Antihypertensive Medications

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Questions and Answers

An individual's blood pressure should be measured annually starting at what age?

  • 16 years
  • 18 years (correct)
  • 21 years
  • 25 years

What percentage reduction in stroke risk is associated with lowering blood pressure through antihypertensive therapy?

  • 10-15%
  • 35-40% (correct)
  • 5-10%
  • 20-25%

To ensure an accurate blood pressure reading, how long should a patient relax before the measurement is taken?

  • Immediately prior
  • 1-2 minutes
  • 10 minutes
  • 3-5 minutes (correct)

According to the 2017 ACC/AHA guidelines, what blood pressure reading is defined as Stage 2 hypertension?

<p>≥140/90 mmHg (B)</p>
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According to the ACC/AHA guidelines, what is the recommended blood pressure target for most patients requiring treatment?

<p>&lt;130/80 mmHg (C)</p>
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Which of the following nonpharmacologic interventions is recommended to reduce blood pressure?

<p>Following the Dietary Approaches to Stop Hypertension (DASH) eating plan (C)</p>
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Essential or primary hypertension is best described as hypertension:

<p>With no identifiable underlying cause (B)</p>
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Which of the following drug classes works by reducing systemic vascular resistance and producing vasodilation?

<p>ACE inhibitors (A)</p>
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If a patient's blood pressure is >20/10 mmHg above their target, which approach is recommended for initiating pharmacotherapy?

<p>Initiate two first-line agents from different classes. (B)</p>
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Which of the following medications is a thiazide diuretic?

<p>Indapamide (A)</p>
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What is the mechanism of action of thiazide diuretics in lowering blood pressure?

<p>Inhibiting the sodium-chloride transporter in the distal tubule (A)</p>
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Which of the following is a common side effect associated with thiazide diuretics?

<p>Hypercalcemia (elevated calcium) (D)</p>
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Which of the following should be monitored within 1-2 weeks, when initiating a thiazide diuretic?

<p>Potassium levels (B)</p>
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Which of the following is a contraindication to using thiazide diuretics?

<p>Active gout (D)</p>
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Which of the following best describes the mechanism of action of ACE inhibitors?

<p>Inhibiting the formation of angiotensin II (A)</p>
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A known possible side effect that is unique to ACE-inhibitors is:

<p>Dry cough (B)</p>
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For what type of patient are ACE-inhibitors a preferred antihypertensive?

<p>Diabetes + albuminuria (D)</p>
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How do Angiotensin II Receptor Blockers (ARBs) lower blood pressure?

<p>Blocking angiotensin II receptors on blood vessels (A)</p>
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What electrolyte imbalance is a potential side effect shared by both ACE inhibitors and ARBs?

<p>Hyperkalemia (A)</p>
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A patient who previously experienced angioedema while taking an ACE inhibitor should NOT be prescribed which of the following medications?

<p>Angiotensin II receptor blocker (C)</p>
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How do dihydropyridine calcium channel blockers lower blood pressure?

<p>By blocking calcium channels in vascular smooth muscle (C)</p>
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Which of the following is a common side effect of dihydropyridine calcium channel blockers?

<p>Peripheral edema (C)</p>
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Non-dihydropyridine calcium channel blockers have which of the following effects in addition to lowering blood pressure?

<p>Reduce heart rate (B)</p>
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A patient with heart failure and bradycardia should avoid:

<p>Non-dihydropyridine calcium channel blockers (D)</p>
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A patient with hypertension and a known sulfa allergy should avoid:

<p>Thiazide diuretics (D)</p>
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What is a key difference between ACE inhibitors and ARBs that informs prescribing decisions?

<p>ARBs are less likely to cause cough. (B)</p>
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Which of the following medication instructions should be given to a patient that is prescribed a beta blocker?

<p>Avoid sudden interruption of therapy, gradually reduce dosage over 1-2 weeks when discontinuing therapy (B)</p>
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Which of the following patients should NOT take a beta blocker?

<p>Patient with asthma (A)</p>
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How do alpha-2 agonists, such as clonidine, lower blood pressure?

<p>By stimulating alpha-2 receptors in the CNS (C)</p>
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Which of the following is a serious side effect associated with the abrupt discontinuation of clonidine?

<p>Rebound hypertension (A)</p>
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Which of the following best describes the mechanism of action of hydralazine in lowering blood pressure?

<p>Dilating arterial vessels (B)</p>
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Which of the following is a potential side effect of hydralazine?

<p>Reflex tachycardia (A)</p>
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Which of the following diuretics is most appropriate for the treatment of hypertension?

<p>Thiazide diuretics (D)</p>
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A patient presents with hypertension and is also being treated for heart failure. Which class of diuretics should be avoided in this patient?

<p>Potassium-sparing diuretics (B)</p>
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According to guidelines, what is the upper limit for sodium intake?

<p>&lt;1500mg/day (D)</p>
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What should the nurse consider prior to blood pressure measurement?

<p>All of the above (D)</p>
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What circumference arm would need a large adult cuff?

<p>35-44 cm (A)</p>
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If initiating 2 first-line agents for blood pressure control, which agents should not be used together?

<p>ACE inhibitor and ARB (A)</p>
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A patient with a history of angioedema is prescribed an antihypertensive. Which of the following medications would be most appropriate?

<p>Diltiazem (C)</p>
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Which of the following is a potential adverse effect that requires monitoring when initiating a patient on chlorthalidone?

<p>Hypercalcemia (A)</p>
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Which antihypertensive medication is considered a preferred first-line agent specifically for patients with concomitant diabetes and albuminuria?

<p>Lisinopril (B)</p>
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A patient is started on lisinopril for hypertension. What specific side effect should the patient be educated about that is unique to ACE inhibitors?

<p>Dry cough (D)</p>
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Why are non-dihydropyridine calcium channel blockers like diltiazem and verapamil typically avoided in patients with heart failure?

<p>They have negative inotropic effects. (D)</p>
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According to the ACC/AHA guidelines, what blood pressure reading would necessitate initiating BP-lowering medication for a patient with diabetes?

<p>≥130/80 mmHg (A)</p>
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What is the primary mechanism by which aldosterone antagonists, such as spironolactone, lower blood pressure?

<p>Inhibiting the reabsorption of sodium and water in the kidneys (A)</p>
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A patient on hydrochlorothiazide (HCTZ) develops hypokalemia. What intervention would directly address this side effect while continuing HCTZ?

<p>Add spironolactone. (C)</p>
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Which of the following dietary modifications would be most beneficial for a patient newly diagnosed with hypertension?

<p>Follow the DASH dietary pattern (A)</p>
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What is the primary mechanism by which loop diuretics, like furosemide, reduce blood pressure, particularly in the context of heart failure?

<p>Reducing sodium and chloride reabsorption in the thick ascending limb of the loop of Henle (C)</p>
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For a patient with hypertension and a stable ischemic heart disease, which of the following antihypertensive classes would be most appropriate as a first-line option?

<p>Beta blockers (A)</p>
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A patient abruptly stops taking clonidine. What potentially serious adverse effect should the healthcare provider be most concerned about?

<p>Rebound hypertension (B)</p>
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Which of the following best describes the action of hydralazine in lowering blood pressure?

<p>Dilates arterial vessels (D)</p>
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Which of the following is a common side effect associated with dihydropyridine calcium channel blockers like amlodipine?

<p>Peripheral edema (A)</p>
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According to guideline recommendations, what is the blood pressure target for most patients receiving antihypertensive treatment?

<p>&lt;130/80 mmHg (D)</p>
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What is a key consideration when selecting an antihypertensive medication for a black patient, according to the information?

<p>CCBs and thiazides are preferred first-line agents (B)</p>
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What is a critical monitoring parameter for patients taking ACE inhibitors or ARBs, especially within the first few weeks of initiation or dose change?

<p>Potassium and Serum Creatinine (B)</p>
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Which situation would warrant initiation of two first-line antihypertensive agents simultaneously?

<p>Blood pressure is &gt;20/10 mmHg above target (B)</p>
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Which diuretic is considered less effective in patients with a CrCl (Creatinine Clearance) < 30ml/min?

<p>Hydrochlorothiazide (D)</p>
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Which parameter signifies a blood pressure reading that is considered 'elevated' according to the guidelines?

<p>120-129/ &lt;80 mmHg (B)</p>
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When is a patient with hypertension typically considered for treatment with an aldosterone antagonist (like spironolactone or eplerenone)?

<p>In cases of primary aldosteronism or resistant hypertension (A)</p>
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What advice should be provided to a patient taking a beta blocker regarding discontinuation of the medication?

<p>The dose should be gradually reduced over 1-2 weeks (D)</p>
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Which of the following is NOT correct regarding thiazide diuretics?

<p>Preferred for patients with CrCl &lt; 30 ml/min (A)</p>
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For a 52 year old male with repeat blood pressure of 135/78 mmHg, no prior hx of HTN or other medical conditions, no current HTN medications, and a calculated ASCVD Risk of 15%, what would you treat with first?

<p>Chlorthalidone (D)</p>
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Flashcards

Hypertension Clinical Presentation

High blood pressure is often the only sign, frequently asymptomatic.

Hypertension Diagnosis

Individuals 18+ should be screened yearly. Diagnosis based on the average of two or more readings taken 1-2 minutes apart AND elevated readings at two or more visits spaced 1-4 weeks apart.

Thiazide Diuretics: Action

Inhibit sodium-chloride transporter in distal tubule in the kidney increasing sodium and chloride excretion. More effective at blood pressure control.

Thiazide Diuretics Examples

Chlorthalidone is preferred, with a longer half-life and support. Hydrochlorothiazide is commonly prescribed. Not appropriate for patients with active gout or CrCl <30ml/min.

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ACE Inhibitors: Action

Blocks the action of angiotensin converting enzyme to inhibit the formation of angiotensin II which leads to vasodilation

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ARBs: Action

Blocks angiotensin II receptors on blood vessels and in tissues in the heart.

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Calcium Channel Blockers: Action

Bind to L-type calcium channels on vascular smooth muscles, cardiac myocytes, and cardiac nodal tissue blocks the entry of calcium into the cells.

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Aldosterone Antagonist Diuretics: Action

Blocks the action of aldosterone at the distal segment of distal tubule cells, increasing secretion of water and sodium; used in primary aldosteronism and resistant HTN.

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Potassium-Sparing Diuretics: Action

blocks the sodium channels in the distal tubule. This has small effects on sodium balance and blood pressure. It is typically used with another diuretic to prevent hypokalemia

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Loop Diuretics: Action

Inhibit sodium-potassium-chloride cotransporter in the thick ascending limb (Loop of Henle). Significant diuresis/natriuresis, less effective for hypertension; used in symptomatic heart failure.

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Beta Blockers: Action

Bind to beta-adrenergic receptors and inhibit the effects of catecholamines at these receptors.

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Alpha-2 Agonists: Action

Alpha-2 receptor agonists act as vasodilators. They act in the central nervous system to reduce sympathetic outflow. This decreases peripheral resistance, renal vascular resistance, heart rate, and blood pressure.

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Vasodilators: Action

Highly specific action on arterial vessels that reduces vascular resistance and arterial pressure.

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Calcium Channel Blockers

This medication class has two sub classes of non dihydropyridines and dihydropyridines, which have slightly different effects.

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ACE inhibitors, ARBs

ACE inhibitors and ARBs are basically the same except that ARBs are less likely to cause cough. ACE inhibitors and ARBs are contraindicated in pregnancy

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Calcium Channel Blockers

Dihydropyridine calcium channel blockers are more effective for blood pressure reduction and non-dihydropyridine CCBs have more effects on heart rate. Non-dihydropyridine CCBs should be avoided in patients with heart failure

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Treating Hypertension

Patients with stage 2 hypertension will likely require >1 drug to reach BP goals

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Blood Pressure Treatment Goal

Per ACC/AHA guidelines, most patients should be treated to a goal blood pressure of <130/80 mmHg

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Angiotensin receptor blockers (ARBs)

Block Angiotensin II receptors; do NOT increase bradykinin; do NOT have cough as a major side effect.

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Spironolactone

More side effects (e.g., gynecomastia; erectile dysfunction) but often less expensive than eplerenone

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ACE Inhibitors: Side Effects

Dry cough, hyperkalemia, transient rise in SCr; Severe side effects: Angioedema

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ARBs: Side Effects

Side effects: hyperkalemia; transient rise in SCr; Severe side effects: Angioedema

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Dihydropyridine Calcium Channel Blockers: Side Effects

Hypotension, dizziness, peripheral edema

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Non-dihydropyridine Calcium Channel Blockers: Side Effects

Hypotension, dizziness, lower extremity edema, constipation, bradycardia

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Aldosterone Antagonist Diuretics: Side Effects

Hyperkalemia; gynecomastia (spironolactone); hyperglycemia; hyponatremia, hypomagnesemia

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Potassium-Sparing Diuretics: Side Effects

Hyperkalemia; hyperuricemia

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Loop Diuretics: Side Effects

Profound diuresis/dehydration (acute kidney injury), -hypomagnesemia; hypokalemia; hyperuricemia and -sun sensitivity

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Beta Blockers: Side Effects

Bronchospasm, bradycardia, dizziness, fatigue, depression and Abrupt cessation of therapy may lead to angina, myocardial infarction, death

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Alpha-2 Agonists: Side Effects

dry mouth; dizziness; sedation and fatigue; hypotension; heart block; rebound hypertension

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Vasodilators: Side Effects

hypotension; edema; palpitations; reflex tachycardia; headaches and flushing and the serious side effects are; lupus-like syndrome (about 10%)

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Study Notes

  • Antihypertensive medications will be reviewed.
  • Hypertension guidelines and the pathophysiology of hypertension will be reviewed.
  • Pharmacotherapy targets will be identified.
  • First-line agents like ACE inhibitors, ARBs, calcium channel blockers, and thiazide diuretics will be covered.
  • Other agents like beta blockers, diuretics, alpha-2 agonists, and vasodilators will be discussed.
  • Case studies will be examined.

Lecture Objectives

  • Pharmacology and mechanism of action of antihypertensive medications will be described.
  • Common and serious side effects of antihypertensive medications will be identified.
  • Monitoring parameters of antihypertensive medications will be listed.
  • Medication selection based on patient medical history and co-morbidities will be discussed.

Hypertension Clinical Presentation

  • Elevated blood pressure is often the only sign.
  • It is often asymptomatic.
  • Signs and symptoms may arise due to cardiovascular, cerebrovascular, retinal, and renal complications of disease.
  • Hypertension is "the silent killer."
  • 7 out of 10 people who have a first heart attack have high blood pressure.
  • 8 out of 10 people who have a first stroke have high blood pressure.
  • 7 out of 10 people who have chronic heart failure have high blood pressure.

Diagnosis and Goals

  • All individuals age 18+ should be screened for hypertension yearly.
  • Diagnoses of hypertension is based on the average of two or more properly measured blood pressure readings taken 1-2 minutes apart.
  • Blood pressure must be elevated when measured at two or more visits spaced 1-4 weeks apart.
  • Individuals with HTN emergency (≥180/120mmHg or ≥160/100mmHg with known end-organ damage) are an exception.
  • Blood pressure lowering: antihypertensive therapy is associated with a 35-40% reduction in stroke, 20-25% reduction in myocardial infarction, and >50% reduction in heart failure.
  • ACC/AHA guidelines include American College of Cardiology and American Heart Association.
  • The 2017 ACC/AHA guidelines includes ASCVD risk scoring.
  • There is direction on screening for masked or white coat hypertension with the 2017 ACC/AHA guidelines.

Blood Pressure Monitoring

  • Monitoring technique to ensure an accurate reading should include:
  • Quiet room, comfortable temperature.
  • No smoking, coffee, or exercise for 30 minutes.
  • Empty bladder and relaxing for 3-5 minutes.
  • Take 3 measurements at 1-minute intervals, use the average of the last 2 measurements. When reading blood pressure, the patient should have their back supported, should not be speaking and the arm bare and resting at heart level. A proper cuff size matters when reading blood pressure
  • Small Adult recommended for 22-26 cm measurement
  • Standard Adult recommended for 27-34 cm measurement
  • Large Adult recommended for 35-44 cm measurement
  • Thigh size recommended for >45 cm measurement

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