Goal BP for most Disease states?

Rule: AHA <130/80mmg
Exception: ADA DM <140/90mmHg

1rst line agents?

All: Thiazide diuretic, CCB
NonBlack: All + ACEi, ARB

When not to use CCB as 1rst line Agent?

Pretty much all comorbidities with the exception of DM/no albuminuria

All comorbidities = HFrEF, HFpEF, SIHD, CKD, 2nd Strk Prev, DM w/alb, DM no alb

B-blocker as 1rst line?

Heart Failure and Ischemic Heart Disease (HFrEF, HFpEF, SIHD)

When not to use thiazide diuretic as 1rst line agent?

Pretty much all comorbidities with the exception of DM/no albuminuria + 2nd Strk Prev.

All comorbidities = HFrEF, HFpEF, SIHD, CKD, 2nd Strk Prev, DM w/alb, DM no alb

When to initiate to HTN drugs at same time?

Stage 2 HTN + BP >20/10mm over goal

Stages of HTN

Normal: 120/80mmHg
Pre: <129/80mmHg
I: <139/89mmHg
II: >140/90mmHg

HTN follow up intervals

Norm: 1yr
Pre: 3-6mo
I+>lI: 1mo until goal met then 3-6mo

Thiazide Diuretic MOA?

Inhibit Na reabsorption at DCT

Thiazide diuretic brand/generic (5 drugs)?

*Chlorothalidone: Generic only
*HCTZ: Microzide
*Metalazone: Zaroxolyn
* = On Top 200 List.

Indapamide: Generic only
Chlorothiazide: Diuril

Thiazide diuretic SEs?

Hypo: K, mg, na
Hyper: gly, uric
Photosensitivity

Thiazide diuretic DIs?

TZDs incr Li tox
TZDs decr DM agent effects
NSAIDS decr HTN agent effects

Thiazide diuretic pearls?

1. Only Metolazone (Zaroxolyn) effective when CrCl <30mL/min
2. Chlorothiazide (diuril) is injectable
3. All have a ceiling dose

Thiazide (all) diuretic Patient ed?

1. Take in AM due to nocturia
2. Wear sunscreen
3. Report muscle cramp due to hypok/mg risk

How loops and thiazide diuretics differ?

1. TZDs inhibits Na at DCT; loop inhibits Na at Ascending Loop of Henle
2. TZDs have ceiling dose; loops do not
3. Loops work when CrCl is <30mL/min; most TZDs do not (except Metolazone)

K sparing diuretic brand/generic (2 drugs)

Amiliride: Generic Only
Triamterene: Dyrenium

* K sparing diuretic's are typically used in combo with HCTZ to stop K loss. *
List K/HCTZ combo drugs (2 drugs)

Triamterene/HCTZ: Dyazide or Maxzide
Amilorude/HCTZ: generic only

Are Aldosterone Receptor Antagonist drugs used for HTN?

Nope; mainly HF.

Aldosterone Receptor Antagonist HCTZ combo products (1 drug)

Spironolactone/HCTZ: Aldactazide

B-blocker MOA?

Binds to B receptors + decrease Cardio Output via:
decr in contractility (neg inotrophic)
+
decr in heart rate (neg chronotropic)

What is the only HYDROPHILIC B-blocker and its advantages?

Atenolol (Tenormin): less likely to cause CNS effects (depression/fatigue)

List cardioselective B-blocker (6 drugs) [BAMBAN]

*Atenolol: Tenormin
*Metoprolol Tartate: Lopressor
*Metoprolol Succinate: Toprol XL, Kapspargo sprinkle
*Nebivolol: Bystolic
* = Top 200 Drug List

Acebutolol: generic only
Betaxolol: generic only

B-blocker CIs?

1. HF - with the exception of 3 drugs: Metoporolol Succ., bisoprolol and carvedilol
2. 2nd deg or higher Heart Block if no PaceMaker

B-blocker S/E?

1. Bradicardia/Heart block/Exercise intolerance (see CIs)
2. HF exacerbations (see CIs)
3. Bronchospasm
4. Cold extremities
5. Fatigue/depression
6. Glucose intolerance
7. Masks hypoglycemia signs (except sweating)

B-blocker DIs?

Using with other neg. chronotrops can result in incr. bradiacardia. 
Examples: digoxin, verapamil, diltiazem, clonidine, ivabradine

B-blocker pearls?

1. Injection: metop succ, labetolol, and propranolol
2. discontinue w/ 2wk taper
3. a1-blocking: labetolol, carvedilol

Advantages of cardioselective B-blockers?

less likely to cause vasoconstriction or bronchconstriction at lower doses

List non-cardioselective B-blocker brand/generic (6 drugs)

*Carvedilol: Coreg
*Propanolol: Inderal, Indopran
* = Top 200 drug List

Labetolol: Trandate
Nadolol: Cogard
Pindolol: Generic only
Timolol: Generic only

B-blocker combo drug: Tenoretic

Atenolol/chlorthalidone

B-blocker combo drug: Ziac

Bisoprolol/HCTZ

B-blocker combo drug: Lopressor HCT

Metop tart./HCTZ

B-blocker combo drug: Dutoprol

Metop succ/HCTZ

B-blocker combo drug: Corzide

Nadolol/bendroflumethazide (Intl TZD)

B-blocker combo drug: Byvalson

Nebivolol/valsartan

ACEi MOA?

Inhibits angiotensin converting enzyme preventing the conv. of angiotensin I to II
Results in:
1. vasodilation,
2.decr. aldosterone production,
3. inhibition of bradykinin breakdown thought to cause dry cough

ACEi/ARB/Ri CIs?

1. pregnancy (All)
2. hyperk (All)

3. bilateral renal artery stenosis (ACEi + Ri)

ACEi/ARB/Ri DIs?

1. Anything causing incr. K (K supplements, K spar diur/ARAs, NSAIDs (All)
2. Other drugs in the renin-angitensin pathway (All)
3. Li - incr tox risk (All)

4. Transplant drugs (...rolimus) - incr risk angioedema (ACEi only!)

5. intraconazole + cyclosporine incr. effects (Ri only)
6. decr effects of Lasix (Ri only)

ACEi/ARB/Ri pearls?

1. Shortest duration of action = captopril
2. Oral form = enalapril (Epaned),  lisinopril (Qbrelis), valsartan (Prexxartan)
3. Inj form = enalapril (Enaliprilat)
4. Avoid taking w/ fatty meals = aliskinren (Tekturna)

List Top 200 ACEi brand/generic (7 drugs)

Benazapril: Lotensin
Enalapril: Epaned, Vasotec
Fosinopril: Generic only
Lisinopril: Qbrelis, Zestril, Prinivil
Quinapril: Accupril
Ramipril: Altace
Trandolipril: Generic only

ACEi combo drug: Lotrel

benazepril/amlodipine

ACEi combo drug: Lotensin HCT

benazipril/HCTZ

ACEi combo drug: Vaseretic

enalipril/HCTZ

ACEi combo drug: Zestoretic

lisinopril/HCTZ

ACEi combo drug: Accuretic

quinapril/HCTZ

ACEi combo drug: Tarka

trandolapril/verapamil

ARB (aka: Angiotensin II Receptor Blockers) MOA?

Blocks binding of angiotensin II to AT1 receptor causing:
vasodilation
aldosterone production decr.
no effect on bradykinin (assumed source of ACEi cough)

ACEi/ARB/Ri S/E?

hyperk
renal impairment
dry cough (ACEi only)
Angioedema
Sprue-like enteropathy (Olmesartan only)
HA, dizzy, diarrhea (Ri only)

List Top 200 ARB brand/generic (6 drugs)

Irbesartan: Avapro
Losartan: Cozaar
Olmesartan: Benicar
Telmisartan: Micardis
Valsartan: Diovan, Prexxartan
Candesartan: Atacand

ARB + HCTZ Combos (6 drugs)

irbesartan = Avalide
losartan = Hyzaar
* * * * * * * * * * * * * * * *
candesartan = Atacand HTC
olmesartan = Benicar HTC
telmisartan = Micardis HTC
valsartan = Diovan HTC

ARB combo drug: EdarbyCLOR

azilsartan/chlorithalidone

ARB combo drug: Azor

olmesartan/amlodipine

ARB combo drug: TRIbenzor

olmesartan/amlodipine + HCTZ

ARB combo drug: Twynsta

telmisartan/amlodipine

ARB combo drug: Exforge

valsartan/amlodipine

ARB combo drug: Exforge HCT

Valsartan/amlodipine/HCTZ

ARB + Amlodipine combo drugs (5 drugs)

Azor (olme)
Tribenzor (olme + HCTZ)
Twynsta (telmi)
Exforge (val)
Exforge HCT (val + HCTZ)

Ri combo drug: Tekturna HCT

...I am pretty sure you can solve this

When not to use ACEi/ARB + Ri in patients with DM

CrCl <60mL/min

CCB MOA?

Binds to L-type channels in heart and arteries preventing influx of Ca which results in vasodilation (smooth muscle relax) and decr contractility (neg. inotrophic)

The difference btwn Dihydropyridines (DHP) and Non-DHP?

DHP = more vascular selective, more potent vasodilator, and no cardio conduction effect.
Non-DHP = less peripheral vasodilation, neg. chronotropic (decr HR)

Top 200 DHP CCB brand/generic drugs (3 drugs)

amlodipine: Norvasc
felodipine: Generic only
nifedipine: Procardia XL, Adalat CC, Afeditab CR

All CCBs have neg inotropic properties except (2 drugs)

1. amlodipine (Norvasc)
2. felodipine

CCB CIs?

DHPs: None!

Non-DHPs: 2nd deg heartblock w/ no pacemaker, HFrEF

CCB SEs

1. Reflex tachycardia (DHPs)
2. HA (DHPs)
3. Flushing (DHPs)

4. Periph Edema (All)
5. Gingival hyperplasia (All)
6. HF exacerbation (except amlodipine and felodipine which have no inotropic/contractility effects) (All)

7. bradycardia/heartblock (Non-DHP)
8. constipation (Non-DHP)

DHP and Non-DHP are ___ substrates; be sure to avoid ________________.

3A4; grapefruit juice + other 3A4 inducers/inhibitors (GPACMAN)

CCB pearls

1. 3A4
2. Injectables: nicardipine, verapamil, diltiazem

CCB DIs

1. 3A4 (All)

2. Use with other neg. chronotropes like: digoxin, B-blocker, clonidine, or ivabradine (Non-DHPs)
3. Incr risk dig tox (Non-DHPs)

Negative chronotropic in layman's terms

decreases heart rate

Negative inotropic in layman's terms

decreases contractility

Brand name of combo drug: amlodipine/celecoxib

Consensi

HTN drugs safe for pregnancy (3 drugs)

methyldopa
labetalol
nifedipine

List Non-DHPs brand generic (2 drugs)

*diltiazem: Cardizem (CD/LA), Cartia XT, Taztia XT, Tiazac
*verapamil: Calan, Verelan
* = Top 200 Drug List

A1 receptor antagonist MOA

Blocks A1 on periph blood vessels resulting in arterial + venous dilation

A1 receptor antagonist brand/generic (3 drugs)

*doxazosin: Cardura
*Terazosin: Generic only
prazosin: Minipress

A1 receptor antagonist CIs?

Do not use with PDE5i like avanafil, slidenafil, tadalifil, vardenafil due to incr risk hypotension

A1 receptor antagonist SEs?

orthostatic hypotension
reflex tachycardia
peripheral edema
HA
Drowsiness
Priapism (prolonged and unwanted erection of the penis)

A1 receptor antagonist pearls?

PM dosing
ALLHAT trial found 25% incr in CV events
Also used for BPH
Cardura XL approved for BPH only
Incr risk of floppy iris during cataract surgery

Central A2 receptor agonist MOA

stimulate A2 receptors in brain leading to release of norepinephrine (sympathetic outflow) and decr of HR and BP

List central A2 receptor agonist brand/generic (2 drugs)

*clonidine: catapres
methyldopa

Central A2 receptor agonist CIs?

none (clonodine)
liver disease (methyldopa only)

Central A2 receptor agonist SEs?

sedation/depression
orthostatic hypotension
peripheral edema
dry mouth
bradiacardia

hepatitis (methyldopa only)

Central A2 receptor agonist DIs?

Use w/ other neg chronotropes like digoxin, verapamil, diltiazem, B-blocker, ivabradine incr risk of bradycardia

Central A2 receptor agonist pearls?

discontinue both w/ 2wk taper
Injection: methyldopa, clonidine (via epidural for pain)

clonidine patch: is applied weekly, patch application should overlap w/ oral tx by 3d when transitioning
clonidine also treats: ADHD, pain (inj)

methyldopa is pregnancy safe!

Be sure to educate patients taking: A1 antags, A2 ags, and direct vasoconstrictors about _______.

...rising slowly from sitting!

List Direct Vasodilators (2 drugs)(not Top 200)

hydralazine: generic only
minoxidil: generic only

Direct Vasodilator CIs

Acute Mi
Aortic dissection (aortic tear!)

Direct Vasodilators MOA?

incr. cGMP leading to vasodilation

Direct Vasodilators SEs

reflex tachycardia
orthostatic hypotension
peripheral edema

lupus-like syndrome (hydrazine only)

Hirsutism (minoxidil only)

Direct Vasodilators key monitoring?

BP, HR
sx of Lupus like stabbing chest pain, fever, rash, joint pain

Direct Vasodilators pearls?

inectable: hydralazine

Minoxidil also avaliable as hair-growth-stimulator and is therefore considered to be absolute last line therapy due to SE profile

Direct Vasodilators DIs

NONE!