mmHg may result in permanent vision loss within a matter of hours to days
Treatment goal and therapy for Open anged Glaucoma
Not recommended till disease progression is VISIBLY NOTICEABLE
Goal is to reduce IOP by 20-30%
Nonselective B-blockers, prostaglandin analogs, brimonidine (alpha 2 agonist) and the combination of timolol and dorzolamide.
trabeculoplasty or iridotomy may be needed
B-blockers
Lowers IOP by reducing aqueous humor production

Contraindications: uncontrolled asthma
heart disease and bradycardia

Interactions: Theophylline, Methacholine, alpha and beta agonists

Instill 1-2 times daily

Monitor IOP, HR, fundoscopic exam, and visual field testing
Non-selective b blockers
levobunolol (betagan)
metipranolol (optipranolol)
timolol (timoptic/timoptic XE)
Selective b blockers
Betaxolol (betoptic S)
Carteolol (also has ISA)
Adrenergic Agonists
Alpha 2: Apraclonidine (iopidine)
Brimonidine (alphagan P)

Nonspecific: Dipivefrin (Propine)
Dipivefrin
Proprine
Nonspecific Adrenergic agonist

Contraindicated in depressed patients esp. those on MAOIs

Dose 2-3 times daily

Monitor IOP and fatigue level
Cholinergic Agonists
Pilocarpine (Isopto carpine and pilocar)

Carbachol (isopto carbachol
Cholinergic Agonist MOA, etc
Causes miosis, constricts ciliary muscle, and lowers IOP

1-2 drops up to 6x daily and HS for the gel dosage form

Monitors IOP, funduscopic exam, and visual field testing
Carbonic Anhydrase Inhibitors
Brinzolamide (Azopt)
Dorzolamide (Trusopt)
Acetazolomide
Carbonic Anhydrase Inhibitors MOAs, etc.
Decrease production of aqueous humor

Interactions: other carbonic anhydrase inhbitors, and salicylates

2-3 times daily dosing

Contraindicated in hepatic, renal, and diabetic patients.

Monitor for sulfa allergy!
Treatment for CAG
Prevent surgery and vision loss by rapidly reducing IOP

Pilocarpine + hyperosmotic agen + a secretory inhibitor
1st line of therapy for glaucoma
B blockers, Brimonidine, Carbonic Anhydrase inhibitors, and prostglandin analogs
Which conjuctivitis subtypes cause mucous/serous discharge?http://www.flashcardexchange.com/mycards/add/1250300
Serous: Allergic and Viral
Muco-perineal: Bacterial
OTC and Prescription allergic conjunctivitis treatment
OTC: opthalmic lubricants/irrigant, cold compresses, alpha adrenergic agonists (vasoconstrictors)

Prescription: antihistamines, NSAIDS, and Mast cell stabilizers
Viral conjunctivitis treatment
cold compresses
topical vasoconstrictors
NO corticosteroids
Ocular irrigants
Hyperacute bacterial conjunctivitis treatment
Gonococcal: Ceftriaxone 1g IM QD OR Cefixime 400mg QD OR Azithromycin 2g QD

Chlamydial: Azithromycin 1g QD OR Doxycycline 100mg BID for 7 days
Acute bacterial conjunctivitis treatment
Broad spectrum topicals
Aminoglycosides
Sulfacetamide 10% solution
Fluoroquinolones
Azithromycin
Self-care assessment
Discharge?
Bilateral/unilateral?
Symptom duration?
Age?
Trauma?
Contact lens?
medication use?
pain/photophobia/blurry vision?
Physiological consequences of asthma
Increased work of breathing, decreased CaO2 w/ organ system stress, and heart failure
Symptoms of asthma
Wheezing, dry hacking cough, tachypnea, tachycardia, pale/cyanotic skin
Beta 2 adrenergic agonists
Ephedrine, epinephrine, metaproterenol, terbutaline, albuterol, levalbuterol, salmeterol, formoterol, arformoterol, and pirbuterol
Albuterol
Proventil, Ventolin
Lasts4-6 hours
Salmeterol
Serevent
Lasts 8-12 hours
What ACT score indicates an asthma that could be better controlled?
< or = 19
Inhaled albuterol MDI
90mcg/puff

ASTHMA MEDICALLY SUPERVISED 4-8 puffs every 30 min up to 4 hours then every 1-4 hours as needed
FOR COPD: every 20 min up to 4 hours

SELF-CARE PRN 2 puffs 3-4 times a day as needed
Nebulizer albuterol
5mg/mL

ASTHMA MEDICALLY SUPERVISED 2.5–5 mg every 20 min for 3 doses, then 2.5–10 mg every 1–4 h as needed, or 10–15 mg/h continuously
FOR COPD: 2.5-5mg diluted with NSS to a total of 3mL

SELF CARE PRN 2.5 mg diluted with NSS to a total of 3ml 3-4 times a day PRN over 5-15 min
SQ epinephrine for acute exacerbation
1mg/mL

0.3-0.5 mg every 20 min for 3 doses
Salmeterol DPI
50mcg every 12 hours
Formoterol DPI
12mcg every 12 hours
Inhaled ipratropium for asthma
MDI: 8 puffs every 20 minutes PRN up to 3 hours
self-care: 2-3 puffs every 6 hours

Nebulizer: 0.5mg every 20 min for 3 doses then PRN medically supervised
self-care 0.25mg every 6 hours
Anticholinergic side effects (ipratropium)
Cough
dry mouth
unpleasant taste
may worsen narrow angle glaucoma
Methylprednisolone IV for acute exacerbations
60–80 mg in 3 or 4 divided doses for
48 h, then 30–40 mg/day until PEF
reaches 70% of personal best
DPI budesonide
ICS

Low-dose:180-600
medium-dose:600-1200
high-dose:>1200
Montelukast
10mg daily in the evening
Cromolyn
MDI: 2 puffs QID
Nebulizer: 20-40mg QID
Omalizumab
Steps 5&6 if patients are allergic

SQ every 2-4 weeks
Target theophylline serum concentration for treating acute asthma exacerbations and chronic therapy
exacerbations: 12-15mg/L
Chronic, stable: 5-12mg/L

Pick a lower range for a patient that has never been on theophylline
Common drug and disease interactions with theophylline and the antileukotrienes
CYP3A4 inducers such as aminoglutethimide, carbamazepine, nafcillin, nevirapine, phenobarbital, phenytoin, and rifamycin
Anti-inflammatory comparisons of activity (highest to lowest)
Corticosteroids
Antileukotrienes
Cromones
Omalizumab
When to obtain steady-state trough and peak serum theophylline concentrations
Trough: obtain just before next dose (identifies lowest dosing interval serum concentration)
Peaks: product-specific (identifies highest dosing interval serum concentration)
Proactive measurements for patients taking medium or high doses of inhaled corticosteroids
Calcium 100-1500 mg/day
Vitamin D 400-800 units/day
May need to add bone-sparing therapy (i.e. bisphosphonate)
Signs of COPD
Dec. FEV1 and FVC1

FEV1/FVC <70%

barrel chest/(enlarged)right heart failure, ankle swelling, bullae

PaO2<60 w/ or w/o PaCO2>45
Symptoms of COPD
chronic cough
chronic sputum production
persistent dyspnea (air hunger)
GOLD COPD goals of therapy
relieve symptoms
prevent disease progression
improve exercise tolerance
improve health status
prevent and treat complications
prevent and treat exacerbations
reduce mortality
Tips for COPD therapy
Vaccines: Influenza for ALL COPD, pneumococcal for all patients >65 and <65 if <40% FEV1 and Novel H1N1 for <65

Avoid beta blockers

Oxygen therapy if PaO2<55 or SaO2<88%

Pulmonary rehabilitation is recommended for stages 2, 3, and 4 of COPD (2months)
inhaled iptatropium for COPD
exacerbations: Neb: 0.5mg every 20 min for 3 doses then PRN; self care 0.25mg every 6 hours
MDI:8 puffs every 20min PRN up to 3 hours; self care 2-3 puffs every 6 hours

maintenance: MDI: 2 inhalations QID (max 12 inhalations/day)
Corticosteroid indication for COPD exacerbation
Prednisone/equivalent 30-40mg/day for 7-10 days
When to add antibiotics for an acute COPD exacerbation
If mechanically ventilated AND if evidence of infection (inc. dyspnea, sputum volume, sputum purulence)
Difference between SBP and DBP
SBP/DBP

SBP =CO =during cardiac contraction
DBP =TPR =during cardiac filling
RAAS changes in blood pressure
Renin is released by catecholamines, dec. renal artery pressure, and dec. Na or Cl delivered to kidneys. ACE converts ANG1 to ANG2 which vasoconstricts, stimulates aldo synthesis, sympathetic outflow, and Na retention.

Also in heart and brain.
Baroreceptor reflex
Baroreceptors sense dec. bp and trigger sympathetic stimulation:
NE: alpha1-constriction alpha2-neg. feedback
EPI: beta1-inc. heart contractility and CO and inc. renin by kidneys
beta2-inc. smooth muscle relaxation
Bradykinin
Vasodilator

Broken down by ACE so there's a balance. Impaired in HTN patients
Secondary causes of HTN
obstructive sleep apnea, thyroid disease, and parathyroid disease

Inc. Na+ retention in CKD, primary aldosteronism, and renal artery stenosis (due to dec. renal perfusion)

Inc. sympathetic NS activity in pheochromocytoma
JNP BP classifications
Pre-HTN 120-139 OR 80-89

STAGE 1 140-159 OR 90-99

STAGE 2 >160 OR >100
Complications in patients with HTN AND LVH
there's a 3x increased risk of CV events in these patients than normal HTN patients due to incomplete filling of the left ventricle by via upregulation of RAAS system.
CKD in HTN patients
GFR < 60ml/min/1.73m^2 for >3mths with or w/o kidney damage

Kidney damage >3mths w or w/o abnormal. GFR

Increases risk of CVD

CKD target organ damange can be functional or structural!! Decreased GFR = functional damage! Elevated SCr indicated decreased filtration also!
HTN patients with PAD
Should be treated as aggressively as CAD patient

ABI: SBP in ankle/SBP in brachial artery.
<0.90 suggests PAD
1.00 is normal
HTN patients with glomerulosclerosis
ACE inhibitors!!!! (DO NOT USE in patients w/ Renal artery stenosis)

inadequate blood flow into bowmans capsule which helps with filtration

Look at fundoscopic findings of retinal vessels
Physical exam to diagnose HTN
Retinopathy (grade 3 changes-exudates and hemorrhages)
neurological
hemiparesis/hemiplegia (stroke/TIA)
Neck (goiter, bruits-inc risk of CVD)
Palpate pulses (PAD)
Lab testing to diagnose HTN
Chem 7 (baseline Na and K, and SCr, glucose)
Fasting lipid panel
CVC (hgb and hct)
ECG (MI, etc)
Urinalysis (proteinuria)
Auscultatory measurements of bp
measure with bell

check right and left arm bp
Follow up times for HTN
Normal: 2 years
Pre-HTN: 1 year
Stage 1: 2 months
Stage 2: 1 month; if >180/110, then 1 week

KEEP IN MIND THAT OTHER RISK FACTORS REQUIRE SOONER FOLLOW-UP
JNC 7 BP goals
General CAD prevention: <140/90
CKD, Diabetes, Angina: <130/80
LVD: <120/80
Lower SBP goal being considered in patients with >500mg/day of proteinuria
Lifestyle modifications to manage pre-HTN or HTN
weight loss (most significant! 5-20mmHg decrease)
DASH
2.4gNa or 6gNaCl intake/day
Physical activity
Moderate alcohol intake
DASH
Dietary Approaches to Stopping HTN

Change to diet rich in fruits, vegetables and low-fat dairy products

Decrease bp by 5-6/3 in pre-htn and 11-12/5-6 in HTN patients
HOPE study
ACE inhibitors are preferred over thiazide because it has more effects rather than just lowering bp because it is thought to prevent platelet aggregation on artherosclerosis
UK diabetic HTN study (UKPDS)
Captopril vs. atenolol

B-blockers don't need to be avoided in diabetics as commonly thought.
In this study, b-blockers reduced risk for diabetes-related complications

Diabetics have the same risk of having a stroke/MI as a person who has experienced these events!
HOT trial
It is not hazardous to have a DBP of <80. In fact, AHA recommends that heart disease patients should have this goal.
CAMELOT
Supports lower BP goal in CAD patients
Thiazide diuretics
HCTZ, chlorthalidone (longest half-life), indapamine, metolazone

First line unless contraindicated (i.e. GFR<30)

Primary MOA:arteriolar vasodilation to increase TPR

6.25-25mg

reduction in target organ damage

Adverse effects: hypokalemia, hyperuricemia, hyperglycemia, gypercholesteremia (last two are most likely temporary

See patient in 1-2 weeks to check chem 7 for dehydration and hypotension (SBP<90-100)

Interact with lithium, NSAIDs, and digoxin (lithium and NSAIDs common w/ all diuretics)

Ethacrynic acid may be used for pt who needs diuretic but is allergic to thiazides
Common side effects in most anti-HTNs
fatigue, headache, impotence, photosensitivity, and dehydration/hypovolemia
Loop diuretics
Furosemide, torsemide, bumetanide

Torsemide has longest half-life

Primary MOA: inhibits Na and Cl reabsorption

hypocalcemia (opposite of thiazide)

Can use for GFR<30, preferred for pts with HF

Interactions: Lithium, NSAIDs, and digoxin
Aldosterone Antagonists
Spironolactone and Eplerenone

MOA: Blocks adlo receptor

Check for hyperkalemia and gynecomastia (>risk in spironolactone) in 1-2 wks

caution when using:
spironolactone in pts with:
SCr>2.5 and K>5.0

CONTRAINDICATED:
Eplerenone in pts with GFR<30, SCr>2.0, and K>5.5

Metabolized by CYP3A4 so increase dose to 25mg MAX if used w/ fluconazole, erythromycin, verapamil, saquinavir, etc.

interacts with potassium sparing diuretics
Potassium sparing diuretics
Amiloride & triamterene

MOA: inhibit the sodium channel

Mostly used in combo with thiazide diuretics to balance K level

Common side effect is hyperkalemia

Monitor Chem7
B-blockers
-lol

First line of therapy for angina, post MI, and systolic HF patients.

MOA: competes with EPI for adrenergic receptor. (inhibits renin &amp; is a neg. ionotrope,chronotrope)

May cause fatigue, impotence, depression, bradycardia, and heart block (common in elderly), bronchospasm, may mask hypoglycemia but not sweating so monitor for this!!

Transient hyperglycemia &amp; hypercholesterolemia may occur but not a good reason to stop!!

Taper patient off b/c it may cause rebound HTN or MI
Nonselective b-blockers
propranolol

Bronchoconstriction occurs!! Avoid in asthmatics!
Cardioselective b-blockers
Metoprolol, nebivolol, atenolol, and nadolol
FDA approved b-blockers for systolic HF and LV dysfunction
Metoprolol XL
Carvedilol (XL also)
Bisoprolol
ACE Inhibitors
-pril

BLOCKS ACE that dec. ANGII (vasoconstrictor) and blocks degradation of bradykinin (vasodilator)

DOC for DM, CKD, post-MI, systolic HF patients

In CKD patients:
nondialysis: lower or d/c if K>5.5

In patients without CKD:
lower or d/c if K>5.1
Often used in combo with diuretic.

Monitor for hyperkalemia, increase in SCr of 0.5-1

Cough, angioedema(life-threatening, COUNSEL)

CONTRAINDICATED for pts with renal artery stenosis, and pregnancy

INTERACTIONS with potassium, potassium sparing diuretics, ARBs and NSAIDs
ARBs
-sartan

MOA: blocks vasoconstrictor and ALDO-secreting effects ANGII

DOC for DM or CKD patients

Usually used in combo with thiazide diuretic

Hepatically metabolized

CONTRAINDICATED in patients with renal artery stenosis, and pregnant pts

INTERACTS with potassium, potassium sparing diuretics, ARBs and NSAIDs
Calcium channel blockers
Nondihydropyridines:
-Diltiazem
-Verapamil

Dihydorpyridines:
-ipine

MOA: Dec. calcium influx leading to arterial and venous vasodilation

hepatically metabolized: most are CYP3A4 inhibitors

Adverse effects:
Constipation
headache
peripheral edema
gingival hyperplasia
bradycardia

VERAPAMIL HAS GREATEST INTERACTIONS and is P-GLYCOPROTEIN INHIBITOR

Interactions: grapefruite juice, digoxin, carbamazepine, cyclosporine, and theophylline
Nondihydropyridines
Diltiazem and Verapamil

DO NOT USE IN PATIENTS WITH LVD or SYSTOLIC HF

Have a greater negative ionotropic and chronotropic effect
Dihydropyridines
-ipine

Greater peripheral vasodilatory effect
Calcium channel blockers
Nondihydropyridines:
-Diltiazem
-Verapamil

Dihydorpyridines:
-ipine

Good for patients you won't see in 1-2 weeks b/c chem 7 isn't so necessary for these drugs.

MOA: Dec. calcium influx leading to arterial and venous vasodilation

hepatically metabolized: most are CYP3A4 inhibitors

Adverse effects:
Constipation
headache
peripheral edema
gingival hyperplasia
bradycardia

VERAPAMIL HAS GREATEST INTERACTIONS and is P-GLYCOPROTEIN INHIBITOR

Interactions: grapefruite juice, digoxin, carbamazepine, cyclosporine, and theophylline
Nondihydropyridines
Diltiazem and Verapamil

DO NOT USE IN PATIENTS WITH LVD or SYSTOLIC HF

Have a greater negative ionotropic and chronotropic effect
Dihydropyridines
-ipine

Greater peripheral vasodilatory effect
HF & HTN
ACEI/ARB and BB and LOOP
POST MI & HTN
ACEI/ARB and BB
HIGH CAD RISK *& HTN
thiazide Diuretic OR ACEI OR ARB & BB OR CCB
Secondary stroke prevention & HTN
ACEI and diuretic
General CAD prevention & HTN
ACEI/ARB, CCB, thiazide (if SBP>160 or DBP>100)
Stable Angina & HTN
BB and ACEI/ARB
Use CCB if BB contraindicated
LVD & HTN
ACEI/ARB and BB
B-blockers that cause increased risk of bradycardia
verapamil
Diltiazem
Digoxin
Aliskiren
Tekturna

MOA: Direct renin inhibitor

Metabolized via CYP 3A4

Can be used alone but combined with HCTZ to inc. RAAS w/ a dec. in diuresis.

Side effects: hyperkalemia, angioedema, diarrhea (elderly and women are more susceptible), and cough
Peripheral alpha 1 blockers
Indirect vasodilators: inc. Na and water retention

Doxazosin, Prazosin, Terazosin

Side effects: somnolence, priapism, dizziness, first dose syncope

Administer at bedtime

Dosing titration restart is necessary if pt stops therapy for several days.
Centrally acting alpha 2 agonists
Clonidine & Methyldopa

Decreased sympathetic outflow & TPR.

Pt should already be on a diuretic before starting this b/c it causes Na and water retention

Common side effects: constipation, drowsiness, depression, and dry mouth
Clonidine vs. Methyldopa
Methyldopa is DOC for pregnant women!

Clonidine: abrupt withdrawal may cause hypertensive crisis.

Adverse effects are dose dependent
Postganglionic Adrenergic Neuron Blockers
Reserpine (nasal stuffiness & depression)
Guanethidine
Guanadrel
direct vasodilators
Hydralazine
Minoxidil
LV dysfunction & HTN
DO NOT USE DILTIAZEM OR VERAPAMIL

ACEI/ARB
BB
DIuretics
AA-add-on only if pt has HF
alpha blockers-only use if pt not on goa with other therapy
STEMI & HTN
ACEI
ARB: only if patient has a cough due to ACEI or intolerant to it
BB
AA: add-on for pts with LV and MI
Dihydropyridine CCBs: inc. mortality if LV is present
Stable Angina, UA, NSTEMI
ACEIs/ARBs
BBs
Non-DHP CCBs (only if BB is contraindicated. DO NOT USE IF LV DYSFUNCTION IS PRESENT)
Bronchospastic airways (asthma, etc)
Cardioselective agents
Pregnancy &amp; HTN
METHYLDOPA or HYDRALAZINE ONLY

DO NOT USE ACEIs, ARBs, OR TEKTURNA!
Renal insufficiency & HTN
Potassium-sparing diuretics and AAs

MONITOR FOR HYPERKALEMIA CLOSELY
Gout & HTN
THIAZIDES (monitor for uric acid buildup)

If 3 or more gout attacks, avoid diuretic
Angioedema & HTN
ARBs and ACEIs
African-Americans
Diuretics or CCBs are best

ACEI angioedema is 2-4x more frequent with blacks then caucasians
SHEP and HYVET
Same BP goal in elderly as other populations
Hypertensive Urgency Vs Hypertensive Emergency
Both: SBP>180 OR DBP>120

Urgency: lower BP w/in hours to days

Emergency: lower right away, within hours!
Hypertensive urgency causes
Nonadherence, suboptimal treatment of HTN, or use of illicit drugs (avoid BBs in these pts)
Hypertensive urgency management
Reduce BP w/in hours
Pt should be re-evaluated w/in 3-4 days

Sodium nitroprusside, nicardipine HCL, Fenoldopam mesylate, Nitroglycerin, Hydralazine hcl, labetalol HCl, and Esmolol HCl
HTN in hospitalized patients
May be higher than 140/90 b/c of acute illness, pain, stress, steroids, or other meds
Normal adult iron level
Males: 75-175ug/dl
Females: 65-16ug/dl