1. ACEi
1.1. first line for non black patients
1.2. also for CKD patients or DM
1.3. AE: cough, angioedema, high K+, dizziness, HA, hypotension, cough, photosensitivity
1.4. CI: pregnancy, angioedema, hypotension, aliskiren, sacubitril
1.5. FIRST LINE
1.5.1. Lisinopril (Prinivil)
1.5.1.1. start 10mg PO qd
1.5.1.1.1. MAX: 80mg/day
1.6. SECOND LINE
1.6.1. Enalapril maleate (Vasotec)
1.6.1.1. start 5mg PO qd
1.6.1.1.1. MAX: 40mg/day
1.6.2. Captopril (Capoten)
1.6.2.1. start 12.5-25mg PO BID/TID
1.6.2.1.1. increase 12.5-25mg/dose q1-2wk
1.6.2.1.2. MAX: 450mg/day
2. ARBs
2.1. first line for non black patients
2.2. no risk of cough
2.3. CI: PREGNANCY, renal impairment, hepatic impairment, volume depletion, CHF, aliskiren
2.4. AE: angioedema, hypotension, hyperkalemia, rhabdo, hepatitis, diarrhea, fatigue, CP, cough, dyspepsia
2.5. FIRST LINE
2.5.1. Losartan (Cozaar)
2.5.1.1. start 50mg PO qd
2.5.1.1.1. MAX: 100mg/day
2.5.2. Valsartan (Diovan)
2.5.2.1. start 80-160mg PO qd
2.5.2.1.1. MAX: 320 mg/day
3. LOOPS
3.1. more effective in patients with poor kidney function
3.2. helps with edema and CHF
3.3. NOT HTN ONLY TREATMENT
3.4. Titrate until you pee like a racehorse
3.5. AE: dehydration, gout, kidney dysfunction, hypokalemia, ototoxicity, dizziness, N/V/D, orhtostatic hypotension, blurred vision, itching
3.6. CI: anuria, lyte imbalances, DM, arrhythmias, SLE, hepatic impairment, urinary retention, gout, elderly, -mycins, lithium, amikacin,
3.7. FIRST LINE
3.7.1. Furosemide (Lasix)
3.7.1.1. "lasts six hours"
3.7.1.2. start 40mg PO BID
3.7.1.2.1. OR start 10-20mg PO BID
3.7.1.2.2. MAX: 600mg/day
3.8. SECOND LINE
3.8.1. Bumetanide (Bumex)
3.8.1.1. start .5mg PO qd
3.8.1.1.1. MAX: 10mg/day
4. POSTASSIUM SPARING DIURETICS
4.1. TRIAMTERENE/HYDROCHL. (Maxzide)
4.1.1. add on for loop diuretics
4.1.2. 37.5mg/25mg PO qd
4.1.2.1. MAX: 75mg/50mg/day
4.1.3. CI: hyperkalemia, PREGNANCY, anuria, renal impairment, hepatic impairment, arrhythmias, gout, SLE, amiloride, dofetilide, other K sparings,
4.1.4. AE: Electrolyte disorders, jaundice, cramps, N/V, rash, impotence, blurred vision, HA, anorexia
4.2. ALDOSTERONE ANTAGONISTS
4.2.1. CHF > HTN use
4.2.1.1. SPIRONOLACTONE
4.2.1.1.1. Hyperaldosteroneism
4.2.1.1.2. Hirsuitism
4.2.1.2. EPLERENONE
5. THIAZIDES
5.1. first line for black patients
5.2. AE: gout, increase BG, inc lipids, inc K+, lyte imbalances, dizziness, cramps, weakness, rash
5.3. CI: Li, NSAIDs, renal dysfunction, anuria, lyte imbalances, dofetilide
5.4. First Line
5.4.1. Hydrochlorothiazide (Esidrix, Hydrodiuril)
5.4.1.1. most common in combos
5.4.1.2. 12.5-50mg PO qd
5.5. Second Line
5.5.1. Chlorothalidone (Hygroton)
5.5.1.1. most proven, lasts longer
5.6. Third Line
5.6.1. Chlorothiazide (Diuril)
5.6.1.1. 250-500mg PO qd-BID
5.6.1.1.1. MAX: 2000mg/day
6. CCB's
6.1. first line for black patients
6.2. decreased peripheral resistance
6.3. AE: dizziness, edema, constipation, bradycardia, CHF, AV block, hypotension
6.4. CI: AV block, hypotension, bradycardia, hepatic/renal impairment, MG, GERD, dofetilide, eliglustat, fibanserin, lomitapide, pimozide, thioridazine, timolol,
6.5. can use with beta blockers
6.6. dihydropyridines for raynauds
6.7. FIRST LINE
6.7.1. VERAPAMIL (Isoptin)
6.7.1.1. non-dihydropyridine
6.7.1.1.1. do not use with beta blockers
6.7.1.2. cardio selective (drop HR)
6.7.1.3. tx angina
6.7.1.4. IR: 80-120mg PO TID
6.7.1.4.1. start 80mg PO TID
6.7.1.4.2. MAX: 480mg/day
6.7.1.5. 12hER: 120-480 mg/day divided into QD-BID
6.7.1.5.1. start 180mg ER PO qAM
6.7.1.5.2. MAX: 480mg/day
6.7.1.6. 24hER:
6.7.1.6.1. AM start 240mg ER PO qAM
6.7.1.6.2. PM start 200mg ER PO qPM
6.7.2. DILTIAZEM (Cardizem)
6.7.2.1. both dihydro/non dihydro
6.7.2.2. for AFIB + HTN
6.7.2.3. 12hER - 120-180mg ER PO BID
6.7.2.3.1. start 60-120mg, titrate over 7-14 days
6.7.2.3.2. MAX: 360mg/day
6.7.2.4. 24hER - 180-480mg ER PO qd
6.7.2.4.1. start 120-240mg ER PO qd, titrate over 7-14 days
6.7.2.4.2. MAX: 540mg/day ER
6.7.3. AMLODIPINE (Norvasc)
6.7.3.1. dihydropyridine
6.7.3.2. start 5mg PO qd
6.7.3.2.1. 2.5mg PO qd if elderly or second agent
6.7.3.2.2. increase after 1-2 weeks
6.7.3.2.3. MAX: 10mg/day
6.7.3.3. CI: simvastatin, griseofulvin, ceritinib, dangtrolene, elglustat, oxcarbazepine
6.7.3.4. AE: angina, MI, hypotension, hepatitis, edema, fatigue, palpitations, nausea, flushing
6.8. SECOND LINE
6.8.1. NIFEDIPINE (Procardia)
6.8.1.1. dihydropyridine
6.8.1.2. raynaud's
6.8.1.3. start 30-60mg ER PO qd
6.8.1.3.1. increase dose q7-14 days
6.8.1.3.2. MAX: 120mg/day
6.8.1.4. CI: HTN, elderly, hepatic impairment, CHF, aortic stenosis, hypotension, sartans, barbitals, -nibs, rifampin
6.8.1.5. AE: CHF, MI, hypotension edema, HA, dizziness, flushing, weakness, nausea, constipation, palpitations, dyspnea
7. β BLOCKERS
7.1. SECOND LINE FOR HTN
7.1.1. first line for HTN + comorbidities
7.1.2. almost exclusively treat post MI
7.2. can increase glucose, decrease HR, blocks adrenaline
7.2.1. can decrease panic/anxiety
7.3. taking PM > AM
7.3.1. it will slow you down = better sleep
7.4. NON SELECTIVE FIRST LINE
7.4.1. Propranolol (Inderal)
7.4.1.1. nonselective
7.4.1.2. works well for HA prevention, tremors
7.4.1.3. START: 40mg PO BID
7.4.1.3.1. increase dose q3-7 days
7.4.1.3.2. MAX: 640mg/day
7.4.1.3.3. OR start at 80mg ER PO
7.4.1.4. AE: bronchospasm, bradycardia, heart block, hypotension, fatigue, dizziness, weakness, N/D, alopecia, purpura
7.4.1.5. CI: asthma, abrupt withdrawal, PREGNANCY, DM, thioridazine
7.5. β1 SELECTIVE FIRST LINE
7.5.1. CI: bradycardia, abrupt withdrawal, heart failure, -ibs, -setrons, -ofens,
7.5.2. AE: CHF, bradycardia, MI, bronchospasm, hypotension, fatigue, dizziness, dyspnea, depression, N/D
7.5.3. Atenolol (Tenormin)
7.5.3.1. β1 selective
7.5.3.2. START: 50mg PO qd
7.5.3.2.1. increase dose after 7-14 days
7.5.3.2.2. MAX: 100mg/day
7.5.3.2.3. taper gradually to D/C
7.5.4. Metoprolol (Lopressor)
7.5.4.1. β1 selective
7.5.4.2. START: 25-100mg PO qd
7.5.4.2.1. increase dose qwk
7.5.4.2.2. MAX: 400mg/day
7.5.4.2.3. taper over 1-2 wk to D/C
7.6. SECOND LINE
7.6.1. CI: bradycardia, AV block, asthma, abrupt withdrawal, DM, thyroid dx, COPD
7.6.2. AE: CHF, bradycardia, heart block, angina, bronchospasm, dyspnea, HA, pruritus, raynauds
7.6.3. Can be used for migraine prophyalxis
7.6.4. Timolol (Blocadren
7.6.4.1. non selective
7.6.4.2. START: 10mg PO bID
7.6.4.2.1. increase dose q7 days
7.6.4.2.2. MAX: 60mg/day
7.6.4.2.3. taper over 1-2 wk D/C
7.6.5. Nadolol (Corgard)
7.6.5.1. non selective
7.6.5.2. START: 40mg PO qd
7.6.5.2.1. increase by 40-80mg.day q2-14 days
7.6.5.2.2. MAX: 320mg/day
7.6.5.2.3. taper over 1-2 wks to D/C
7.6.6. Acebutolol (Sectral)
7.6.6.1. β1 selective
7.6.6.2. don't decrease in pulse
7.6.6.3. START: 400mg PO qd
7.6.6.3.1. MAX: 1200mg/day
7.6.6.3.2. MAX in elderly = 800mg
7.6.6.3.3. taper over 2wk to D/C
8. α & β BLOCKERS
8.1. FIRST LINE
8.1.1. CI: bradycardia, heart block, shock, hepatic impairment, abrupt withdrawl, --dines, -profen, -insulin,
8.1.2. AE: CHF, bradycardia, heart block, bronchosapsm, dizziness, fatigue, diarrhea, hypotension, HA, N/V, syncope
8.1.3. MONITOR: BUN/Cr, BP, HR,
8.1.4. Carvedilol (Coreg)
8.1.4.1. mostly CHF and post MI
8.1.4.2. START: 6.25mg PO BID
8.1.4.2.1. increase q1-2 wks to 12.5 PO BID
8.1.4.2.2. then 25mg PO BID
8.1.4.2.3. MAX: 50mg/day
8.1.4.2.4. give with food
8.1.4.2.5. taper dose over 1-2 weeks to D/C
8.1.5. Labetalol (Trandate)
8.1.5.1. used for refractory HTN and post MI
8.1.5.1.1. used for substance abuse + HTN
8.1.5.1.2. can be used in pregnancy
8.1.5.2. START: 100mg PO BID
8.1.5.2.1. increase by 200mg/day q2-3 days
8.1.5.2.2. MAX: 2400 mg/day
8.1.5.2.3. taper over 1-2 weeks to D/C
9. α BLOCKERS
9.1. for HTN + comorbidities
9.1.1. BPH
9.2. for dyslipidemia + HTN
9.3. alpha 1 = BPH
9.4. CI: elderly, hypotension, cataract surgery, -zosins, -alafil
9.5. AE: orthostatic hypertension
9.6. take PM - caution orthostasis
9.7. FIRST LINE
9.7.1. Prazosin (Minipress)
9.7.1.1. START: 1mg PO BID-TID
9.7.1.1.1. MAX: 20mg/day
9.7.1.2. AE: hypotension, syncope, priapism, asthenia, dizziness, HA, palpitaitons, nausea, edema, dyspena
9.7.2. Terazosin (Hytrin)
9.7.2.1. START: 1mg PO qhs
9.7.2.2. MAX: 20mg/day
10. CENTRAL SYMPATHOLYTICS
10.1. FIRST LINE
10.1.1. CLONIDINE (Catapres)
10.1.1.1. alpha 2 selective
10.1.1.2. for anxiety, panic, withdrawl, substance abuse +HTN
10.1.1.3. START: .1mg BID
10.1.1.3.1. rebound HTN
10.1.1.3.2. increase by .1mg/day qwk
10.1.1.3.3. MAX: 2.4mg/day
10.1.1.3.4. taper over 2-4 days to D/C
10.1.1.4. CI: abrupt withdrawal, elderly, renal impairment, CV dx, hypotension, MI, CAD, dehydration, depression, etoh, BETA BLOCKERS, -GILINE,
10.1.1.5. AE: hypotension, syncope, bradycardia, AV block, HA, fatigue, nightmares, URI, irritability, otalgia, sexual dysfunction
10.1.1.6. MONITOR: Cr, VS, HR, BP
10.2. SECOND LINE
10.2.1. METHYLDOPA (Aldomet)
10.2.1.1. HTN control in pregnancy
10.2.1.2. START: 250mg PO BID-TID
10.2.1.2.1. adjust q2 days
10.2.1.2.2. MAX: 3g/day
10.2.1.3. CI: Hepatitis, cirrhosis, elderly, renal impairment, -zines, -giline,
10.2.1.4. AE: Myocarditis, leukopenia, bradycardia, sedation, HA, weakness, CHF, angina, V/D/C, hyperprolactinemia,
10.2.1.5. MONITOR: CBC, HR, LFT
11. VASODILATORS
11.1. ARTERIOLAR
11.1.1. HYDRALAZINE (Apresoline)
11.1.1.1. relaxes smooth muscle = vasodilation
11.1.1.2. used with nitrates in CHF/HTN
11.1.1.3. Start 10mg PO qid x 2-4days, then 25mg PO qid x 1 week
11.1.1.3.1. MAX: 300mg/day PO
11.1.1.3.2. OR 10-40mg IM/IV q4-6hrs
11.1.1.4. CI: CAD, rheumatic heart disease, hypotension, renal impairment, thioridazine,
11.1.1.5. AE: MI, hypotension, neutropenia, SLE, HA, tachycardia, angina, palpitations, N/V/D
11.1.1.6. Monitor Cr & BP, ANA,
11.1.2. MINOXIDIL (Loniten)
11.1.2.1. more potent
11.1.2.2. START: 5mg PO qd
11.1.2.2.1. increase dose q3 days
11.1.2.2.2. MAX: 100mg/day
11.1.2.3. AE: tachycardia, palpitations, hair growth, edema, CHF, SJS, HA, parasthesia
11.1.2.4. CI: pheo, renal failure, post MI, CHF, tachycardia, -azoles, -dones, -ils,
11.2. ARTERIOLAR AND VENULE
11.2.1. SODIUM NITROPRUSSIDE
11.2.1.1. HTN emergency
11.2.1.1.1. START: .25-.3mcg/kg/hr IV
11.2.1.2. BLACK BOX: hypotension, must dilute, cyanide tox
11.2.1.3. CI: aortic coarctation, CHF, renal impairment, anemia, hypothyroidism, hypovolemia, B12 deficiency, avanafil, riociguat
11.2.1.4. AE: hypotension, nausea, dizziness, HA, diaphoresis, acidosis, bradycardia, cyanide tox, flushing, rash
11.2.1.5. MONITOR Cr, BP, ABG, thiocyanate
12. RENIN INHIBITOR
12.1. ALISKIREN
12.1.1. new - $$$
12.1.2. Start: 150 mg PO qd
12.1.2.1. MAX: 300mg/day
12.1.3. decreases AGT I & II
12.1.4. OK with HCTZ
12.1.5. CI: ACE/ARB, PREGNANCY, renal dx, volume depletion, hyponatremia, CHF, post MI,
12.1.6. AE: angioedema, hypotension, renal failure, diarrhea, hyperkalemia, BUN/Cr elevation