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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)
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
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
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
Which antihypertensive class is recommended for all compelling indications?
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
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
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
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)
Unfavorable effects of diuretics
- hyperkalemia - avoid AAs and potassium-sparing
- Renal insufficiency - avoid AAs and potassium-sparing
- diabetes (high dose)
What effect do loop diuretics have on potassium and calcium?
they decrease both
What effect do thiazide diuretics have on potassium and calcium?
decrease potassium and increase calcium
Which 6 Beta-blockers work on only beta-1 receptors?
- nebivolol (< 10 mg)
Which 6 beta-blockers work on both beta-1 and beta-2 receptors?
Which 2 beta-blockers work on alpha-1, beta-1, and beta-2 receptors?
What is ISA and which 5 beta-blockers can cause it?
Intrinsic Sympathomimetic Activity (reflex tachycardia)
- pindolol (the most likely to cause it)
Conditions favoring use of BBs
- tachycardia, atrial fibrillation
- esophageal varices
- essential tremor
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
- heart block
- peripheral vascular disease
Important warning with beta-blockers
Do not abruptly discontinue - taper off
Name the 6 dihydropyridine Calcium Channel Blockers
Name the 2 non-dihydropyridine CCBs
Conditions favoring use of CCBs
- angina, AMI
- tachycardia, atrial fib (not heart block)
- diabetes with proteinuria
- (ok to use in heart failure)
CCBs may have unfavorable effects on:
- heartblock (non-DHP)
- heart failure (non-DHP)
What is the warning with CCBs?
do not stop abruptly - risk of rebound HTN/angina
Which ACE inhibitor is short-acting?
Which 5 ACE inhibitors are intermediate-acting?
Which 4 ACE inhibitors are long-acting?
Compelling indications for ACEIs
ALL of them (HF, post MI, high coronary disease risk, diabetes, CKD, recurrent stroke prevention)
Conditions favoring use of ACEIs
- preferred in diabetics
- T1DM nephropathy
- peripheral edema from CCB
ACEIs can have unfavorable effects on:
- bilateral renal artery stenosis
Name a very common adverse reaction to ACEIs
angioedema from previous ACEI, pregnancy, bilateral renal artery stenosis
Name 7 angiotensin II receptor blockers (ARBs)
Conditions favoring use of ARBs
- T2DM nephropathy
- ACEI-induced cough
ARB unfavorable effects
- bilateral renal artery stenosis
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
Name the non-selective Peripheral-acting Alpha-1 Receptor Blockers (alpha-1 antagonists)
Which alpha-blocker/antagonist is selective? What is it selective for?
tamsulosin - selective to prostate, so not used for HTN
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
Compelling indications for alpha-1 antagonists
Conditons favoring use of Alpha-1 Antagonists
Alpha-1 unfavorable effects
Elderly - 1st dose syncope and postural hypotension
Should alpha-1 antagonists be used in combos?
no - risk of severe hypotension (exception is tamsulosin, but it's not used for BP anyway)
What trial compared CCB v. ACEI v. alpha-blockers for monotherapy use in HTN?
What 2 centrally-acting Alpha-2 Agonists are used clinically?
Clonidine (Catapres) and Methyldopa (Aldomet)
Conditions favoring use of alpha-2 agonists
- pregnancy/breastfeeding (methyldopa)
- drug addiction (clonidine)
Alpha-2 Agonists unfavorable effects
Alpha-2 agonists warning
do not abruptly d/c - can cause rebound angina/HTN
What type of agent is Reserpine?
Indirect Vasodilating Agent - OLD!
Name 2 direct-acting arterial vasodilators
Conditions favoring use of direct-acting vasodilators
- Heart failure - hydralazine
- Hair growth desired - minoxidil
What does aliskiren (Tekturna) inhibit?
Renin - directly
Which meds are FDA approved for HTN in pregnancy? Which have the most data?
- None are approved
- Methyldopa and labetalol have the most data
Which HTN meds are contraindicated in pregnancy?
ACEIs and ARBs
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)
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
Which antihypertensive meds have favorable effects in CKD?
ACEIs and ARBs
Which antihypertensives are preferred for use in diabetics?
ACEIs, ARBs are preferred
What is the recommended tx HTN in a pt with migraines?
- beta-blockers (especially non-selective)
Which meds should be avoided in a HTN pt with asthma/COPD with bronchospasm?
Beta-blockers (especially the non-specific ones)
What HTN drugs should be avoided in pts with depression?
- Alpha-2 agonists
Which HTN meds should be avoided in pts with bradycardia/AV block?
- Non-DHP CCBs
What are the recommended HTN treatments for a pt with tachycardia/atrial fib?
- non-DHP CCBs
What are the preferred HTN meds for a pt with diabetes?
ACEIs and ARBs
What HTN meds are recommended in pregnancy? Which should be avoided?
- Recommended - methyldopa, labetalol
- Avoid - ACEIs, ARBs
Which HTN medication is recommended treatment for osteoporosis?
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)