Hypertension

Primary (essential) htn

cause unknown

Secondary hypertension

identifiable cause such as renal disease

Drugs that can increase BP

Increased sympathomimetic activity (ADHD drugs)

Increased sodium and water retention (NSAIDs)

Increased blood viscosity (epoetin alfa)

Oral contraceptives

VEGF inhibitors

Pathophys of htn

activation of sympathetic nervous system and renin-angiotensin-aldosterone system (RAAS)

Hypertension diagnosis process

based on average of at least two BP readings at least two separate occasions

Normal BP

Systolic <120

Diastolic <80

Hypertension stage 1 BP

SBP 130-139 OR DBP 80-89

Hypertension stage 2 BP

SBP: >140 OR DBP: >90

Lifestyle management

weight loss

heart healthy diet (DASH)

Reduced sodium intake (<1,500 mg daily)

How to correctly use a BP monitoring devices

Go to restroom and empty bladder

Sit in chair with both feet on ground

Relax 5 min

Support arm at heart level

Wait 1-2 min between measurements

Natural medications

Garlic

Fish oil

When to start htn treatment

Stage 1 htn and any of the following:

-Clinical CVD (stroke, HF, coronary artery disease)

-7.5% PREVENT risk score or 10% ASCVD score

-Does not meet BP goal after 6 months of lifestyle modifications

Stage 2 htn

BP goal

<130/80 mmHg

When to start with 2 drugs

baseline average BP is >20/10 mmHg above goal (>150/90 mmHg)

4 preferred drug tx classes

thiazide diuretic

DHP CCB

ACE or ARB

when to choose ACE or ARB first

CKD

Lisinopril/hydrochlorothiazide

zestoric

Losartan/hydrochlorothiazide

Hyzaar

Olmesartan/hydrochlorothiazide

Benicar HCT

Valsartan/hydrochlorothiazide

Diovan HCT

Benazepril/amlodipine

Lotrel

Valsartan/amlodipine

Exforge

Atenolol/chlorthalidone

Tenoretic

Bisoprolol/hydrochlorothiazide

Ziac

Triamterene/Hydrochlorothiazide

Maxzide or Maxzide-25

First line tx for non-severe chronic hypertension pregnant pt with htn diagnosis prior to pregnancy

labetolol

Nifedipine-Extended release

Methyldopa

preeclampsia

abnormal condition associated with pregnancy, marked by high blood pressure, proteinuria, edema, and headache

Tx for pregnant patients high risk for preeclampsi

daily low dose asa

Thiazide diuretic MOA

inhibit sodium reabsorption in the distal convoluted tubule causing increased excretion of sodium and water (decreased preload and BP) and K+ and magnesium

Chlorthalidone dosing

12.5-25 mg daily

Hydrochlorothiazide dosing

12.5-50 mg daily

Thiazide diuretics CI

Hypersensitivity to sulfonamide-derived drugs

Thiazide diuretics warnings

precipitate or exacerbate SLE, gout, dyslipidemia, diabetes

Thiazide diuretics side effects

Decreases Na, K, Mg

Increased Ca, UA, LDL, TG, BG

Photosensitivity

Impotence

Thiazide diuretics monitoring

electrolytes, renal function, BP

CrCl that diminishes effects of Thiazide diuretics

<30

When to take Thiazide diuretics

early in the day to avoid nocturia

What is the only Thiazide diuretics available in IV

Chlorothiazide

What drugs decrease Thiazide diuretics effectiveness

NSAIDs

Thiazide diuretics effect on lithium clearance

Decreases renal clearance and increases risk of toxicity

List DHP CCB

Amlodipine

Nicardipine

Nifedipine

Felodipine

Isradipine

Nisoldipine ER

list the non-DHP CCB

Verapamil

Diltiazem

MOA of DHP CCB

selective for vascular smooth muscles and causes peripheral vasoconstriction

MOA non-DHP CCB

More selective for myocardium, negative inotropy (Decrease ventricular force) causes BP decrease and negative chronotropic (decrease HR) effects

Which CCB is preferred for HTN

DHP CCB

Amlodipine

norvasc

Nicardipine

Cardene IV

Nifedipine

Procardia XL

DHP CCB warnings

hypotension

DHP CCB Nifedipine IR warning

do not use for chronic HTN or acute BP reduction in non-pregnant adults due to risk of significant hypotension or death

DHP CCB side effects

vasodilatory effects (peripheral edema, headache, flushing, palpitations, reflex tachycardia)

Gingival hyperplasia (gum overgrowth)

DHP CCB monitoring

Peripheral edema

can amlodipine be used in a HF pt

if a DHP CCB must be used to lower BP, yes

Drug of choice in pregnancy

nifedipine ER

DHP CCB injection

clevidipine

Clevidipine CI

soybean or egg allergy

Clevidipine warnings

Hypotension, reflex tachycardia, infections

Clevidipine kcal/mL due to being a lipid emulsion

2 kcal/mL

Clevidipine maximum time of use after via puncture

12 hrs

Primary use of non-DHP

control HR in arrythmias

Dilitazem

Cardizem or Tiazac

Diltiazem availability

IR tablet

ER tablet

ER capsule

Injection

Non-DHP CCB CI

Diltiazem: Acute MI and pulmonary congestion

Verapamil: Severe left ventricular dysfunction

Non-DHP CCB warnings

HF (may worsen sx)

bradycardia

Non-DHP CCB side effects

constipation (more with verapamil)

gingival hyperplasia

edema (more with diltiazem)

What are all CCBs (except clevidipine) substrates for

CYP3A4

What do non-DHP increase the concentration of

statins

which statins require a dose decrease if using a non-DHP

simvastatin and lovastatin

Benefit of RAAS inhibitors in HF

protect myocardium from remodeling and improve survival

How do ACE cause angioedema

increase bradykinin levels

If a pt has a hx of angioedema can they try a different RAAS inhibitor

no

MOA of ACE-I

block conversion of Ang I to Ang II causing a decrease in vasoconstriction and decrease in aldosterone secretion.

Block degradation of bradykinin

benazepril

lotensin

enalapril

vasotec

Enalaprilat

vasotec IV

lisinopril

zestril

quinapril

accupril

ramipril

altace

ACE-I boxed warnings

Injury and death to developing fetus

D/C as soon as pregnancy detected

ACE-I CI

do not use if hx of angioedema

Do not use within 36 hrs of entresto

ACE-I warnings

angioedema

hyperkalemia

renal impairment increase risk with bilateral renal artery stenosis

hypotension

cough

ACE-I monitoring

BP

K

renal function (Scr)

ARB MOA

block Ang II from binding to the AT1 receptor on vascular smooth muscle, preventing vasoconstriction, and on the adrenal gland preventing aldosterone secretion

Irbesartan

avapro

losartan

cozaar

olmesartan

benicar

valsartan

diovan

Differences of ARB and ACE

ARB:

-no washout to start entresto

-no risk of cough

-less angioedema

Olmesartan warning

sprue like enteropathy (severe diarrhea with weight loss)

list direct renin inhibitor

aliskiren

ACE and ARB effect on lithium

decrease renal clearance and increase risk of toxicity

Can NSAIDs be used with ACE or ARB

yes cautiously due to renal impairment

Which electrolyte do all RAAS inhibitors increase

potassium

Potassium sparing diuretics triamterene and amiloride MOA

directly blocking sodium channels in late distal convoluted tubule and collecting duct, this increased sodium and water excreting but conserves potassium

Are Potassium sparing diuretics preferred for HTN

no primarily used in combo with thiazide diuretics to counteract the mild K losses

List Potassium sparing diuretics

triamterene

amiloride

spironolactone

eplerenone

Potassium sparing diuretics spironolactone and eplerenone MOA

inhibit sodium channels by blocking the aldosterone receptor site

Preferred add on for resistant htn

Spironolactone or eplerenone

Difference between spironolactone and eplerenone

Spironolactone is non selective aldosterone receptor antagonist so it blocks androgen also

Eplerenone is selective

Triamterene + HCTZ brand

Maxzide

Maxzide 25