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Name 4 drugs/drug classes that may lead to secondary HTN
- Adrenocorticosteroids (prednisone)
- Antidepressants (Effexor, SNRIs, TCAs, MAOIs)
- NSAIDS, Cox-2 Inhibitors
- Sympathomimetics (decongestants, anorectics)(sudafed, phenylephrine)
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Categories for classifying BP as set forth by the JNC VII - Seventh Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure
- Normal: Systolic < 120, Diastolic < 80, no drug therapy needed
- Prehypertension: Systolic 120-139, Diastolic 80-89, no drug therapy needed
- Stage 1 HTN: Systolic 140-159, Diastolic 90-99, Drug therapy = thiazide or other monotherapy
- Stage 2 HTN: Systolic >/= 160, Diastolic >/= 100, Drug therapy = 2 drug combo
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Goals of therapy for HTN
- Uncomplicated HTN - BP goal < 140/90
- Diabetes mellitus - < 130/80
- Chronic kidney disease - < 130/80
- CAD, high CAD risk (CAD risk equivalent or 10 year Framingham risk score > 10%), HF - < 130/80
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What are the high risk conditions with compelling indications?
- heart failure
- post MI
- high coronary disease risk
- diabetes mellitus
- chronic kidney disease
- recurrent stroke prevention
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Which antihypertensive class is recommended for all compelling indications?
ACE inhibitors
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What are lifestyle modifications to reduce HTN?
- weight reduction
- diet (reduced fat)
- moderation of alcohol intake (men NMT 2 drinks/day, women NMT 1 drink/day)
- physical activity
- moderation of dietary sodium
- potassium intake (caution in pts susceptible to hyperkalemia - renal insufficiency, ACEIs or ARBs)
- cigarette smoking
- caffeine - causes an ACUTE rise in BP
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Guidelines for pharmacological treatment of HTN
- 1. Begin with lowest dose of antihypertensive
- 2. If BP is uncontrolled after 2 months, pt is compliant, and no intolerable effects, increase dose
- 3. If response is inadequate after reaching full dose, a. add 2nd drug if tolerating 1st, b. d/c and start new agent if pt is not tolerating d/t SEs or had no response
- 4. BP measurement in early AM covers surge in BP after rising, measurement in late PM ensures adequate coverage throughout the day
- 5. Once controlled, follow up q 3-6 months
- 6. Monitoring parameters - a. efficacy - BP, compliance; b. safety - SEs, DIs, CIs, allergies
- 7. Resistant HTN: assess med adherence, lifestyle factors, white-coat syndrome, drug regimen
- 8. Pt counseling: a. won't feel BP if too high, maybe if too low; b. compliance is important to prevent stroke, AMI, etc; c. ask about OTCs that can interfere with BP meds; d. SEs of individual meds, dizziness; e. what to do for missed doses; f. do not abruptly stop taking BP meds
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5 types of diuretics and examples of each
- Loops (bumetanide, ethacrynic acid, furosemide, torsemide) - primary in HF, not really used for HTN
- Thiazides (chlorothiazide, HCTZ, metolazone, chlorthalidone, indapamide) - primarily used for HTN
- Potassium-sparing (amiloride, triamterene) - not usually used alone - not often used for HTN
- Aldosterone Antagonists (AAs) (eplerenone, spironolactone) - not usually used alone - not often used for HTN
- Carbonic anhydrase inhibitors (acetazolamide) - very rarely used in HTN
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Conditions favoring use of diuretics
- Chronic renal failure (loops - don't increase K+)
- Osteoporosis prevention (thiazides - can increase calcium in body) (don't work well in pts with renal failure)
- Cirrhosis (AAs)
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Unfavorable effects of diuretics
- hyperkalemia - avoid AAs and potassium-sparing
- Renal insufficiency - avoid AAs and potassium-sparing
- gout
- dyslipidemia
- diabetes (high dose)
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What effect do loop diuretics have on potassium and calcium?
they decrease both
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What effect do thiazide diuretics have on potassium and calcium?
decrease potassium and increase calcium
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Which 6 Beta-blockers work on only beta-1 receptors?
- acebutolol
- atenolol
- betaxolol
- bisoprolol
- metoprolol
- nebivolol (< 10 mg)
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Which 6 beta-blockers work on both beta-1 and beta-2 receptors?
- cartelol
- nadolol
- penbutolol
- pindolol
- propranolol
- timolol
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Which 2 beta-blockers work on alpha-1, beta-1, and beta-2 receptors?
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What is ISA and which 5 beta-blockers can cause it?
Intrinsic Sympathomimetic Activity (reflex tachycardia)
- acebutolol
- carteolol
- labetalol
- penbutolol
- pindolol (the most likely to cause it)
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Conditions favoring use of BBs
- tachycardia, atrial fibrillation
- migraine
- angina
- esophageal varices
- essential tremor
- hyperthyroidism
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Unfavorable effects of BBs
- bronchospastic disease (any respiratory disease - especially the drugs that hit B-2 receptors - skip BBs altogether in asthma)
- diabetes
- acute heart failure
- depression
- heart block
- peripheral vascular disease
- dyslipidemia
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Important warning with beta-blockers
Do not abruptly discontinue - taper off
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Name the 6 dihydropyridine Calcium Channel Blockers
- amlodipine
- felodipine
- isradipine
- nicardipine
- nifedipine
- nisoldipine
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Name the 2 non-dihydropyridine CCBs
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Conditions favoring use of CCBs
- non-DHP:
- angina, AMI
- tachycardia, atrial fib (not heart block)
- migraine
- diabetes with proteinuria
- DHP:
- PVD
- (ok to use in heart failure)
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CCBs may have unfavorable effects on:
- heartblock (non-DHP)
- heart failure (non-DHP)
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What is the warning with CCBs?
do not stop abruptly - risk of rebound HTN/angina
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Which ACE inhibitor is short-acting?
captopril
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Which 5 ACE inhibitors are intermediate-acting?
- benazepril
- enalapril
- moexipril
- quinapril
- ramipril
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Which 4 ACE inhibitors are long-acting?
- fosinopril
- lisinopril
- perindopril
- trandolapril
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Compelling indications for ACEIs
ALL of them (HF, post MI, high coronary disease risk, diabetes, CKD, recurrent stroke prevention)
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Conditions favoring use of ACEIs
- preferred in diabetics
- proteinuria
- T1DM nephropathy
- peripheral edema from CCB
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ACEIs can have unfavorable effects on:
- Pregnancy
- bilateral renal artery stenosis
- hyperkalemia
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Name a very common adverse reaction to ACEIs
dry cough
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ACEI CIs
angioedema from previous ACEI, pregnancy, bilateral renal artery stenosis
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Name 7 angiotensin II receptor blockers (ARBs)
- candesartan
- eprosartan
- irbesartan
- losartan
- olmesartan
- telmisartan
- valsartan
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Conditions favoring use of ARBs
- proteinuria
- T2DM nephropathy
- ACEI-induced cough
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ARB unfavorable effects
- bilateral renal artery stenosis
- hyperkalemia
- pregnancy
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Should ARBs be used when a pt has ACEI-induced angioedema?
Don't use if the reaction was severe and if there is no compelling indication to use it
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Name the non-selective Peripheral-acting Alpha-1 Receptor Blockers (alpha-1 antagonists)
- alfuzosin
- doxazosin
- prazosin
- terazosin
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Which alpha-blocker/antagonist is selective? What is it selective for?
tamsulosin - selective to prostate, so not used for HTN
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Which alpha-1 antagonists are the "best" d/t the fact that they are less expensive and need to be dosed less frequency?
doxazosin and terazosin
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Compelling indications for alpha-1 antagonists
none
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Conditons favoring use of Alpha-1 Antagonists
BPH
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Alpha-1 unfavorable effects
Elderly - 1st dose syncope and postural hypotension
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Should alpha-1 antagonists be used in combos?
no - risk of severe hypotension (exception is tamsulosin, but it's not used for BP anyway)
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What trial compared CCB v. ACEI v. alpha-blockers for monotherapy use in HTN?
ALLHAT
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What 2 centrally-acting Alpha-2 Agonists are used clinically?
Clonidine (Catapres) and Methyldopa (Aldomet)
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Conditions favoring use of alpha-2 agonists
- pregnancy/breastfeeding (methyldopa)
- drug addiction (clonidine)
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Alpha-2 Agonists unfavorable effects
depression
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Alpha-2 agonists warning
do not abruptly d/c - can cause rebound angina/HTN
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What type of agent is Reserpine?
Indirect Vasodilating Agent - OLD!
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Name 2 direct-acting arterial vasodilators
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Conditions favoring use of direct-acting vasodilators
- Heart failure - hydralazine
- Hair growth desired - minoxidil
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What does aliskiren (Tekturna) inhibit?
Renin - directly
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Which meds are FDA approved for HTN in pregnancy? Which have the most data?
- None are approved
- Methyldopa and labetalol have the most data
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Which HTN meds are contraindicated in pregnancy?
ACEIs and ARBs
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How is CKD defined?
- Decrease in GFR of 60 ml/min/1.73m2
- or SCr > 1.5 in men or > 1.3 in women
- or albuminuria
- (must be decreased CrCl due to increased SCr)
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What is the BP goal in CKD and what drugs are usually used?
- Goal: < 130/80
- Often 3 or more drugs are needed to control HTN
- Usually ACE/ARB/loop diuretic
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Which antihypertensive meds have favorable effects in CKD?
ACEIs and ARBs
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Which antihypertensives are preferred for use in diabetics?
ACEIs, ARBs are preferred
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What is the recommended tx HTN in a pt with migraines?
- beta-blockers (especially non-selective)
- verapamil
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Which meds should be avoided in a HTN pt with asthma/COPD with bronchospasm?
Beta-blockers (especially the non-specific ones)
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What HTN drugs should be avoided in pts with depression?
- Beta-blockers
- Alpha-2 agonists
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Which HTN meds should be avoided in pts with bradycardia/AV block?
- Beta-blockers
- Non-DHP CCBs
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What are the recommended HTN treatments for a pt with tachycardia/atrial fib?
- beta-blockers
- non-DHP CCBs
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What are the preferred HTN meds for a pt with diabetes?
ACEIs and ARBs
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What HTN meds are recommended in pregnancy? Which should be avoided?
- Recommended - methyldopa, labetalol
- Avoid - ACEIs, ARBs
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Which HTN medication is recommended treatment for osteoporosis?
Thiazides
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Which HTN meds are recommended and which should be avoided in pts with renal insufficiency?
- Recommended: ACEIs, ARBs, Loop Diuretics
- Avoid: K+ sparing diuretics, thiazides (don't work well)
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