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HYPERTENSION Julie A. Johnson, Pharm.D.

, BCPS, FCCP, FAHA • • • HTN Prevalence: It’s on the rise Hypertension is usually one of the earliest forms of the cardiovascular diseases, and is the 1st cardiovascular disease a patient acquires. Guidelines used: The 7th Report of the Joint National Committee on the Detection, Evaluation and Treatment of High Blood Pressure (JNC 7). Expected update (JNC 8) November 2011. Approximately 75 million Americans have HTN • It is the most common medical condition among adults • It is the most common reason why patients take chronic medications • There are an additional 70 million patients with prehypertension • Over half of the population are either hypertensive or prehypertensive • 1 billion worldwide 1 in 3 of adults has HTN From 1990 – 2000 • US population within this decade increased 13%, but Hypertension increased 30%. The rate of hypertension is exceeding our population growth. Increase is attributed largely to 2 factors: 1. Aging population 2. Obesity epidemic (more importantly) Differences in prevalence among ethnic groups • Caucasians: 28.1% • African Americans: 41.4% (Highest rate of HTN) • Mexican-Americans: 30% • Asian-Americans and Pacific Islanders: 26% • American Indians: 32% Prevalence increases with age Ages 20 to 34 the rate of hypertension is relatively low (<10%) with a much higher rate in men than women at this age group With the increase of each decade of life the prevalence of hypertension also increases • Approximately 10% increase per year after the 20 to 34 year mark Approximately 70% of individuals over the age of 70 have hypertension resulting in a very common disease with aging Up to age 55, prevalence is greater among men than women, after which the reverse is true. in life be• Reasons being that men who have HTN earlier gin to die, AND women at the age of ~55 begin to experience menopause Among those 60 or older with HTN • 60% of Caucasians • 71% of African Americans • 61% of Hispanic Americans

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The rate of control in the mid-70s was terrible at • only 10%. are they treated for their high blood pressure.May be due to patients not experiencing symptoms with HTN.5% have BP controlled . In this situation we might need to look at an alternative Treatment intensity gap (therapeutic inertia) • 47. This caused the federal government to become very aggressive in promoting a public awareness campaign to increase public knowledge about the risk of hypertension and its detection. and is their blood pressure under control? This is data over several decades. We now have a high percent of patients that are aware of their hypertension and are treated Control is defined as blood pressure < 140/90.Patients take medication for their HTN and find that it does not lower their blood pressure and therefore become noncompliant . and physicians are not sensitive enough to patients having side effects from there medications which could affect their adherence. • • • • Pharmacists can make a difference in HTN! Prevention • Obesity is major preventable cause of HTN – educate your patients about lifestyle modifications and risks of obesity! Identification gap • 22% of patients don’t know they are hypertensive. This percentage has continued to rise. but later experiencing side effects from the treatment of HTN and deciding not to take their medications .Only 13% of office visits w/high BP result in a regimen change 2 . There has been dramatic improvements in the number of patients being treated for hypertension over • the past few decades. In the most recent surveys hypertension awareness has increased to 78% with still leaves over 20% of patients who are unaware of their HTN. BUT now still < 50% of patients who have high blood pressure have their condition under control Statistics point out that a large number of patients who are unaware they have hypertension have been ★ seen by their physician the previous year – thus the major problem is lack of healthcare providers taking action in recognizing and addressing hypertension. Home blood pressure monitors did not exist in the mid-70s.Only 68% of those being treated are controlled . In the mid-70s the awareness rate of hypertension was only around • 50%.Trends in awareness of hypertension Are patients aware that they have high blood pressure. Ask patients about their blood pressure and if YOU can check for BP control Treatment gap • 10% who know they have HTN are not treated . Pharmacist can encourage patients to check their blood pressure.Not being educated on the long-term risk of elevated blood pressure. From the mid-70s to the next decade and a half the number of patients treated for hypertension nearly doubled. and has now leveled off at around 70%.

Pheochromocytoma.Chronic kidney disease • Drug induced • Other uncommon causes . • Majority of secondary HTN .g.g. Sleep apnea. Primary Aldosteronism. decongestants. anorectics. Cushing’s syndrome or chronic steroid therapy. Note drugs that cause HTN. In many cases. cocaine. the cause of hypertension is unknown Secondary HTN – In 5-10% there is an identifiable cause of the hypertension.Coarctation of the aorta. bitter orange) Proposed Pathophysiologic Mechanisms Of Primary (Essential) Hypertension • • • • • • • • • • • Cardiac output x Peripheral resistance = blood pressure Elevation in blood pressure occurs by increasing either of the 2 variables (cardiac output / peripheral resistance) Cardiac output is determined by preload and contractility 3 . amphetamine) • E.Renovascular disease .g. correction of the primary abnormality will correct the blood pressure. Pseudoephedrine should be avoided in patients with HTN Erythropoetin Cyclosporine/tacrolimus – cause very predictable elevations of BP Licorice (included in chewing tobacco) Certain OTC herbal products (e. ephedra.renal which includes… .• • Etiology of HTN Primary (essential) HTN – In 90-95% of the cases. The most common causes of the secondary hypertension are related to renal disease (constituting about 4% of all patients with hypertension). Ma Huang. Thyroid or parathyroid disease Drug Induced HTN NSAIDS and COX-2 inhibitors – lead to sodium and water retention which results in HTN Oral contraceptives – have consistently shown to elevate blood pressure Adrenocorticoids – also leads to sodium and water retention Sympathomimetics (e.

Thus. rather than a β-blocker. ACEI. Were to the major antihypertensive drug classes work in this scheme • • • • Beta blockers – work primarily by blocking beta-1 adrenergic receptor which reduces contractility and HR seen with sympathetic activation. VERY important concept to LEARN! Studies have generally shown a significant correlation between response to: ★ • ACEI/ARB and β-blockers • CCB and Thiazide diuretics • Good combinations would include CCB + ACEI or Thiazide diuretic + ACEI This means that those who are responsive e. • Thiazide diuretics cause diuresis early in therapy. but the volume returns to baseline over several weeks so the long-term lowering of blood pressure by thiazide diuretics is believed to be caused by this cell membrane mechanism ACEIs / ARBs – are mediated on the renin-angiotensin side of the equation by either inhibiting the formation of angiotensin-2 (ACEI) or blocking angiotensin-2 and the receptor level. 4 . This may also lead to structural hypertrophy Obesity – clearly causes a hyper-insulinemia which contributes to a structural hypertrophy. Cell membrane calcium alterations – leads to vasoconstriction due to the increases of intracellular calcium.• • • • • Excess sodium intake – (salt sensitive hypertension) leads to an increase in fluid volume (preload) which results in increased blood pressure. but are less effective antihypertensives than thiazide diuretics. it would be most logical to next try a • diuretic or CCB. Secondarily they decrease the release of norepinephrine and have affects of lowering the sympathetic nervous system activation Calcium channel blockers (CCBs) – work at the cell membrane level of lowering blood pressure From this it should be apparent that many of the drugs pointed to the same mechanism causing the hypertension. The renin angiotensin system ALSO releases norepinephrine • Angiotensin-2 results in vasoconstriction of the arterial wall. BUT long-term use of thiazide diuretics affect the cell membrane in the arterial vasculature. There may also be some stimulation of the RAS and sympathetic nervous system. This causes a stiffening of the arterial wall which results in higher pressure that the heart must pump against leading to an increase in BP. to ACEI/ARB are likely to also be responsive to β-blocker • and those responsive to Thiazide diuretics are also likely to be responsive to CCB.g. Beta blockers also decrease the release of renin Thiazide diuretics – work by affecting sodium renal retention.g. Salt sensitive HTN is one phenotype of HTN Genetic alterations – may cause patients to hold on to sodium more avidly than others Stress causes ↑ Sympathetic nervous system [norepinephrine beta-1 selective (↑ contractility) and alpha-1(↑ vasoconstriction) receptor agonist] and increases Renin which activates the renin angiotensin aldosterone system (RAS) and results in angiotensin-2 which is one of the most potent vasoconstrictors in the body. How do we know this? • Loop diuretics are much more potent at affecting sodium retention in the kidney. if a patient fails to achieve a good response to e. • Inefficacy shares similar correlations. and not in the kidney. Loop diuretics are believed NOT to have the cell membrane affect. but also causes structural hypertrophy in the arterial vessels.

89 Diastolic (mmHg) ★ Documented on at least 2 occasions. 126/94 = stage 1 hypertension). eyes) that can be damaged by high blood pressure.g. with or without papilledema 5 . kidney. prior coronary revascularization. and least 3 days apart Recommendations for pressure follow-up The recommendation to recheck BP in 1-2 years will probably be changed **Patient should be started on lifestyle modifications • Target Organ Damage/Clinical Cardiovascular Disease These are the 5 organs (heart.5 mg/dl (130 μmol/L). A person is considered to have target organ damage IF those occurrences in the right hand side of this chart have occurred. Serum creatinine > 1. Another example patient with BP of 166/96 = stage 2 hypertension Category Optimal Prehypertension Hypertension • • Stage 1 Stage 2 140 . angina. This is based off the diastolic of 94 mmHg. aneurysm.139 Systolic (mmHg) < 80 80 .99 ≥ 100 < 120 120 . proteinuria (1+ or greater). with or without intermittent claudication. Cardiac Cerebrovascular Peripheral vascular Renal Retinopathy Left ventricular hypertrophy. peripheral vasculature. microalbuminuria Hemorrhages or exudates.• • Definition and classification of HTN by JNC 7 Categorizing patients based on the higher level whether systolic or diastolic (e. brain. heart failure Transient ischemic attacks (TIA) or stroke Absence of 1 or more major pulses in the extremities. prior myocardial infarction.159 ≥ 160 90 .

For this course we will use the current JNC7. Diabetic patients may be at higher risk with lower blood pressure Benefits of antihypertensives may extend beyond their BP lowering effects. Recent data have suggested there may be minimal benefits associated with the lower BP targets – so these may change with the new JNC8 guidelines. which means < 140/90 mmHg except for those with diabetes and renal disease. This is the primary goal of reducing high blood pressure BP reduction (to < 140/90 or 130/80 in some) is surrogate marker for achieving our primary goal Minimize / control other risk factors Minimize risks / adverse effects of drug therapy – this would increase adherence Target blood pressures Uncomplicated HTN: < 140/90 mmHg Diabetes: < 130/80 mmHg – this could change with newer guidelines (JNC8) Renal disease: < 130/80 mmHg Notes about BP targets in others • For the purposes of this course – we will focus only on JNC7 BP targets.• • • • • • • • Goals of Therapy Reduce / prevent target organ damage (and associated morbidity and mortality) associated with HBP. As a health professional you will need to be aware as these recommendations change. most evident to date w/ACEIs and ARBs Management of HTN • 6 .

most days of the week) → 4 to 9 mmHg reduction Moderation of alcohol consumption – limit consumption to no more than 2 drinks per day [1 ounce ethanol (e. vegetables. or 3 oz 80 proof whiskey)] in most men and no more than 1 drink per day in women and lighter weight persons → 2 to 4 mmHg reduction 7 .• • • • • Lifestyle Modifications Sodium restriction Weight reduction (if overweight) Increased physical activity Smoking cessation • May not necessarily lower blood pressure but is another risk factor on top of hypertension if continued DASH diet • Good data on this diet lowering the pressure similar to monotherapy with a single drug.9) → 5 to 20mmHg reduction / 10 kg weight loss Adopting DASH diet – consume a rich diet in fruits. This is a diet high in fruits and vegetables. 10 oz wine.5-24.4 g sodium or 6 g sodium chloride) → 2 to 8 mmHg reduction Physical activity – engage in regular aerobic exercise such as brisk walking (at least 30 min/ day. and low-fat dairy products with a reduced content of saturated and total fat → 8 to 14 mmHg reduction Dietary sodium restriction – reduced dietary sodium intake to no more than 100 mEq/L (2.g. 24 oz beer. low-fat dairy products and low in saturated fats Lifestyle modifications to manage hypertension • • • • • Weight reduction – maintain normal weight (BMI = 18.

) • Have in past been considered appropriate first line therapy but no longer due to poor results with doxazosin in ALLHAT trial. eplerenone has favorable BP effects as add-on therapy in blacks requiring multi-drug therapy for BP control. Spironolactone is rarely used as antihypertensive. • 2 European trials LIFE and ASCOT showed atenolol inferior to comparator drug. but some data suggest the benefits may extend beyond their blood pressure lowering effects Calcium channel blockers • These include both the dihydropyridine and the non-dihydropyridine classes Angiotensin II receptor blockers • Smaller number of clinical trials. • • • • • • • • 8 . BUT this may be due to the half-life of a atenolol not warranting once daily dosing. Typical use will be in combination. doxazosin.Drug therapy of HTN First line drugs • Thiazide diuretics • Based on JNC7 guidelines are recommended as preferred initial therapy for all patients with uncomplicated hypertension. etc. European guidelines have recently removed beta blockers from first-line therapy for uncomplicated HTN. and lack of any clinical trial evidence that they improve outcomes. most often used by hypertension specialists on refractory hypertension Renin inhibitors • Aliskerin. Aldosterone receptor antagonists • Spironolactone and eplerenone. Centrally acting agents • e. There are clear racial differences in response to thiazide diuretics. Rarely used because of side effects. as a group are rarely used because of frequency of side effects Direct vasodilators • Minoxidil and hydralazine. clonidine. There are also concerns about adverse metabolic effects and increasing the risk of newly onset diabetes Beta-blockers • The role as first-line therapy has recently become controversial. This recommendation is controversial to many. reserpine.g. Clonidine most commonly used. Approved as first line therapy (but not first line in guidelines yet may be included as first-line therapy in JNC8). For now JNC7 guidelines still recommend as first-line therapy. methyldopa. Similar actions to other drugs affecting RAS system. usually with a thiazide or CCB. Metoprolol has now overtaken atenolol as the most commonly used beta blocker in the United States ACE inhibitors • Newer to the first-line therapy group. but still substantial evidence for their benefit as first-line therapy Other drug therapy of HTN Second line Drugs • Alpha1-blockers (prazosin. BUT this could changed in the JNC8 guidelines.

and titrate up • Remember to counsel patients that initial doses does not always control BP adequately If necessary.Interpatient variability in response to antihypertensive drugs • • • • • • • • • • • Only 50% of patients will respond well to any single antihypertensive drug This chart is from the VA Cooperative study of antihypertensive drugs This chart shows the percentage of patients that achieved controlled blood pressure Selecting a drug randomly gives about a 1 in 2 chance of achieving control blood pressure Benefits of treatment of HTN Coronary heart disease (ischemic) CHD – 15% ↓ Stroke – 30-40% ↓ CHF – approximately 50% ↓ Renal failure – approximately 50% ↓ Cardiovascular mortality – approximately 15% ↓ Total mortality – approximately 10% ↓ Considerations in Drug Therapy Selection Concomitant diseases • Compelling indications .Beta blockers worsen asthma Patient demographics • Age. and question patients on adverse effects especially during early therapy Use drugs with once or twice daily dosing. and supplement therapies such as potassium Initial Dosing and Titration Lowest dosage used initially.Angina has a compelling indication for beta blockers. and non-dihydropyridine CCBs • Concomitant drug benefit . race. and gender Avoidance of adverse effects Treatment costs – including lab test. Reasons for poor response Non-adherence to therapy Drug-related causes Treatment cost • Inadequate dose Inadequate patient education on the disease • Inappropriate drug state and the risk of HTN • Inappropriate drug combinations • Adverse effects • Effects of other drugs such as NSAIDs • Inconvenient dosing • • • • • • • • • 9 .Treating 2 diseases with a single drug • Adverse effects of drug on concomitant disease or its therapy . (AVOID tid dosing) If response to treatment is inadequate after 1-3 months assess possible explanations for lack of response to therapy. dosage increases made after several weeks of therapy • Dose titrations every 1 to 2 weeks are reasonable • Reduce BP slowly.

compelling indications. When atenolol was used as an add-on drug to HCTZ • the effect in blacks was significantly decreased. Knowledge is power for patients. concomitant diseases • • • • • • • African Americans HTN is more common. Whites had lesser response When HCTZ was added to atenolol monotherapy • blacks had a synergistic effect (~12mmHg ↓). all first line drugs work reasonably well • • • • • • Data from a study done at the University of Florida Average response to atenolol monotherapy AA had almost no blood pressure lowering effect Whites had a significant response to monotherapy with • atenolol (~10mmHg ↓) Monotherapy with HCTZ was very significant in ★ AA. ARBs and beta-blockers are less effective as monotherapy.ideal first therapy ACE inhibitors. ACEIs and ß-blockers are equally efficacious in blacks and whites. Thiazide diuretics and calcium channel blockers tend to be less effective Although. ACE inhibitors or ARBs are good initial therapy. and are most likely to have resistant hypertension which mean blood pressure is not controlled on 3 or more hypertensive medications Caucasians More likely to have high renin. BUT in combination with a diuretic. Educate patients on disease and risk factors of HTN Once daily dosing has greatest affect adherence Home monitoring of BP also has important positive affect on adherence Ask about BP and encourage patient to see physician when BP not controlled Special populations. high cardiac output HTN Less likely to have salt-sensitive HTN Beta-blockers. and has earlier onset with the African-American patient • Onset of action is approximately 10 years earlier More likely to have low plasma renin activity (PRA) and to have salt-sensitive HTN Diuretics . Whites showed a less effect.• • • • • The Pharmacist: Improving BP control and therapy adherence The most effective therapy prescribed by the careful clinician will control HTN only if patients are motivated and adherent. Calcium channel blockers also seemed to be very effective Eplerenone has shown very good efficacy in black hypertensives. Represents good potential add-on therapy – unlikely to have a role as first line therapy. Many African-Americans will require multiple drugs to control HTN. more severe. When HCTZ was given 1st there was significant more • blood pressure lowering in both blacks and whites The study tended to show that HCTZ may be priming the patient’s RAS system • The combination of the 2 drugs eliminated the racial differences ★ 10 .

For many years this was not treated. labetalol. the consequences of a fall from hypotension are more likely to be serious in the elderly than in younger patients. but should generally not be used as primary monotherapy. Additionally. Women Pregnancy Chronic hypertension – HTN that existed before pregnancy OR diagnosed before the 20th week of gestation Preeclampsia – hypertension that occurs after 20 weeks of gestation and goes away after pregnancy The risk of hypertension is substantial for both the mother and baby. carvedilol and many older drugs) should be avoided or used cautiously as elderly are more sensitive to the effects and have diminished baroreceptor response. It was only recognized recently as being a high risk of morbidity and mortality from CHD. This HTN must be treated during pregnancy. ISH is due to the stiffening of the vascular wall with aging Treatment benefits in elderly are now well documented Diuretics preferred initial therapy in the elderly The difference spoken of between blacks and whites tend to be in ages < 60 years of age Hypertension in the elderly tend to be more about vascular stiffness in which both calcium channel blockers (specifically diltiazem) and diuretics are very effective at treating Orthostatic hypotension • AVOID drugs that cause orthostatic hypotension (alpha1-blockers. hydralazine. stroke and CVD. but consideration should be given to risk versus benefit of ERT in hypertensive women due to the cardiovascular nature Men Benign prostatic hypertrophy – Addition of an alpha 1-blocker for additional BP control in men with HTN and BPH seems reasonable. labetalol. • • • • • • 11 .• • • • • • Elderly Isolated systolic HTN – elevated systolic pressure with a normal diastolic pressure. labetalol and hydralazine • ARBs and ACEIs contraindicated in pregnancy due fetal malformations • Package insert says after first trimester • Recent data suggest problems also with 1st trimester exposure • Many obstetricians are comfortable with using methyldopa. Treatment includes magnesium (seizure prevention). CCBs to manage chronic hypertension throughout pregnancy • Diuretics should NOT be used because of concern over amniotic fluid volume Oral contraceptives – are drugs that elevate blood pressure and consideration needs to be given to women who are hypertensive or pre-hypertensive Estrogen replacement therapy – tends to have less effect than contraceptives.

D/c HCTZ and start amlodipine . He has been treated for 3 months with HCTZ 25 mg qd.NO. recently diagnosed HTN • • KR is a 36 year old BF who is 5’2” and 182 lbs. Her family history is significant for hypertension in both parents and two siblings and her father had CABG at age 51. He has no significant past medical history and no significant family or social history.JNC7 guidelines recommend HTCZ as preferred first-line therapy in African-Americans d. maximal blood pressure lowering dose is 25 mg HCTZ daily .Educate and implement the DASH diet b. this would decrease his exercise tolerance by decreasing his heart rate c. overweight.Reduce salt intake – African American female are more salt sensitive . Start HCTZ .Case presentations African American female. patients with documented hypertension are not treated with lifestyle modifications only c.A non-responder to HCTZ would also make him a non-responder to a CCB e.Alpha blocking effects would caused orthostatic hypotension d. recently diagnosed HTN. Initiate lifestyle modifications for up to 6 months . Which of the following is most appropriate for management of KR’s hypertension? a. with minimal BP response.NO.Reduce her caloric intake and increase exercise . 2 drugs of the same drug class b.Thiazide diuretics are highly effective in the elderly .Not a first-line drug . Start labetalol 12 • • • . Relevant information is that PL is a runner. She has no other significant medical history. Which of the following would you recommend for PL? a. D/c HCTZ and start ramipril Elderly.Always institute lifestyle modifications + drug therapy b. with average blood pressure over 3 visits of 146/96. Initiate lifestyle modifications + start amlodipine . Initiate lifestyle modifications + start HTCZ . averaging 20 miles/week. D/c HCTZ and start metoprolol . non-responder to HCTZ. Increase HCTZ to 50 mg qd . Which of the following is most appropriate? a. Start doxazosin . Change HCTZ to chlorthalidone .NO.Tends to be less effective with African-Americans as monotherapy White male.Increasing to 50 mg would probably only increase side effects (hypokalemia) d.Studies show good reductions in adverse cardiac outcomes c. She has been recently diagnosed with hypertension. runner • PL is a 46 year old white male who was recently diagnosed with HTN. average blood pressure now is 138/98.NO. Initiate lifestyle modifications + start metoprolol .This would be moving to a drug with a different pathophysiologic mechanism . white male FC is a 72 year old white male whose blood pressure is 152/82. Institute lifestyle modifications .

but diastolic blood pressure remains consistently >95 mm Hg. planning to become pregnant GG is a 38 year old white female with a 4 year history of hypertension. Continue current therapy during her pregnancy . AND she was controlled with lisinopril c. this drug is more selective. Discontinue lisinopril and allow GG to be hypertensive during her pregnancy as the risks of HTN are over a lifetime.Calcium channel blocker + thiazide diuretic is not a combination to consider d.This is NOT a good combination because they have the same pathophysiology c..Also works with the same pathophysiology as lisinopril. Start HCTZ + amlodipine . and hesitation and dribbling during urination.Thiazide diuretic works at a different pathophysiology and she might not respond .Carvedilol is nonselective with alpha blocking effects . Start HCTZ + carvedilol . Start HCTZ b.There are theoretical concerns with thiazide diuretics that they would have an effect on the amniotic fluid volume. Felodipine .ACEI + thiazide diuretic is a great combination.Has alpha blocking activity along with beta blocking effects .Beta blockers are not a concern in pregnancy . especially at nighttime. with benign prostatic hyperplasia HJ is a 58 year old black male with hypertension. ACEI are contraindicated in pregnancy especially after the 1st trimester b. They tend to be avoided during pregnancy Black male. Benazepril . currently treated with HCTZ 25 mg qd. except that he complains of urinary frequency. HJ’s medical history is nonsignificant.NO. stage 2 hypertension FC is a 72 year old white male whose blood pressure is 166/92.Atenolol is beta-1 selective agent Young white female. white male. Which of the following is most appropriate? Guidelines in this patient calls for a 2 drug therapy. but does not address the BPH symptoms 13 • • • • . His blood pressure has decreased on this medication.NO.NO. She has been well controlled on lisinopril 20 mg qd. Tamsulosin .Has both blood pressure lowering properties AND effective for BPH symptoms c.Need to avoid in elderly because of orthostatic hypotension e. and has less effect blood pressure b. No treatment is warranted .The alpha blocking effects leads to orthostatic hypotension d. a.Patient has stage 1 hypertension (SBP 152mmHg) and needs treatment • • Elderly. Terazosin . Discontinue lisinopril and start HCTZ . Which of the following would be the most appropriate addition to HJ’s current antihypertensive regimen? a. She is planning to become pregnant. elevated blood pressure will present substantial risk to both mother and child d. Which of the following would be the most appropriate management of GG? a. His PMH is otherwise nonsignificant. and 9 months of uncontrolled HTN will not pose any important risks to GG .Provides additional therapy needed to control patient’s blood pressure . Start chlorthalidone + atenolol . Discontinue lisinopril and start metoprolol .

black male.ISDN are not first-line treatment for angina.If we elect to swap out drugs we need to stay within the same pathophysiology . and 3 p. Substitute metoprolol 50 mg bid for quinapril . but do we need 3 antihypertensive medications for this patient c. with concomitant angina pectoris • BL is a 64 year old black male with a 25 year history of HTN. Substitute diltiazem SR 180 mg qd for HCTZ . because of the same pathophysiology and treatment is with only 2 drugs • 14 . Findings on exercise treadmill test are consistent with ischemic heart disease and a diagnosis of angina pectoris. to current regimen .This would be a good choice. He has now been referred to cardiology clinic for evaluation of chest pain with exertion.Possible. BL’s current medications are HCTZ 25 mg qd and quinapril 20 mg qd. treat HTN and CO-existent CV disease with the same drug to reduce polypharmacy Insure that antihypertensive therapy is not adversely affecting the concomitant CV disease Elderly.Treatment of patients with hypertension and concomitant diseases 1.m. This regimen provides good blood pressure control. but ACEI have good data showing prevention of MI d. Add metoprolol 50 mg bid . Which of the following would you recommend for management of BL? a. and does not have chronic BP lowering properties b.m. 2. Principles driving treatment of patients with CO-existent CV disease If possible. Add ISDN 40 mg at 7a.Possible.

add furosemide and enalapril .Amlodipine has no role in a post-MI patient and this regimen lacks a beta blocker White female.Guidelines call for an ACEI when evidence of heart failure d.Hopefully. On hospital day two.g.White male. Add HCTZ 25 mg qd . start metoprolol and enalapril .Regimen does not include beta blocker or ACEI which are needed for HF c.Do no harm in adding drugs that could worsen heart failure (e. Discontinue diltiazem. and dyspnea on exertion DOE. Discontinue amlodipine.Beta blockers that are indicated in post MI patients. Her EF is 28% by echo. Which of the following is the most appropriate antihypertensive regimen for RT? a. On PE she has a 2+ pedal edema. start amlodipine and lisinopril .There is NO role for diltiazem in a post MI patient b.Best choice. RT has had HTN for the past 9 years. but must have NO intrinsic sympathomimetic activity (ISA). which responded well to IV furosemide. Discontinue diltiazem. he had an episode of SOB.Guideline post MI therapy includes a beta blocker and an ACEI . add furosemide.Regimen does not include beta blocker d. Continue diltiazem . She has longstanding HTN which has only been recently treated with amlodipine 10 mg qd. this will also control his blood pressure e. Discontinue diltiazem. concomitant heart failure • • HH is a 72 year old white female who presents to clinic with symptoms of SOB. because it adds the therapies needed in heart failure . +HJR and +JVD. and was diagnosed with an anterior STEMI. CCB have native inotropic effects) • 15 . add furosemide . amlodipine has no role in the treatment of patients with heart failure . Discontinue amlodipine. This would exclude pindolol c. Discontinue diltiazem. enalapril and carvedilol (titrated slowly) . with bilateral rales on auscultation. fatigue. start metoprolol . Which of the following is the most appropriate pharmacotherapy regimen for HH? a. treated with diltiazem SR 180 mg qd. post MI • RT is a 56 year old white male who was admitted to the CCU two days ago.Not potent enough of a diuretic for this patient’s fluid overload .Again. Discontinue amlodipine. start pindolol .This regimen is missing many of the heart failure drugs b.

NO.Here we can control the ventricular rate AND blood pressure with a single drug . Paramedics noted a heart rate of 35 bpm and she was admitted to the CCU. the therapeutic goal is to control DS’s rapid ventricular rate. DS’s ventricular response rate is 160 bpm and he is going to be anticoagulated then undergo cardioversion in about 4 weeks. but this would by using 2 drugs when 2 drugs may not be needed d. Lisinopril .Diltiazem would slow conduction through the AV node . or sick sinus syndrome • PJ is an 81 year old white female who is brought to the ER by ambulance for a syncopal episode. Add atenolol to current regimen . bradycardia. currently controlled with nifedipine and HCTZ. Substitute diltiazem for nifedipine . heart block. He now presents with atrial fibrillation.NO.Hispanic male. this drug would slow SA node firing and is contraindicated d.Digoxin has NO antihypertensive effects b. Diltiazem .NO. Substitute metoprolol for nifedipine . it is noted that the patient’s HTN is poorly controlled. this drug would slow SA node firing and is contraindicated • • 16 . Which of the following would be the most appropriate? a. Doxazosin . and diltiazem would offer the same blood pressure control as nifedipine c. which based on his history of present illness has probably been present for at least 3-4 weeks. Atenolol . and not a drug of 1st choice b. because we would not have confidence in a patient who responded to nifedipine would respond to metoprolol because of the difference in pathophysiology Elderly white female. with concomitant atrial fibrillation and HTN • DS is a 67 year old Hispanic male with longstanding hypertension. Currently. PMH significant for HTN treated with HCTZ.Possible.Good choice. After placement of a temporary pacemaker.NO. Verapamil . this drug would slow SA node firing and is contraindicated c. Which of the following would you recommend? a. and no detrimental effects on heart rate e. Add digoxin to current regimen . could cause orthostatic hypotension.NO. good combination with HCTZ.Nifedipine does not slow conduction through the AV node.

• • Black female with dyslipidemia CV is a 47 year old black female with a recent diagnosis of HTN. but inadequately controlled with metoprolol 100 mg bid. CV has no other significant PMH.Never use a non-dihydropyridine CCB and beta blocker together c. LDL-C-166 mg/dl.NO. TG-115 mg/dl. Add HCTZ . start acebutolol and fosinopril . She had an inferior MI and has not had any medical problems since her discharge from the hospital for the STEMI.More effective as monotherapy in the African-American population b.NO. HDL-C-62 mg/dl. She presents to clinic for a post MI checkup. Metoprolol . there is no role for CCB in the post MI patient . she had a fasting lipid profile run.NO. start diltiazem . Lisinopril . Add diltiazem . dyslipidemia. Which of the following would you recommend for management of FG’s HTN? a. This a.Not as effective in African-American females as monotherapy Black female. D/c metoprolol. A recent lipid profile also revealed the following: total cholesterol . Before her MI. D/c metoprolol. Add enalapril .Might lower blood pressure. TG -115 mg/dl. HDL-C 62 mg/dl.CCB are neutral in effects on lipid profile .250 mg/dl.We will not discontinue metoprolol because of the benefits in a post MI patient outweighs the risk of dyslipidemia • • 17 . but no benefits post MI and could adversely affect lipid profile e.NO. Which of the following antihypertensives would you choose for initial therapy for CV? a. acebutolol has ISA and has no benefits related to post MI therapy . She has a 10 year history of HTN which is now being treated. which is as follows: 250mg/dl. HCTZ .m. and post MI FG is a 56 year old black female with an STEMI 6 weeks ago.Best choice. LDL-C=166 mg/dl.NO. beta blockers can increase triglycerides and lower HDL d. her BP had been well controlled with diltiazem. adverse effects on lipid profile c. beta blockers and ACEI are first-line therapy for post MI d. Diltiazem . beta blockers are first-line therapy in post MI patients b.

HCTZ – impair glucose tolerance. Furosemide . because as renal function declines so also does the ability to excrete potassium d. 2.A potent arterial peripheral vasodilator which might help the symptoms of PVD c. Atenolol – Beta blockers impaired glucose control. we know that ACEI tend to be very beneficial CV protective effects Treatment of HTN w/coexistent non-CV diseases 1. Quinapril (ACEI/ARB) – ACEIs slow the progression of diabetic nephropathy.Additionally. Doxazosin – has no beneficial or detrimental effects in patients with diabetes d. Describe the pros and cons of use of each of the following antihypertensive agents in SD. Atenolol . and not as effective as ACEI in real failure • • KL is a 54 year old MAM with Type-2 DM and HTN.Thiazide diuretics offer no potential risk or benefits b. mask symptoms of hypoglycemia. Metoprolol . Diltiazem – has no beneficial or detrimental effects in patients with diabetes c. and slow recovery from a hypoglycemic episode b. who was recently diagnosed with HTN and her average BP is 148/102 mmHg.Worst choice then HCTZ alone.Patient has stage 2 hypertension and needs combination therapy 18 • • .• • White male with PVD BL is a 59 year old white male with significant peripheral vascular disease and intermittent claudication.Not considered drug of 1st choice. Which of the following is the most appropriate antihypertensive for KL? a. a. Which of the following would be the most appropriate initial pharmacotherapy for her HTN? a. e.If not titrated appropriately ACEI can cause worsening of renal function. HCTZ . BUT there is an abundance of evidence showing that ACEI slow the progression of renal disease.Arterial vasodilation effect may be beneficial in a patient with PVD . and has adverse effects on lipid profile White female with metabolic syndrome JL is a 48 yo white female. HCTZ/triamterene combo . Ramipril (1st choice) . Which of the following would be most appropriate antihypertensive therapy for a patient such as BL? a. Her lipid profile is significant for Tg = 212 mg/dl and a waist circumference of 41 inches. • • Try to insure that antihypertensive does not negatively impact other disease If specific antihypertensive beneficial in disease. May need to add a CCB to get patient controlled at < 130/80 e.Maybe an effective diuretic but have little effect on blood pressure c. Diltiazem . Captopril (ACEI/ARB) .Lose efficacy with decreasing renal function b. Nifedipine . HCTZ . use it first SD is a 58 year old black male with chronic renal insufficiency (estimated CrCl=30 ml/min) and a 25 year history of HTN.Theoretical recommendations are to avoid beta blockers in patients with PVD especially nonselective beta blockers where you have beta-2 blockade d.

Enalapril . Irbesartan .Not as effective in Caucasians as monotherapy c.Atenolol provide some risk of newly onset diabetes patients • • • PM is a 41 year old white female with a history of asthma for which she takes chronic inhaled corticosteroids and prn inhaled beta-agonists. HCTZ . Diltiazem . and a cough can increase asthma exacerbation e.Best choice because amlodipine is neutral for diabetic risk.There is a cough associated with ACEIs. because patients rely on beta-2 stimulation for bronchodilation b. She was recently diagnosed with HTN. Amlodipine + irbesartan .Not as effective in Caucasians as monotherapy d.Diuretic + beta blocker would not be a good choice c. Chlorthalidone + metoprolol . Atenolol . HCTZ + lisinopril .Best choice for this patient 19 .Not a good choice because of the HCTZ d. Which of the following would be the most appropriate initial therapy for the treatment of her HTN? There are not any antihypertensive medications that are beneficial for asthma Avoid beta blockers in patients with asthma a.Beta blockers can worsen asthma.b. Atenolol + amlodipine . and ARBs are potentially protective in diabetes risk the same way ACEI are e.