CPJE 2026

Hypertension Definition and 2017 ACC/AHA Goal

Normal: <120/80

Elevated: SBP 120-129 and DBP<80

Stage 1: Systolic 130-139 OR DBP 80-89

Stage 2: >=140/>=90 (or)

GOAL: <130/80

Diuretics

- medications that reduce fluid volume in the body

- Careful for orthostasis

- LITHIUM should NOT be given with diuretics because clearance is decreased and toxicity is increased

THIAZIDES

Work in DCT by inhibiting Na-Cl pump (weaker diuretic but better HTN control)

- SULFA allergy (photo-sensitivity and rash)

- Decrease K and Na

- Increase blood glucose, TG, uric acid (caution in T2DM and gout)

- Thiazides increase Calcium

* Diuretic of choice is no renal impairment

DDI: Lithium and dofeletide

IF CRCL is <30 m/min, diminished diuretic effect except metolazone

Diuril

Clorothiazide

- SULFA allergy (photo-sensitivity and rash)

- Decrease K and Na

- Increase blood glucose, TG, uric acid (caution in T2DM and gout)

- Thiazides increase Calcium

Microzide, Hydrodiuril

HCTZ

- SULFA allergy (photo-sensitivity and rash)

- Decrease K and Na

- Increase blood glucose, TG, uric acid (caution in T2DM and gout)

- Thiazides increase Calcium

Thalidone, Hygroton

chlorthalidone (longer duration that HCTZ)

- SULFA allergy (photo-sensitivity and rash)

- Decrease K and Na

- Increase blood glucose, TG, uric acid (caution in T2DM and gout)

- Thiazides increase Calcium

Dyazide, Maxzide

HCTZ/triamterene

Zaroxolyn

Metolazone

- Can be used in renal dysfunction (VERY POTENT)

- SULFA allergy (photo-sensitivity and rash)

- Decrease K and Na

- Increase blood glucose, TG, uric acid (caution in T2DM and gout)

- Thiazides increase Calcium

Loop Diuretics

Works in loop of henle by inhibiting Na-K pump

- SULFA Allergy (except edecrin)

- Diuretic of choice in renal disease

- Helpful in fluid overload (HF, CKD)

- IV form is light sensitive

- OTOTOXICITY

- Decrease K and Na

- Increase blood glucose, TG, uric acid (caution in T2DM and gout)

- loops DECREASE Calcium

Lasix

Furosemide

- Ototoxicity

- Oral loop dose equivalency: 40 mg

Demadex

Torsemide

- Ototoxicity

- Oral loop dose equivalency: 20 mg

Bumex

Bumetanide

- Ototoxicity

- Oral loop dose equivalent: 1mg

Edecrin

ethacrynic acid

- ONLY loop diuretic ok in SULFA allergy

- Caution with aminoglycosides!!

Potassium Sparing Diuretics

- Monitior for HYPERKALEMIA! (Range 3.5-5 mEq/L)

- Decrease in Calcium

- Caution in gout

- CI if CrcL <30 ml/min

Dyrenium

triamterene

Midamor

amiloride

Aldactone, Carospir

Spironolactone

- gynecomastia (only aldosterone antagonist with this ADR)

- Useful in HF, HTN (resistant HTN)

- CI in pregnancy

Inspra

Eplerenone

- No gynecomastia

- Useful in HF, HTN (resistant HTN)

- CI in pregnancy

Drug Induced Kidney Disease Risk Factors

Risk factors: Elderly, existing CKD, decreased kidney blood flow (HF, hypotension, dehydration,) and drugs

Examples of Nephrotoxic drugs

- Aminoglycosides (concentration dependent. Lower risj by extending interval)

- Amphotericin

- Cisplatin

- Cyclosporine

- Loop diuretics

- NSAIDS

- Polymixin

- Contrast Dye

- Vanco

- Tacrolimus

ACE-I

BBW: CI in pregnancy and bilateral renal artery stenosis

Angioedema - mostly in black pts - do not rechallenge for exam

- SCr may increase up to 30% (normal)

- do NOT use ACE/ARB together

- Monitor SCr and k (K increase may be insidious)

- Bradykinin Cough

- Angioedema

- AVOID NSAIDs

- lithium toxicity

ACE-I Compelling indications

CKD

- egfr <60 or albuminuria

HF

- EF <= 40%

- Reduce morbidity and mortality

STRONG CYP3A4 Inhibitors

G-PACMAN

- Grapefruit, protease inhibitors, azole antifungals, cyclosporin/cobicistat, macrolides (except azithromycin), amiodarone, Non-DHP CCBs

Lotensin

Benazapril

Capoten

captopril

- shortest acting, needs empty stomach

Vasotec, Enalaprilat (IV)

Enalapril

Monopril

fosinopril

safest in renal impairment

Zestril, Prinivil

Lisinopril (40 mg)

Univasc

moexipril

Accupril

Quinapril

Altace

ramipril

Mavik

trandolapril

Aceon

perindopril

ARB (angiotensin-2 receptor blockers)

do not use in pregnancy

does not affect bradykinin (less cough)

can be used if patient has cough with ACE-I

Cannot be used if pt had angioedema with ace/arb

BBW: CI in pregnancy and Bilateral renal artery stenosis

- Caution with potassium and scr

Atacand

Candesartan

Tevetan

Eprosartan

AVAPRO

irbesartan

Avalide

irbesartan/hydrochlorothiazide

Cozaar

Losartan

Diovan

valsartan

Benicar

olmesartan

* enteropathy: severe chronic diarrhea

Micardis

telmisartan

Edarbi

azilsartan

Direct Renin inhibitors

Stops conversion of angiotensinogen to angiotensin 1

- No evidence for HF/CKD

- Additive risk of hyperkalemia (spironolactone)

- Caution w/ other RAAS (renal impairement, hypotention, hyperkalemia)

- 36 hr wash out with entresto

- Lithium (lower clearence means more toxicity)

Tekturna

Aliskiren plus HCTZ

increased levels of cyclosporin and itraconazole

Valturna

aliskirin plus valsartan

Beta blocker Indications

- heart failure (bisoprolol, carvidelol, metoprolol)

- post MI

- Stable IHD

- Tachyarrhythmias

- Non-cardiac: migraines, anxiety, variceal hemorrhage prophylaxis

- HTN - 2nd line

Beta Blocker Contraindications

- Diabetes (caution use with thiazides) - may mas symptoms

- Asthma and COPD

- Bradycardia (HR <60 bpm)

- Heart block

- Caution in unstable HF

Beta blocker ADRs

- weight gain

- dyslipidemia

- fluid rentention

- fatigue

- depression

- bradycardia

- DECREASED libido

- Dizziness

- Avoid abrupt discontinuation

- caution in reynauds/peripheral vascular disease

Cardioselective Beta Blockers (AMEBBA)

- Beta 1 selective: decrease HR and contractility)

- Pref in asthma/copd

- Atenolol, metoprolol, esmolol, bisoprolol, betaxolol, acebtaolol

Tenormin, Tenoretic

Atenolol

atenolol plus chlorthalidone

Toprol XL, Lopressor, Kapspargo Sprinkle

- Metoprolol succinate: can be split but not crushed or chewed

- Tartrate is same TDD but divided

- ER capsule that may be opened

- HTN: 400 mg/d

- HF: 200 mg/d

Brevibloc (IV only)

Esmolol (crash cart)

- used in HTN emergency only

Zebeta, Ziac

Bisoprolol (+hctz)

Sectral

Acebutolol

Beta Non selective (B1 and B2) blockers

- decrease HR and contractility, INCREASE brochospasm

- Caution in bronchospastic diseases

Hemandeol, Inderal, Innopran XL

Propranolol

- take with FOOD

- IR is BID, ER is QD

- Used in anxiety (more lipohillic but also more CNS adrs)

Timoptic, betimol, istalol

timolol

- normally used for glaucoma now

- If oral, dosed BID

Viskazide (+HCTZ)

Pindolol

Corgard

Nadalol

Betapace, Sorine, Sotylize

Sotalol - antiarrhythmic

COMBO B1, B2, Alpha Nonselective

- SAME adrs

- More aggressive BP reduction

Normodyne, Trandate

Labetalol

DOC in pregnancy

take with food

Coreg, Coreg CR

Carvidelol

take with food

CR not 1:1

Bystolic

Nebivolol

also increase nitic oxide

Cartrol

carteolol

BB

ophthalmic only

Ocupress - gluacoma

Kerlone

betaxolol (beta blocker)

betopic-s: opthalmic

Drug interactions with all Beta blockers

- anything with additive bradycardia risk (dilt, verapamil, digoxin, clonidine, amiodarone)

- insulin and SFU: addive risk of hypoglycemia PLUS can mask symptoms except sweating and possible hunger

NON- DHP CCBS

- Increase selectivity for heart

- Negative inotrope and chronotrope (BRADYCARDIA)

- CI in 2-3rd AV block, acute MI

- Useful in arrythmias, angina, preferred in CKD and diabetic nephropathy

Significant CYP3A4 inhibitor and inducer rxn as CCBs are substrates

- Simvastatin and lovastatin

- ALL CCBS are vasodilators: CI in CHF (VERAPAMIL AND DILT ARE OK IF EF IS NORMAL)

Cardizem

Diltiazem

- PO and IV

- SE: gingiva hyperplasia, constipation, bradycardia

Calan, Isoptin, Verelan, Covera

Verapamil

- PO

- SE gingival hyperplasia, constipation, bradycardia

DHP CCBs

- increased selectivity for vasculature

- peripheral arterial vasodilation (why its good for htn)

- less bradycardia but can cause REFLEX tachycardia

- Not effective for arrhythmias

DHP CCB ADRS

- EDEMA

- headaches

- flushing

Norvasc, Katerzia

amlodipine

- oral suspention is katerzia

- Caution in HF - but safest if needed

Lotrel

benazapril plus amlodipine

exforge

amlodipine plus valsartan

azor

olmesartan plus amlodipine

Plendil

Felodipine ER

Dynacirc

Isradipine CR

Cardene (IV)

Nicardipine

- CI for severe aortic stenosis due to increased hypotension

Adalat cc, Procardia XL

Nifedipine

- NEVER use IR nifedipine due to profound hypotension, MI, death

- Osmotic capsule in poop

- USEFUL in angina and reynauds

Sular

Nisoldipine

Nymalize, Nimotop

Nimodipine

Clevidipine (IV)

- Used in ICU

- Hypotension, increased infection risk and reflex tachycardia

- 20% lipid emulsion (high trigs)

- CI in egg allergy, soy bean and soy product allergy

Central acting Adrenergic drugs

- do NOT stop abruptly - must be tapered

- syncope due to orthostasis

- dizziness, fatigue

- 2/3rd line for htn, USEFUL in BPH

Cardura

Doxazosin

- 16 mg HTN, 8mg BPH

Hytrin

Terazosin

- 20 mg htn, 10 mg bph

Minipress

Prazosin

*only one dosed twice daily

- 5mg BID-TID HTN, 2mg BID BPH

- Used for PTSD nightmares

Flomax

tamsulosin [Sulfa allergy]

Uroxatral

Alfuzosin

Centrally acting alpha 2 agonist

- Do not abruptly DC due to rebound HTN, anxiety, tremor, sweating

- Bradycardia, hypotension

- CNS: fatigue, dizziness, somnulence

- Dry mouth

- Impotence

Catapres

clonidine

- Transdermal is useful for adherence

Methydopa

- CI with MAOI or liver disease

- myocarditis

- Risk of hemolytic anemia (coombs test)

- DILE

- Can be used in pregnancy

Apresoline

Hydralazine

- Direct vasodilator

- Reflex tachy

- DILE

Loniten (PO), Rogaine (topical)

Minoxidil

- direct vasodilator; boxed warning for pericardial effusion

- Reflex tachy

- Hair growth

- fluid retention

Serpasil

reserpine

Hypertensive Crisis (emergency vs urgency)

- BP greater than or equal to 180/120

- If acute organ damage (encephalopathy, stroke, aki, acs) then this is hypertensive emergency.

- If severe ASYMPTOMATIC HTN, then hypertensive urgency

Hypertensive emergency

- IV Medications

- Decrease BP by 25% in first hour and then to ~160/100 in 2-6 hours

DHP CCBs: Clevidipine, nicardipine

ACE-1: enaliprillat

BB: esmolol, labetalol

Vasodilator: Hydralazine, NTG, nitroprusside

NTG: Glass bottles due to leaching

Nitroprusside is most effective due to fats onset and offset

HTN in Pregnancy

- Leading cause of fetal harm

- Preeclampsia - HA, vision changesm seizures, RUQ pain, proteinura, edema

TX threshold: >=140 or >=90

Goal: 120-139/80-89

Methyldopa and labetalol are first line, then hydralazine, nifedipine and BB. if BP is >=160 or >=110 dbp, WILL NEED IV

Very RARE: PO nifedipine IR

Low dose ASA in pts with chronic HTN or renal disease

Aldomet

Methyldopa (alpha-2 agonist)