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HTN treatment :couple_with_heart: - Coggle Diagram
HTN treatment :couple_with_heart:
DIABETES
THIAZIDE
ARB/ACEi
CCB
CKD
first line: ACEi
second line: ARB
if proteinuria
2nd line
maybe MRA
non DHP CCB
avoid DHP
1st line ACEi/ARB
maybe loop diuretic
PRO
better BP control in edematous pt
better diuresis
good in CKD 4-5
CONS
sulfa allergy
not enough evidence, not as effective in non-edematous pt
worsen
diabetes
gouts
pre-diabetes
hyponatremia
furosemide erratic absorption
hypotension
dosing
furosemide
40mg
max 200mg
switch to more potent bumex or torsemide
Bumex
1mg
max 10mg
torsemide
20mg
max 100mg
ethacrynic acid
50mg
max 100mg
CKD AFTER TRANSPLANT
beta blockers
HF
HFrEF
first line
ACEi
ARB
BETA BLOCKER
second line
HYDRALAZINE
NITRATES
MRA
adjunctive therapy
avoid: non DHP CCB
verapamil
diltiazem
HFpEF
first line: diuretics
second line
ACEi
ARB
MRA
avoid CCB
STROKE
THIAZIDE
ACEi
ARB
AORTIC HEART DISEASE
BETA BLOCKER
VALVULAR HEART DISEASE
ACEi/ARB
CCB
THIAZIDE
AVOID: beta blocker
MI/STABLE ANGINA
first line
ARB
#
ACEi
PRO
prevent MI and CHF
improve LVEF and cardiac remodeling
improve proteinuria in CKA
well studied
dosing
best to dose in evening
RAS activation at night
peak renin 4am
peak aldosterone 5am
sympathetic nervous system
peak epinephrine at awakening
peak norepinephrine at standing
onset: work in a few days
duration: wear off 1-2 months
CONS
not effective in low renin pt
african
elderly
:forbidden: :pregnant_woman:
CKD
caution initiating in CKD4
use agent with hepatic clearance
no initiate in CKD5
diet sodium ruins response
increase peak but decrease trough level aka flat response curve
BP escape: works initially then BP returns to pre-treatment
side effect/ how to correct
hyperkalemia
restrict potassium intake
combine with MRA/ potassium sparring diuretics
cough
nephrotoxicity/ check chemistry one week after initiation
if Scr increases > 30 % - d/c drug
if CrCl increases less than 30%, continue + f/u in 1-3 months
sulfa allergy
BETA BLOCKER
PRO
good for pre-existing disease MI, HF
good for arrhythmia
good for pre-operative in ISH patient
reduce performance anxiety
CONS
atenolol << valsartan
caution
bronchoconstriction/ asthma
switch to metoprolol/atenolol
avoid high dose
depression
use hydrophilic agent
mask s/s hypoglycemia
sexual dysfunction
avoid low blood pressure
start PDE5
hyperlipidemia/ glucose intolerant
diet modification
switch to
ISA
alpha blocking properties
bradycardia
avoid tx with non DHP CCB
adjust dose to target BP
dosing
QAM
second line
THIAZIDE
PRO
effective in reducing CV events
good in special population
African
elderly
with ISH
diabetes
metabolic sx
moderate diuresis
loop diuretic at lowering BP
chlorthalidone >> HCTZ
CONS
high risk + lean patients: thiazide + ACE << CCB + ACE
worsen
pre-diabetes
diabetes
gout
Side effects/how to correct
hypokalemia ~ hyperglycemia/hyperlipidemia
potassium supplement
oral
dietary
combined with ACEi, ARB, K sparing diuretics
modify diet
hyponatremia
avoid if on
SSRI
d/c when [Na] <130
hyperuricemia
start allopurinol
d/c if refractory gout
volume depletion ~ orthostatic hypotension
sexual dysfunction
hypercalcemia
counsel on Ca intake, i.e. OTC Calcium
switch to loop diuretics
avoid when CrCL <30ml/min
dosing
chlorthalidone
12.5-25mg
QAM
duration 40-60 hours
HCTZ
12.5-25mg
QAM
duration 6-12h
metolazone
2.5-10mg
QAM
duration 24h
DHP CCB
drugs
nifedipine
nicardipine
amlodipine
isradipine
felodipine
PRO
effective in all age group
well studied, highly effective preventing CV events
prevent concurrent diseases
raynauds
migraine
improve HTN caused by CSA
CONS
:forbidden: heart block
worsen HF
DHP worsen proteinuria
DDI in non DHP (CYP3A4 inhibitor)
do not use short acting DHP CCB = hypotension
SIDE EFFECT/how to correct
tachycardia
start beta blocker if problematic
avoid vasodilator
hydralazine
minoxidil
headache
titrate slowly
counsel pt that tolerance developed in 2 weeks
peripheral edema
reduce salt intake
start ACE/ARB to blunt AE
monitor edema
MRA
PRO
adjunctive HF
good for proteinuria
reduce hypokalemia when on thiazide/loop
useful in low-renin, salt sensitive hypertensives
DM
African
elderly
CONS
hyperkalemia if on ACE/ARB
mild diuresis
not strong evidence
gynecomastia
delayed onset - 6 weeks
ATRIAL FIBRILLATION
ARB
maybe non DHP CCB
OTHER STUFFS
potassium sparring diuretic
cons
hyperkalemia if on ACE/ARB
mild diuresis
not enough evidence
pro
useful when combined with thiazide/loop - fixed hyperkalemia
renin inhibitor
modest lowering BP
not enough evidence
DDI with furosemide
:forbidden: :pregnant_woman:
alpha blocker
PRO
modest blood pressure reduction
treat
BPH
good lipid profile
CONS
inferior to other agents
volume expansion +weight gain
combine thiazide to fix
orthostatic hypotension/syncope
administer at night
titrate dose
CI :forbidden: HF d/t volume overload
alpha agonist/ clonidine (alpha receptor in the brain, downstream effect of sympathetic outflow)
pro
adjunctive therapy for
resistant HTN
available in oral + patch + injection
cons
lack CV outcome data
adverse events/how to fix
rebound HTN
avoid abrupt d.c
counsel on adherence
change patch qweek
bradycardia
titrate to heart rate
max daily dose 0.6,g
avoid combining
beta blocker
non DHP CCB
fatigue
titrate dose
risk of rebound HTN
dosing
oral
0.1 -0.2mg bid
max 0.6mg/day
patch
catapres TTS 1 patch 0.1mg/day
ctapress TTS 2 patch - 0.2mg/day
catapress TTS 3 patch - 0.3mg/day
change qweek
vasodilator
cons
minoxidil : hirsutism
hydralazine: lupus like sx in slow acetylators
fluid retetion
tachycardia
short half life, dose 4 times/day
pro
adjunctive for
resistant HTN
combined with
beta blocker
diuretic
GOOD in pregnancy
nonpharmacology
reduce salt intake
exercise
30 minutes moderate exercise everyday
3 times/week resistant training
avoid OTC
NSAID
contraception
alcohol
man: 2 drinks/day
woman: 1 drink/day
lose weight
10% of current weight in 6 months
diet
at restaurant
limit portion
no chips
no soup at restaurant
lettuce wrap hamburger
limit condiment
at home
use herb and spices
limit salt while cooking
salt shaker is fine
read food label
bread: the whiter the bread, the more sodium they get (270mg white toast, 460mg plain bagel)