CARDIO TSU HTN

lifestyle modifications

• weight reduction

  • 1 mmHg/1 kg lost

  • goal BMI = 18.5 - 24.9 kg/m2

• DASH

  • 5 - 8 mmHg

  • fruits, veggies, low fat dairy

• dietary sodium restriction

  • 6 - 8 mmHg

  • 2300 mg/day (ideal: 1500 mg/day)

• K supplementation

  • 5 - 7mmHg

• physical activity

  • 4 - 10 mmHg

  • 30 mins/day

• moderation of alcohol

  • 4 - 6 mmHg

  • men = </= 2 drinks/day

  • women </= 1 drink/day

does smoking directly cause HTN?

no

hypertensive crisis

• severe abrupt elevation in BP

• > 180 / 120

difference between severe HTN vs hypertensive emergency

• presence of end-organ damage = hypertensive emergency

goal of severe HTN

• lower BP over 24 - 48 hours

• oral meds

goal of hypertensive emergency

• reduce SBP 20 - 25% within 1st hour

• then

  • lower to 160/100-110 over next 2 - 6 hours

  • normalize within 24 - 48 hours

Nitroprusside (Nipride)

• class

• risks

• route

• use

• avoid

• nitric oxide vasodilator

• nitric oxide donor

• cyanide toxicity, thiocyanate toxicity

• IV

• use

  • aortic dissection w/ BB, HF

• avoid

  • acute renal failure, stroke, encephalopathy

nitroglycerin

• class

• risks

• route

• use

• nitric oxide vasodilator

• nitric oxide donor

• HA, tachyphylaxis

• acute coronary syndrome, HF

Nicardipine (Cardene)

• class

• use

• DHP CCB

• acute renal failure, ischemic stroke, encephalopathy, aortic dissection w/ BB, acute coronary syndrome

Clevidipine (Cleviprex)

• class

• risk

• DHP CCB

• hypertriglyceridemia

Esmolol (Brevibloc)

• class

• caution

• use

• avoid

• cardio selective beta blocker

• HF, heart block

• aortic dissection

• use

  • acute coronary syndrome

• avoid

  • acute HF

Labetalol (Trandate)

• class

• caution

• use

• avoid

• mixed alpha + beta blocker

• acute HF, airway disease

• use

  • acute renal failure, ischemic stroke, hypertensive encephalopathy, aortic dissection, acute coronary syndrome

• avoid

  • acute HF

Fenoldopam (Corlopam)

• class

• function

• use

• D1 receptor agonist

• increase renal blood flow

• acute renal failure

Enalaprilat (Vasotec)

• class

• caution

• avoid

• IV ACE inhibitor

• acute kidney injury, hyperkalemia, angioedema

• acute renal failure

Hydralazine

• class

• caution

• avoid

• smooth muscle relaxant

• coronary ischemia

• avoid

  • aortic dissection

  • acute coronary syndrome

Target BP goal

< 130 / 80 mmHg

2 criteria to start meds

• BP > /= 140/90 mmHg

• BP 130 - 139 / 80 - 89 mmHg + one of the following

  • CVD

  • CKD

  • >/= 7.5% PREVENT score

  • maintains the same after 3 - 6 months of non-pharm therapy

1st line agents

• thiazides

• ACEis

• ARBs

• CCBs (DHPs)

2nd line and Alternative agents

• Loop and K+ sparing diuretics

• non-DHPs CCBs

• beta blocker

• alpha blockers

• central alpha agonists

• direct renin inhibitors

• direct vasodilators

diuretics

• dosed when?

• effects blunted by..

• DDI

• AM

• high sodium diet

• lithium

thiazides

• place in therapy

• CI

• ADE

• 1st line for HTN

• poor renal function (GFR < 30 mL/min or SCr > 2.5)

• hypokalemia, hypercalcemia, hyperuricemia, hyperglycemia

hydrochlorothiazide

• brand

• dosing

• Microzide

• 25 - 50mg

chlorthalidone

• dose

12.5 - 25 mg

Metolazone

• brand

• Zaroroxlyn

Loop diuretics

• place in therapy

• ADE

• pearl

• preferred in those w/ CKD (GFR < 30), HF, edema

• hypokalemia, hypocalcemia, hypmagnesia, hyperuricemia, hyperglycemia

• sulfa allergy → use ethacrynic acid

Furosemide

• brand

• dosing

• Lasix

• 20 - 300 mg

Bumetamide

• brand

bumex

Torsemide

• brand

Demedex

K+ Sparing Diuretics

• place in therapy

• ADE

• caution

• drugs

• combo w/ another diuretic

• hyperkalemia, hyperuricemia

• ACEis, ARBS, direct renin inhibitors, K supplements,

• Amiloride, Triamterene

K+ Sparing Diuretics: MRAs

• common in HF

• caution in impaired kidneys and diabetes w/ proteinuria

Spironolactone

• brand

• dosing

• side effect

• aldactone

• 25 - 100 mg

• gynecomastia

Eplerenone

• CI

• CrCl < 50 mL/min

• SCr > 1.8 mg/dL in women

• SCr > 2 mg/dL in men

ACEis

• MOA

• place in therapy

• indications

• inhibit ACE and inhibit breakdown of bradykinin

• 1st line HTN

• post MI, HF, diabetes, CKD

Lisinopril

• brand

• dosing

• Zestril

• 10 - 40 mg

Enalapril

• brand

• dosing

• Vasotec

• 5 - 40 mg

Benazepril

• brand

• dosing

• Lotensin

• 10 - 40 mg

Ramipril

• brand

Altace

Quinapril

• brand

• Accupril

ARBs

• MOA

• place in therapy

• block ang receptor that mediates ang II

• alternative for pts who cannot tolerate ACEi- induced cough

Losartan

• brand

• dosing

• Cozaar

• 50 - 100 mg

Valsartan

• brand

• dosing

• diovan

• 80 - 320 mg

Irbesartan

• brand

Avapro

Olmesartan

• brand

Benicar

direct renin inhibitors

• block RAAS at activation

• alternative to 1st line

• monotherapy or combo

• Aliskerin

ACEi/ARB/Direct Renin inhbitors ADE

• dry cough - ACEi

• hyperkalemia

• acute renal failure

• changes to GFR

• angioedema

• avoid in

  • ARF, renal artery stenosis

  • pregancy/breastfeeding

CCBs

• DHP

• inhibits calcium influx

• long acting preferred add on for ISH HTN

• kinda repeat from Elsaid

Amlodipine

• brand

• dosing

• Norvasc

• 2.5 - 10 mg

Nifedipine

• brand

• dosing

• Procardia

• 60 - 120 mg

Diltiazem

• brand

• dosing

• cardiazem

• 120 - 480 mg

Verapamil

• brand

• dosing

• Calan, Vereian

• 120 - 480 mg

Beta blockers place in therapy

• indications

• ADE

• clinical pearl

• DDI

• not inital therapy

  • add on or alternative

• post MI, stable angina, HFrEF

• bradycardia, fatigue, sex dysfunction, bronchospasm, mask hypoglycemia effects in diabetics

• avoid abrupt discontinuation

  • taper 1 - 2 weeks

• amiodarone and non-DHPs

metoprolol tartrate, metoprolol succinate

• brand

• dosing

• Lopressor, Toprol XL

• 25 - 400 mg

Atenolol

• brand

• dosing

• Tenormin

• 25 - 100mg

Carvedilol

• brand

• dosing

• Coreg

• 6.25 - 50mg

Propranolol

• brand

Inderal

Nebivolol

• brand

Bystolic

Labetalol

• brand

Normodyne

alpha 1 blockers

• place in therapy

• ADE

• clinical pearls

• DDI

• alternative agents used in combo w/ first line

• benefit w/ BPH

• 1st dose phenomenon, orthostatic hypotension

• PTSD nightmares w/ Prazosin, caution w/ elderly

• phosphodiesterase-5 inhibitors

• Prazosin

• Doxazosin

• Terazosin

• Tamsulosin

• Minipress

• Carduran

• Hytrin

• Flomax

central alpha 2 agonist

• MOA

• place in therapy

  • Clonidine

  • Methyldopa

• ADE

• clinical pearls

• stimulate brain receptors

• clonidine (Catapress) = resistant HTN

• methyldopa = pregancy-induced HTN

• edema, anti-SLUD, orthostatic hypotension

• avoid abruption → taper, caution in elderly

Direct vasodilators

• MOA

• place in therapy

• ADE

• clinical pearl

• relax arteriolar muscle

• Hydralazine (Apresoline 25 - 100mg)

• Minoxidil

• tachycardia, edema

• same as Elsaid

• chronic use in combo w/ diuretic and BB

Efficacy monitoring

re evaluate BP 1 month after starting/changing terapy

safety monitoring

check labs 2 - 4 weeks after starting new agent or increasing dose

combination therapy

• when to use

• preferred combo

• start w/ 2 1st-line drugs for pts w/ stage 2

• ACEi/ARB + CCB DHP

• ACEi/ARB + diuretic

• DO NOT COMBINE ACEi + ARB

Post Mi / stable Angina

• BB, ACEi, or ARB

HFeEF

ACEi or ARB, BB, MRA

diabetes or CKD w/ albuminuria

ACEi or ARB

recurrent stroke

thaizide, ACEI, or ARB

resistant HTN

uncontrolled BP being on 3+ drugs at max dose (1 being diuretic)

or

controlled BP requires 4+ agents

Resistant HTN: treatments

• rule out anything else

• chlorithalidone » HCTZ

• loop diuretics in renal dysfuncition

• spironolactone = best add on

• new therapy = aprocintentan

HTN elderly

• low isolated systolic HTN (elevated SBP, normal/low DBP)

• treat when < 130/80

• risk for AE and orthostatic hypotension

orothostatic hypotension

• drop in BP when standing

• SBP decrease of > 20 mmHg or DBP decrease of 10 mmHg

• treat by low dose and titrate

• Midodrine oor Fludrocortisone

gestational HTN

new onset HTN arising mid pregnancy w/ absence of proteinuria

preeclampsia

BP > 140/90 after 20 week gestation w/ proteinuria

• treatment

  • delivery

  • bed rest + monitoring

  • IV antihyperensives

eclampsia

onset of convulsions, medical emergency

pregnancy HTN

• treatment

• CI

• nifedipine, labetalol

• alternative: methydopa

• CI ACEi, ARB. renin inhibitors, atenonol, nitroprusside, MRAs

HTN in children/adolescents

• type of HTN

• risk factors

• treatment

• CI

• secondary

• family hx, overweight

• lifestyle modification, reduce to 90th percentile, ACEi/ARB. BB, CCB, thiazides

• ACEi/ARB, renin inhibitors in sexually active girls