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135 Cards in this Set
- Front
- Back
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What is the cause of 90-95% of HTN?
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Unknown
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Who tends to have higher levels of BP?
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Lower education and socioeconomic status
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What SBP and DBP is considered to be Normal?
- What's considered to be pre-HTN (SBP, DBP & drug therapy)? - What's Stage 1 HTN (SBP, DBP & drug therapy)? - What's Stage 2 HTN (SBP, DBP & drug therapy)? |
Normal = 120/80
-Pre-HTN= 120-139/80-89 (compelling indications for drug therapy) - Stage 1 HTN= 140-159/90-99 (Diuretics, ACEI, ARB, BB, CCB prn) - Stage 2 HTN= higher than 160/100 (2 drug combo or as above |
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What's the DM or chonic kidney disease BP goal?
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130/80
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At what level is a BMI score considered a major risk factor for HF and HTN?
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over 30
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At what level is a GFR considered a major risk factor for HF and HTN?
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GFR < 60 mL/min... or microalbuminuria
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At what age are men and women at a higher risk for HTN and HF?
- At what age would FxHx of premature cardiovascular disease be a risk factor? |
Men > 55 y.o.
Women > 65 y.o. - Same |
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What are some examples of target organ damage to the heart?
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LVH, angina or prior MI, CHF, prior coronary revascularization
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What are some examples of target organ damage to the brain?
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-Stroke
- Transient ischemic attack (TIA) |
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What are some examples of target organ damage to kidneys?
- to arterials? - to eyes? |
Chronic kidney disease (proteinuria, increased BUN/Cr)
- peripheral arterial disease - retinopathy (av nicking, arteriolar narrowing) |
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What are some estimated identifiable causes of HTN?
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- Sleep apnea
- drug-related - Chronic kidney disease - primary aldosteronism - chronic steroid therapy - pheochromocytoma - coarctation of the aorta - thyroid or parathyroid disease (Pg. 76) |
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What's the relationship of taking oral contraceptive pills (OCPs) and HTN?
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HTN increases 2-3 times if taking (OCPs)
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What region in the U.S has a higher prevalence of HBP and stroke?
-rank the most prevalent HBP in these races (whites, hispanics and blacks) |
Southestern U.S. (all that fried food and gumbo!)
- Blacks, whites and then hispanics... women lower in all |
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At the ages of 60 and older, rank the following races with the highest to lowest prevanlence of HTN: (AA, mexican americans, Whites, Japanes american males, native americans)?
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1) Japanese American males (ages 71-93)
2) African americans 3) Mexican americans 4) whites 5) native americans (higher in women than men in this age group and race) |
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In persons over 50 yo, what is more important CVD risk factor than DBP?
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SBP of over 140
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After a BP of 115/75, CVD risk doubles with each increment of _____ mm Hg?
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20/10
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Normotensive persons at age 55 have a ___ risk for HTN?
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90%
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What changes need to occur in pre-HTN?
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Lifestyle changes/modifications
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Most patients will require __ or more meds to achieve a goal BP...
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2
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If BP is over 20/10 mm Hg, what should you consider?
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Initiating therapy with 2 agents, one of which should be a thiazide
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What are JNC 7 goals?
- plus it's BP goals for most patients, if DM, if proteinuria |
To decrease morbidity and mortality
- most patients < 140/90 - for DM < 130/80 - proteinuria < 125/75 |
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What are AHA BP goals, Tx, and if/no use of BB for:
- Low CAD risk - High CAD risk - Wit CAD - HF |
-low CAD <140/90, ACEI ARB CCB thiazide, no BB
- high CAD <130/80, ACEI ARB CCB thazide, no BB - With CAD <130/80, BB and ACEI or ARB, use 1st line BB - HF < 120/80, BB ACEI or ARB diuretics and aldosterone antagonist, use 1st line BB |
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HTN in a young person causes an increase or decrease in a patient's: MAP, CO, SVR?
- How about middle age persons? - How about elderly persons? (pg. 81) |
- Young: Map & CO (UP), SVR (down)
- Middle-age: MAP & SVR (up), CO (down) - Elderly: MAP (up), CO (down), SVR (WAY up) |
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Why treat HTN? (pg. 81 slide 2)
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Because it:
- Increases workload to heart/blood vessels - Long term damage to vasculature, organs - Changes result in stroke, LVH, CHF, renal failure --- [SLCR accronym] |
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What are some lifestyle modifications that need to be done with HTN?
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- Stop smoking!!!!!!!
- Reduce cholesterol/sat. fats (DASH diet) - Reduce Na++ intake - Increase physical activity - weight loss if overweight - adequate intake of K+ - Restrict alcohol |
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Uncomplicated HTN should be treated with what?
- What should you do if BP goal is not met or BP is 20/10 above the goal? |
-Thiazide diuretics (ALLHAT trial)
- Use 2+ meds |
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DM w/ HTN should be treated with?
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-ACE I
-ARBs -Ditiazem - Verapamil (+ microalbuminuria) ---- may also use BBs |
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MI patient with HTN should be treated with?...
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- BBs
- ACE I - Aldosterone antagonisst |
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Asymptomatic HF with HTN should be treated with?
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- ACE I
- BBs... if cough... BB and ARBs |
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Symptomatic HF or End-stage HF with HTN should be treated with?
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ACE I, BB, ARB, aldosterone antagonist (along with loop diuretics= get rid of fluid)
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Stable angina patient with HTN should be treated with...?
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BB (initial drug of choice); alternative could be CCB
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Chronic kidney disease with HTN should be treated with?...
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ACE I
ARB (add loop diuretic in advanced renal disease) |
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Older persons with HTN should be treated with?
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lower initial doses
"start low... go slow"... |
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If a patient has recurrent strokes and HTN, what should you use to treat the HTN?
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ACE I with thiazide diuretic OR ACE I plus dihydropyridine CCB
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A black patient with HTN, what should you use to treat the HTN?
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CCBs plus diuretics (must have adequate dose of diuretics)
- They have a reduced response to monotherapy with BB, ACE I and ARBs |
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A patient with an isolated systolic HTN must be treated with what for the HTN?
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CCB, diuretics (clorathalidone)
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A pregnant patient should be treated with what for HTN?
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Methyldopa, BB, vasodilators
- NO ACEI or ARBS!!!! Messes with kidneys. |
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A patient with peripheral artery disease should be treated with what for their HTN?
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ANY class of drugs can be used for most cases; but have caution with BBs.
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A patient with LVH should be treated with what for their HTN?
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All classes except direct vasodilators (minoxidil, hydralazine)
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A patient with acute coronary syndrome (unstable angina or MI) should be treated with what for HTN?
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BB and ACEI
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Who do you give a diuretic to?
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It's your initial drug choice...
- DM - Ostepoprosis |
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Who do you prescribe BB to?
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-Post MI patients
- Angina - A. Fib & A. Tach. - Essential tremor - Hyperthyroidism - Migraine - pre-op HTN |
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Who would you prescribe alpha and beta blockers to?
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HF patients (carvedilol)
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Who would you prescribe ACE Inhibitors to?
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Type-2 DM
- CHF - Chronic kidney disease |
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Who would you prescribe ARBs to?
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-Type-2 DM
- CHF - Chronic kidney disease |
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Who would you prescribe calcium channel blockers to?
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- Angina
- A. Fib & A. Tach (non-DHP) - type-2 DM w/proteinuria - Migraine (non-DHP) - MI (non-DHP) |
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How/who would you prescribe alpha-agonists to?
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It's an add on agent.
Prescibe if patient has anxiety, or is taking methyl-dopa for pregnancy. |
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Who do you prescribe alpha-blockers to?
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patients with an enlarged prostate (BPH)... DON'T prescribe to females... can cause incontinence.
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What are the 4 types of diuretics?
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- Loop diuretics
- Thiazide, thizide-like diuretics - Potassium sparing diuretics |
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What's the method of action for loop diuretics?
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- Work in the thick ascending loop of henle
- Prevent 20-25% resorption of Na - decrease Na and water - useful for diminishing swelling (CHF, pulmonary congestion) - Extra renal effects - lungs, decrease preload |
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What are some adverse drug reactions (ADRs) for loop diuretics?
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- Orthostasis
- decreases electrolytes (Na, K, Cl, HCO3, Mg) - Increase glucose, uric acid, cholesterol - increase BUN/Cr if over-diuresis (due to volume depletion - Photosensitivity |
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What are the therapeutic uses of loop diuretics?
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- decrease edema (CHF)
- decrease preload (ventricular filling pressure) - Ancillary medication in treating HTN |
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What's the main Thiazide diuretic?
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HCTZ (Hydrochlorothiazide)
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What's the mechanism of action for Thiazide Diuretics?
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Work in distal tubule
- decrease Na reabsorbtion - Do NOT work well if CrCl < 30 mL/min |
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What are some adverse drug reactions (ADRs) with Thiazide diuretics?
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Decrease K+
- orthostasis, weakness - Same as for loop diuretics (thiazides increase Ca absorption) |
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What are some therapeutic effects of Thiazide Diuretics?
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- Effective agent to treat HTN
- MOST effective diuretic to treat HTN - They are adjunctive to other antihypertensives to increase their efficacy (BBs, ACEI, ARBs) - Isolated systolic HTN - NOT for getting rid of fluid |
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IMPORTANT!!!!!!!!!
- what is the starting dose of HCTZ? - What's the max effective dose? |
- Starting dose of HCTZ is 12.5 mg qd
- MAX EFFECTIVE dose is 25 mg qd... |
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What's the mechanism of action for Thiazide-like Diuretics?
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- Work in distal tubule, just like HCTZ
- May produce diuresis in Cr Cl < 20 mL/min (unlike HCTZ) - Also decreases Na reabsorption |
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What are some adverse drug reactions (ADRs) for thiazide-like diuretics?
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WAY decrease K+ (need to check this a few days after starting)
- decreases electrolytes and cholesterol |
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What are thiazide-like diuretics therapeutic effects?
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They increase the effect of loop diuretics in patients with CHF
- (give meolazone 30 minutes before furosemide) - Use in place of HCTZ when patient has impaired renal function (in this case, use metolazone) |
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What's the mechanism of action of potassium sparing diuretics?
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- Excrete Na in exchange for K
- Triamterene and amiloride inhibit Na reabsorbtion - Spirolactone is an aldosterone antagonist |
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What are the adverse drug reactions to potassium sparing diuretics?
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- WAY increase K+
- cause leg cramps - Spironolactone may produce endocrine effects (gynecomastia, menstral irregularities in women, impotence in men) |
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What's potassium sparing diuretics' therapeutic effect?
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Can use spironolactone for:
- ascites, premature edema, PCOS, refractory acne Use for mild diuresis Can use triamterene/amiloride in combination with K depleters to offset K loss |
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IMPORTANT:
What are some DRUG INTERACTIONS with diuretics? |
- NSAIDs offset beneficial effects of all diuretics
- Potassium sparers + drugs that INCREASE potassium may cause hyperkalemia (this includes K+ supplements and ACEI and ARBs) |
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What should you MONITOR after giving a diuretic?
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- BP
- K - Electrolytes - BUN/Cr - Glucose - Lipids |
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What are Beta Blockers mechanism of action?
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- Block beta receptors (selective target the heart; nonselective target both heart and lungs)
- Decrease CO -Decrease HR, myocardial contractility - Increase systemic vascular resistance - Central effects (decrease sympathetic outflow... decrease plasma renin activity) - Have sypathomimetric activity |
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IMPORTANT:
What are some adverse drug reactions (ADRs) with Beta Blockers? unimportant others are on page 96 |
- Bronchospasm (MAIN ONE)
- Lethargy/drowsiness/nightmares - May block symptoms of hypoglycemia - May decrease exercise capacity - Cause peripheral vasoconstriction |
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IMPORTANT:
What are some drug interactions with Beta Blockers? |
- BB+NSAIDs = decrease antihypertensive effects
- BB+inducer (barbiturates, rifampin, smoking)= decrease antihypertensive effects - BB+verapamil or diltiazem= AV block - BB+sympathomimetrics= increased BP - BB+cimetidine or inhibitors (certain SSRIs)= extended pharmacologic effects (hypotension or bradycardia) |
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What should you monitor with a patient on BBs?
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- BP
- HR - ECG - Adverse drug effects (ADRs) - CAN'T stop drug abruptly!!!!! Must slowly be tapered off... |
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What are some examples of BBs?
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- Metoprolol
- Carvediolol - Atenolol - Propranolol - Labetalol |
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What are BBs therapeutic use?
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- NOT 1st line for HTN (per AHA)
- Highly effective: post MI, angina, HF - Atenolol NOT 1st line BB, metoprolol is a better option - In pregnancy- labetalol is highly used - Prophylaxis for migranes - good for performance anxiety (I need that for this test!!!!!!!!!) |
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What's the mechanism of action for ACE inhibitors?
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- Block conversion of angiotensin 1 to angiotensin 2 (in lungs)
- |
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What are the ADRs of ACEIs?
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-Hypotension
-Renal insufficiency (renal artery stenosis) -cough -hyperkalemia -angioedema -teratogenicity (birth defects) |
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What are the important drug interactions of ACEIs?
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ACEIs + NSAIDS = decreased effect
ACEIs + antacids= decreased effect ACEIs + lithium= increases lithium eff. ACEIs + inducers= decreased effect *K concentrations increase when ACEIs mix w/ some Abx and K sparing diuretics |
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What should you monitor w/ ACEIs?
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BP
BUN/Cr K Cough |
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ACEIs are often combined with what to increase the antihypertensive effect?
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hydrochlorothiazide (HCTZ)
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What are some common ACEIs?
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*it it ends in -pril
Captopril Enalapril Lisinopril Fosinopril Ramipril Quinapril Benazepril |
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Who should be placed on ACEI therapy?
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-DM pts with HTN
-prevent neuropathy in pts w/ DM -pts w/ CHF -Post MI w/ systolic dysfunction *DO NOT USE IN PREGNANCY |
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What is the MOA of ARBs?
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-prevents binding of angiotensin II to AT1 receptor in vascular smooth muscle, adrenal glands, other tissues
-provide a more complete/effective inhibition of the RAS -Relaxes smooth muscle-promotes vasodilation |
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What are the ADRs of ARBs?
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-hypotension
-dizziness, fatigue -HA -less likelihood of cough than ACEI -Teratogenicity (birth defects) |
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Common ARBs:
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*if it ends in -sartan
Losartan Irbesartan Valsartan Telmisartan Candesartan |
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ARBs are combined with _____ to increase its antihypersensitive efficacy.
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HCTZ (hydrochlorothiazide)
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What should be monitored w/ ARB therapy?
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-BP
-Electrolytes, if combined w/ HCTZ |
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Who should be placed on ARB therapy?
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-as an alternative to ACEI tx of HTN and CHF if causing cough
-type 2 DM pts w/ HTN -prevent nephropathy in pts w/ diabetes |
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When are ARBs contraindicated?
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-do not use if pt experienced angioedema w/ ACEIs
-DO NOT USE IN PREGNANCY -do not combine w/ ACEIs |
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What is the name of a Direct Renin Inhibitor?
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Aliskiren
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What is the MOA of DRIs?
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-directly inhibits renin, which blocks the first step of the RAAS
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What are the ADRs of DRIs?
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-diarrhea
-cough-->less common -rash-->less common -angioedema (rare) -Teratogenicity (birth defects) |
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What should be monitored w/ DRI therapy?
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-BP
-Electrolytes if combined w/ HCTZ -K, if combined w/ ACEIs or ARBs -high fat meals decrease absorption |
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Who should be placed on DRI therapy?
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-not known yet
-more complete inhibition of RAAS than ACEIs or ARBs. -maybe DM or renal disease |
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What are the two different types of CCBs?
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--Non dihydropyridines: verapamil, diltiazem
--Dihydropyridines: "The Dipines" Nifedipine Amlodipine Felodipine Isradipine |
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What is the MOA of CCBs?
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Block Ca++ channels and cardiac and smooth muscle cells who use them
-provents activation of contractile proteins in cardiac cells -dilates arterial vessels and decreases BP -lowers SVR, afterload, LVH |
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What are the ADRs of Non-dihydropyridines?
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-can cause AV block
-lowers HR -lowers myocardial contractility -may precipitate CHF -Verapamil may produce constipation |
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What are the ADRs of dihydropyridines?
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-swelling
-edema -dizziness -headache -gingival hyperplasia |
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What are the main drug interactions of CCBs?
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-Nondihydropyridines + BBs or digoxin = AV block
-CCBs + macrolides = hypotension, or bradycardia -CCBs + inducers = increased BP |
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Who should be placed on CCB therapy?
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-as an add on agent when BP is not controlled
-Angina -Isolated systolic hypertension Non-dihydropyridines: -when a pt can't use a BB and need to lower HR -prevent nephropathy in DM pts who can't use ACEIs or ARBs -migraine prophylaxis |
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What is the MOA of Central Alpha Agonists?
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-block NE release
-normalize BP at rest/during exercise |
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What are the ADRs of alpha agonists?
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lethargy, sedation
depression clonidine may = constipation *rebound HTN from abrupt D/C of clonidine |
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What are 3 examples of alpha agonists?
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*clonidine (main one)
methyldopa guanfacine |
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Who is indicated for alpha agonist therapy?
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-it's an add on agent, not 1st line
-clonidine is useful for GAD and can help control BP and be good for pts trying to quit smoking -Methyldopa is the drug of choice to treat HTN during pregnancy |
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What is the drug of choice to treat HTN during pregnancy?
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Methyldopa or Labetolol
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What is the MOA of Alpha-1 blockers?
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-block alpha receptors in the periphery, producing arterial/venous dilation
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What are the ADRs of Alpha-1 blockers?
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-first dose= syncope
-lethargy/drowsiness -stress incontinence in females |
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What should you monitor with alpha 1 blockers?
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-BP
-First dose syncope, titrate dose slowly -poor compliance = re-titrate |
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What are 3 examples of alpha 1 blockers?
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*ends with -azosin
-Doxazosin -Prazosin -Terazosin |
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What are alpha 1 blockers place in therapy?
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-add on agents, when pt has HTN and isn't responding to other drugs
-add on for pts with HTN and prostatic hypertrophy |
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What are two examples of Vasodilators?
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-Hydralazine
-Minoxidil |
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What is the MOA of vasodilators?
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-decrease SVR
-increase CO/HR |
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What are the ADRs of vasodilators?
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-edema
-reflex tachycardia -Hyralazine: lupus -Minoxidil: increased hair (hypertrichosis) -increase LVH |
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What is the vasodilator's place in therapy?
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-add on agent
-cannot use with monotherapy -hydralazine + nitrates is used when pts can't use ACEIs or ARBs for CHF |
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Drug therapy should provide _____ hour efficacy with a once daily dose, with at least ____% of the peak effect remaining at the end of the ____ hours.
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24 hour
50% 24 hours *helps protect for early AM and missed dose |
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What resource is provided in helping select drug therapy?
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JNC 7
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What is the drug of choice for uncomplicated HTN?
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Thiazide Diuretics
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What are the compelling indications for HTN pts with DM?
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ACEIs
ARBs diltiazem verapamil BBs |
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What are the compelling indications for HTN pts with a hx of MI?
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BBs
ACEIs Aldosterone Antagonist |
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What are the compelling indications for HTN pts with Asymptomatic Heart Failure?
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ACEIs
BBs |
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What are the compelling indications for HTN pts with Symptomatic Heart Failure?
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ACEIs
BBs ARBs Aldosterone antagonist (w/ loop diuret.) |
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What are the compelling indications for HTN pts w/ Stable Angina?
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BBs
CCB |
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What are the compelling indications for HTN pts w/ chronic kidney disease?
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ACEIs
ARBs add Loop diuretic in advanced disease |
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What are the compelling indications for older HTN pts?
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lower initial doses
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What are the compelling indications for HTN pts w/ recurrent stroke prevention?
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ACEI w/ thiazide diuretic
ACEI w/ dihydropyridine CCB |
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What are the compelling indications for black pts w/ HTN?
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CCBs + diuretics
-Lower response to monotherapy with BB, ACEI, ARB |
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What are the compelling indications for HTN pts during pregnancy?
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Methlydopa
BB vasodilators NO ACEI or ARB!!!! |
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What are the compelling indications for HTN pts w/ peripheral artery disease?
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Any class
only caution with BBs |
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What are the compelling indications for HTN pts w/ Left Ventricular Hypertrophy?
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All classes except direct vasodilators
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What are the compelling indications for HTN pts w/ Acute Coronary Syndrome (unstable angine or MI)?
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BB + ACEI
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What are the specific indications for diuretics?
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DM
Osteoporosis (thiazides) |
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What are the specific indications for Alpha/Beta blockers?
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Heart Failure (carvedilol)
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What are the specific indications for ACEIs?
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Type 2 DM
CHF chronic kidney disease |
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What are the specific indications for ARBs?
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type 2 DM
CHF chronic kidney disease |
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What are the specific indications for CCBs?
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Angina
A-fib A-tach Type 2 DM w/ proteinuria migraine MI |
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What are the specific indications for alpha agonist?
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add on agent
anxiety methyldopa in pregnancy |
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What are the specific indications for alpha blockers?
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BPH (prostatic hypertrophy)
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What is the normal creatinine clearance for normal, non-geriatric population?
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100 mL/min
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What amount of creatinine clearance signals a renal insufficiency?
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< 50 mL/min
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