IM HTN

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Author:
TerryZ
ID:
246100
Filename:
IM HTN
Updated:
2013-11-27 09:38:55
Tags:
internal medicine IM hypertension HTN
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IM
Description:
Internal Medicine - Hypertension
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  1. Secondary HTN - causes
    • Renal parenchymal
    • renovascular
    • primary aldosteronism
    • mendelian
    • pheochromocytomaOSA
    • drug-induced
    • H/HoThy
    • chronic steroid TX
    • Cushing's syndrome
    • coarctation of the aorta
  2. Suspect identifiable causes of HTN when...
    BP responds poorly to drug tx, suddenly increases, with unprovoked HoK, HCa, ^Cr, Abnl UA
  3. Hypertensive emergency (malignant hypertension)
    • >180/120 w/ s/sx acute end-organ damage
    • - myocardial/cerebral ischemia/infarct
    • - pulmonary edema
    • - renal failure
    • Severe HA, visual chgs, papilledema, CP
    • Grade IV hypertensive retinopathy (exudates, hemorrhages, papilledema)
    • CV/renal compromise
    • Encephalopathy
    • MUST be hospitalized
    • May lead to stroke, MI, AKI, death
  4. HTN stage I - tx
    • Thiazide-type diuretics
    • ?ACEi, ARB, BB, CCB, combo
  5. HTN stage II - tx
    2-drug combo (thiazide diuretic + ACEi or ARB or BB or CCB)
  6. Loop diuretics
    • X: furosemide, torsemide
    • M: inhib active Cl Xsport in thick ascending LoH
    • S: interstial nephritis, HoK, /succinylcholine, aminoglycoside ototxicity
    • C: anuria
  7. Thiazide diuretics
    • X: chlorothiazide, hydrochlorothiazide
    • M: inhib NaCL reabsorption (DCT)
    • S: insulin resist, HoK, HoNa, HTrigly, HUrice-mia, ED, photosens, /non-depol musc relax
    • C: anuria
  8. Potassium-sparing diuretics
    • X: amiloride, triamterene
    • M: xNa channel in late DCT & collect duct
    • S: fatal HK w/ salt substitute, ACEi, ARB, ^K foods, NSAIDS
    • C: HSens, ^K+, other K-preservers, anuria, a/c K insuff, diabetic neuropathy
  9. Aldosterone receptor blockers
    • X: eplerenone, spironolactone
    • M: competes w/aldo for receptors in DCT; ^Na, H20 excretion; conserves K+, H+
    • S: HK+, spiro->gynecomastia, BPH, impotence
    • C: anuria, acute renal insufficiency, HK+
    • NOT: "ARB"
  10. ACE inhibitors
    • X: captopril, lisinopril, ramipril, benazepril
    • M: x angiotensin I->II, x aldosterone
    • S: cough, HK+, angioedema, leukopenia, fetal toxicity, cholestatic jaundice
    • C: h/o angioedema w/ ACEi, B renal a. sten., 2nd/3rd trimesters
  11. Angiotensin II antagonists
    • X: losatran, valsartan, irbesartan
    • M: x angiotensin II, mediates vasodilation, activates NO
    • S: HK+, angioedema, fetal toxicity
    • C: B renal a. stenosis, pregnancyYES: "ARB"
  12. Alpha-1 blockers
    • X: doxazosin, prazosin, terazosin
    • M: inhib alpha1 recept->vasodil arterioles/veins
    • S: orthoHoTN, drug tol, ankle edema, CHF, 1st dose, /HoTN with PDE-5
    • C: HSens
  13. Central alpha-2 agonists/centrally acting drugs
    • X: clonadine, methyldopa, guanfacine, reserpine
    • M: alpha adrenergic agonist->vSympath heart, kidney & peripheral vasculature
    • S: depress, dry mouth, lethargy, ED, rebound HTN (clonadine), coombs, hemolytic anemia & LFTs (methyl)
    • C: MAOI use, liver dz
  14. Beta blockers
    • X: atenolol, metoprolol, propranolol, bisoprolol
    • M: v sympath stim of <3 & vessels
    • S: insulin resist, <3 block, acute decomp CHF, bronchospasm, depress'n, nightmares, fatigue, cold extremities, claudicat'n, SJS, agranulocyt
    • C: sev bradycard, decomp HF, <3 block, HoTN
  15. CCBs - non-dihydropyridines
    • X: diltiazem, verapamil
    • M: Ca channel block Ca current-> smooth muscle relax, vContractility, vMyocardial O2 demand, vPVR, VHD
    • S: brady, AVblock, constip, syst fn, CHF, gingival edema/hypertrophy, ^cyclosporine, esophageal reflux
    • C: sev LV dysfn, HoTN, sick sinus syndrome, 2/3o <3 block, aFlut, aFib, WPW
  16. CCBs - dihydropyridines
    • X: amlodapine, nicaridipine, nifedipine
    • M: Ca channel block Ca current-> smooth muscle relax, vContractility, vMyocardial O2 demand, vPVR, VHD
    • S: HA, flush, ankle edema, CHF, gingival hyperplasia, esophageal reflux
    • C: HSens
  17. Direct vasodilators
    • X: hydralazine, minoxidil
    • M: direct relax vasc sm musc in resistance vessels, reflex activat'n of autonomic reflexes, stimulates RAAS
    • S: reflex tachy, fluid retent'n, hirsuitism & pericard effusion w/ minox; lupus w/hydral
    • C: HSense, mitral valve rheum <3 dz, pheochr
  18. Treating HTN - with cerebrovascular dz
    ACEi + thiazide diuretic
  19. Treating HTN - with postural HoTN
    • SBP v10 mmHg+, dizzy/faint
    • More freq in elderly, syst HTN, DM, taking diuretics, venodilators, psychotropics
    • Avoid volume depletion/rapid titration
    • Low dose thiazide diur + dhp CCB +/- ACEi, ARB
  20. Treating HTN - with T2DM
    • <130/80
    • 3-5 drugs
    • ACEi/ARB
    • thiazide/loop diuretic
    • dhp CCB after ACEi/ARB
  21. Treating HTN - with CKD
    • <130/80
    • Aggressive BP mgmt (3+ drugs)
    • ACEi + ARBs
    • /renal dz -> /loop diuretics
  22. Treating HTN - with HF
    • Asympt: ACEis + BB
    • Sympt:  ACEis, BB, ARBs, aldost, + loop diur
  23. Treating HTN - with ischemic HD
    • IHD: BB (or long-acting CCB)
    • UA/MI: BB + ACEi
    • Post-MI: ACEi, BB, Aldost antag
  24. Treating HTN - with pregnancy
    methyldopa + BB + vasodilators

    DO NOT use ACEis, ARBs
  25. Treating HTN - with children/adolescents
    • Lifestyle mods
    • Doses smaller for children
    • X ACEi/ARB in pregnant/sexually active girls
    • X anabolic steroids
  26. Treating HTN - in minorities
    • CCB + diuretic
    • ( BP response to mono-tx w/ BB, ACEi, ARB)
    • ACEi-induced angioedema 2-4x in AA

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