Pharmacotherapy Lecture 3 + 4

Front 1

What do we look for when we do medical evaluation for HTN?

Back 1

-look medical (family) history
-PE
-Lab/diagnostic testing

Front 2

-When evaluating an individual, what do we need to assess?

Back 2

-target organ damage
-identify CVD risk factors
-rule-out secondary forms of HTN

Front 3

T/F: primary HTN is the second most reason for physician's office visit.

Back 3

True

Front 4

What organs can possibly be damaged by uncontrolled HTN?

Back 4

-cardiac: hypertrophy, failure, infarction
-large vessel: aneurysm, dissection
-cerebral: ischemia, thrombosis, hemorrhage
-renal: nephrosclerosis, ESRD
-Urgency/emergency: accelerated malignant

Front 5

What is the leading causes of death in 2007?

Back 5

Heart Disease (1st)
Cerebrovascular diseases (3rd)
Hypertension and hypertensive renal disease (13th)

Front 6

HTN prevalence: age, sex, and ethnicity

Back 6

age: >60 YO
sex: male
ethnicity: non-hispanic black

Front 7

What are the non-modifiable stroke prevention factors?

Back 7

-increasing age
-gender (m>w)
-family hx
-prior stroke or TIA

Front 8

What are the modifiable stroke prevention factors?

Back 8

-htn
-diabetes
-CAD
-atrial fibriallation
-hyperlipidemia
-tobacco
-inactivity
-EtOH and drug abuse

Front 9

Starting at _____ mmHg, CVD risk doubles with each increments of 20/10 mmHg throughout the BP range.

Back 9

115/75 mmHg

Front 10

Reduction of sodium intake to less than 2.4 g a day is equivalent to a single drug therapy for HTN. T/F

Back 10

True, in JNC7

Front 11

ACE inhibitors will increase or decrease bradykinin?

Back 11

Increase; ACE increase the breakdown of bradykinin; therefore ACEI will decrease the metabolism of bradykinin. Bradykinin is a vasodilator

Front 12

Angiotension I ---> Angiotension II by what enzyme?

Back 12

ACE; blocking

Front 13

Aldosterone inhibitors increase or decrease BP?

Back 13

decrease; in the RAAS, angiotension II will increase the release of aldosterone and it acts to increase the reabsorption of sodium and water; increase volume.

Front 14

Angiotensinogen ---> Angiotensin I is catalyzed by which enzyme? And what drug class block this enzyme?

Back 14

Renin; BB and renin inhibitors will block this process

Front 15

Volume or V hyptension is predominately renin-angiotensin mediated. T/F

Back 15

False, predominately sodium-volume mediated

Front 16

Drug class that are effective in tx V HTN.

Back 16

-reduce sodium-volume factor
-diuretics, CCB, sprironolactone, alpha1-blockers

Front 17

R hypertension characteristics

Back 17

-plasma renin activity > .65 ng/ml/hr
-direct renin > 5uU/mL
-progressively more renin-angiotension mediated

Front 18

Drug class for R HTN.

Back 18

-block plasma renin-angiotensin system
-ACEI, ARB, DRI, BB

Front 19

Blood pressure = cardiac output x ________

Back 19

Peripheral resistnace

Front 20

MAP = CO x ________

Back 20

total peripheral resistance (TPR)

Front 21

high blood pressure are due to:

Back 21

-increase CO
-and or increase PR

Front 22

sympathetic overactivity is the common pathway that connects obesity and hypertension. T/F

Back 22

true; glucose, high leptin, and insulin can increase sympathetic tone

Front 23

Overall effectiveness of anti-HTN monotherapies.

Back 23

thiazide: 50-55%
ACEI (ARB): 50-60
BB: 45-50
CCB: 40-45
alpha 1 blocker: 35-40
alpha 2 agonist: 30-35

Front 24

When using a diuretic and ACE inhibitors, racial differences in respondents disappear. T/F

Back 24

True, when use diuretic and ACE inhibitor, all pt respond similarly. This can be the best combination to treat HBP

Front 25

When choosing a combination anti-htn drug, they need to be:

Back 25

In different drug class, drugs with complementary MOA

Front 26

What time of the day pt BP most elevated?

Back 26

most elevated at noon and morning upon waking up. Decrease when sleep called dipping. non-dipping pts have more chance of CVD.

Front 27

Describe systolic and diastolic pressure as we age.

Back 27

Systolic increases as age increases; diastolic increases until 50-60 years old, then plateau and decrease. So if patients are HTN before 50 yo, it may be cause by diastolic hypertension. Above 50, more likely it is systolic hypertension.

Front 28

Describe the blood pressure and CHD death rates relating to differences in diastolic and systolic pressure.

Back 28

The greater the diff in systolic and diastolic, the more risk of CHD deaths. Ex. systolic 160 and distolic 70.

Front 29

Describe the arterial pressure waves

Back 29

In older adults the arterial pressure wave travels faster than normal and is quickly reflected off the peripheral resistance.
The reflected wave returns to the central aorta in systole rather than diastole where it augments the systolic pressure, increases cardiac work, and reduces diastolic pressure upon which coronary flow is dependent.

Front 30

Arterial stiffness is the major cause of HF, stroke and myocardial ischemia

Back 30

Fact

Front 31

T/F: treating stage 1 systolic hypertension 140-159 mmHg) should be withheld if pt is under 30 yo b/c there is no benefit.

Back 31

False: JNC 7 conclusively proven the benefits of treating individuals with stage 1 sysolic htn; therapy should not be withheld on the basis of age; unless DBP is lovered to 55 or 60 mmHg by treatment.

Front 32

“Are newer types of antihypertensive agents, which are currently more costly, as good or better than diuretics in reducing CHD incidence and progression?”

Back 32

no...new drugs and old drugs have similar results

Front 33

ALLHAT trial: why is doxazosin did not complete study?

Back 33

Increase hospitalization due to HF

Front 34

in the ALLHAT study: which medication seems to be more effective in treating HTN: chlorthalidone, amlodipine, lisinopril

Back 34

Chlorthalidone: systolic control are best and diastolic better than amlodipine.

Front 35

in the ALLHAT study: describe the results of primary outcome in chlorthalidone, amlodipine, and lisinopril.

Back 35

All 3 treatment has no significant difference in primary outcome (fatal CHD and nonfatal MI)

Front 36

Lisinopril group had a 15% higher risk for stroke compare to chlorthalidone.

Back 36

True. There is no difference with amlodipine.

Front 37

The ALLHAT trial summary:

Back 37

thiazide-type diuretics should be considered first for pharmacologic therapy in patients with hypertension. They are unsurpassed (i.e., they are equal) in lowering BP, reducing clinical events, and tolerability, and they are less costly

Front 38

Furosemdie

Back 38

-not as effective for lowering bp
-used if GFR is below 25-3o ml/min
-most potent, but short duration of action ~6 hours

Front 39

HCTZ

Back 39

-most commonly prescribed, but not as effective as chlorthalidone
-shorter duration compare to chlrothalidone

Front 40

Chlorthalidone

Back 40

diuretic-like
-used in most major clinical trials
-long t1/2 and duration
-work during sleep so provide dipping bp

Front 41

what non-metabolic side effects of chlorthalidone?

Back 41

dizziness, lightheadedness, weakness, fatigue, nausea, male impotence

Front 42

What are metabolic side effects of chlorthalidone?

Back 42

hypokalemia, hypomagnesemia, hyperglycemia, hyperuricemia, hypercholesterolemia.

Front 43

hypokalemia caused by chlorthalidone ca be minimized by:

Back 43

using loser dose and combine with low salt diet.