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116 Cards in this Set
- Front
- Back
What is JNC 7? |
National Guideline - 7th edition of joint national committee on detection, evaluation, and treatment of high BP |
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Cardiovascular morbidity and mortality risk directly correlated with __________ |
Blood Pressure - AntiHTN drug therapy reduces cardiovascular and mortality risk |
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What are the target organs that can be damaged due to HTN? |
1) Brain: Stroke, TIA, dementia 2) Eyes: Retinopathy 3) Heart: Left ventricular hypertrophy, Angina 4) Kidney: Chronic kidney disease 5) Peripheral Vasculature: Peripheral arterial disease |
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What is Normal BP? |
<120/70 - Always encourage life style modifications |
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What is the range of Prehypertension? |
120-139/80-89 - Life style modification - No drug therapy needed |
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What is the range of Stage 1 Hypertension? |
140-159/90-99 - Life style modification - Thiazide type diuretic (1st line) - May also consider ACEI, ARB, BB, CCB - Or Combination therapy - Drugs for other compelling indications PRN |
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What is the range of Stage 2 Hypertension? |
>or= 160/100 - Life style modification - Two drug combination (Thiazide + ACEI or ARB or BB or CCB) - Drugs for other compelling indications PRN |
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What are the components for evaluation? |
1) Medical history 2) Physical examination 3) Routine laboratory tests 4) Optional tests |
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What are the causes of Secondary HTN? |
1) CKD 2) Cushings Syndrome 3) Coarctation of the aorta 4) OSA 5) Parathyroid Dz 6) Pheochromocytoma 7) Primary Aldosteronism 8) Renovascular disease 9) Thyroid disease |
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What prescription drugs can cause Secondary HTN? |
1) Prednisone, fludrocortisone,triamcinolone 2) Amphetamines/anorexiants: phendimetrazine, phentermine, sibutramine 3) Antivascular endothelin growth factor agents 4) Estrogens: usually oralcontraceptives 5) Calcineurin inhibitors: cyclosporine, tacrolimus 6) Decongestants: phenylpropanolamine& analogs 7) Erythropoiesis stimulating agents:erythropoietin, darbepoietin 8) NSAIDs, COX-2 Inhibitors 9) Venlafaxine 10) Bupropion 11) Bromocriptine 12) Buspirone 13) Carbamazepine 14) Clozapine 15) Ketamine 16) Metoclopramide |
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What situations can cause secondary HTN? |
1) When b-Blocker or centrally acting a-Agonists are abruptly discontinued 2) when treating pheochromocytoma with b-Blocker without a-blocker first |
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What food substances can cause secondary HTN? |
1) Sodium 2) Ethanol 3) Licorice |
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What are the Street drugs that causes Secondary HTN? |
1) Cocaine 2) Cocaine withdrawal 3) ??? |
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Other natural products causing secondary HTN |
?? |
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What are the mechanisms of pathogenesis in HTN? |
1) Increased Cardiac Output (CO) 2) Increased Peripheral resistance (PR) |
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What are the components of Increased Cardiac output (CO)? |
1) Increased Preload - Increased fluid volume - Excess sodium intake - Renal sodium retention 2) Venous constriction - Excess RAAS stimulation - Sympathetic nervous system overactivity |
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What are the components of Increased peripheral resistance (PR)? |
1) Functional Vascular constriction - Excess RAAS stimulation - Sympathetic nervous system overactivity - Genetic alterations of cell membranes - Endothelial-derived factors 2) Structural Vascular hypertrophy - Excess RAAS stimulation - Sympathetic nervous system overactivity - Genetic alterations of cell membranes - Endothelial-derived factors - Hyperinsulinemia due to obesity, metabolic syndrome |
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What are the blood pressure determinants? |
1) CO - HR - SV: Contractility & Volume 2) SVR **** Direct relationship**** |
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Increase in CO or SVR will result in ___________ |
Increase in BP |
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Decrease in volume will result in __________ |
1) Decrease in BP 2) will then result in increase in HR 3) will then result in increase in CO 4) will then hopefully restore the BP |
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What are goals of HTN management and prevention?
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1) To reduce morbidity and mortality by the least intrusive means possible **Maintain SPB < 120, DBP < 80 & controlling other CV risk factors** |
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What are some medications that can be used as treatment option for HTN? |
1) Diuretics 2) Beta blockers 3) ACE inhibitors 4) Angiotensin II receptor blockers 5) Calcium channel blockers 6) Alpha blockers (Alpha 1 antagonist) 7) Centrally acting alpha agonists 8) Direct vasodilators 9) Peripheral adrenergic blockers |
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What are some life style modifications options for treatment of HTN? |
Begin or continue lifestyle modifications 1) Lose weight 2) Limit Alcohol 3) Increase physical activity 4) Reduce sodium 5) Maintain potassium 6) Maintain calcium and magnesium 7) Stop smoking 8) Reduce saturated fat & Cholesterol |
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Algorithm for treatment of HTN |
1) Begin or continue lifestyle modifications "If Not at goal BP (<120/80)- (lower goals for patients with diabetes or renal disease)" 2) Initial drug choices - influenced by other disease states - Start at low dose and titrate upward - low dose combination may be appropriate |
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What is mechanism of action of Diuretics? |
1) Reduce volume 2) Prevent sodium reabsorption 3) Diuretic potency associated with proximal action --(the increase in potency on nephron - the more decrease in resultant BP) 4) Mild vasodilation |
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Name the types of Diuretics and which part of kidney they act on? |
1) Carbonic anhydrase inhibitor - Proximal convoluted tubule 2) Thiazide diuretics - distal convoluted tubules 3) Potassium-sparing diuretics - collecting tubules 4) Loop diuretics - peritubular capillary |
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What is the mechanism of action of Carbonic Anhydrase inhibitors? |
1) Acts at luminal membrane of proximal tubule 2) Enhances bicarbonate reabsorption in proximal tubules ** Inhibitors block sodium bicarbonate reabsorption ** -- Diuretics |
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Carbonic Anhydrase inhibitors are _____________ Name 2 carbonic anhydrase inhibitors. |
Weak diuretics 1) Acetazolamide (Diamox) - PO - Injectable 2) Dorzolamide (truspopt) - Ophthalmic solution |
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Carbonic anhydrase inhibitor - Acetazolamide are _______ |
1) Well absorbed 2) Onset of action 30 mins 3) Peak action at 2 hours 4) Excreted via kidneys (tubular secretion) |
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What are some indications for clinical uses of Acetazolamide? |
1) Glaucoma (decreased rate of aqueous humor formation) 2) Urinary alkalinization 3) Metabolic alkalosis 4) Mountain sickness |
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What is the mechanism of action of Loop Diuretics? |
1) Inhibit sodium reabsorption in the thick ascending limb of the loop of henle 2) Some proximal tubule action 3) Well and rapidly absorbed
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Name 4 Loop Diuretic drugs. |
1) Furosemide (Lasix) 2) Ethacrynic acid (Edecrin) 3) Bumetanide (Bumex) 4) Torsemide (Demadex) - fastest absorption |
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Which one of the loop diuretic drug is not a sulfonamide? |
Ethacrynic acid (Edecrin) |
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What are the adverse effects of Loop diuretics? |
1) Hypovolemia 2) Hypokalemia 3) Metabolic alkalosis 4) Hypomagnesemia 5) Hypocalcemia 6) Hyperuricemia 7) Ototoxicity |
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What are some Indications/clinical uses of loop diuretics? |
1) Acute pulmonary edema 2) Hypercalcemia 3) Maintenance in CHF |
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What is the mechanism of action of Thiazides? |
1) Block sodium reabsorption in the distal tubule 2) Sulfonamide derivatives 3) Require normal renal function to be effective |
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What are the adverse effects of thiazides? |
1) Hypokalemia 2) Hypomagnesemia 3) Hypercalcemia 4) Hypertriglyceridemia 5) Hyperglycemia 6) Hyperuricemia |
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Name 6 Thiazide drugs. |
1) Hydrochlorothiazide 2) Chlorthalidone (Hygroton) 3) Chlorothiazide (Diuril) 4) Methyclothiazide (Enduron) 5) Indapamide (Lozol) 6) Metolazone (Zaroxolyn) |
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What are some indications/clinical uses of thiazide drugs? |
1) HTN 2) CHF (combination with loop diuretic) 3) Nephrolithiasis |
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What is the maximum dose of HCTZ? |
Highest dose is 25mg PO BID --- Maximum per dose = 25mg --- Maximum per day = 50mg Doses available are 12.5mg, 25mg, 50mg |
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What are the names of potassium sparing diuretic drugs? (3) |
1) Spironolactone (Aldactone) 2) Triamterene 3) Amiloride *** Low Potency *** |
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____________ is competitive antagonist of aldosterone? |
Spironolactone (Aldactone) |
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What are some adverse effects of potassium sparing diuretic drugs? |
1) Hyperkalemia 2) Metabolic acidosis 3) Antiandrogenic effects |
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What is the name of Osmotic Diuretics drug? |
1) Mannitol ** Used in the reduction of intraoccular and intracranial pressure** |
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Name some Combination diuretic Therapies. |
1) Thiazides plus potassium sparing - Dyazide = HCTZ + triamterene - Maxzide = HCTZ + triamterene - Aldactazide= HCTZ + Spironolactone 2) Thiazides plus loop diuretics |
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What are some benefits of Diuretics? |
1) Work well in all groups of patients 2) Cheap |
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What type of diuretic is primarily used for CHF patients? |
Loop diuretics (furosemide) **Combination of loop diuretics and thiazides (or other diuretics) can also be used** |
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What are some problems with diuretics? |
1) Limited dosing
2) Fluid and electrolyte imbalance 3) Decreased glucose control (Thiazides only) 4) Hypertriglyceridemia (Thiazides only) |
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What are compelling indications for diuretics? |
1) Isolated Systolic HTN 2) CHF ** Indication unless Contraindicated** |
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What is a possible favorable effects of Diuretics (Thiazides)? |
Osteoporosis |
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What are possible unfavorable effects of diuretics? |
1) DM 2) Gout 3) Renal insufficiency |
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What is mechanism of action of Beta-Blockers? |
1) Effective in reducing blood pressure 2) Negative Chronotropy 3) Negative inotropy |
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Name the Beta-blocker drugs for HTN. |
1) Propranolol (Inderal) - Nonspecific Beta Blocker 2) Atenolol (Tenormin) - Beta 1 antagonist 3) Metoprolol (Lopressor) - Beta 1 antagonist |
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What are the contraindications of Beta-blocker? |
1) Asthma - Causes Bronchospasm 2) DM - Masks the hypoglycemia symptoms 3) CHF - Causes a negative inotropic effect (decreased contractility) |
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What hormone is released by the kidney in response to low BP? |
Renin **Renin binds to angiotensinogen and converts it to Angiotensin I** |
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What is the function of Angiotensin I? |
**Nothing** It is useless |
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What converts the Angiotensin I to Angiotensin II? |
ACE = Angiotensin converting enzyme **ACE is secreted and released by the lungs** |
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What receptor does Angiotensin II binds to? |
AT1 receptor |
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What is one of the effect of Angiotensin II? |
1) Potent Vasoconstriction *** results in increase systemic vascular resistance and increase BP*** |
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What is the mechanism of action of ACEI? |
1) Block the conversion of the relatively inactive Angiotensin I to Angiotensin II -- Decreases the level of Angiotensin II -- Lowers BP by reducing peripheral vascular resistance |
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What is the other mechanism of action of ACEI? |
-- Increases the level of bradykinin (leads to s/e dry cough) |
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What is the function of bradykinin? |
** Nitric oxide and prostacyclin are potent vasodilators** |
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Summarizing the effects of ACE inhibitors___
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1) Decrease Angiotensin II
- Decrease vasoconstriction 2) Increase Bradykinin - Enhanced vasodilation |
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How does the ACE inhibitor affect the preload and afterload? |
1) Decreases the preload and afterload thus decreases the cardiac work |
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What are the adverse effects of ACEI? |
1) Dry cough 2) Renal dysfunction 3) Hyperkalemia |
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What is the comorbid condition that can lead to renal dysfunction when ACEI is used? |
Renal Artery Stenosis ** narrowing of B/L renal arteries** |
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What are some resultant effects of reduced circulating angiotensin II levels? |
1) Decreased secretion of aldosterone (from adrenal cortex) Results in - decrease sodium and water retention |
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ACEI are less effective in __________ |
African Americans |
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Name the ACE inhibitors. |
1) Captopril (Capoten)
2) Enalapril (Vasotec) 3) Lisinopril (Prinivil) 4) Benazepril (Lotensin) 5) Quinapril (Acupril) 6) Ramipril (Altace) 7) Fosinopril (Monopril) 8) Trandolapril (Mavik) |
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What is the mechanism of action of the Angiotensin II receptor blockers (ARBs)? |
Blocks the AT1 receptors by binding to them (have high affinity to the receptors) **decreasing the activation of the AT1 receptors by Angiotensin II** |
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What are the pharmacological effects of ARBs? |
1) Block Aldosterone secretion by blocking Angiotensin II 2) Produce arteriolar and venous dilation **Thus lowers BP and decrease salt and water retention** |
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ACEI and ARBs can be used as _________ therapy for HTN |
First line therapy *** Especially in patients with compelling indications of DM, CKD, or HF*** |
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What the the adverse effects of ARBs? |
1) Renal dysfunction 2) Hyperkalemia |
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Can ACEI and ARBs be used as combination therapy? |
ACEI and ARB should not be combined due to similar mechanisms and adverse effects |
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Name the Angiotensin II blocker drugs. |
1) Losartan (Cozaar) 2) Valsartan (Diovan) 3) Irbesartan (Avapro) 4) Candesartan (Atacand) 5) Telmisartan (Micardis) 6) Olmesartan (Benicar) |
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What is the mechanism of action of Direct Renin inhibitor? |
1) Inhibits the Renin production 2) Decreases plasma renin activity 3) Improving RAAS suppression *** Similar efficacy to ACEI & ARB*** |
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Name the Renin Inhibitor |
Aliskiren (Tekturna) |
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What are the side effects of direct renin inhibitors? |
1) Headaches 2) Dizziness 3) Diarrhea |
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What is the result of the RAAS inhibition? |
All agents that inhibit RAAS, including renin inhibitors
1) Suppresses the negative feedback loop 2) Leading to compensatory rise in plasma renin concentration 3) Increase in plasma renin activity (when treated with ACEI & ARBs) |
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What is the mechanism of action of Alpha-1 Antagonists? |
1) Vasodilation **Good second line agent** **Beneficial to person with HLD** |
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What are the adverse effects of Alpha-1 Antagonists? |
1) First dose hypotension & syncope 2) Reflex tachycardia |
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Name the Alpha-1 Antagonists drugs. |
1) Prazosin (Minipress) 2) Terazosin (Hytrin) 3) Doxazosin (Cardura) |
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What is the mechanism of action of alpha-beta blocker? |
1) Potent adrenergic blocker for rapid blood pressure reduction **At higher doses - Alpha blocking effects dominate** |
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Name the alpha-beta blocker |
Labetalol |
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What is the indication/clinical use of Labetalol? |
1) Management of gestational HTN (preeclampsia?) **will not induce pre-term labor as the beta-blocking effects are small** 2) HTN urgencies and emergencies |
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What is the mechanism of action of the Alpha-2 agonists? |
1) Produces inhibition to sympathetic vasomotor center --- Decreases the sympathetic outflow to the periphery |
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What are the effects of Alpha-2 agonists? |
Decreases peripheral resistance - thus decreases BP |
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Name the 2 Alpha-2 agonists |
1) Clonidine (Catapres) (PO & Patch) 2) Methyldopa (Aldomet) (PO & IV) |
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What are the indication/clinical use of Clonidine & Methyldopa? |
1) Clonidine - HTN urgencies 2) Methyldopa - HTN in pregnancy |
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What are the adverse effects of Alpha-2 agonists? |
1) Sedation / Sleepy 2) Depression 3) Sexual dysfunction |
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What is the mechanism of action of the direct vasodilators? |
Vasodilation |
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Name the direct vasodilators. |
1) Hydralazine (Apresoline) 2) Minoxidil **3rd or 4th line treatment for HTN** **Can occasionally be used on pregnant women with HTN** |
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What are the adverse effects of direct vasodilators? |
1) Water retention (peripheral edema) 2) Reflex tachycardia |
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Name the Calcium channel blockers |
1) Verapamil (Calan) 2) Diltiazem (Cardizem) 3) Dihydropyridines |
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What is the mechanism of action of Verapamil? |
Affects the cardiac and vascular smooth muscle cells - Negative inotropic effect
Primary effect 1) Decrease contractility 2) Decrease automaticity and conduction Secondary effect 1) Vasodilation |
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What is the contraindication for verapamil? |
Should never be used for patient with HF **due to its effect of decrease in contractility** |
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What is the most common adverse effect of verapamil? |
Constipation **decrease peristalsis movement (contraction) in intestines** |
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What is the mechanism of action of diltiazem? |
Also affects the cardiac and vascular smooth muscle cells ** however less of the negative inotropic effect compared to verapamil** ** more favorable side effects compared to verapamil** |
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What is the mechanism of action of dihydropyridines? |
Primary effect -- Vasodilation |
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Name the dihydropyridines calcium channel blockers |
1) Nifedipine(Procardia, Adalat) - Sustainedrelease preparations (XL vs. CC) 2) Felodipine (Plendyl) 3) Nicardipine (Cardene) –also available IV 4) Isradipine (Dynacirc) 5) Amlodipine(Norvasc) 6) Nisoldipine (Sular) |
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What are some combined therapies for HTN treatment? |
1) b-adrenergicblockers and diuretics 2) ACE inhibitors and diuretics 3) Angiotensin II receptor antagonistsand diuretics 4) Calcium channel blockers and ACEinhibitors 5) Other combinations |
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What are the initial drug choices for stage 1 & stage 2 HTN treatment? |
1) Thiazide diuretics 2) b-Blockers 3) ACEI, ARBs 4) CCBs |
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How many drugs should be in the therapy for Stage 1 and Stage 2 HTN treatment? |
Stage 1 = 1
Stage 2 = 2 |
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What should be the options if the BP goal (<120/80) has not yet met after the initial drug choices? |
1) If no response or trouble some side effects --- Substitute another drug from different class 2) If inadequate response but well tolerated --- Add second agent from different class --- Diuretic if not already used 3) If the goal is still not met --- Continue adding agents from other classes --- Consider referral to HTN specialist (if already on 3 agents with uncontrolled HTN) |
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What are some special considerations when selecting drug therapy? |
1) Demographics 2) Coexistingdiseases and therapies 3) Qualityof life 4) Physiologicaland biochemical measurements 5) Druginteractions 6) Economicconsiderations |
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How to treat HTN in Pregnancy? |
1) Important to differentiate preeclampsia from chronic, transient & gestational HTN 2) Preeclampsia = >140/90 after 20 weeks of gestation w/ proteinuria |
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What is the drug of choice for HTN treatment in pregnancy? |
1) Methyldopa ** 2) Labetalol **Definitive treatment - Delivery** Patient education - restricted activity, bed rest, close monitoring |
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What is the benefit of combination therapy? |
May provide additional efficacy with fewer adverse effects |
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How to dose for drug therapy? |
1) Low dose of initial drug should be used -- Slowly titrating upwards 2) Optimal formulation should provide 24-hour efficacy with once daily dose -- with at least 50% peak effect remaining at the end of 24 hours |
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When should be the next follow up appointment after starting drug therapy? |
Within 1-2 months after initiating therapy |
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What should be some considerations after initiating therapy? |
1) Recognizethat high-risk patients often require high dose or combination therapies andshorter intervals between changes in medications. 2) Considerreasons for lack of responsiveness if blood pressure is uncontrolled afterreaching full dose. 3) Considerreducing dose and number of agents after 1 year at or below goal. |
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What are some agents used for HTN emergencies? |
1) Nitroprusside 2) Nicardipine 3) Nitroglycerin 4) Phentolamine (potent a-blocker for emergency) |
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What are some agents used for HTN urgencies? |
1) Labetalol 2) Atenolol(?) 3) Esmolol(continuous infusion) (not well during emergency 4) Enalaprilat (IV push) 5) Hydralazine |
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What are some special consideration for HTN treatment in older person? |
1) Starting doses for drug therapy should be lower than those in younger adults 2) Goal of therapy is the same -- Although interim goal of SBP <160 may be necessary |
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What agent should not be the drug of choice for initial therapy for older patients? |
Alpha-1 Blockers |
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Which class medications is indicated for HLD patients that have HTN as well? |
Alpha 1- Blockers ("Zosins") - Increases HDL - Decreases LDL |