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Block 2.3
Day 4: Dr. Williams Hypertension
| Question | Answer |
|---|---|
| What causes secondary hypertension? | Amphetamines, decongestants, corticosteroids, antidepressants, estrogen, NSAIDS, and many others. Caffeine, alcohol, Illicit substances like cocaine |
| What causes primary hypertension? | Environmental: excess sodium, alcohol intake, sedentary lifestyle, overweight or obesity Genetic: family history Stiffening of arterial vasculature with inc. age |
| What is normal BP? | <120 and <80 |
| What is elevated BP? | 120-129 and <80 |
| What is stage 1 HTN? | 130-139 OR 80-89 |
| What is stage 2 HTN? | ≥140 OR ≥90 |
| T/F BP classifications can only be assigned for UNtreated patients. | T |
| What is the treatment BP goal for everyone? | <130/80 |
| T/F If patient has stage 1 HTN and a clinical ASCVD >10%, start BP therapy and lifestyle modifications. | T |
| T/F If patient has stage 1 HTN and a clinical ASCVD <10%, start lifestyle modifications and reassess in 3-6 months. | T |
| What are the treatment recommendation for pt BP of <120/<80? | promote optimal lifestyle habits |
| What are the treatment recommendation for pt BP of 120-129/<80? | non-pharmacological therapy |
| What are examples of non-pharmacologic therapies? | physical activity, weight loss, reduce sodium intake, increase potassium intake, moderate EtOH intake, DASH diet, tobacco cessation, and stress reduction |
| What is the treatment for stage 1 HTN? | if CVD risk <10%, initiate non-pharm tx, if CVD or 1-year CVD risk ≥10%, initiate non-pharm treatment a 1 BP lowering med |
| What is the treatment for stage 2 HTN? | Non pharm tx and 1-2 BP-lowering meds |
| What are the first line antihypertensive? | thiazide diuretics, ACEi, ARBs, CCBs (Amlodipine, etc). Initiate HALF the maximum effective dose. If BP at goal, eval every 3-6months, if BP NOT at goal, evaluate every 4 wks, INC to max dose if BP not at goal, add additional agent if warranted. |
| If pt BP is ≥150/90 mmHg, consider initiating 2 first-line drugs | T |
| T/F If BP of pt is not reached after adding a 2nd antihypertensive med, add and titrate a 3rd first-line drug. | T |
| What should be considered when to avoid certain meds? | D= Dec Na or CrCl, BB= asthma, 2/3 AVB, ACEi= K>5, preg, angioedema, ARB= K>5, preg, CCB= 2/3 AVB, HFrEF, Aldo= K>5, dec. CrCl, alpha-antag= HFrEF |
| What med recommendations are to treat HFrEF? | ACEi or ARBs, ARNIs, MRAs, diuretics, and certain BBs |
| What med recommendations are to treat CKD? | ACEi or ARB (regardless of race) |
| What med recommendations are to treat DM? | If ACR ≥ 300mg/g, start with ACEi or ARBs (regardless of race), if no albuminuria, no preference among first- line antihypertensives (race considerations) |
| What are some race considerations with antihypertensives? | Black pts have increased salt sensitivity. ACEi and ARBs should still be used if there is a compelling indications, sometimes before CCBs/thiazides. Can be used as add-on therapy to achieve BP goal. |
| What are some age considerations with antihypertensives? | avoid centrally acting agents and alpha 1 blockers |
| What are some treatment options of chronic hypertension in pregnant patients? | Methyldopa, traditional first line agent. Labetalol, increasingly preferred over methyldopa due to fewer side effects |
| What medications are C/I in pregnant patients? | ACEi/ARBs/Direct Renin inhibitors |
| T/F If pt has uncontrolled HTN despite using 3 or more appropriately titrated drugs (resistant HTN), use aldosterone antagonists (eplerenone or spironolactone). | T |
| T/F If pt has uncontrolled HTN despite using 3 or more appropriately titrated drugs (resistant HTN), ensure adequate diuretic therapy, use chlorthalidone | T |
| T/F If an African-American pt has hypertension and nothing else ,give thiazide diuretics or CCBs. | T |
| What are ACEi? Examples? MOA? Compelling indications? | prevent conversion of Angiotensin I to Angiotensin II in the lungs, benazepril (Lotensin), fosinopril (Monopril), perinodopril (Aceon), ramipril (Altace), quinapril (Accupril) etc. Used for HFrEF, proteinuria/CKD, post MI, post stroke. |
| What are ARBs? Examples? MOA? Compelling indications? | seletively antagonist angiotensin II AT1 receptors, azilsartan (Edarbi), candesartan (Atacand), etc. HFrEF, proteinuria/CKD, post MI. |
| T/F ACEi/ARBs reduce glomerular pressure and are preferred agents in proteinuria therefore renal protection. | T |
| What is the problem with ACEi/ARB renal protection? | SCr increase, so they are often held in the setting of AKI. SCr increase is reversible; expect an increase <30% from baseline SCr. |
| What are ADRs, C/I, and monitoring for ACEi/ARBs? | Cough, hyperkalemia, increase in SCr, angioedema. C/I in preg, bilateral renal artery stenosis, do NOT combine ACEi + ARBs, monitor SCr/electrolytes 2-3 weeks after initiation, no more than 30% increase from baseline. |
| What are Thiazide diuretics? MOA? Examples? | Block the Na+Cl- cotransporter in the DCT. Chlorthalidone, HCTZ, indapamide, and metolazone. Most evidence is for chlorthalidone or indapamide, yet most use with HCTZ. Performed best in the 2002 ALLHAT Trial compare to lisinopril and amlodipine. |
| T/F Switch to chlorthalidone if not meeting BP goal/resistant hypertension. | T |
| T/F Consider loop diuretics when CrCl <30 ml/min | T |
| What is the main ADR of thiazide diuretics? C/I? | Photosensitivity, Hyperuricemia (be wary of someone who has gout). C/I in sulfa allergies, Ethacrynic acid is an alt. , Anuria/severe renal failure. |
| What are CCBs? MOA? types? | Block inward flow of calcium ions from extracellular fluid. DPHs (-pines) and non-DHPs. DHPs inhibit arterial smooth muscle, no chronotropic effects. Non-DHPs inhibit calcium channels of the AV node, have negative chronotropic effects (slow HR). |
| T/F DHPs preferred for HTN. | T |
| What are the C/I for non-DHPs? | heart block, HF |
| What are the ADRs for CCBs? | peripheral edema, flushing, HA, 3A4 substrates, Non-DHPS-bradycardia, heart block. |
| T/F Loops are preferred over thiazides if SCr <30 ml/min | T |
| What BBs are selective? | AMEBBA Atenolol Metoprolol Esmolol Bisoprolol Betaxolol Acebutolol |
| What BBs are non-Cardioselective? | Propranolol Timolol Nadolol Pindolol |
| What BBs have nitric oxide activity? | Nebivolol |
| What BBs have apha1-blocker activity? | Carvedilol Labetalol |
| T/F BBs are not 1st line HTN agents but often 1st like cardiac drugs. | T |
| What are some ADRs of BBs? | bradycardia, rebound tachycardia, ED, reduced exercise tolerance; fatigue, can mask symptoms of low blood glucose, and can worsen cardiac ischemia with concomitant cocaine use |
| What are some C/I of BBs? | Severe bradycardia, decompensated HF, 2nd or 3rd degree AV block, cardiogenic shock |
| T/F Prazosin may have some benefit treating nightmares. | T |
| How should we monitor/counsel pts on ACEi/ARBs? | hyperkalemia/elevated SCr, C/I in preg, cough and angioedema (mostly ACEi) |
| How should we monitor/counsel pts on diuretics? | Hypokalemia/natremia, hyperuricemia, gynecomastia with spironolactone, K+ sparing=kyperkalemia |
| How should we monitor/counsel pts on CCBs? | peripheral edema, non-DHP=bradycardia, 3A4 substrates |
| How should we monitor/counsel pts on BBs? | bradycardia, fatigue, don't stop abruptly |
| How should we monitor/counsel pts on A1 blockers/A2 agonists? | Orthostatic hypotension, dizziness, don't stop abruptly on alpha agonist |
| How should we monitor/counsel pts on direct vasodilators? | reflex tachycardia, edema, DILE (hydralazine), hypertrichosis (minoxidil) |
| What are some examples of direct vasodilators? | Hydralazine and minoxidil |
| What are some examples of A2 agonists? | methyldopa, clonidine, guanfacine |
| T/F Alpha 1 blockers may be stopped abruptly | T |
Created by:
SPangKee
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