Mspa 2017 - Htn

Front 1

What is JNC 7?

Back 1

National Guideline - 7th edition of joint national committee on detection, evaluation, and treatment of high BP

Front 2

Cardiovascular morbidity and mortality risk directly correlated with __________

Back 2

Blood Pressure

- AntiHTN drug therapy reduces cardiovascular and mortality risk

Front 3

What are the target organs that can be damaged due to HTN?

Back 3

1) Brain: Stroke, TIA, dementia

2) Eyes: Retinopathy

3) Heart: Left ventricular hypertrophy, Angina

4) Kidney: Chronic kidney disease

5) Peripheral Vasculature: Peripheral arterial disease

Front 4

What is Normal BP?

Back 4

<120/70

- Always encourage life style modifications

Front 5

What is the range of Prehypertension?

Back 5

120-139/80-89

- Life style modification

- No drug therapy needed

Front 6

What is the range of Stage 1 Hypertension?

Back 6

140-159/90-99

- Life style modification

- Thiazide type diuretic (1st line)

- May also consider ACEI, ARB, BB, CCB - Or Combination therapy

- Drugs for other compelling indications PRN

Front 7

What is the range of Stage 2 Hypertension?

Back 7

>or= 160/100

- Life style modification

- Two drug combination (Thiazide + ACEI or ARB or BB or CCB)

- Drugs for other compelling indications PRN

Front 8

What are the components for evaluation?

Back 8

1) Medical history

2) Physical examination

3) Routine laboratory tests

4) Optional tests

Front 9

What are the causes of Secondary HTN?

Back 9

1) CKD

2) Cushings Syndrome

3) Coarctation of the aorta

4) OSA

5) Parathyroid Dz

6) Pheochromocytoma

7) Primary Aldosteronism

8) Renovascular disease

9) Thyroid disease

Front 10

What prescription drugs can cause Secondary HTN?

Back 10

1) Prednisone, fludrocortisone,triamcinolone

2) Amphetamines/anorexiants: phendimetrazine, phentermine, sibutramine

3) Antivascular endothelin growth factor agents

4) Estrogens: usually oralcontraceptives

5) Calcineurin inhibitors: cyclosporine, tacrolimus

6) Decongestants: phenylpropanolamine& analogs

7) Erythropoiesis stimulating agents:erythropoietin, darbepoietin

8) NSAIDs, COX-2 Inhibitors

9) Venlafaxine

10) Bupropion

11) Bromocriptine

12) Buspirone

13) Carbamazepine

14) Clozapine

15) Ketamine

16) Metoclopramide

Front 11

What situations can cause secondary HTN?

Back 11

1) When b-Blocker or centrally acting a-Agonists are abruptly discontinued

2) when treating pheochromocytoma with b-Blocker without a-blocker first

Front 12

What food substances can cause secondary HTN?

Back 12

1) Sodium

2) Ethanol

3) Licorice

Front 13

What are the Street drugs that causes Secondary HTN?

Back 13

1) Cocaine

2) Cocaine withdrawal

3) ???

Front 14

Other natural products causing secondary HTN

Back 14

??

Front 15

What are the mechanisms of pathogenesis in HTN?

Back 15

1) Increased Cardiac Output (CO)

2) Increased Peripheral resistance (PR)

Front 16

What are the components of Increased Cardiac output (CO)?

Back 16

1) Increased Preload

- Increased fluid volume

- Excess sodium intake

- Renal sodium retention

2) Venous constriction

- Excess RAAS stimulation

- Sympathetic nervous system overactivity

Front 17

What are the components of Increased peripheral resistance (PR)?

Back 17

1) Functional Vascular constriction

- Excess RAAS stimulation

- Sympathetic nervous system overactivity

- Genetic alterations of cell membranes

- Endothelial-derived factors

2) Structural Vascular hypertrophy

- Excess RAAS stimulation

- Sympathetic nervous system overactivity

- Genetic alterations of cell membranes

- Endothelial-derived factors

- Hyperinsulinemia due to obesity, metabolic syndrome

Front 18

What are the blood pressure determinants?

Back 18

1) CO

- HR

- SV: Contractility & Volume

2) SVR

**** Direct relationship****

Front 19

Increase in CO or SVR will result in ___________

Back 19

Increase in BP

Front 20

Decrease in volume will result in __________

Back 20

1) Decrease in BP

2) will then result in increase in HR

3) will then result in increase in CO

4) will then hopefully restore the BP

Front 21

What are goals of HTN management and prevention?

Back 21

1) To reduce morbidity and mortality by the least intrusive means possible

**Maintain SPB < 120, DBP < 80 & controlling other CV risk factors**

Front 22

What are some medications that can be used as treatment option for HTN?

Back 22

1) Diuretics

2) Beta blockers

3) ACE inhibitors

4) Angiotensin II receptor blockers

5) Calcium channel blockers

6) Alpha blockers (Alpha 1 antagonist)

7) Centrally acting alpha agonists

8) Direct vasodilators

9) Peripheral adrenergic blockers

Front 23

What are some life style modifications options for treatment of HTN?

Back 23

Begin or continue lifestyle modifications

1) Lose weight

2) Limit Alcohol

3) Increase physical activity

4) Reduce sodium

5) Maintain potassium

6) Maintain calcium and magnesium

7) Stop smoking

8) Reduce saturated fat & Cholesterol

Front 24

Algorithm for treatment of HTN

Back 24

1) Begin or continue lifestyle modifications

"If Not at goal BP (<120/80)- (lower goals for patients with diabetes or renal disease)"

2) Initial drug choices

- influenced by other disease states

- Start at low dose and titrate upward

- low dose combination may be appropriate

Front 25

What is mechanism of action of Diuretics?

Back 25

1) Reduce volume

2) Prevent sodium reabsorption

3) Diuretic potency associated with proximal action

--(the increase in potency on nephron - the more decrease in resultant BP)

4) Mild vasodilation

Front 26

Name the types of Diuretics and which part of kidney they act on?

Back 26

1) Carbonic anhydrase inhibitor - Proximal convoluted tubule

2) Thiazide diuretics - distal convoluted tubules

3) Potassium-sparing diuretics - collecting tubules

4) Loop diuretics - peritubular capillary

Front 27

What is the mechanism of action of Carbonic Anhydrase inhibitors?

Back 27

1) Acts at luminal membrane of proximal tubule

2) Enhances bicarbonate reabsorption in proximal tubules

** Inhibitors block sodium bicarbonate reabsorption ** -- Diuretics

Front 28

Carbonic Anhydrase inhibitors are _____________

Name 2 carbonic anhydrase inhibitors.

Back 28

Weak diuretics

1) Acetazolamide (Diamox)

- PO

- Injectable

2) Dorzolamide (truspopt)

- Ophthalmic solution

Front 29

Carbonic anhydrase inhibitor - Acetazolamide are _______

Back 29

1) Well absorbed

2) Onset of action 30 mins

3) Peak action at 2 hours

4) Excreted via kidneys (tubular secretion)

Front 30

What are some indications for clinical uses of Acetazolamide?

Back 30

1) Glaucoma (decreased rate of aqueous humor formation)

2) Urinary alkalinization

3) Metabolic alkalosis

4) Mountain sickness

Front 31

What is the mechanism of action of Loop Diuretics?

Back 31

1) Inhibit sodium reabsorption in the thick ascending limb of the loop of henle

2) Some proximal tubule action

3) Well and rapidly absorbed

Front 32

Name 4 Loop Diuretic drugs.

Back 32

1) Furosemide (Lasix)

2) Ethacrynic acid (Edecrin)

3) Bumetanide (Bumex)

4) Torsemide (Demadex) - fastest absorption

Front 33

Which one of the loop diuretic drug is not a sulfonamide?

Back 33

Ethacrynic acid (Edecrin)

Front 34

What are the adverse effects of Loop diuretics?

Back 34

1) Hypovolemia

2) Hypokalemia

3) Metabolic alkalosis

4) Hypomagnesemia

5) Hypocalcemia

6) Hyperuricemia

7) Ototoxicity

Front 35

What are some Indications/clinical uses of loop diuretics?

Back 35

1) Acute pulmonary edema

2) Hypercalcemia

3) Maintenance in CHF

Front 36

What is the mechanism of action of Thiazides?

Back 36

1) Block sodium reabsorption in the distal tubule

2) Sulfonamide derivatives

3) Require normal renal function to be effective

Front 37

What are the adverse effects of thiazides?

Back 37

1) Hypokalemia

2) Hypomagnesemia

3) Hypercalcemia

4) Hypertriglyceridemia

5) Hyperglycemia

6) Hyperuricemia

Front 38

Name 6 Thiazide drugs.

Back 38

1) Hydrochlorothiazide

2) Chlorthalidone (Hygroton)

3) Chlorothiazide (Diuril)

4) Methyclothiazide (Enduron)

5) Indapamide (Lozol)

6) Metolazone (Zaroxolyn)

Front 39

What are some indications/clinical uses of thiazide drugs?

Back 39

1) HTN

2) CHF (combination with loop diuretic)

3) Nephrolithiasis

Front 40

What is the maximum dose of HCTZ?

Back 40

Highest dose is 25mg PO BID

--- Maximum per dose = 25mg

--- Maximum per day = 50mg

Doses available are 12.5mg, 25mg, 50mg

Front 41

What are the names of potassium sparing diuretic drugs? (3)

Back 41

1) Spironolactone (Aldactone)

2) Triamterene

3) Amiloride

*** Low Potency ***

Front 42

____________ is competitive antagonist of aldosterone?

Back 42

Spironolactone (Aldactone)

Front 43

What are some adverse effects of potassium sparing diuretic drugs?

Back 43

1) Hyperkalemia

2) Metabolic acidosis

3) Antiandrogenic effects

Front 44

What is the name of Osmotic Diuretics drug?

Back 44

1) Mannitol

** Used in the reduction of intraoccular and intracranial pressure**

Front 45

Name some Combination diuretic Therapies.

Back 45

1) Thiazides plus potassium sparing

- Dyazide = HCTZ + triamterene

- Maxzide = HCTZ + triamterene

- Aldactazide= HCTZ + Spironolactone

2) Thiazides plus loop diuretics

Front 46

What are some benefits of Diuretics?

Back 46

1) Work well in all groups of patients

2) Cheap

Front 47

What type of diuretic is primarily used for CHF patients?

Back 47

Loop diuretics (furosemide)

**Combination of loop diuretics and thiazides (or other diuretics) can also be used**

Front 48

What are some problems with diuretics?

Back 48

1) Limited dosing

2) Fluid and electrolyte imbalance

3) Decreased glucose control (Thiazides only)

4) Hypertriglyceridemia (Thiazides only)

Front 49

What are compelling indications for diuretics?

Back 49

1) Isolated Systolic HTN

2) CHF

** Indication unless Contraindicated**

Front 50

What is a possible favorable effects of Diuretics (Thiazides)?

Back 50

Osteoporosis

Front 51

What are possible unfavorable effects of diuretics?

Back 51

1) DM

2) Gout

3) Renal insufficiency

Front 52

What is mechanism of action of Beta-Blockers?

Back 52

1) Effective in reducing blood pressure

2) Negative Chronotropy

3) Negative inotropy

Front 53

Name the Beta-blocker drugs for HTN.

Back 53

1) Propranolol (Inderal)

- Nonspecific Beta Blocker

2) Atenolol (Tenormin)

- Beta 1 antagonist

3) Metoprolol (Lopressor)

- Beta 1 antagonist

Front 54

What are the contraindications of Beta-blocker?

Back 54

1) Asthma

- Causes Bronchospasm

2) DM

- Masks the hypoglycemia symptoms

3) CHF

- Causes a negative inotropic effect (decreased contractility)

Front 55

What hormone is released by the kidney in response to low BP?

Back 55

Renin

**Renin binds to angiotensinogen and converts it to Angiotensin I**

Front 56

What is the function of Angiotensin I?

Back 56

**Nothing**

It is useless

Front 57

What converts the Angiotensin I to Angiotensin II?

Back 57

ACE = Angiotensin converting enzyme

**ACE is secreted and released by the lungs**

Front 58

What receptor does Angiotensin II binds to?

Back 58

AT1 receptor

Front 59

What is one of the effect of Angiotensin II?

Back 59

1) Potent Vasoconstriction

*** results in increase systemic vascular resistance and increase BP***

Front 60

What is the mechanism of action of ACEI?

Back 60

1) Block the conversion of the relatively inactive Angiotensin I to Angiotensin II

-- Decreases the level of Angiotensin II

-- Lowers BP by reducing peripheral vascular resistance

Front 61

What is the other mechanism of action of ACEI?

Back 61

1) Inhibits the breakdown of Bradykinin

-- Increases the level of bradykinin (leads to s/e dry cough)

Front 62

What is the function of bradykinin?

Back 62

A peptide that increases the production of Nitric oxide (NO) and prostacyclin

** Nitric oxide and prostacyclin are potent vasodilators**

Front 63

Summarizing the effects of ACE inhibitors___

Back 63

1) Decrease Angiotensin II

- Decrease vasoconstriction

2) Increase Bradykinin

- Enhanced vasodilation

Front 64

How does the ACE inhibitor affect the preload and afterload?

Back 64

1) Decreases the preload and afterload

thus decreases the cardiac work

Front 65

What are the adverse effects of ACEI?

Back 65

1) Dry cough

2) Renal dysfunction

3) Hyperkalemia

Front 66

What is the comorbid condition that can lead to renal dysfunction when ACEI is used?

Back 66

Renal Artery Stenosis

** narrowing of B/L renal arteries**

Front 67

What are some resultant effects of reduced circulating angiotensin II levels?

Back 67

1) Decreased secretion of aldosterone (from adrenal cortex)

Results in

- decrease sodium and water retention

Front 68

ACEI are less effective in __________

Back 68

African Americans

Front 69

Name the ACE inhibitors.

Back 69

1) Captopril (Capoten)

2) Enalapril (Vasotec)

3) Lisinopril (Prinivil)

4) Benazepril (Lotensin)

5) Quinapril (Acupril)

6) Ramipril (Altace)

7) Fosinopril (Monopril)

8) Trandolapril (Mavik)

Front 70

What is the mechanism of action of the Angiotensin II receptor blockers (ARBs)?

Back 70

Blocks the AT1 receptors by binding to them

(have high affinity to the receptors)

**decreasing the activation of the AT1 receptors by Angiotensin II**

Front 71

What are the pharmacological effects of ARBs?

Back 71

1) Block Aldosterone secretion by blocking Angiotensin II

2) Produce arteriolar and venous dilation

**Thus lowers BP and decrease salt and water retention**

Front 72

ACEI and ARBs can be used as _________ therapy for HTN

Back 72

First line therapy

*** Especially in patients with compelling indications of DM, CKD, or HF***

Front 73

What the the adverse effects of ARBs?

Back 73

1) Renal dysfunction

2) Hyperkalemia

Front 74

Can ACEI and ARBs be used as combination therapy?

Back 74

ACEI and ARB should not be combined due to similar mechanisms and adverse effects

Front 75

Name the Angiotensin II blocker drugs.

Back 75

1) Losartan (Cozaar)

2) Valsartan (Diovan)

3) Irbesartan (Avapro)

4) Candesartan (Atacand)

5) Telmisartan (Micardis)

6) Olmesartan (Benicar)

Front 76

What is the mechanism of action of Direct Renin inhibitor?

Back 76

1) Inhibits the Renin production

2) Decreases plasma renin activity

3) Improving RAAS suppression

*** Similar efficacy to ACEI & ARB***

Front 77

Name the Renin Inhibitor

Back 77

Aliskiren (Tekturna)

Front 78

What are the side effects of direct renin inhibitors?

Back 78

1) Headaches

2) Dizziness

3) Diarrhea

Front 79

What is the result of the RAAS inhibition?

Back 79

All agents that inhibit RAAS, including renin inhibitors

1) Suppresses the negative feedback loop

2) Leading to compensatory rise in plasma renin concentration

3) Increase in plasma renin activity (when treated with ACEI & ARBs)

Front 80

What is the mechanism of action of Alpha-1 Antagonists?

Back 80

1) Vasodilation

**Good second line agent**

**Beneficial to person with HLD**

Front 81

What are the adverse effects of Alpha-1 Antagonists?

Back 81

1) First dose hypotension & syncope

2) Reflex tachycardia

Front 82

Name the Alpha-1 Antagonists drugs.

Back 82

1) Prazosin (Minipress)

2) Terazosin (Hytrin)

3) Doxazosin (Cardura)

Front 83

What is the mechanism of action of alpha-beta blocker?

Back 83

1) Potent adrenergic blocker for rapid blood pressure reduction

**At higher doses - Alpha blocking effects dominate**

Front 84

Name the alpha-beta blocker

Back 84

Labetalol

Front 85

What is the indication/clinical use of Labetalol?

Back 85

1) Management of gestational HTN (preeclampsia?)

**will not induce pre-term labor as the beta-blocking effects are small**

2) HTN urgencies and emergencies

Front 86

What is the mechanism of action of the Alpha-2 agonists?

Back 86

1) Produces inhibition to sympathetic vasomotor center

--- Decreases the sympathetic outflow to the periphery

Front 87

What are the effects of Alpha-2 agonists?

Back 87

Decreases peripheral resistance

- thus decreases BP

Front 88

Name the 2 Alpha-2 agonists

Back 88

1) Clonidine (Catapres) (PO & Patch)

2) Methyldopa (Aldomet) (PO & IV)

Front 89

What are the indication/clinical use of Clonidine & Methyldopa?

Back 89

1) Clonidine - HTN urgencies

2) Methyldopa - HTN in pregnancy

Front 90

What are the adverse effects of Alpha-2 agonists?

Back 90

1) Sedation / Sleepy

2) Depression

3) Sexual dysfunction

Front 91

What is the mechanism of action of the direct vasodilators?

Back 91

Vasodilation

Front 92

Name the direct vasodilators.

Back 92

1) Hydralazine (Apresoline)

2) Minoxidil

**3rd or 4th line treatment for HTN**

**Can occasionally be used on pregnant women with HTN**

Front 93

What are the adverse effects of direct vasodilators?

Back 93

1) Water retention (peripheral edema)

2) Reflex tachycardia

Front 94

Name the Calcium channel blockers

Back 94

1) Verapamil (Calan)

2) Diltiazem (Cardizem)

3) Dihydropyridines

Front 95

What is the mechanism of action of Verapamil?

Back 95

Affects the cardiac and vascular smooth muscle cells - Negative inotropic effect

Primary effect

1) Decrease contractility

2) Decrease automaticity and conduction

Secondary effect

1) Vasodilation

Front 96

What is the contraindication for verapamil?

Back 96

Should never be used for patient with HF

**due to its effect of decrease in contractility**

Front 97

What is the most common adverse effect of verapamil?

Back 97

Constipation

**decrease peristalsis movement (contraction) in intestines**

Front 98

What is the mechanism of action of diltiazem?

Back 98

Also affects the cardiac and vascular smooth muscle cells

** however less of the negative inotropic effect compared to verapamil**

** more favorable side effects compared to verapamil**

Front 99

What is the mechanism of action of dihydropyridines?

Back 99

Primary effect

-- Vasodilation

Front 100

Name the dihydropyridines calcium channel blockers

Back 100

1) Nifedipine(Procardia, Adalat)

- Sustainedrelease preparations (XL vs. CC)

2) Felodipine (Plendyl)

3) Nicardipine (Cardene) –also available IV

4) Isradipine (Dynacirc)

5) Amlodipine(Norvasc)

6) Nisoldipine (Sular)

Front 101

What are some combined therapies for HTN treatment?

Back 101

1) b-adrenergicblockers and diuretics

2) ACE inhibitors and diuretics

3) Angiotensin II receptor antagonistsand diuretics

4) Calcium channel blockers and ACEinhibitors

5) Other combinations

Front 102

What are the initial drug choices for stage 1 & stage 2 HTN treatment?

Back 102

1) Thiazide diuretics

2) b-Blockers

3) ACEI, ARBs

4) CCBs

Front 103

How many drugs should be in the therapy for Stage 1 and Stage 2 HTN treatment?

Back 103

Stage 1 = 1

Stage 2 = 2

Front 104

What should be the options if the BP goal (<120/80) has not yet met after the initial drug choices?

Back 104

1) If no response or trouble some side effects

--- Substitute another drug from different class

2) If inadequate response but well tolerated

--- Add second agent from different class

--- Diuretic if not already used

3) If the goal is still not met

--- Continue adding agents from other classes

--- Consider referral to HTN specialist (if already on 3 agents with uncontrolled HTN)

Front 105

What are some special considerations when selecting drug therapy?

Back 105

1) Demographics

2) Coexistingdiseases and therapies

3) Qualityof life

4) Physiologicaland biochemical measurements

5) Druginteractions

6) Economicconsiderations

Front 106

How to treat HTN in Pregnancy?

Back 106

1) Important to differentiate preeclampsia from chronic, transient & gestational HTN

2) Preeclampsia = >140/90 after 20 weeks of gestation w/ proteinuria

Front 107

What is the drug of choice for HTN treatment in pregnancy?

Back 107

1) Methyldopa **

2) Labetalol

**Definitive treatment - Delivery**

Patient education - restricted activity, bed rest, close monitoring

Front 108

What is the benefit of combination therapy?

Back 108

May provide additional efficacy with fewer adverse effects

Front 109

How to dose for drug therapy?

Back 109

1) Low dose of initial drug should be used

-- Slowly titrating upwards

2) Optimal formulation should provide 24-hour efficacy with once daily dose

-- with at least 50% peak effect remaining at the end of 24 hours

Front 110

When should be the next follow up appointment after starting drug therapy?

Back 110

Within 1-2 months after initiating therapy

Front 111

What should be some considerations after initiating therapy?

Back 111

1) Recognizethat high-risk patients often require high dose or combination therapies andshorter intervals between changes in medications.

2) Considerreasons for lack of responsiveness if blood pressure is uncontrolled afterreaching full dose.

3) Considerreducing dose and number of agents after 1 year at or below goal.

Front 112

What are some agents used for HTN emergencies?

Back 112

1) Nitroprusside

2) Nicardipine

3) Nitroglycerin

4) Phentolamine (potent a-blocker for emergency)

Front 113

What are some agents used for HTN urgencies?

Back 113

1) Labetalol

2) Atenolol(?)

3) Esmolol(continuous infusion) (not well during emergency

4) Enalaprilat (IV push)

5) Hydralazine

Front 114

What are some special consideration for HTN treatment in older person?

Back 114

1) Starting doses for drug therapy should be lower than those in younger adults

2) Goal of therapy is the same

-- Although interim goal of SBP <160 may be necessary

Front 115

What agent should not be the drug of choice for initial therapy for older patients?

Back 115

Alpha-1 Blockers

Front 116

Which class medications is indicated for HLD patients that have HTN as well?

Back 116

Alpha 1- Blockers ("Zosins")

- Increases HDL

- Decreases LDL