Term
| What is primary hypertension calculated by and caused by? |
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Definition
BP = CO * PR
CO - increased preload due to fluid volume
PR - constriction due to RAAS |
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Term
| What are the secondary identifiable causes of HTN? |
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Definition
- Sleep apnea due to metabolic syndrome
- CKD
- Aldosteronism
- Renovascular disease
- Chronic Steroid/Cushing syndrome |
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Term
| What drugs can induce secondary hypertension? |
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Definition
- Any adrenal steroid (Prednisone, fludricortisone)
- Amphetamine/phentermine
- VEGF agents for cancer
- Estrogens in oral contraceptives
- Calcineurins for transplant patients (Tacrolimus, cyclosporin)
- Decongestants
- Epogen - increases BV
- NSAIDS and CoxII inhibitors
- Venlafaxine, Reglan, and Wellbutrin
- Street drugs and withdrawal, licorice |
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Term
| What target organ damage is possible if HTN goes untreated? |
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Definition
| retinopathy in the eyes, risk of stroke/TIA, LVH, CHD, and heart failure, ESRD, and peripheral artery disease |
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Term
| What calculates are taken with blood pressure? |
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Definition
Pressure pulse = Systolic - Diastolic
Mean Arterial Pressure = 1/3(systolic) + 2/3(diastolic) |
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Term
| What are some tenants of good BP technique? |
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Definition
- Refrain from stimulants for 30 min and rest for 5 min. Take reading w/ good posture at heart level.
- Use an appropriate sized cuff
- ablate radial pulse first! and palpate for artery. Curvature forward on stethescope
- Release pressure slowly, deflate 10/20 mmHg after last sound
- Avg 2 measurements 5 min apart, no talking |
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Term
| Why would home BP monitoring not be useful? |
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Definition
| Complex, not how studies were completed, and values can be fabricated |
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Term
| How does BP increase affect mortality? |
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Definition
| For every 20 mmHg systolic or 10 mmHg diastolic increase in BP, there is a doubling of mortality from both ischemic heart disease and stroke. |
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Term
| What drugs are thiazide diuretics? |
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Definition
| Chlorthalidone/Hygroton, HCTZ/Microzide, Indapamide/Lozol, and Metolazone/Zaroxolyn |
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Term
| In what case do Thiazides not work? |
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Definition
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Term
| What are adverse effects of thiazides? What do they interact with? |
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Definition
Hypokalemia, photosensitivity, hyperglycemia and uric acid levels.
Increased lithium levels, Bile acid sequestrants |
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Term
| What are the main monitoring parameters and counseling points for thiazides? |
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Definition
Monitor BP and baseline SrCr
Dose in the morning
Doses greater than 25 ineffective |
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Term
| What drugs are loop diuretics? When would you use these over thiazides? |
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Definition
| Furosemide/Lasix, Bumetanide/Bumex, Torsemide/Demadex. Can use in decreased CrCl |
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Term
| What is the main side effect and monitoring parameters of loop diuretics? When are they dosed? |
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Definition
| WILL cause hypokalemia, must monitor K+ along with electrolytes, glucose, uric acid, and fluid status. Dose at least BID, avoid sulfa allergy. |
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Term
| Which drugs are K-sparing diuretics? What are their monitoring parameters? |
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Definition
Amiloride/Midamor, Triamterene/Dyrenium
Mainly K+, then BP, SrCr, BUN, Na, Glu |
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Term
| What is the contraindication for using potassium sparing diuretics? |
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Definition
K+ > 5.5 mEq/L
Increased Hyperkalemia risk with trimethoprim, AceI, ARBs, and aldosterone inhibitors. |
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Term
What drugs are aldosterone inhibitors?
What are their side effects and monitoring? |
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Definition
Eplerenone/Inspra and Spironolactone/Aldactone
Both cause hyperkalemia, Inspra causes high triglycerides, Aldacone causes gynecomastia. Monitor K+ prior to, within first week of, and after 1 month of therapy |
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Term
| What drug interaction risks exist with aldosterone antagonists? |
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Definition
Any drug that also causes hyperkalemia
Eplerenone Contraindicated with potent Cyp3A4 inhibitors - itraconazole and ketaconazole
Eplerenone cautioned with moderate cyp3A4 inhibitors - erythromycin, fluconazole, saquinavir, verapamil - use lower starting dose. |
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Term
| What are contraindications for using aldosterone antagonists? |
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Definition
K+ > 5.5
Eplerenone: CrCl < 50 mL/min or SrCr > 1.8 in women or 2 in men, DM2 w/ microalbuminuria, Potent Cyp3A4 use, other drugs that increase K+ |
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Term
| What drugs are Ace inhibitors? |
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Definition
| Benazepril/Lotensin, Captopril/Capoten, Enalopril/Vasotec, Lisinopril/Prinivil, Quinipril/Accupril, Ramipril/Altace, Trandolapril/Mavik |
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Term
| What adverse effects are seen in Ace inhibitors? How are these drugs monitored? |
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Definition
- HYPERkalemia, transiently increased SrCr, COUGH, ANGIOEDEMA
- Monitor BP, HR, K+
- Monitor dry cough and angioedema, use lower doses in renal dysfunction |
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Term
| What are absolute contraindications for having an AceI? |
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Definition
-Bilateral renal artery stenosis
- PREGNANCY
- History of angioedema |
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Term
| What are the two main side effects of AceI and their causes? |
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Definition
- dry, unproductive cough - within the first few months, due to bradykinin, Pgs, or substance P. D/c therapy, switch to ARB
- Angioedema - swelling of mucous membranes most common in lips and tongue, life threatening. Stop drug and go to the hospital |
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Term
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Definition
| Candesartan/Atacand, Irbesartan/Avapro, Losartan/Cozaar, Valsartan/Diovan |
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Term
| What are side effects and contraindications of ARBs? |
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Definition
| Do not use in pregnancy, BRAS. Causes hyperkalemia |
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Term
| What drugs are DHP CC blockers? |
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Definition
| Amlodipine/Norvasc, Felodipine/Plendil, Nifedipine ER/Adalat or Procardia. Never use IR Nifedipine |
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Term
| What are the main side effects and cautions of DHP CC blockers? |
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Definition
| Peripheral edema (Norvasc) and reflex tachycardia, caution in angina. Monitor dizziness and edema. Treat constipation w/ bulk forming laxatives |
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Term
| What drugs are non-DHP CCB? |
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Definition
Diltiazem SR or ER/ Cardizem
Verapamil/Calan or Isoptin or Verelan |
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Term
| What are the main side effects and contraindications in Non-DHP CCBs? |
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Definition
- Side effects: Bradycardia and constipation
- Contraindications - 2nd/3rd AV block, SSS, acute MI, pulmonary congestion, heart failure |
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Term
| What are guidelines to be used when counseling on non-DHB CCBs? |
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Definition
| Do not give with BBs, do not crush/chew, monitor bradycardia. |
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Term
| What drug interactions are seen with non-DHP CCBs? |
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Definition
Diltiazem and Verapamil are major 3A4 substrates, avoid Cyp3A4 inducers (which use up drug quickly): Rifampin, Phenytoin, Barbituates, Epitol
Also 3A4 inhibitors, increases concentrations of drugs metabolized by 3A4. Diltiazem > Verapamil in interactions |
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Term
| Which beta blockers are non-selective? |
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Definition
Nadalol/Coragard, Propanalol/Inderal
At higher strengths, all non-selective |
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Term
| Which beta-blockers are cardioselective for B1? |
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Definition
| Atenolol/Tenormin, Metoprolol/Lopressor/Toprol |
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Term
| Which beta blockers have ISA characteristics? |
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Definition
Acebutolol/Sectral, Pindolol/Visken
Cannot use in coronary artery disease/post-MI |
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Term
| What drugs are mixed alpha and beta blockers? |
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Definition
Carvedilol/Coreg, Labetalol/Normodyne
No reflex tachycardia |
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Term
| What are the main adverse effects and contraindications of beta blockers? |
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Definition
Sinus bradycardia, 2nd/3rd AV block, decompensated HF, shock, pregnancy
Causes bradycardia and fatigue. Interacts with non-DHP which also cause bradycardia
Blunts signs of hypoglycemia |
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Term
| What is the only sign of hypoglycemia not block by beta blockers? |
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Definition
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Term
| What drugs are alpha blockers? |
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Definition
| Doxazosin/Cardura, Prazosin/Minipress, Terazosin/Hytrin |
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Term
| How are alpha blockers monitored and counseled on? |
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Definition
| Cause postural hypotension, measure sitting and standing BP. Do not use w/ PDE-5 inhibitors. Take at bedtime and rise slowly, use in BPH |
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Term
| How does the direct renin inhibitor work and what are it's cautions? |
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Definition
| Aliskiren/Tekturna. Same as AceI - monitor BP, SCR, and K+, no pregnancy and watch hyperkalemia |
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Term
What drugs are alpha agonists?
What are they used for, their side effects? |
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Definition
Clonodine/Catapres - available in patch
Methyldopa/Aldomet
Used for resistant HTN. Always causes dry mouth, sedation. Rebound HTN if abruptly discontinued |
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Term
Which drugs are arterial vasodilators?
What must be monitored and side effects? |
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Definition
Minoxidil/Loniten, Hydralazine/Apresoline
Monitor BP for tachycardia, minoxidil causes fluid retention so I/O. Caution in renal disease, stroke, or CAD. Take w/ food and rise slowly. Used in severe HTN. Hydralazine causes lupus-like symptoms |
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Term
| What lifestyle modifications should be counseled on? |
|
Definition
- Stop smoking
- Exercise 30 min/day most days -- at least 60-90 min/week
- DASH diet, limit sodium to 2.4 g
- Limit alcohol to 2 drinks/day - 12 oz beer/5 oz wine/1.5 oz liquer
- Weight loss of at least 10 lb |
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Term
| What are the HTN goals according to JNC7? |
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Definition
| Less than 140/90 unless DM2 or ESRD, then less than 130/80 |
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Term
| What is the initial choice for most HTN patients? |
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Definition
| HCTZ 25 mg po daily unless there is a compelling indication |
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Term
| In african americans, which drugs have proven less effective? |
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Definition
| AceI, ARBs, and beta blockers. Good response to Na restriction and diuretics |
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Term
| What considerations are there in the elderly? |
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Definition
| Use lower doses and avoid alpha blockers/agonists and labetalol |
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Term
| What considerations are there in pregnant patients? |
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Definition
Do not use AceI and ARBs.
Use Labetalol or Methydopa |
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Term
| When do you substitute drugs from a different class? |
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Definition
| When there is little response and no compelling indication, or bad side effects. |
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Term
| What is the difference between hypertenion urgency and emergency? |
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Definition
BP >180/120 in both. Emergency - signs of target organ damage, requires IV therapy.
IV drugs - Labetalol, hydralazine, Enalaprilat |
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