HTN Summary

• Patient's with Raynaud's or Cold extremities (caused by BBs)

  1. DHP-CCB eg, nifedipine
• Pt with BPH

  
  

  1. Alpha-blockers
• Pts with CKD:

  
  

  1. ACEI/ARB to preserve remaining kidney function
• Pts with ESRD

  
  

  1. Loops & others (caution with ACE/ARB due to the risk of hyperkalemia)
• Avold BBs with asthma & COPD,

  use a Beta-1 selective BB (MAN BABE)
• DM pts should take caution with BBs

  > BBs mask symptoms of hypoglycemia.
• With Sulfa allergy: Avoid Thiazides & Loops
• With increase sun exposure: Avoid Thiazides
• Pts with ESRD: Avoid or caution with ACE/ARB due to the ⬆️ risk of hyperkalemia
• Pts with Raynaud's: Avoid BBs, ergots, and triptans to prevent ischemia of affected fingers
• Pts with Gout or Kidney stones :

  Caution with Thiazides/Loops
• Thiazide diuretics adverse effects

  • ⬇️Na+
  • ⬇️cl-
  • ⬇️K
  • ⬇️Mg
  • ↑ Glucose
  • ↑ Cholesterol
  • ↑ Uric Acid
  • ↑ Ca
  • Sun sensitivity
• Loop diuretics: Similar side effects as thiazides except loop diuretics reduce Ca" levels (loop diuretics can be used to treat hypercalcemia)
• With thiazides and loop diuretics

  • ⬇️Na+ : watch for lithium toxicity
  • ⬇️K+ & ⬇️Mg+2 : watch for digoxin toxicity
  • ↑ Uric acid : watch for gout flare-ups
  • Sulfa allergy (ethacrynic acid is the exception)
  • Sun sensitivity
• Hyperkalemia with class of drugs

  1. ACEI
  2. ARBs
  3. K+ Sparing diuretics
• ESRD: End-Stage Renal Disease patients cannot excrete K" efficiently; therefore, K levels increase (Hyperkalemia)
• Salt substitute: Salt substitutes are KC, instead of NaCl
• Beta-Blockers: Caution/Contraindications

  • Heart blocks-1st, 2nd or 3rd degree heart blocks
  • HTN
  • Bradycardia : s cause AV node block (50-60 bpm is a caution and bpm < 50 is a contraindication)
  • Raynaud's-Avoid BBs, ergots, and triptans in Raynaud's patients to prevent ischemia of fingers
  • Asthma-Avoid BBs as they can cause bronchoconstriction. Stable COPD is not a contraindication
  • DM-Caution Beta-blockers may mask symptoms of hypoglycemia
  • HF NYHA IV-Caution with higher doses of BBs due to negative inotropic effects (BBs help with M+M in HF)
  • Cocaine overdose - Unopposed alpha receptors stimulation
• IV Beta-blockers {MAPLES}

  • Metoprolol
  • Atenolol
  • Propranolol
  • Labetalol
  • Esmolol
  • Sotalol
• Beta-blockers used in CHF {MBC}

  • Carvedilol (Coreg) (with food)
  • Metoprolol succinate (Toprol XL)
  • Bisoprolol (Zebeta)
• Beta-1 selective BBs {MAN-BABE}

  • Metoprolol
  • Atenolol
  • Nebivolol
  • Bisoprolol
  • Acebutolol
  • Betaxolol
  • Esmolol
• Beta-blockers with ISA

  • Acebutolol
  • Pindolol
  • Penbutolol
• Intrinsic Sympathomimetic Activity (ISA)


  Partial beta-adrenergic agonist response-used to lower BP while maintaining HR: ISA APP: Acebutolol , Pindolol & Penbutolol
• Beta-blockers adverse effects

  • Fatigue - take QHS
  • Sexual Dysfunction
  • Bradycardia (-ve chronotropic effects)
  • Heart failure (-ve inotropic)
  • Raynaud's Phenomenon
  • Mask hypoglycemia
• Beta-blockers uses

  • HTN
  • Hypertensive emergency
  • s/p MI
  • CHF
  • arrhythmias originating above AV node (AFib, Atrial flutter, PSVT)
  • migraine prophylaxis
  • stage fright
  • thyroid storm
• Beta-blockers NOT used for HTN:

  
  

  Esmolol (for hypertensive emergency)

  Sotalol (only indicated for arrhythmias)
• Calcium channel blockers: Contraindication/cautions

  • CHF (due to Non-DHP CCBS' negative inotropic effects)
  • Heart blocks and bradycardia (due to Non-DHP CCBs' negative chronotropic effects]
• DHP-CCBs have minimal effect on heart contractility and conduction, and thus, safer than Non-DHPS
• DHP-CCBs (e.g, amlodipine, nifedipine, nicardipine) affect mostly the arterial blood vessels
• Verapamil affects mostly the heart (strong negative inotrope and negative chronotrope)
• Diltiazem works on bath - vasodilates arteries and has negative inotropic/chronotropic properties
• CCB uses

  • HTN
  • hypertensive emergency
  • arrhythmias
  • Raynaud's
  • Prinzmetal's angina
• CCB side effects

  • Edema, and constipation with DHPS
  • (-) inotropic, (-) chronotropic effects with Non-DHPS (Diltiazem & Verapamil.
• ACEI reduce BP by two mechanisms:

  
  

  1) Reducing circulatory volume and preload: By blocking RAAS pathway, ACEI will decrease aldosterone levels leading to ↑ urinary Na' excretion and subsequent decrease in circulatory volume and preload.

  2) Dilating arterial vessels and reducing afterload: ACEI block formation of body's vasoconstrictor (angiotensin II) and therefore, cause dilation of arterial blood vessels ( afterload)
• ACEI can ↑ K: avoid in "K" conditions (ESRD, salt substitutes, K' sparing diuretics, renal artery stenosis)
• ACEI can ↓ Na': caution with lithium; Hyponatremia can predispose patients to lithium toxicity
• ACEI can cause initial ↑ in SCr: an initial rise up to 30% above baseline is acceptable and NOT a reason to withhold therapy, as long as K" is within normal limits
• ACEI can cause angioedema: A history of angioedema of any cause is a contraindication for ACEI or ARNI therapy. If a patient develops or has had angioedema, regardless of the cause, ACE inhibitors or ARNI should be discontinued indefinitely and neither an ACE inhibitor nor ARNI should be used thereafter. In patients with HFrEF who require ongoing therapy, we generally replace the ACE inhibitor or ARNI with an ARB
• ACEI can cause dry cough: If it persists, can switch to ARB (or ARNI if HF), or add CCB to reduce cough reflex
• ACEI reduce morbidity & mortality in patients with history of MI and HF