+ Therapeutics 1 Tutoring Sarah Darby October 3, 2016

+ Lectures Covered Hypertension Hypertensive Crises

+ HTN Staging patients with hypertension SystolicDiastolic Normal<120<80 Pre-HTN Stage Stage 2≥160≥100

+ HTN TH is a 56 yo male who comes into your pharmacy today for his first MTM session. His BP reading today is 156/90. What BP stage is this? A. Normal B. Pre-HTN C. Stage 1 D. Stage 2 E. Can’t know

+ HTN JT is a 49 yo male who comes into the clinic today for a follow up visit. You last saw him on August 1 st, and his BP reading was 148/92. Today his BP is 155/98. A. Normal B. Pre-HTN C. Stage 1 D. Stage 2 E. Can’t know

+ HTN HK is a 62 yo female. At her last visit on August 1 st her BP was 150/105. Today her BP is 155/110. A. Normal B. Pre-HTN C. Stage 1 D. Stage 2 E. Can’t know

+ HTN Which activity does not impact measuring blood pressure? A. Recent caffeine intake B. Talking during the reading C. Going to the bathroom right before D. Placing the cuff over a shirt sleeve

+ HTN Determining BP goals Age Disease

+ HTN

+ Let’s look at specific patient populations… Age>80 yo Goal is <150/90 According to all guidelines Gen. Pop ≥60 yo JNC8 says goal is <150/90 ASH/ISH says goal is <140/90 Gen. Pop<60 yo Goal is <140/90 According to all guidelines Diabetes Goal is <140/90 According to all guidelines CKD Goal is <140/90 According to JNC8, ASH/ISH, and KDIGO KDIGO makes special recommendation for albumin excretion ≥30mg/24h

+ HTN In other words… Choose a goal of <140/90 EXCEPT General patients ≥60 yo (JNC8) Patients >80 yo (ASH/ISH) CKD patients with albumin excretion ≥30mg/24h (KDIGO)

+ HTN What is the BP goal for an 85 yo female according to JNC8? A. <150/90 B. <140/90 C. <130/80

+ HTN What is the BP goal for an 65 yo female according to JNC8? A. <150/90 B. <140/90 C. <130/80

+ HTN What is the BP goal for an 85 yo female according to ASH/ISH? A. <150/90 B. <140/90 C. <130/80

+ HTN What is the BP goal for an 65 yo female according to ASH/ISH? A. <150/90 B. <140/90 C. <130/80

+ HTN At what age do the JNC8 guidelines increase the goal BP from <140/90 to <150/90? A. 60 B. 65 C. 70 D. 75 E. 80

+ HTN At what age do the ASH/ISH guidelines increase the goal BP from <140/90 to <150/90? A. 60 B. 65 C. 70 D. 75 E. 80

+ HTN MR is a 55 yo male with T2DM and CKD. His urine albumin excretion is 15mg/24h.What is his BP goal according to the ADA guidelines? A. <150/90 B. <140/90 C. <130/80

+ HTN MR is a 55 yo male with T2DM and CKD. His urine albumin excretion is 40mg/24h. What is his BP goal according to the ADA guidelines? A. <150/90 B. <140/90 C. <130/80

+ HTN MR is a 55 yo male with T2DM and CKD. His urine albumin excretion is 36mg/24h. What is his BP goal according to the KDIGO guidelines? A. <150/90 B. <140/90 C. <130/80

+ HTN Determining agent of choice – JNC8

+ HTN Determining agent of choice – JNC8 TLC for EVERYONE!!! Then pick out specific disease populations Consider age for BP goal Consider race If SBP>20mmHg above goal, start with 2 drug therapy

+ HTN - JNC8 Non-black Thiazide ACEI or ARB CCB Black Thiazide CCB Diabetes No CKD present CKD No matter what race ACEI or ARB +/- other agents Look at race

+ HTN Determining agent of choice – ASH/ISH

+ HTN Determining agent of choice – ASH/ISH TLC for EVERYONE!!! Then consider what stage of HTN Consider race Consider age

+ HTN - ASH/ISH Stage 1 Non-black Age<60 – ACEI or ARB Age≥60 – CCB or thiazide Black CCB or thiazide Stage 2** ACEI or ARB AND CCB or thiazide **start with 2 drugs

+ HTN JT is a 68 yo white male with stage 1 HTN. No significant PMH. According to JNC-8, what is his BP goal? A. <150/90 B. <140/90 C. <135/85 D. <130/80

+ HTN JT is a 68 yo white male with stage 1 HTN. No significant PMH. According to JNC8, what is your initial treatment recommendation? A. Metoprolol B. Clonidine C. Lisinopril D. Furosemide

+ HTN JT is a 68 yo white male with stage 1 HTN. No significant PMH. According to ASH/ISH, what is your initial treatment recommendation? A. Amlodipine B. Lisinopril C. Metoprolol D. Losartan

+ HTN DK is a 58 yo AA female with stage 2 HTN. No significant PMH. According to ASH/ISH, what is your initial treatment recommendation? A. Amlodipine B. Chlorthalidone C. Amlodipine + Chlorthalidone D. Amlodipine + Lisinopril E. Lisinopril + Losartan

+ HTN DK is a 58 yo AA female with stage 2 HTN. No significant PMH. Therapy has been maximized on Amlodipine and Lisinopril, but his BP is still not at goal. What additional treatment do you recommend? A. Losartan B. Benazepril C. HCTZ D. Atenolol

+ HTN BH is a 62 yo AA male with T2DM and CKD. According to JNC8, what is your initial treatment recommendation for his HTN? A. Chlorthalidone B. Benazepril C. Felodipine D. Atenolol

+ HTN In which scenario is recommending a beta- blocker and ACEI not appropriate? A. Coronary artery disease B. HFrEF C. Stroke D. Post-ACS

+ HTN In what patient would you recommend spironolactone as add-on therapy? A. CKD B. HFrEF C. Stroke D. DM

+ HTN According to the ISHIB guidelines, what is the target BP for an AA male with CVD and CrCL=40ml/min? A. <150/90 B. <140/90 C. <130/80 D. <135/85

+ HTN Which lifestyle modification has the biggest impact on blood pressure reduction? A. Weight loss B. Sodium reduction C. Alcohol reduction D. Exercise

+ HTN Crises DS is a 65 yo male presenting to the ED with a BP of 232/145. His wife states he has been confused for the past few days with SOB starting in the last hour. PMH: COPD, HF. Physical exam is WNL except for pulmonary edema noted on CXR and papilledema noted on ophthalmic exam. How should this patient be treated? A. HTN emergency – admit the patient for inpatient treatment B. HTN urgency – admit the patient for inpatient treatment C. HTN emergency – send patient home with oral antihypertensive D. HTN urgency – send patient home with oral antihypertensive

+ HTN Crises DS is a 65 yo male presenting to the ED with a BP of 232/145. His wife states he has been confused for the past few days with SOB starting in the last hour. PMH: COPD, HF. Physical exam is WNL except for pulmonary edema noted on CXR and papilledema noted on ophthalmic exam. How fast should his BP be lowered? A. Reduce the BP as quickly as possible to <140/90 B. Reduce the MAP by 50% in the first hour, then to less <140/90 in the next 24 hours C. Reduce the MAP by 20-25% in the first hour, then <160/110 in the next 24 hours D. Reduce the MAP by 20-25% in the first hour, then <160/110 in the next 2-6 hours

+ HTN Crises DS is a 65 yo male presenting to the ED with a BP of 232/145. His wife states he has been confused for the past few days with SOB starting in the last hour. PMH: COPD, HF. Physical exam is WNL except for pulmonary edema noted on CXR and papilledema noted on ophthalmic exam. Which agent do you prefer to lower the BP? A. Nicardipine 20mg PO TID B. Nicardipine 5mg/h IV C. SL Nitroglycerin D. Labetalol 40mg IV bolus q 10 min

+ HTN Crises TH is a 59 yo female presenting to clinic with BP of 225/238. She takes Lisinopril 10mg daily but states has forgotten a few doses this week. Physical exam shows neuro, cardio, and ophthalmic exam are normal. How should this patient be treated? A. HTN emergency – admit the patient for inpatient treatment B. HTN urgency – admit the patient for inpatient treatment C. HTN emergency – send patient home with oral antihypertensive D. HTN urgency – send patient home with oral antihypertensive

+ HTN Crises TH is a 59 yo female presenting to clinic with BP of 225/238. She takes Lisinopril 10mg daily but states has forgotten a few doses this week. Physical exam shows neuro, cardio, and ophthalmic exam are normal. How fast should her BP be lowered? A. Reduce the BP as quickly as possible to <140/90 B. Reduce the MAP by 20-25% in the first hour, then <160/110 in the next 2-6 hours C. Reduce the BP to <160/110 over hours to days D. Reduce the BP to <140/90 over hours to days

+ HTN Crises TH is a 59 yo female presenting to clinic with BP of 225/238. She takes Lisinopril 10mg daily but states has forgotten a few doses this week. Physical exam shows neuro, cardio, and ophthalmic exam are normal. What do you recommend for treatment? A. Lisinopril 20mg PO daily B. Losartan 50mg PO daily C. Nicardipine 5mg/h IV D. Nicardipine 20mg PO TID

+ HTN Crises What is the DOC for BP reduction in eclampsia? A. Hydralazine B. Enalaprilat C. Nitroglycerin D. Sodium nitroprusside

+ HTN Crises Which agent is not given via intermittent bolus? A. Hydralazine B. Enalaprilat C. Labetalol D. Clevidipine

+ HTN Crises Which agent does not increase intracranial pressure? A. Hydralazine B. Nicardipene C. Nitroglycerin D. Sodium nitroprusside

+ HTN Crises Which agent causes “coronary steal?” A. Nitroglycerin B. Sodium nitroprusside C. Nicardipine D. Clevidipine

+ HTN Crises Which agent is the DOC for hypertensive emergencies associated with renal disease? A. Labetalol B. Fenoldopam C. Hydralazine D. Esmolol

+ Therapeutics 1 Tutoring Questions? Sarah Darby October 3, 2016