Hypertension- Follen

Normal Blood pressure is <____/____ mmHg

Hypertension is high blood pressure ≥_____mmHg systolic and ≥______mmHg diastolic

Normal Blood pressure is <____/____ mmHg

Hypertension is high blood pressure ≥_____mmHg systolic and ≥______mmHg diastolic

normal: <120/80 mmHg

High bp: ≥130/80 mmHg

Most pts. with hypertension are _______________.

a. symptomatic

b. asymptomatic

b. asymptomatic

What is the difference between primary and secondary hypertension?

in primary were preventing a cardiac event and usually cause is unknown.

in secondary, HTN is a RESULT of something else (ex: CKD) and were preventing another cardiac event.

Which of the following agents would not cause an increase in bp?

a. Antidepressants- SNRIs

b. NSAIDs

c. Amphetamines

d. decongestants- nasal saline/ intranasal corticosteroids

d

To diagnose HTN, it is based on the average of ____ or more properly measured BP readings from _____ or more clinical encounters.

a. 1,2

b. 2,2

c. 2,3

d. 3,2

b. 2,2

Elevated BP is when SBP is _____-______ and DBP is < _____.

when SBP is 120-129 and DBP is <80

Stage 1 HTN is classified as SBP _____-______mmHg or DBP _____-_____mmHg.

SBP is 130-139 or DBP 80-89

Stage 2 HTN is classified as SBP ≥_____ or DBP ≥______.

SBP ≥140 or DBP ≥90

How would you classify this patient? (normal, elevated, stage 1, stage 2)

SBP= 136

DBP= 76

stage 1

How would you classify this patient? (normal, elevated, stage 1, stage 2)

SBP= 121

DBP= 79

elevated

How would you classify this patient? (normal, elevated, stage 1, stage 2)

SBP= 134

DBP= 99

Stage 2

What are the steps to taking a person’s blood pressure?

1. prepare the patient- relaxed, sitting in a chair for at least 5 min, no caffeine, exercise, or smoking for at least 30 minutes before

2. use proper technique- support patients arm, use correct cuff size

3. take proper measurements- separate repeated measurements by 1-2 minutes, inflate the cuff 20-30 mmHg above estimated SBP

4. document

5. average the readings

6. provide patient BP reading

BP= ______ x _______

CO x TPR

Normally, Angiotensin II causes vaso__________.

vasoconstriction

What are some of the things that Ang II stimulates in the body? FYI

• sympathetic activity

• Na and water reabsorption

• aldosterone secretion

• vasoconstriction

• ADH secretion

ALL RESULT IN: water and salt retention, increase in circulating volume

Renin catalyzes the conversion of _____________ to ______________ in the blood. ACE enzyme converts __________ to _________.

Renin- angiotensinogen to Ang I

ACE- Ang I to Ang II

When Ang II increases aldosterone synthesis, that does what to plasma volume, TPR, and BP?

increase ALL of them

Receptor Review- describe each of the following receptors:

b1

b2

a1

a2

b1- heart/ contractility and HR

b2- lungs/ vasodilation and airway dilation

a1- vasoconstriction

a2- decrease central sympathetic outflow/ inhibit NE release

What are the 4 preferred drug classes that are FIRST line for initial HTN tx?

1. Thiazide Diuretics

2. ACE inhibitors

3. ARBs

4. CCBs

Examples of Thiazide Diuretics:

• Hydrochlorothiazide

• Chlorothiazide

• Chlorthalidone

• Indapamide

• Metolazone

We are NOT going to use a thiazide diuretic for HTN if our SCr clearance is <_____ml/min. What is the one exception to this?

• do NOT use if <30 ml/min

• one exception: metolazone

Thiazides are contraindicated if you have hypersensitivity to _________________.

sulfonamides

Thiazides cause what type of electrolyte disturbances? (K, Na, Ca, etc.)

• ↓ K, Mg, Na

• ↑ Ca, uric acid, blood glucose

What drugs interact with Thiazide Diuretics?

• NSAIDs

• Lithium

• Dofetilide

Pts should take thiazide diuretics early in the day to avoid ____________.

nocturia

ACE inhibitor generic names all end in “-______”

-pril

MOA of ACE inhibitors

• block conversion of Ang I to Ang II by blocking ACE enzyme

• also blocks bradykinin degradation

BOXED WARNING of ACE inhibitors

fetal toxicity- aka do NOT use when pregnant

do not use ACE inhibitors if you have a history of _____________.

angioedma

Can I use an ACEi, ARB, or renin inhibitor in combination?

NO

Do not use an ACE inhibitor within 36 hours of _________________.

sacubitril/valsartan

ADRs of ACE Inhibitors

• dry COUGH

• Hyperkalemia

• hypotension/dizziness

ARBs generic names end in “-_________”

-sartan

MOA of ARBs

• block binding of Ang II to the AT1 receptor on vascular smooth muscle

Boxed warning of ARBs

fetal toxicity

Do not take an ARB if you have _____________.

angioedema

If you see angioedema when taking an ACE Inhibitor and want to switch to an ARB, how long do you have to wait?

6 weeks

Compared to an ACE inhibitor, ARBs have less ________________.

angioedema

ACE inhibitors and ARBs have identical ADRs except for what?

ACE inhibitors can cause a cough, ARBs NO COUGH

What are drug interactions of ACEI, ARB, and Renin Inhibitors?

• meds that increase potassium

• lithium

DHP CCBs generic names end in “-_____”

-pine

When using the CCB Nifedipine do we use the ER or IR version?

ER

What are the 2 non-DHP CCBs?

1. diltiazem

2. verapamil

Which CCB is preferred in pregnancy?

Nifedipine

Which CCBs are primarily used in the tx of HTN?

DHPs or non-DHPs?

DHPs

MOA of CCBs:

• inhibit Ca²+ ions from entering vasculature and myocytes

  • causes dilation

DHPs are more selective for ________________.

a. vascular smooth muscle

b. myocytes

a

Non-DHPs are more selective for ______________.

a. vascular smooth muscle

b. myocytes

b

Certain ____________ should not be used in hypotension, cardiogenic shock, AV blocks, sick sinus syndrome, acute MI, pulmonary congestion, severe left v dysfunction, a flutter/ a fib.

non-DHPs

Are CCBs recommended in pts. with hypotension?

no

Are CCBs recommended in a patient with heart failure?

NO (if you have to use, use amlodipine)

Non-DHPs should not be used in __________cardia.

bradycardia

ADRs of DHPs and non-DHPs

• peripheral edema

• HA

• gingival hyperplasia

Drug interactions of CCBs:

• use caution w/ other drugs than decrease HR (ex: b-blockers)

• CYP3A4 inhibitors

• grapefruit juice

Are beta-blockers recommended for 1st-line tx of HTN?

NO

When would we use a beta-blocker?

when the patient has a comorbid condition (Ex: post-MI, SIHD, HF)

What b-blockers should be used if the pt has chronic heart failure?

• bisoprolol

• carvedilol

• metoprolol succinate

MOA of b-blockers:

• decrease bp by blocking beta-adrenergic receptors

Examples of b1 selective b-blockers:

• atenolol

• esmolol

• metoprolol tartrate/succinate

• acebutolol

• betaxolol

• bisprolol

• nebivolol

b1 selective b-blockers are preferred in pts with:

asthma, COPD (any lung problem)

Examples of non-selective b-blockers:

• propanolol

• nadolol

• pindolol

• timolol

Examples of mixed b-blockers:

• carvedilol

• labetalol

Intraoperative floppy eye syndrome has occurred in pts who were on or previously treated with an _________________.

a1 blocker

Are b-blockers preferred to have or not have ISA activity?

no ISA activity preferred

BOXED WARNING of b-blockers:

do NOT abruptly discontinue

B-blockers should NOT be used if you have _________ or severe ___________.

if you have heart failure or severe bradycardia

ADRs of b-blockers:

• bradycardia

• fatigue, dizzy, depression

• cold extremities

• hypotension

• impotence (Erectile dysfunction)

Drug interactions of b-blockers:

• insulin

• sulfonylureas

• other meds that decrease HR

• CYP2D6

What beta-blocker is the drug of choice in pregnancy?

labetalol

When are loop diuretics chosen over thiazides when treating HTN?

if the pt has heart failure, loop best

Can loop diuretics be used if the CrCl is <30 ml/min ?

Yep

MOA of loop diuretics:

• inhibit Na reabsorption

  • increase excretion of water, Na, K, Mg, Ca

Loop Diuretics should not be used if you have what allergy? What is the exception?

• sulfa allergy

• exception: ethacrynic acid

Unique ADR of loop diuretics:

ototoxicity

Loop diuretics cause what electrolyte abnormalities?

• ↓ K, Na, Cl, Ca

• ↑ uric acid

Mineralcorticoid Receptor Antagonists (K+ sparing diuretics) are preferred agents in __________________ and __________________.

primary aldosteronism and resistant HTN (common add on therapy)

ADRs of MRAs (K+ sparing diuretics)

• hyperkalemia

• gynecomastia (in spironolactone)

Drug interactions of MRAs (K+ sparing diuretics)

• other K+ sparing drugs

• lithium

• CYP3A4 inhibitors

Hydralazine is associated with __________ and minoxidil is associated with ____________.

• idk how important to know this is but it’s underlined

hydralazine- lupus

minoxidil- hirsutism

a1 blockers can cause _____________ hypotension.

orthostatic

What is an example of a direct renin inhibitor?

aliskeren

What a2 agonist is preferred in pregnancy?

methyldopa

If BP is classified as “elevated” what is the recommended tx? When should be re-assess?

• nonpharm therapy

• reassess in 3-6 months

If BP is classified as “stage-1” with no comorbid conditions, and a ASCVD risk <10% what is the recommended tx? When should be re-assess?

• nonpharm tx

• reassess in 3-6 months

If BP is classified as “stage-1” and there is a comorbid condition, like CVD, DM, CKD, or the ASCVD risk is >10% what is the recommended tx and when should we reassess?

• nonpharm tx + BP lowering medication

• reassess monthly till bp controlled

If BP is classified as “stage-2” what is the recommended tx and when should we reassess?

• nonpharm tx + 2 BP lowering meds

• reassess monthly till BP goal met

Examples of nonpharm/ lifestyle modifications for HTN:

• Weight loss

• DASH diet

• reduced salt intake

• increase K intake

• physical activity

• alcohol moderation

  • 2 for men, 1 for women

• smoking cessation

What is the 2017 ACC/AHA Blood pressure Goal?

<130/80

_________ daily dosing and _______________ pills can improve adherence.

once daily dosing and combination pills can improve adherence.

What medications should be used 1st line if the pt has HTN and HF?

• RAAS Drugs (ACE, ARB, or ARNI)

• MRA (K+ sparing diuretic)

• Diuretic

• beta blocker

  • carvedilol, metoprolol succinate, bisoprolol

What HTN medications should be AVOIDED if the pt has HTN and HF?

Non-DHPs!!!!!!!!!

What medications should be used 1st line and if there are compelling indications if the pt has HTN and SIHD?

• b-blockers

  • 1st LINE

• ACEI or ARB

  • consider compelling indications

If a pt has HTN and SIHD and blood pressure is STILL not controlled using a b-blocker or ACE/ARB, what could be possible add on therapies?

• DHP

• thiazide

• MRA (K+ sparing diuretic)

Out of the add-on therapies for a pt with HTN and SIDH, what is the best add-on therapy if the pt has angina?

DHP

What medications should be used 1st line if the pt has HTN and DM in the presence of albuminuria?

• ACE or ARB

What medications should be used 1st line if the pt has HTN and DM with NO albuminuria?

• ACE or ARB

• CCB

• diuretic

If a BLACK ADULT with DM and HTN, but no HF or CKD, what would be intial treatment?

• CCB

• thiazide

If a black adult has DM, HTN, and CKD, would we treat the pt. based on CKD guidelines or guidelines for black adults?

CKD guidelines

What medications should be used 1st line if the pt has HTN and CKD in the presence of albuminuria?

• ACEI preferred

• can use an ARB though

What medications should be used 1st line if the pt has HTN and CKD with NO albuminuria?

• our usual 1st line meds

• ACEIs, ARBs, CCBs, thiazides