HTN

Bld pressure target < 130/80 stage 1 = 130-139/80-89

Stage 2 >140/90

HTN Management
Population TTT
Normal use all “Diuretics,BB,CCB,ACE”
DM without All classes
albuminuria
CKD / DM wz ACEI , ARBS
albuminuria
ESRD/ dialysis CCB , thiazides – CI ACE , ARB
Black “CT  hatshofo CCB , Thiazides – IF wz CKD : ACE, ARB
white”
Low CAD Risk Thiazides, ACE , ARB , CCB Do not recommend BB
Stable ischemic heart d 1st line BB - ACE ,ARB
SIHD
HF ACE,ARB , BB with cation – CI CCB
Preg: Labetalol , methyl dopa , Nifedipine – CI ACE, ARB

I. Diuretics:

1. Thiazides: CI for CrCl <30 xpt meto – Sulfa allergy

SE ; inc glucose , Uric A , Lipids – Sex Dysf -
 HCTZ “Microzide”
 Chlorothiazide “Duril”
2. Thiazide like: inc Ca
 Indapamide “Lozol”
 Chlorthalidone “Thalitone” long acting -QD better than HCTZ
 Metolazone “Zaroxolyn”  For Renal [Me too Zoro]

3. Loop:  For renal failure - Dec Ca – Sulfa allergy

 SE: Ototoxicity , inc: Glucose, Lipids , Uric A , Sexdys
 Furosemide “Lasix”
 Bumeteide “Bumex” 1mg :40 mg lasix oral
 Ethacrinic Acid “Edecrin”  No Sulpha
 Torsemide : Demadex
4. K Sparing Not for CrCl<30 – SE: Hyperkalemia
 Ald antagonist:
 SpironoLACTone “Aldactone” TC Gynecomastia
 Eplerenone “Inspra “ [Abla inspira-tion] Both can be given for CHF wz max dose 50
mg qd
  Amiloride “Medamor “ [ Amly ride el madame amor ]
 Triametrine Dyrenium [ Tri uranium]
II. BB :
Only used with ischemic heart disease
 IV MAPLES: Metoprolol , Atenolol, Propranolol , Labetolol , Esmolol , Sotalol
 B1 selective: For COPD
MAN BABE: Metoprolol, Atenolol, Nebivolol , Bisoprolol , Acebutolol , Betaxolol ,
Esmolol
 With NO activity: Nebivolol “Bystolic” Bi Nipples manfo5a NO
 With alpha activity: Carvedilol, Labetalol
 For CHF : Cardinal met the bishop “ Carvedilol – Metoprolol - Bisoprolol
 ISA “intrinsic sypathomimetic activity” PAP : Pindolol – Acebutolol –
Penbutolol

III. RAAS System

a. ACE :
SE : Hyperkalemia /Hyponatremia - Angioedema “emergency allergy”
 Captopril Shortest TID
 Enalapril Only IV ACEI
 Ramipril Altace only capsules
b. ARB:
Losartan: Cozaar Candesartan : Atacand
Irbesartan :Avapro Valsartan : Diovan
Telmisartan : Micardis Olmesartan : Benicar
c. DRI :
Aliskirin “Tekturna” QD Max 300 mg  SE Severe Diarrhea

IV. CCB :
A. Non Dihydropyridine:
 Verapamil : Calan / Isoptin / Verelan [PO/IV]
 Diltiazem : Dilt / Matizem / Tiazac / Taztia / Cardizem [PO/IV]
B. Dihydropyridines:
 Amlodipine Novasc Nimodipine : Nimotop subarchad.
hemorrag
 Nifedipine : Procardia, Adalat Clevidipine : Cleviprex IV only “soy-egg
allergy
 Felodipine : Plendil Nicardepene : Cardene PO/IV
V. Alpha 1 Blocker
Prazocin “Minipress” Only one for HTN
 Doxazocin “Cardura” - HTN BPH Terazosin “Hytrin” HTN – BPH
Tamsulosin Flomax BPH Alfuzosin “Uroxatrol BPH

VI. Alpha 2 agonist :

SE : Sedation / Anticholinergic effect/ rebound HTN “
 Clonidine Tab,Patch weekly
 Guanfacine “Tenev”
 Methyl dopa : PO/ IV  Pregnancy
VII. Vasodilators :
 Hydralazine Arbsoline safe in Pregnancy not 1 st line/ PO IV
o BIDIL : Hydralazine + NO

Hypertensive Emergency
BP > 180/80 – End organ damage
Nitroprusside IV  Cyanide toxicity
Nitroglycerin IV – Clevidipine – Nicardipine – Hydralazine – Enalapril IV –
Labetalol -Esmolol
Phentolamine “Alpha blocker IV” Cocaine overdose
Fenoldopam “Corlopam IV” : Selective DA 1 agonist and diuretic –
Inc blood flow to kidney  useful in Renal Hypertensive crisis”
 CHF
HFrEF== <40% “Reduced ejection fraction”
HFpEF== >50% “Preserved ejection fraction” TC No: inotropics
If the pt has high PCWP “ pulmonary capillary wage pressure”… Give him Lasix “ el
pt bey3’ra2”

Management :
Heart IS DBDB
I : Ivabradine “Corlanor” Selective SA node inh when HR >70 Eva
Brady  Cor el noor

S : SGLT 2 inh CI CrCl < 30

D : Diuretic
o Loop
o ARNI > ACE>ARB  Arni CI SBP < 100
o Aldosterone inh: “Spironolactone – Eplerenone “

B : B B “Cardinal met Bishop” Carvedilol – Metoprolol – Bisoprolol CI

pulse <50
D : Digoxin
B: Bidil “Hydralazine – Isosorbide”
These are essential – the rest are add on
For End Stage :
 Milrinone IV--- Reunion
 Vericiguat PO --- Very squad “ hynzl mesh hytl3”
For Emergency :
 IV Loop – O2 – seated
 Add dilators / Milrinone / Vasopressor
“DA/Dobutamine” as needed

Digoxin DI
Clarithromycin, Verapamil , Quinidine ,
Amiodarone  inc Dig level  Toxicity
Loop , ACEI   Pot.  Toxicity
 Digoxin Toxicity :
TTT: Digifab
Therapeutic Range : CHF 0.5-0.8 ng/dl … Arrythmia : 0.8-2 ng/dl
For arrhythmia : Atropine 0.5-1 mg iv
Hypokalemia correction : 10 mEq  inc. K 0.1 mm/dl --- Max 10meq Q1h
peripheral line

 Milrinone : End stage HF - IV- Inotropic - Vasodilator

 Ivabradine Corlanor: PO for stable HF if resting hr is above 70
Selective Sinus node inhibitor [ Not IV – Brady “SA node” ]

 Vericiguat “Verquo”: PO after stabilization at hospital –

Vasodilator “smooth ms relaxant” inc cGMP === End stage HF

CI : Nitrates – PDE5 “ED” - Pregnancy

 TC Wz
Edema causing meds : Pioglitazone /Nsaids / Lyrica / Gabapentin

Angina
Chronic stable :
1. BB
2. CCB :
 Either dihydropyridine “Amlodipine- Nifedipine” add on BB OR
 Non-dihydropyridine “ Verapamil – Diltiazim” alone
3. LA Nitrates “Nitrate free period”
4. Ranolazine “Ranexa”  Run O Late --- I can’t, I have angina
Qt prolongation tc : quinidine , doflitide , sotalol

Prinzmetal Vasospastic “Variant” Angina:

1. CCB
2. LA Nitrates
TC : NO BB With Prinzmetal
All Pts must be on IR Nitrates :
 Nitroglycerin Sublingual tab : Nitrostat
 Nitroglycerin Sublingual Spray : NitroMist – NitroLingual “prime 10 times
before use – Every 6 weeks
 NTG SL Powder : GONitro

Acute Coronary Syndrome

ACS
Diagnosis :
STEMI : High Troponins – Elevated ST
Non Stemi : High troponins – Normal ST
UA “unstable angina” : Neg Troponins – Normal ST – Not relieved by NTG

Management
 STEMI :

ER: MONA BAS

Morphine – O2 – NTG – ASA – BB – ACE – Statin high dose
TTT :
I. PCI “stent” : Percutaneous Coronary intervention
 Bare Metal Stent BMS : Dual Anti Platelet Treatment for 1 month then
monotherapy
 Drug eluting Stent DES : DAPT for 12 months Normal ... If ↑ ischemic
risk inc DAPT … If high hemorrhagic risk Only 3 M --- uses Sirolimus or
Paclitaxel
II. CABG “Coronary Artery Bypass Graft “ open heart
III. Thrombolytics : If PCI gonna be delayed for > 2hrs , should started
within 30 min

Discharge : NAABAS
1. NTG
 2. AA Dual Anti Platelet : Clopidogrel , Ticagrelor “ Brlinta” , Prasugrel
“Effient”
3. BB : Metoprolol 25mg if not HTN – 50mg if HTN
4. ACE
5. Statin

For DAPT :
Clopidogrel and Prasugrel are prodrugs  TC with Omeprazole
Clopidogrel is least efficient so better with high bleeding risk pts
Loading dose Clopidogrel 300-600 mg “4-8 tab” then 75 mg qd
Effient 60 mg then 10 mg qd
Brlinta 180 mg then 90 mg qd

 Non Stemi / UA :
Never Thrombolytics
DAPT – Parenteral Anti Coagulants

Arrythmia
Afib/Flutter Management:
1. Rhythm control :
Electrical
Pharmacological : Amiodarone , propafenone , Dofetilide ,Ibu
<48 hrs start anticoag and continue for 4 weeks
>48 hours  Echocardiogram look for clot
+ clot : antocoag 4-12 weeks before and 4 weeks after
cardioversion
-ve Clot : cardiovert and anticoag for 4 weeks
2. Rate control :
AV blocker : Amiodarone – Digoxin , BB , CCB
1st line BB – CCB : Esmolol , Metoprolol , Propranolol , Verapamil , Dilt.

3. Clot Control:
Warfarin
DOAC : Dabigatran “Pradaxax”/ Rivaroxaban/ Apixaban /
Edoxaban “Savaysa”
 DOAC “Direct oral anticoag” are preferred over warfarin as
they do not need bridging after Heparin and INR monitoring .
“Apixaban – Rivaroxaban are the best”
 Warfarin only with ESRD – valvular heart disease
 Pregnant use LMWH – NO warfarin or DOAC
Assessment of Stroke Risk
CHA2DS2 - VAS
CHF- HTN – AGE >75 +2 – DM – STROKE +2 – VASCULAR D – AGE (65-74)+1 –
SEX FEMALE +1
Phases
Phase 0 : Depolarization Na moves in  Class 1 [ Na blocker]
Phase 1 : CA in, K move out
Phase 2 : Plateau “slow Ca in – K continue to move out” Class 4 [CA
blocker]
Phase 3 : K Out  Class 3 repolarization [ K blocker]
Phase 4 : NA move out /K in “normal state”  Class 2 [BB]
Classes :

Class 1:
1a : Quinidine , Disopyramide “Norpace” CI HF , Procainamide
“ I am queen , I have pyramid, and I am pro caine”
1b : Lidocaine , Mexiletine … I don’t P on the Lid or in Mixed restroom
1c : Flecainide TC HF exacerbation, Propafenone “Rythmol” I don’t C Feno ? …
he flew away

Class 2
BB
IV for emergencies
“Metoprolol – Carvedilol – Bisoprolol “ Long-acting PO
Used for Ventricular rate control

Class 3 Adidas (amiodarone- dronedarone- Ibutilide -Dofilitide -

Sotalol )
1. Amiodarone “Pacerone Cordarone– Nextrone “
 A: Alveoli” CXR” – IOD : Thyroiditis “TSH” – O :Photosensitivity – Corneal
deposits “Eye”

D: drug interactions “LFT” /Blue smurfy skin – E electrolytes imbalance / EKG

DI  Warfarin / Digoxin – Sofosbuvir /Harvoni -

2. Dandorone “ Multaq” Drone  HF /LF / RF – doesn’t cause pulmonary
toxicity and Thyroiditis as Amiodarone
3. Sotalol “Betapace” PO/IV  CI CrCl < 40
4. Ibulitide “Corvert” : IV chemical convert
5. Dofilitide “Tikosyn” : Take my son 3 days  3 days under observation in
facility
CI : CrCl < 20 --Check for CrCl/ EKG/Electrolytes /

Class 4
CCB : Verapamil – Diltiazem

Clas Name Uses SE Notes

s
1A Quinidine Malaria IV/ Thrombocytopenia
V arr/ Afib PO
Dysopiramide Ventricular arr HF
Norpace
Procainamide IV/IM Vent. arr Lupus like ana
1B Lidocaine VFib – pulseless CNS
“xylocaine” VT
Mexiletine PO
1C Propafenone Afib- Neg inotropic “HF”- Chemical
“Rhythmol” PO Seizures cardioversion
Flecainide Exacerbate CHF CC
3 Ibutilide “Corvert” Chemical Torsade’s CC
IV convers
Amiodarone Ventr tachy
Pulseless VT 300 mg rapid Iv
bol.
Dronedarone Afib HF/RF/LF – no thyroid se Drone is falling
Multag
Sotalol “Betapace” CI : Crcl<40
Dofetilide PO CI Crcl<20 EKG during ttt
Tikosyn 3 days in facility
 ER
 Supraventricular Tachycardia PSVT : HR >150BPM [ PST ya din omy]
o DOC Adenosine 6 mg IV Push – No Response in 1-2 mins  12 mg
Fail  BB or CCB IV
 Torsades des pointes : IV Magnesium [ pointy needles  Magnet]
 Pulseless Electrical Activity “ PEA” or Asystole “flat line” : Epinephrine 1
mg q 3-5 min
 Ventricular Fib : Shock --- fails  Epinephrine 1 mg q 3-5 mins + Defibrillator +
CPR 
Amiodarone 300 mg IV bolus may repeat 150 mg in 3-5 mins or
Lidocaine
 Symptomatic Bradycardia < 50 bpm :
Atropine 0.5 mg q 3-5 min MAX 3 mg [Bra day  7ot atra]
Fails : Dopamine 2-20 mcg/kg/min or Epinephrine 2-10 mcg/min

Stroke / CVA
Ischemic : 85%  Alteplace
Hemorrhagic  Surgical intervention
Alteplace: TPA
 Door to needle 60 mins optimum , 3-4.5 hrs maximum
 BP must be 185/110 Use labetalol , Nicardipine , Clevidipine OR
Nitroprusside as 2nd line
 BG 140-180
 No other anticoagulants
 O2 > 94%

After Stabilization :
 Early mobilization
 Aspirin 325 – other anticoagulants or DOAC “ direct oral anticoagulants”
Warafarin
 High dose statin
 BP 130/80