Therapeutics I > HTN > Flashcards

HTN Flashcards

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1
Q

What is HTN?

A

Elevation in pressure from normal

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2
Q

What is systolic vs diastolic?

A

Cardiac contraction and after contraction when the cardiac chambers are filling

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3
Q

What is MAP? Who do you calculate it?

A

Average pressure throughout cardiac cycle of contraction

MAP=1/3 SBP + 2/3 DBP
MAP= CO x PVR
CO=HR x SV

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4
Q

How does increasing CO lead to high BP?

A
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5
Q

How does increasing PVR lead to high BP?

A
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6
Q

What are the infrarenals of the RAAS?

A
  1. Renal purfusion pressure
  2. Catecholamines
  3. Angiotensin II
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7
Q

What are the extrarenals of RAAS?

A

Na+, K+, Cl-

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8
Q

Describe the presynaptic regulations of HTN?

A
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9
Q

Describe the postsynaptic regulations of HTN?

A
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10
Q

Describe the endothelial mechanisms?

A

Vasodilating substances → prostacyclin, bradykinin, nitric oxide
Vasoconstricting substances → angiotensin IIand endothelin I

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11
Q

What are the consequences of HTN?

A
  1. Stroke
  2. MI
  3. HF
  4. Angina
  5. Vision loss
  6. Kidney failure
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12
Q

What are some modifiable risk factors?

A
  1. Smoking
  2. DM
  3. Obesity/Physical inactivity
  4. DIet
  5. High cholesterol
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13
Q

What is normotensive?

A
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14
Q

What is elevated BP?

A
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15
Q

What is Stage 1 BP?

A
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16
Q

What is Stage 2 BP?

A
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17
Q

What is HTN crisis number?

A
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18
Q

What is essentinal HTN?

A

No underlying cause

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19
Q

What is secondary HTN?

A

Identifiable cause

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20
Q

What is resistant HTN?

A

≥130/80 mm Hg with concurrent use of 3 antiHTN meds of different classes

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21
Q

What is masked HTN?

A

Elevated BP at home despite office BP lower than 140/90

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22
Q

What is white coat HTN?

A

Normal BP at home but elevated in office

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23
Q

What are the environmental causes of essential HTN?

A
  1. Obesity
  2. Sodium intake
  3. Potassium intake
  4. PE
  5. Alcohol intake
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24
Q

What are common causes of secondary HTN?

A
  1. Renal disease
  2. Renovascular disease
  3. Aldosteronism
  4. Obstructive sleep apnea
  5. Drugs or alcohol
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25
What are some med that can cause elevated BP?
1. Alcohol 2. Amphetamines 3. Antidepressants 4. Caffeine 5. Decongestants 6. Oral contraceptives 7. NSAIDs 8. Recreational drugs 9. Systemic corticosteroids
26
What are the clinical presentations of HTN?
1. Asymptomatic 2. Elevated BP 3. Require 2 or more measurements taken during 2 or more clinical encounters is required for diagnose
27
What are the clinical evals of HTN?
1. Comprehensive med hisotry 2. Physical examination 3. Laba and diagnostics
28
What are the goals of evaluation?
1. Identify secondary causes 2. Identify CV risks and cormorbidity 3. Assess for the presence or absence of HTN associated complications
29
What are some historical features to be aware of in primary HTN? Secondary?
P: Lifestyle factors, family history S: Obstructive sleep apnea, weight
30
What are goals for HTN according to ACC/AHA? Alone? DM? CKD? Elderly?
31
What are the ACC/AHA goals of HTN? Why is it not used as often?
1. Each patient is unique 2. Balance benefit and harm Insurance don't abide by it
32
What is the purpose of trials of HTN?
Reducing morbidity and mortality of disease states and medications
33
What is the algorithm for normal BP?
34
What is the algorithm for elevated BP?
35
What is the algorithm for stage 1 HTN?
36
What is the algorithm for stage 2 HTN?
37
What needs to be considered when someone reaches stage 2?
2 antiHTN of different classes Those ≥160/100 should be treated promptly
38
What are some non-pharm strategies for HTN?
1. Weightloss 2. DASH 3. Sodium reduction 4. Potassium supplements 5. Increased physical activity 6. Reduction in alcohol consumption
39
What are the weight loss goals?
IBW, expect about 1 mmHg for every 1 kg reduction in body weight (max: 5)
40
What consists of the DASH diet?
fruits, veggies, whole grains, low-fat dairy
41
What is the goal for Na+ intake?
<1500 mg/d
42
What is the goal for potassium supplements?
3500-5000 mg/d
43
What is the alcohol intake rec?
Men: ≤2 Women: ≤1
44
Who would respond more to sodium reduction?
1. Blacks 2. Older people Most fast foods are processed and have high sodium
45
What are strategies for reducing sodium?
1. Fresh foods 2. Use food labels 3. Sub 4. Control
46
How do you calculate heart rate reserve?
Max HR- resting HR Usually 220-age
47
What are the types of physical activity?
Aerobic Dynamic resistance Isometric resistance
48
What is aerobic?
Brisk walking, swimming, rowing, jumping rope, cycling, running
49
What is dynamic resistance?
Concentric and eccentric contractions (joint movement) Bicep curls, tricep dip, squats
50
What is isometric resistance?
Contracting a muscle for a prescribed amount of time Planking, wall sit
51
What is considered a standard drink?
12 fl oz (beer) = 1.5 fl ox (double shot) = 5 fl oz (wine)
52
What are alternative strategies for HTN (limited evidence)?
1. Probiotics 2. Increased protein and fiber 3. Ca2+ supplements
53
What is 1st line diuretic for HTN?
Thiazides
54
What are the adrenergic HTN drugs?
1. Non selective a atangonist 2. alpha 1 blocker 3. beta blockers 4. centrally acting
55
What are the vasodilators for HTN?
CCB Direct acting VD K+ channel openers
56
What is the initial med for non-black?
1. TZD 2. CCB (DHP) 3. ACEI 4. ARB
57
What is the initial med for blacks?
TZD or CCB
58
How do we decide med for basic HTN patients?
59
What is the MOA of thiazides?
1. Inhibit reabsorption of Na+ in the DCT 2. Increases the excretion of sodium and water and potassium
60
What are the thiazides used for HTN?
1. Chlorthalidone (stronger and higher efficacy) 2. HCTZ 3. Indapamide 4. Metolazone (not really used)
61
What are some pearls to know about TZD?
1. first line of HTN 2. PO QAM to avoid nocturnal diuresis 3. May worsen gout 4. Decreased efficacy withCrCl <30mL/min 5. Sulfonamide allergy
62
What is the MOA of CCB? what the difference between the two classes?
Blocks inward flow of Ca2+ through L channels of arterial smooth muscle DHP: dilate arteries not veins Non-DHP: reduce HR and contractility, not used for HTN
63
What are some pearls for DHP?
1. Peripheral edema on arterial and increased venous pressure → edema 2. Nifedipine may cause yo-yoing 3. Avoid use in patients with patients with HFrEF (amlodipine or felodipine) 4. Potent peripheral VD
64
What are some Non-DHP pearls?
1. ER products for HTN (not commonly used) 2. Avoid use in HFrEF 3. Avoid with beta blockers 4. For arterial tachyarrhythmia 5. CYP3A4 substrates and moderate inhibitors DDI
65
What are the DHP drugs?
66
What are the nonDHP?
67
What is the MOA of ACEI?
1. Block the conversion of angiotensin II 2. Increase bradykinin blocking breakdown Coughing, angioedema
68
ACEI drugs?
69
ACEi Pearls?
1. Strong rec for: stroke, CAD, HF, CKD, DM, albuminuria 2. Reduce proteinuria 3. DDI with ARB or renin inhibitor 4. Hyperkalemia 5. Angioedema 6. Fetal toxicity 7. Reduce dose 50% who are on diuretic or elderly 8. Reno-protective
70
What is the MOA of ARBS?
Blocks angiotensin II receptor (AT1) → vasodilation
71
Types of ARBs?
72
ARB pearls?
1. No increased production of BK 2. DDI with renin inhibitors and ACEis? 3. hyperkalemia 4. Risk for AKI 5. Angioedema 6. Fetal toxicity 7. Reduce dose 50% who are on diuretic or elderly
73
What need to be considered in black patients with HTN?
1. Most require ≥2 AHTN med to achieve BP control 2. TZD and CCBs are more effective 3. ACEi are less effective and higher risk of angioedema
74
What are some thing to be aware of for HTN geriatrics?
Less intensive BP control High burden of comorbidity and limited life expectancy
75
TZD and geriatrics?
Increased SIADH (electrolyte abnormalities)
76
CCB and geriatrics?
Greater hypotensive response Constipation No CNS effect
77
ACEis and getriatrics?
Favorable side effect profiles, hyperkalemia
78
Beta blockers and geriatrics?
Less hemodynamic response and more bradycardia
79
What are some thing to be aware of for HTN pregnancies?
1. BP decline 1st trimester than slowly rises 2. ARB and ACEi are fetotoxic 3. Nifedipine, labetalol, methyldopa, hydralazine 4. Preeclampsia are risk facotrs
80
What are comorbidities of HTN?
1. Stable ischemic heart disease 2. A fib 3. HF 4. PAD 5. CKD 6. DM 7. CVD 8. Metabolic syndrome
81
HTN treatment for stable ischemic heart disease?
GDMT w/ beta blocker (not for HTN but for disease state)
82
What is the guideline for HFrEF?
Find optimal regimen for HF not HTN ACEi or ARB, ARNI, MCR antagonists, diuretics, GDMT beta blockers Don't use Non-DHP Goal: <130/80
83
What is the guideline for HfpEF?
Goal: <130/80 ACEi or ARB, beta blocker, MRA Volume overload treatment with diuretics
84
How does HTN effect CKD?
Major contributor to decline in GFR 30% of patients have masked HTN
85
Guidelines for CKD?
86
What is the difference between acute intracerbral hemorrhage and ischemic stroke? Secondary stroke prevention?
Hem: Increased BP → pressure in vessels → leakage in brain Stroke: Lack of O2 → damage → treatment is permissive HTN Secondary: management of stroke
87
How do you treat PAD with HTN?
Normal patient
88
How do you treat DM with HTN?
1. First line 2. With albuminuria: ACEi/ARB
89
What is metabolic syndrome? What is the treatment?
Metabolic dysregulation by visceral fat accumulation, insulin resistance, hyperinsulinemia, hyperlipidemia Thiazides due to increased insulin resistance Don't use beta blockers → deterioration of glucose tolerance and dyslipidemia
90
What is the most common cormorbidie associated with HTN?
A fib
91
What is the goal for Afib HTN?
Control HTN to aid a fib prevention ARB
92
What is the standard for clinical monitoring of HTN?
1. Reevaluation 2-4 weeks after initiating or changing therapy 2. Once at goal → monitor every 3-6 months Self monitoring and ABP can be used in combo
93
How do we monitor ADRs?
Pharmacist must know common side effects and lab parameters
94
How do you lab monitoring for HTN?
1. 2-4 weeks after agent initiation or dose increase 2. Every 6-12 months for stable patients 3. More intensive follow up for aldosterone antagonists → K+ and renal function evaluation within 3 days then again for 1 week
95
What are the signs and symptoms of HTN to look out for?
1. Ischemic chest pain 2. Vision 3. One side weakness 4. Slurred speech 5. Loss of balance Ey exam Proteinurina
96
Recommendations for non adherence?
1. Focus on clinical outcomes 2. Empowerment 3. Implement a team 4. Advocate for health policy reform
97
Preferred HTN combos?
1. ACEI/CCB 2. ARB/CCB 3. ACEi/thiazide 4. ARB/thiazide
98
How do you diagnose resistant HTN?
1. Failure to achieve BP control with 3 meds 2. BP control but requires ≥4 meds
99
Risk factors of resistant HTN?
1. Older 2. Obesity 3. CKD 4. Black 5. DM
100
Common 3 drug regimen?
CCB, RAAS inhibitors, Chlorthalidone
101
What are recommended combo with spironolactone?
Hydralazine or minoxidil
102
What is the treatment algorithm for resistant HTN?
Confirm resistance → Exclude pseudo resistance → Identify and reverse lifestyle factors → discontinue substances → screen for secondary causes → pharm treatment → refer to specialist
103
What diuretics are more potent than HCTZ?
Chlorthalidone and indapimide
104
What can be used in place of thiazides if patient has decreased renal function?
Loops
105
What are guidelines for alpha-1 blockers?
Sodium and H2O retention First dose phenomenon
106
What are guidelines for central a2 blockers?
Significant CNS activity Induce HTN crisis
107
What are guidelines for renin inhibitors?
DDI with RAAS inhibitors Long acting
108
What are guidelines for loop?
HF, CKD
109
What are guidelines for K+ sparing?
Avoid CKD For thiazide induced hypokalemia
110
Overall algorithm for HTN?
111
Overall algorithm for HTN with cormorbidieis?
Therapeutics I
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