Term
Blood Pressure TARGETS in different patients:
- Home
- Office
- CKD
- Diabetes |
|
Definition
Blood Pressure targets in different patients:
- Home 135/85
- Office 140/90
- CKD: 130/80
- Diabetes 130/80 |
|
|
Term
| Drugs/Factors that worsen HTN: |
|
Definition
Drugs/Factors that worsen HTN:
- Alcohol (excessive use)
- Calcineurin inhibitors
- steroids
- EPO and analogues
- Midodrine
- MAOIs
- NSAIDs
- hormones/oral contraceptives
- stimulants
- vasoconstricting, sympathomimetic decongestants
- venlafaxine
- Salt intake
- Sleep apnea |
|
|
Term
Diagnosis based on:
diabetes, CKD, home measurement, etc. |
|
Definition
Drugs/Factors that worsen HTN:
- DBP >130 with major artery dissection
- HTN compromising vital organ function
- 2 office visits BP > 180/110 no comorbidities
- 2 office visits BP>140/90 in diabetes, CKD, atherosclerotic or cerebrovascular disease.
- 2 visits at home
- 3 or more visits BP > 160/100
- 5 or more visits BP < 160/100 |
|
|
Term
| Initial Lab testing, for HTN |
|
Definition
Initial Lab testing, HTN:
- lipid profile
- renal panel
- BP
- ECG
- electrolyte |
|
|
Term
Rank these interventions in terms of lowering BP:
Weight loss (4.5kg)
Reduce alcohol
Exercise 3x/week
Sodium reduction (1800mg)
DASH diet |
|
Definition
Rank these interventions in terms of lowering BP:
1)DASH diet
2)Exercise 3x/week
3)Reduce alcohol
4)Weight loss (4.5kg)
5)Sodium reduction (1800mg)
6)Smoking |
|
|
Term
Diuretics
- line
- major side effect
- When to consider alternate agent
- Good idea using diuretics to prevent hypokalemia
- what kind of diuretic in patients with renal dysfunction
- What may diuretics worsen? |
|
Definition
Diuretics
- 1st line for uncomplicated HTN
- watch for hypokalemia
- QT prolongation syndrome, or predisposition to serious arrhythmia consider alternate agent
- Combine with K-sparing diuretics
(spironolactone, Amiloride, Triamere [SAT])
- loop diuretics in patients with renal dysfunction.
- May worsen dysglycemia |
|
|
Term
Beta-Blockers
- 1st line in who?
- NOT 1st line in who ?
- May be ineffective in people who do what ? |
|
Definition
BBs
1st line: <60 years, HF, stable angina, MI
NOT 1st line: >60
Smokers, BBs maybe ineffective |
|
|
Term
| What RAAS classes are contraindicated in pregnancy ? |
|
Definition
ALL OF THEM !
ACEIs, ARBs, aliskiren (DRI) |
|
|
Term
When are the following indicated/not indicated:
ACEIs
ARBs
DRI (aliskiren) |
|
Definition
When are the following indicated/not indicated:
ACEIs
indicated: first line uncomplicated HTN, diabetes, ischemic heart disease, MI, HF, CKD. It is NOT first line for blacks, and contraindicated in pregnancy
ARBs - indicated uncomplicated HTN, diabetes, ischemic heart disease. Good alternative to ACEIs if untolerated. Contraindicated in pregnancy.
DRI (aliskiren) - Not first line, not enough data. |
|
|
Term
CCBs - NonDHP & DHP, which is which?
Which are inotropic?
Which formulations should not be used as they increased CV events? |
|
Definition
CCBs - NonDHP & DHP, which is which?
NonDHP - Verapamil & Diltiazem --> INOTROPIC
DHP - Amlodipine, Nifedipine
PERIPHERAL
Short acting CCBs increase CV events, avoid them |
|
|
Term
Combining drugs
What is more efficacious, increasing a dose of a hypertensive or using combinations?
Which drug combinations are less effective?
What is desirable to use in combination?
Which combination of two classes should be avoided due to renal/electrolyte disturbances.
When would you want to use intermediate acting drugs? Why would you not want to use short acting antihypertensives? |
|
Definition
Combinations have 5-fold improvement over dose increase in anti-hypertensive effects.
Combining BBs, ACEIs, & ARBS.
Use of diuretics in combination with other antihypertensives is desirable.
Avoid use of ARBs with ACEIs. Can cause renal impairment and hyperkalemia.
Use intermediate acting antihypertensives in hypertension emergencies. Short acting antihypertensives can cause HoTN. |
|
|
Term
Which antihypertensives are first line for use in pregnancy ?
Which antihypertensives should be avoided in pregnancy? classes or individual drugs.
clue (1 ccb, 1 BB, 1 centrally acting antihypertensive)
Which drugs should be used/avoided in breastfeeding? |
|
Definition
Methyldopa, labetolol, nifedipine XL
AVOID RAAS system drugs in pregnancy.
atenolol is associated with intrauterine growth restriction(IUGR).
AVOID thiazides and loop diuretics.
Spironolactone should be avoided.
breastfeeding in HTN --> Use/avoid same drugs as in pregnancy. |
|
|
Term
Hypertension without other compelling indications:
Target BP ?
Initial therapy ?
When is combination therapy indicated?
BB in patients over 60 ?
How to avoid hypokalemia when prescribed diuretics?
What is not recommended initially in black patients?
Which classes are teratogenic?
Which combination is not recommended due to renal/electrolyte disturbances? |
|
Definition
Hypertension without other compelling indications:
Target BP - <140/90
Initial therapy - Thiazides, ACEi, ARB, BB, long acting CB.
When is combination therapy indicated?
Combination therapy is indicated if SBP > 20 mm Hg DBP is > 10 mm Hg over target.
BB in patients over 60 - NO!
How to avoid hypokalemia when prescribed diuretics - Give with potassium sparing diuretics
What is not recommended initially in black patients? ACEIs
Which classes are teratogenic? RAAS system drugs
Which combination is not recommended due to renal/electrolyte disturbances?
ACEIs with ARBs |
|
|
Term
Isolated systolic HTN
target?
Therapy options? |
|
Definition
Isolated systolic HTN
target SBP <140mm Hg
Therapy options - Long acting DHP CCBs (amlodipine nifedipine), Thiazide diuretics, |
|
|
Term
Diabetes HTN - with albuminuria
Target BP ?
1st line?
2nd line?
How is albuminuria defined? |
|
Definition
Diabetes HTN
Target BP 130/80
1st line - ACEIs or ARBs
2nd line - Adding thiazide diuretics, cardioselective BB, long acting CCB
Albuminuria is defined as a albumin:creatinine ratio of > 2mg/mmol in men and > 2.8 mg/mmol in women |
|
|
Term
Diabetes HTN - WithOUT albuminuria
Target BP ?
1st line?
2nd line?
How is albuminuria defined? |
|
Definition
Diabetes HTN - WithOUT albuminuria
Target BP < 130/80
1st line - ACEIs, ARBs, long acting DHP CCB, thiazide diuretics.
2nd line - Combination of first line
How is albuminuria defined - Albumin:creatnine ratio of over 2mg/mmol in men and > 2.8 mg/mmol in women. |
|
|
Term
| HTN in CAD Initial therapy Second line |
|
Definition
| HTN in CAD Initial therapy - ACEIs or ARBs + BB for patients with stable angina Second line - DHP CCBs in combination with ACEIs/ARBs for high risk patients |
|
|
Term
HTN in prior MI
Initial therapy
Second line |
|
Definition
HTN in prior MI
Initial therapy - ACEIs + BBs
Second line - Long acting CCBs |
|
|
Term
HTN in HF
Initial therapy
Second line |
|
Definition
HTN in HF
Initial therapy - ACEIs + BB. Patients with NYHA class III symptoms also spironolactone
Second line - ARB + ACEI (*rarely see this combo)
Hydralazine+Isosorbide dinitrate or combination of initial with thiazides. |
|
|
Term
Left Ventricular Hypertrophy
Initial therapy
Second line
What drugs can worsen LVH? |
|
Definition
Left Ventricular Hypertrophy
Initial therapy - ACEIs, ARBs,long acting CCBs, BB, thiazide diuretics
*SAME AS NO COMPELLING INDICATIONS*
Second line - combinations
LVH - minoxidil, hydralazine |
|
|
Term
Past stroke or TIA
Initial therapy
Second line |
|
Definition
Past stroke or TIA
Initial therapy - ACEI and diuretic
Second line |
|
|
Term
Non diabetic CKD HTN with proteinuria
Initial therapy
Second line
Monitoring parameters |
|
Definition
Non diabetic CKD HTN with proteinuria
Initial therapy - ACEIs, diuretic
Second line - combos
Monitoring parameters - K and SCr when using ACEIs and ARBs |
|
|
Term
HTN in renovascular disease, peripheral artery disease, or dyslipidemia
Initial therapy - |
|
Definition
HTN in renovascular disease
*SAME AS NO COMPELLING INDICATIONS*
Initial therapy - Thiazides, ACEi, ARB, BB, long acting CB. |
|
|
Term
Diuretics
name some
Adverse effects
Interactions
Comments/monitoring parameters
Contraindications
Something important about metolazone |
|
Definition
Diuretics
HCTZ, metolazone, indapamide, chlorthalidone
Adverse effects - Hypotension, sulfa reaction, photosensitivity, hyponatremia, hypercalcemia, hyperglycmia, hypokalemia,
Interactions - digoxin, lithium, NSAIDs, antihyperglycemics (decreases their effects)
Comments - monitor electrolyte panel, kidney function,
Hold if SCr increases 30% from baseline
Contraindicated in Gout.
Metolazone is effective in moderate to severe renal function. |
|
|
Term
non selective BBs without ISA
name some, which has ISA?
Adverse effects
Interactions
Comments |
|
Definition
non selective BBs without ISA
name some - timolol, propranolol, nadolol, pindolol
Adverse effects - bradycardia, HA, impotence, rare: *hyperglycemia (only for nonselective), depression, HF, heartblock
Interactions - Digoxin, nonDHP CCBs(bradycardia) & amiodarone.
Comments - BB should not be used in patients over 60, avoid in patients with asthma, |
|
|
Term
B1 selective BBs without ISA
name some
Adverse effects
Being selective has what affect on adverse effects ?
Interactions
Comments |
|
Definition
name some - BAM! Bisoprolol, Atenolol, Metoprolol
Adverse effects - bradycardia, HA, impotence, * NO hyperglycemia (only for nonselective), depression, HF, heartblock --> LESS non-cardio effects.
Interactions - Digoxin, nonDHP CCBs(bradycardia) & amiodarone.
Comments - BB should not be used in patients over 60, avoid in patients with asthma |
|
|
Term
non selective BB with ISA
Adverse effects
Interactions
Comments/contraindications
ISA in general |
|
Definition
non selective BB with ISA - pindolol
Adverse effects (same as other nonselectives) - hyperglycemia* Nonselective, depression, bradycardia, dyslipidemia, bronchspasm
Interactions - Bradycardia with NonDHP CCBs,
Comments - worsens CHF, AVOID in > 60, Avoid in asthma, taper before d/c, PAD, 2nd or 3rd degree heartblock. Avoid in diabetes.
ISA - avoid use in history of MI, angina. Cause less bradycardia |
|
|
Term
Selective BB with ISA
name it
Adverse effects
Interactions
Comments |
|
Definition
Selective BB with ISA
name it - Acebutalol
Adverse effects - Depression, bradycardia (less than non ISAs), bronchospasm (less with selective), impotence,
Interactions
Comments |
|
|
Term
BB with alpha 1 antagonism
Name it
SEs
Interactions
Comments/contraindications
What is it special for among BBs? |
|
Definition
BB with alpha 1 antagonism
Name it - labetolol
SEs - Edema, Depression, bradycardia, bronchospasm, *Postural hypotension --> alpha 1 blocker
Interactions - Digoxin, bradycardia with nonDHP CCBs, cardiopressant effects with non DHP CCBs and amiodarone
Comments/contraindications - < 60, HF, 2nd or 3rd degree block, PAD, patients with asthma, avoid abrupt withdrawal
Special - 1st line vs. pregnancy, other BBs not recommended. |
|
|
Term
BBs in general
AEs
Interactions
Comments/contraindications |
|
Definition
BBs in general
AEs - Depression, insomnia, vivid dreams, bronchospasm (worse in nonselective), bradycardia (worse in non ISA), hyperglycemia (worse in nonselective), impotence, dyslipidemia (worse in nonselective)
Interactions - bradycardia with nonDHP CCBs, digoxin, CNS depression with amiodarone and nonDHP CCBs
Comments/contraindications |
|
|
Term
ACEIs
AEs
Interactions
Comments/contraindications |
|
Definition
ACEIs: -prils
AEs: Hyperkalemia, *DRY COUGH, can precipitate renal failure, rarely angioedema
Interactions- K+ sparing diuretics, lithium, NSAIDS can worsen renal function in combination.
Comments/contraindications- *PREGNANCY CONTRAINDICATION with RAAS. Arterial stenosis, history of angioedema contraindicated. Monitor SCr, Potassium |
|
|
Term
ARBs
AEs:
Interactions:
Comments/contraindications- |
|
Definition
ARBs
AEs: Hyperkalemia, can precipitate renal failure, rarely angioedema
Interactions- K+ sparing diuretics, lithium, NSAIDS can worsen renal function in combination.
Comments/contraindications- *PREGNANCY CONTRAINDICATION with RAAS. Arterial stenosis, history of angioedema contraindicated. Monitor SCr, Potassium
*SAME EVERYTHING EXCEPT DRY COUGH AS ACEIs |
|
|
Term
Direct Renin inhibiton
AEs:
Interactions:
Comments/contraindications- |
|
Definition
Direct Renin inhibiton
AEs: Dry cough, hyperkalemia BOTH less incidence than ACEIs
Interactions: low!
Comments/contraindications- may take 4 weeks to see maximum hypotensive effect. |
|
|
Term
nonDHP CCBs
AEs:
Interactions:
Comments/contraindications- |
|
Definition
nonDHP CCBs
Diltiazem, verapamil,
AEs: bradycardia, exacerbate HF,
Interactions: 3A4 substrate, BBs and digoxin
Comments/contraindications- avoid in 2nd/3rd degree heartblock |
|
|
Term
DHP CCBs:
AEs:
Interactions:
Comments/contraindications-
Which is intermediate acting? when should it be used? |
|
Definition
DHP CCBs: Filodipine, amlodipine, nifedipine
AEs: Ankle edema, palpitations, flushing
Interactions: 3A4
Which intermediate acting - filodipine, should be used emergency situations. |
|
|
Term
Centrally acting antihypertensive agent
AEs:
Interactions: |
|
Definition
Centrally acting antihypertensive agent
AEs: Sedations, dry mouth, impotence, orthostatic HoTN, depression
Interactions: Iron salts reduce absorption, may exacerbate Li side effects without raising Li Levels |
|
|
Term
Alpha 1 antagonists
AEs:
Interactions: |
|
Definition
Alpha 1 antagonists
Doxazosin, terazosin, prazosin
AEs: Ortho HoTN, priapism, syncope, sedation, nasal congestion
Interactions: syncope possible with other HoTN causing agents.
3rd line agent. |
|
|
Term
In Isolated Systolic HTN
1st line?
Add on ?
What should be avoided |
|
Definition
In Isolated Systolic HTN
1st line - Thiazides, ARBS, LA-DHP-CCBs
2nd line - combinations
What should be avoided - BB |
|
|
Term
LVH - compelling indications
1st line?
Add on ? |
|
Definition
LVH
1st line - Diuretic + ACEI + BB
2nd line - ARB or Aldosterone antagonist |
|
|
Term
Post MI - Compelling indications
1st line?
Add on ? |
|
Definition
Post MI - Compelling indications
1st line - BB + ACEIs
Add on - Aldosterone antagonist |
|
|
Term
CAD - compelling indications
1st line?
Add on? |
|
Definition
CAD - compelling indications
1st line - BB + ACEI or ARB
Add on - CCB or diuretic |
|
|
Term
Diabetes - compelling indications
1st line?
Add on?
More add ons?
If SCr is greater than 150 umol/L which diuretic should you use for add on |
|
Definition
Diabetes - compelling indications
1st line - ACEI or ARB
Add on - thiazide diuretic
More add ons - BB or CCB
If SCr is > 150mmol/L use loop diuretic (eg furosemide) instead of thiazide diuretic |
|
|
Term
CKD - compelling indications
1st line? |
|
Definition
CKD - compelling indications
1st line - ACEIs or ARBs |
|
|
Term
Recurrent Stroke - compelling indications
1st line - ACEI + diuretic |
|
Definition
Recurrent Stroke - compelling indications
1st line - ACEI + diuretic |
|
|
Term
HF - compelling indications
1st line -
Add on when patients NYHA class III or IV |
|
Definition
HF - compelling indications
1st line - BB + ACEI
Add on when patients NYHA class III or IV - aldosterone |
|
|
Term
| When should spironolactone be used? |
|
Definition
When should spironolactone be used?
Post MI with significant LV dysfunction, or HF with LV dysfunction |
|
|
Term
Which antihypertensive can be used in stable angina?
How about prinzmetal angina ? |
|
Definition
Which antihypertensive can be used in stable angina?
BB + ACEI
for prinzmetals LA-DHP CCB |
|
|
