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Year 3 - Clinical > 15 - Hypertension > Flashcards

15 - Hypertension Flashcards

1
Q

What is the trend of age related to HTN?

A
  • Males more likely than females from 35-64

- From 65 and older females become more likely

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2
Q

What determines BP?

A

Cardiac output * peripheral resistance

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3
Q

Why do we want to lower BP?

A

For long-term prevention of heart attacks, strokes, kidney failure, eye damage, etc.

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4
Q

HTN is a significant risk factor for…?

A
  • Cerebrovascular disease
  • Coronary artery disease
  • Congestive heart failure
  • Renal failure
  • Peripheral vascular disease
  • Dementia
  • Atrial fib
  • Erectile dysfunction
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5
Q

Goals of therapy for adults w/ HTN

A
  • Systolic BP less than 140 mmHg
  • Diastolic BP less than 90 mmHg
  • Mortality greatly increases if systolic BP > 160 mmHg and/or if diastolic > 90-100 mmHg
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6
Q

Benefit of HTN tx

A
  • *Benefit is related to risk

- Those w/ lower CV risk will have less benefit than those w/ greater CV risk

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7
Q

Describe the sprint study

A
  • Studied px at high risk of CVD (average 10-year CVD risk = 20%), no DM2 (px w/ LVEF < 35% or stroke also excluded)
  • Not blinded
  • Studied intensive (SBP < 120) vs. standard (SBP < 140) BP control; any standard anti-hypertensive could be used; follow-up after 3.3 years
  • Took 2 anti-HTN meds to get px to an average of 135/76
  • Took 3 anti-HTN meds to get px to an average of 121/69 (couldn’t get them to an average of 120 SBP)
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8
Q

Describe the results of the sprint study

A
  • ARR (absolute risk reduction) using intensive for primary outcome (ex: MI, ACS, stroke, HF, CV death) was 1.6%; NNT = 62
  • ARI (absolute risk increase) using intensive for renal (AKI or ARF) was 1.8%; NNH = 56
  • ARI using intensive for >/ 30% decrease in eGFR to < 60 mL/min was 2.7%; NNH = 37
  • ARI using intensive for serious adverse effects (life-threatening, permanent disability, hospitalization) was 2.2%; NNH = 46
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9
Q

What are the current Canadian recommendations for HTN tx?

A
  • For high-risk px aged >/ 50 years w/ SBP >/ 130 mmHg, intensive management to target a SBP < 120 mmHg should be considered
  • Px selection for intensive management is recommended & caution should be taken in certain high-risk groups
  • High-risk adults as candidates for intensive management:
    • Clinical or subclinical CVD or
    • Chronic kidney disease or
    • Estimated 10-year global CV risk >/ 15% or
    • Age >/ 75 years
  • Px w/ >/ 1 clinical indication should consent to intensive management
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10
Q

Most important drug causes of HTN

A
  • NSAIDs
  • Decongestants
  • Alcohol
  • Estrogen
  • Also some herbal supplements (when mixed w/ Rx)
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11
Q

What are some options for non-drug therapy for HTN?

A
  • Allow 3-6 months of lifestyle modification before considering medication (in most cases)
  • Examples – exercise (150 min/week of mild-moderate); diet (caffeine intake, fat intake); 1-2 cups of coffee per day isn’t a big deal; stress management; weight reduction
  • DASH diet (fruits, vegetables, low-fat dairy, dietary fiber, grains, etc.)
  • Reduce sodium intake toward 2000 mg (5 g of salt or 87 mmol Na) per day
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12
Q

MOA of CCBs

A

Decrease contractility and vasoconstriction

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13
Q

MOA of thiazide diuretics

A

Decrease sodium/water reabsorption => decrease TPR

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14
Q

Describe the ALLHAT study

A
  • Studied over 33,000 patients w/ HTN & at least 1 other risk factor for CHD events
  • Followed them for 5 years on chlorthalidone 12.5-25 mg (thiazide), lisinopril 10-40 mg (ACE inhibitor), or amlodipine 2.5-10 mg (DHP CCB)
  • Results = BP reduction chlorthalidone > amlodipine > lisinopril; however, no difference between 3 agents in fatal coronary heart disease or non-fatal MI or mortality
  • *Similar efficacy overall
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15
Q

Adverse reactions w/ thiazide diuretics

A
  • Electrolyte imbalances
  • Increased uric acid
  • Decreased glucose
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16
Q

Adverse reactions w/ ACE inhibitors

A
  • Dry cough

- Increased potassium

17
Q

Adverse reactions w/ ARBs

A

Increased potassium and sCr

18
Q

Adverse reactions w/ beta-blockers

A
  • Cold extremities
  • Fatigue
  • Nausea
  • Decreased exercise tolerance
19
Q

Adverse reactions w/ DHP CCBs

A
  • Flushing
  • Ankle edema
  • Headache
  • Increased HR
20
Q

Are beta-blockers useful for lone HTN?

A
  • Better reduction of CV events vs. placebo in < 60 y/o; no benefit in > 60 y/o
  • Vs. other anti-HTN agents – beta-blockers have similar reduction of CV events in < 60 y/o, but worse in > 60 y/o (small increase in strokes)
21
Q

Should beta-blockers ever be used first line for HTN?

A

Yes, if CHF or angina, or as an option for A Fib

22
Q

What are some special considerations for anti-HTN agents?

A
  • Thiazides are less effective if Clcr < 30 mL/min
  • ACE inhibitors, ARBs, & beta blockers may be less effective in black patients
  • CCBs have CYP 3A4 interactions
23
Q

What are some generalizations about choosing an anti-HTN agent?

A
  • Efficacy, convenience, & cost are all similar

- Safety/adverse effects is what varies & what determines the agent based on pt

24
Q

Which agent should be chosen for initial thiazide therapy?

A
  • HCTZ considered (at best) equal to and very likely inferior to chlorthalidone
  • Therefore, consider chlorthalidone or indapamide when initiating thiazide diuretic therapy for HTN
25
Q

What is the recommendation for HTN in type 2 diabetes?

A
  • Meta-analyses of over 73,000 px concluded that if SBP < 140 mmHg, further tx associated w/ increased risk of CV death, w/ no observed benefit
  • Didn’t persuade CHEP or CDA to change guidelines that state BP target is 130/80
26
Q

Which anti-HTN agent is best for type 2 diabetes?

A
  • CHEP 2018 recommendation = ACE inhibitor, ARB, DHP CCB, or thiazide/thiazide-like diuretic (no preference)
  • Dipiro = ACE inhibitor or ARB
27
Q

Describe the ALLHAT study of diabetes subgroup

A
  • Looked at over 13,000 px taking chlorthalidone, lisinopril, & amlodipine
  • No difference in incidence of end-stage renal disease between chlorthalidone & lisinopril
  • No difference in coronary heart disease, stroke, or combined CV disease between the 3
28
Q

Describe the role of ACE inhibitors/ARBs in renal protection for type 2 diabetes

A
  • When compared to placebo or other anti-HTN in px w/o albuminuria (no kidney disease):
    • ACEi are only agents shown to reduce incidence of microalbuminuria in diabetics
    • No significant decrease in incidence of double of sCr or ESRD
  • Vs. placebo or other anti-HTN in px w/ albuminuria -> reduced progression of nephropathy -> ESRD
29
Q

Describe the general rules for HTN in type 2 diabetes

A
  • Best evidence for target of DBP < 85-90 mmHg and SBP < 140 mmHg
  • Long-term CV protection is similar for first-line agents
  • For those w/o diabetic kidney disease, ACEi & ARB reduce likelihood of developing microalbuminuria but not doubling of sCr or ESRD
  • For those w/ diabetic kidney disease, ACEi & ARB both delay progression of nephropathy to ESRD
30
Q

Describe the research done regarding combination therapy for HTN?

A
  • Summary of 354 HTN trials => using half-standard doses results in 20% less BP reduction
  • 119 trials compared mono vs. combo therapy => greater incidence of adverse effects w/ combo (5.2% w/ mono vs. 7.5% w/ combo)
31
Q

What is the general consensus of combination therapy in HTN?

A
  • Use of 2 drugs initially generally not a rational approach
  • Smaller doses often do almost as good of a job at BP reduction as larger doses
  • Adding an agent is additive for BP reduction, but less than additive for adverse effects
32
Q

What is the importance of treating HTN in elderly?

A
  • Elderly more sensitive to symp inhibition & volume depletion => increased orthostatic hypotension => increased risk of falls & morbidity
  • Low BP may be associated w/ dementia, cancer, HF, & MI
  • Age > 85 y/o w/ low SBP (< 120) associated w/ increased mortality
  • Age ~ 70 y/o w/ low DBP (< 65) associated w/ increased stroke & CV event risk
  • Isolated systolic HTN & wide pulse pressures increase risk of MI, stroke, & renal failure
33
Q

What was the HYVET study researching?

A

HTN in the very elderly

34
Q

Describe the HYVET study

A
  • Over 3,000 px aged 80 y/o and older; SBP >/ 160 mmHg (baseline 173/91)
  • Target BP was 150/80
  • Active-tx group = indapamide 1.5 mg OD + perindopril 2-4 mg OD added if necessary, vs. placebo
  • Placebo decreased BP to 159/84; active decreased to 144/78 (20% of placebo reached target; 48% of active reached target)
  • Reduction to < 150/80 decreased CV events by 3% over 3 years and decreases mortality by 2.2% -> is this worth it to the pt? probably not
35
Q

What is the general approach to treating HTN in the elderly?

A
  • BP reduction in very elderly w/ HTN is beneficial
    • Target = < 150/80 (likely not applicable to frail elderly)
  • Outcome benefits apparent w/in first year
  • Agent doesn’t matter; thiazide or ACEi reasonable first line options
  • 50% will reach target BP w/ 2 agents, but only start w/ 1 (think about tx burden)

Year 3 - Clinical (30 decks)

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