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35 Cards in this Set
- Front
- Back
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Algorithm for treatment of HTN
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Lifestyle modifications
If still not at goal BP (<140/90 or 130/80 for diabetes and chronic kidney disease), use drugs With compelling indications (coexisting morbidity, where using antihypertensive drug will treat morbidity and lowers HTN) -Select drug for the compelling indication Without compelling indications -Stage 1: Thiazide type diuretics for most, may consider ACEI, ARB, BB, CCB, or combination -Stage 2: 2 drug combination, usually thiazide-type diuretic and ACEI, or ARB, or BB, or CCB If still not at goal BP -optimize dosages or add additional drugs until goal BP is achieved |
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Three types of diuretics
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Thiazide
Loop K+ sparing |
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Loop diuretics MOA
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Loop diuretics poison pump.
Blocks reabsorption of Na+ (~25%), K+, Cl- at ascending loop of henle Na+ and K+ are excreted, water follows, drops blood volume Tons of urination |
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Thiazide diuretics MOA
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Poison Na+ reabsorption (~5%) at distal tubule
Na+ excreted and water follows Modify arteriolar tone and cause vasodilation |
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K+ sparing diuretics MOA
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Blocks aldosterone which prevents Na+ reabsorption (1-2%) but doesn't increase K+ excretion, affects K+ exchange at distal renal tubules
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Examples of thiazide diuretics
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Hydrochlorothiazide (HCTZ)
Chlorthalidone Metolazone (most potent) Indapamide 1x a day Onset ~2 hours Duration ~24 hours |
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Thiazide diuretics side effects
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decrease potassium
decrease magnesium decrease sodium hyperglycemia gout (increased uric acid) dehydration rash (agents have sulfer, patients might be sensitive) |
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Examples of loop diuretics
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Furosemide
Bumetanide Torsemide Ethacrynic acid Onset <1hr Duration ~4-6 hrs |
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Loop diuretics side effects
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decrease potassium
decrease magnesium decrease sodium hyperglycemia gout (increased uric acid) dehydration rash (all agents have sulfer except ethacrynic acid, patients might be sensitive) |
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K+ sparing diuretics
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Spironolactone (aldosterone antagonist)
Eplerenone (aldosternone antagonist) Triamterene (channel blocker) Amiloride (channel blocker) |
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K+ sparing diuretics side effects
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Spironolactone
-Hypercalemia -Gynecomastia Eplerenone -Hyperkalemia Triamterene -Hyperkalemia -Rash Amiloride -Hyperkalemia -Rash |
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Diuretics therapeutic pearls
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Work well in all ethnicities but especiallly the African American patient
Use with caution: elderly If not first line, then excellent add on agent (2nd or 3rd) As anti-HTN: Thiazides > K+ sparing > loop diuretics Administer early in the day Check BMP Lowers BP ~10-15 mmHg |
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ACE inhibitors/ARBs MOA
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Angiotensin converted to Angiotensin I by Renin
Angiotensin I converted to Angiotensin II by ACE Angiotensin II binds to Angiotensin receptors which leads to: -Vasoconstriction -Increased aldosterone -Increased vasopressin -Increased sympathetics ACE also causes breakdown of bradykinin to inactive peptides. With ACEI, bradykinin increases and causes vasodilation. ACEI block ACE so angiotensin II can't be formed and create effects ARBs block receptors so angiotensin II can't bind and create effects |
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ACE inhibitors and ARBs terminology
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ACEI
- all end in -pril ARBs - all end in -sartan |
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ACE inhibitors examples
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Captopril
-3 times a day -difficult to use -short acting used in critical care Enalapril -inactive drug, metabolized to enalaprilat -enalaprilat can be given IV -1x a day Lisinopril -1x a day -good for preventing heart failure Ramipril -treats HTN and heart failure -lowers HTN a little less than other ACEI |
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ARB examples
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1x a day drug
All last 24 hours Losartan -studied in HTN -generic |
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Renin inhibitor example
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Aliskiren
-1x a day -24 hour duration -takes ~2 weeks to work |
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Adverse effects/contraindications of ACEI, ARB
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Adverse effects:
Cough (ACEI only) -due to bradykinin accumulation in pulmonary tissues -ACEI first line unless cough develops, then give ARBs Hyperkalemia Positive serum creatinine/ARF Angioedema (less risk with ARBs) Contraindications: Bilateral Renal Artery Stenosis Pregnancy Angioedema to other ACEIs Hyperkalemia (K+>5meq/L) |
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ACEI/ARB therapeutic pearls
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Cross sensitivity between ACEI/ARBs
Use in renal insufficiency or dialysis ACEI induced cough Work well in all ethnicities & age; not as effective in African American patient; add diuretic Lowers pressure ~10-15 mmHg |
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Beta blockers MOA
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Block beta receptors
Also block release of renin in kidneys |
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Beta blocker examples
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Atenolol
-low lipid solubility (won't cross BBB) -B1 selective Metoprolol -Moderate lipid solubility -B1 selective -Good for CAD, HTN Esmolol -short acting -IV only Propanolol -High lipid solubility -Not B1 specific Labetalol -Moderate lipid solubility -Alpha-1, B1, B2 selective Carvedilol -Moderate lipid solubility -Alpha-1, B1, B2 selective -Good for HTN, heart failure |
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Beta blocker side effects/contraindications
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Drowsiness
Lethargy Confusion Bronchoreactive events AV nodal blockade Contraindications: Symptomatic Bradycardia/Hypotension Decompensated HF Use with caution: asthma, diabetes |
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Calcium channel blockers MOA
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Inhibit L-type calcium channel
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CCB examples (non-dihydropyridine)
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Verapamil
-Decrease HR -Decrease contractility -Decrease vascular resistance Diltiazem -Decrease HR -Decrease contractility -Decrease vascular resistnace Compelling indications: Angina, AFib w/RVR Contraindications: Bradycardia, systolic HF |
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CCB examples (dihydropyridine)
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-ipine
Amlodipine -takes a couple days to kick in -decrease vascular resistance Compelling indicaiton: -Angina Contraindications: -Hypertensive emergency, AMI |
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CCB clinical pearls
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Work well in all ethnicities especially African-American pt;
Work well in elderly ADRs: -DHP: pedal edema -NDHP: conduction abnormalities, rash, constipation |
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Peripheral alpha-1 receptor blockers
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Terazosin (Hytrin®); doxazosin (Cardura®; prazosin (Minipress®)
Reserved for unique cases: males with benign prostatic hypertrophy. Adverse Effects (1st dose syncope, dizziness, lethargy) ↑ in CV events when used as monotherapy |
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Alpha2 receptor blockers
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Clonidine
Methyldopa Used as add-on therapy Bad side effects -dry mouth -rebound hypertension |
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Vasodilators
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Hydralazine
Minoxidil -hair growth as side effect Use with diuretic and beta-blocker to counteract compensatory changes |
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Heart failure compelling indication drugs
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Diuretics
BB ACEI ARB Aldo ant |
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Post MI compelling indication drugs
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BB
ACEI Aldo Ant |
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High coronary disease risk compelling indication drugs
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Diuretics
BB ACEI CCB |
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Diabetes compelling indication drugs
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Diuretics
BB ACEI ARB CCB |
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Chronic kidney disease compelling indication drugs
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ACEI
ARB CCB |
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Recurrent stroke prevention compelling indication drugs
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Diuretics
ACEI |
