Hypertension

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jannabogie
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49911
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Hypertension
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2010-11-18 20:59:57
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Hypertension
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Therapeutics Week 11 - Hypertension
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  1. 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)
  2. 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
  3. 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
  4. 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
  5. Which antihypertensive class is recommended for all compelling indications?
    ACE inhibitors
  6. 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
  7. 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
  8. 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
  9. 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)
  10. Unfavorable effects of diuretics
    • hyperkalemia - avoid AAs and potassium-sparing
    • Renal insufficiency - avoid AAs and potassium-sparing
    • gout
    • dyslipidemia
    • diabetes (high dose)
  11. What effect do loop diuretics have on potassium and calcium?
    they decrease both
  12. What effect do thiazide diuretics have on potassium and calcium?
    decrease potassium and increase calcium
  13. Which 6 Beta-blockers work on only beta-1 receptors?
    • acebutolol
    • atenolol
    • betaxolol
    • bisoprolol
    • metoprolol
    • nebivolol (< 10 mg)
  14. Which 6 beta-blockers work on both beta-1 and beta-2 receptors?
    • cartelol
    • nadolol
    • penbutolol
    • pindolol
    • propranolol
    • timolol
  15. Which 2 beta-blockers work on alpha-1, beta-1, and beta-2 receptors?
    • carvedilol
    • labetalol
  16. 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)
  17. Conditions favoring use of BBs
    • tachycardia, atrial fibrillation
    • migraine
    • angina
    • esophageal varices
    • essential tremor
    • hyperthyroidism
  18. 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
  19. Important warning with beta-blockers
    Do not abruptly discontinue - taper off
  20. Name the 6 dihydropyridine Calcium Channel Blockers
    • amlodipine
    • felodipine
    • isradipine
    • nicardipine
    • nifedipine
    • nisoldipine
  21. Name the 2 non-dihydropyridine CCBs
    • diltiazem
    • verapamil
  22. 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)
  23. CCBs may have unfavorable effects on:
    • heartblock (non-DHP)
    • heart failure (non-DHP)
  24. What is the warning with CCBs?
    do not stop abruptly - risk of rebound HTN/angina
  25. Which ACE inhibitor is short-acting?
    captopril
  26. Which 5 ACE inhibitors are intermediate-acting?
    • benazepril
    • enalapril
    • moexipril
    • quinapril
    • ramipril
  27. Which 4 ACE inhibitors are long-acting?
    • fosinopril
    • lisinopril
    • perindopril
    • trandolapril
  28. Compelling indications for ACEIs
    ALL of them (HF, post MI, high coronary disease risk, diabetes, CKD, recurrent stroke prevention)
  29. Conditions favoring use of ACEIs
    • preferred in diabetics
    • proteinuria
    • T1DM nephropathy
    • peripheral edema from CCB
  30. ACEIs can have unfavorable effects on:
    • Pregnancy
    • bilateral renal artery stenosis
    • hyperkalemia
  31. Name a very common adverse reaction to ACEIs
    dry cough
  32. ACEI CIs
    angioedema from previous ACEI, pregnancy, bilateral renal artery stenosis
  33. Name 7 angiotensin II receptor blockers (ARBs)
    • candesartan
    • eprosartan
    • irbesartan
    • losartan
    • olmesartan
    • telmisartan
    • valsartan
  34. Conditions favoring use of ARBs
    • proteinuria
    • T2DM nephropathy
    • ACEI-induced cough
  35. ARB unfavorable effects
    • bilateral renal artery stenosis
    • hyperkalemia
    • pregnancy
  36. 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
  37. Name the non-selective Peripheral-acting Alpha-1 Receptor Blockers (alpha-1 antagonists)
    • alfuzosin
    • doxazosin
    • prazosin
    • terazosin
  38. Which alpha-blocker/antagonist is selective? What is it selective for?
    tamsulosin - selective to prostate, so not used for HTN
  39. 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
  40. Compelling indications for alpha-1 antagonists
    none
  41. Conditons favoring use of Alpha-1 Antagonists
    BPH
  42. Alpha-1 unfavorable effects
    Elderly - 1st dose syncope and postural hypotension
  43. Should alpha-1 antagonists be used in combos?
    no - risk of severe hypotension (exception is tamsulosin, but it's not used for BP anyway)
  44. What trial compared CCB v. ACEI v. alpha-blockers for monotherapy use in HTN?
    ALLHAT
  45. What 2 centrally-acting Alpha-2 Agonists are used clinically?
    Clonidine (Catapres) and Methyldopa (Aldomet)
  46. Conditions favoring use of alpha-2 agonists
    • pregnancy/breastfeeding (methyldopa)
    • drug addiction (clonidine)
  47. Alpha-2 Agonists unfavorable effects
    depression
  48. Alpha-2 agonists warning
    do not abruptly d/c - can cause rebound angina/HTN
  49. What type of agent is Reserpine?
    Indirect Vasodilating Agent - OLD!
  50. Name 2 direct-acting arterial vasodilators
    • hydralazine
    • minoxidil
  51. Conditions favoring use of direct-acting vasodilators
    • Heart failure - hydralazine
    • Hair growth desired - minoxidil
  52. What does aliskiren (Tekturna) inhibit?
    Renin - directly
  53. Which meds are FDA approved for HTN in pregnancy? Which have the most data?
    • None are approved
    • Methyldopa and labetalol have the most data
  54. Which HTN meds are contraindicated in pregnancy?
    ACEIs and ARBs
  55. 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)
  56. 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
  57. Which antihypertensive meds have favorable effects in CKD?
    ACEIs and ARBs
  58. Which antihypertensives are preferred for use in diabetics?
    ACEIs, ARBs are preferred
  59. What is the recommended tx HTN in a pt with migraines?
    • beta-blockers (especially non-selective)
    • verapamil
  60. Which meds should be avoided in a HTN pt with asthma/COPD with bronchospasm?
    Beta-blockers (especially the non-specific ones)
  61. What HTN drugs should be avoided in pts with depression?
    • Beta-blockers
    • Alpha-2 agonists
  62. Which HTN meds should be avoided in pts with bradycardia/AV block?
    • Beta-blockers
    • Non-DHP CCBs
  63. What are the recommended HTN treatments for a pt with tachycardia/atrial fib?
    • beta-blockers
    • non-DHP CCBs
  64. What are the preferred HTN meds for a pt with diabetes?
    ACEIs and ARBs
  65. What HTN meds are recommended in pregnancy? Which should be avoided?
    • Recommended - methyldopa, labetalol
    • Avoid - ACEIs, ARBs
  66. Which HTN medication is recommended treatment for osteoporosis?
    Thiazides
  67. 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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