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. THIAZIDES
2.1. first line for black patients
2.2. AE: gout, increase BG, inc lipids, inc K+, lyte imbalances, dizziness, cramps, weakness, rash
2.3. CI: Li, NSAIDs, renal dysfunction, anuria, lyte imbalances, dofetilide
2.4. First Line
2.4.1. Hydrochlorothiazide (Esidrix, Hydrodiuril)
2.4.1.1. most common in combos
2.4.1.2. 12.5-50mg PO qd
2.5. Second Line
2.5.1. Chlorothalidone (Hygroton)
2.5.1.1. most proven, lasts longer
2.6. Third Line
2.6.1. Chlorothiazide (Diuril)
2.6.1.1. 250-500mg PO qd-BID
2.6.1.1.1. MAX: 2000mg/day
3. β BLOCKERS
3.1. SECOND LINE FOR HTN
3.1.1. first line for HTN + comorbidities
3.1.2. almost exclusively treat post MI
3.2. can increase glucose, decrease HR, blocks adrenaline
3.2.1. can decrease panic/anxiety
3.3. taking PM > AM
3.3.1. it will slow you down = better sleep
3.4. NON SELECTIVE FIRST LINE
3.4.1. Propranolol (Inderal)
3.4.1.1. nonselective
3.4.1.2. works well for HA prevention, tremors
3.4.1.3. START: 40mg PO BID
3.4.1.3.1. increase dose q3-7 days
3.4.1.3.2. MAX: 640mg/day
3.4.1.3.3. OR start at 80mg ER PO
3.4.1.4. AE: bronchospasm, bradycardia, heart block, hypotension, fatigue, dizziness, weakness, N/D, alopecia, purpura
3.4.1.5. CI: asthma, abrupt withdrawal, PREGNANCY, DM, thioridazine
3.5. β1 SELECTIVE FIRST LINE
3.5.1. CI: bradycardia, abrupt withdrawal, heart failure, -ibs, -setrons, -ofens,
3.5.2. AE: CHF, bradycardia, MI, bronchospasm, hypotension, fatigue, dizziness, dyspnea, depression, N/D
3.5.3. Atenolol (Tenormin)
3.5.3.1. β1 selective
3.5.3.2. START: 50mg PO qd
3.5.3.2.1. increase dose after 7-14 days
3.5.3.2.2. MAX: 100mg/day
3.5.3.2.3. taper gradually to D/C
3.5.4. Metoprolol (Lopressor)
3.5.4.1. β1 selective
3.5.4.2. START: 25-100mg PO qd
3.5.4.2.1. increase dose qwk
3.5.4.2.2. MAX: 400mg/day
3.5.4.2.3. taper over 1-2 wk to D/C
3.6. SECOND LINE
3.6.1. CI: bradycardia, AV block, asthma, abrupt withdrawal, DM, thyroid dx, COPD
3.6.2. AE: CHF, bradycardia, heart block, angina, bronchospasm, dyspnea, HA, pruritus, raynauds
3.6.3. Can be used for migraine prophyalxis
3.6.4. Timolol (Blocadren
3.6.4.1. non selective
3.6.4.2. START: 10mg PO bID
3.6.4.2.1. increase dose q7 days
3.6.4.2.2. MAX: 60mg/day
3.6.4.2.3. taper over 1-2 wk D/C
3.6.5. Nadolol (Corgard)
3.6.5.1. non selective
3.6.5.2. START: 40mg PO qd
3.6.5.2.1. increase by 40-80mg.day q2-14 days
3.6.5.2.2. MAX: 320mg/day
3.6.5.2.3. taper over 1-2 wks to D/C
3.6.6. Acebutolol (Sectral)
3.6.6.1. β1 selective
3.6.6.2. don't decrease in pulse
3.6.6.3. START: 400mg PO qd
3.6.6.3.1. MAX: 1200mg/day
3.6.6.3.2. MAX in elderly = 800mg
3.6.6.3.3. taper over 2wk to D/C
4. α BLOCKERS
4.1. for HTN + comorbidities
4.1.1. BPH
4.2. for dyslipidemia + HTN
4.3. alpha 1 = BPH
4.4. CI: elderly, hypotension, cataract surgery, -zosins, -alafil
4.5. AE: orthostatic hypertension
4.6. take PM - caution orthostasis
4.7. FIRST LINE
4.7.1. Prazosin (Minipress)
4.7.1.1. START: 1mg PO BID-TID
4.7.1.1.1. MAX: 20mg/day
4.7.1.2. AE: hypotension, syncope, priapism, asthenia, dizziness, HA, palpitaitons, nausea, edema, dyspena
4.7.2. Terazosin (Hytrin)
4.7.2.1. START: 1mg PO qhs
4.7.2.2. MAX: 20mg/day
5. LOOPS
5.1. more effective in patients with poor kidney function
5.2. helps with edema and CHF
5.3. NOT HTN ONLY TREATMENT
5.4. Titrate until you pee like a racehorse
5.5. AE: dehydration, gout, kidney dysfunction, hypokalemia, ototoxicity, dizziness, N/V/D, orhtostatic hypotension, blurred vision, itching
5.6. CI: anuria, lyte imbalances, DM, arrhythmias, SLE, hepatic impairment, urinary retention, gout, elderly, -mycins, lithium, amikacin,
5.7. FIRST LINE
5.7.1. Furosemide (Lasix)
5.7.1.1. "lasts six hours"
5.7.1.2. start 40mg PO BID
5.7.1.2.1. OR start 10-20mg PO BID
5.7.1.2.2. MAX: 600mg/day
5.8. SECOND LINE
5.8.1. Bumetanide (Bumex)
5.8.1.1. start .5mg PO qd
5.8.1.1.1. MAX: 10mg/day
6. α & β BLOCKERS
6.1. FIRST LINE
6.1.1. CI: bradycardia, heart block, shock, hepatic impairment, abrupt withdrawl, --dines, -profen, -insulin,
6.1.2. AE: CHF, bradycardia, heart block, bronchosapsm, dizziness, fatigue, diarrhea, hypotension, HA, N/V, syncope
6.1.3. MONITOR: BUN/Cr, BP, HR,
6.1.4. Carvedilol (Coreg)
6.1.4.1. mostly CHF and post MI
6.1.4.2. START: 6.25mg PO BID
6.1.4.2.1. increase q1-2 wks to 12.5 PO BID
6.1.4.2.2. then 25mg PO BID
6.1.4.2.3. MAX: 50mg/day
6.1.4.2.4. give with food
6.1.4.2.5. taper dose over 1-2 weeks to D/C
6.1.5. Labetalol (Trandate)
6.1.5.1. used for refractory HTN and post MI
6.1.5.1.1. used for substance abuse + HTN
6.1.5.1.2. can be used in pregnancy
6.1.5.2. START: 100mg PO BID
6.1.5.2.1. increase by 200mg/day q2-3 days
6.1.5.2.2. MAX: 2400 mg/day
6.1.5.2.3. taper over 1-2 weeks to D/C
7. ARBs
7.1. first line for non black patients
7.2. no risk of cough
7.3. CI: PREGNANCY, renal impairment, hepatic impairment, volume depletion, CHF, aliskiren
7.4. AE: angioedema, hypotension, hyperkalemia, rhabdo, hepatitis, diarrhea, fatigue, CP, cough, dyspepsia
7.5. FIRST LINE
7.5.1. Losartan (Cozaar)
7.5.1.1. start 50mg PO qd
7.5.1.1.1. MAX: 100mg/day
7.5.2. Valsartan (Diovan)
7.5.2.1. start 80-160mg PO qd
7.5.2.1.1. MAX: 320 mg/day
8. CCB's
8.1. first line for black patients
8.2. decreased peripheral resistance
8.3. AE: dizziness, edema, constipation, bradycardia, CHF, AV block, hypotension
8.4. CI: AV block, hypotension, bradycardia, hepatic/renal impairment, MG, GERD, dofetilide, eliglustat, fibanserin, lomitapide, pimozide, thioridazine, timolol,
8.5. can use with beta blockers
8.6. dihydropyridines for raynauds
8.7. FIRST LINE
8.7.1. VERAPAMIL (Isoptin)
8.7.1.1. non-dihydropyridine
8.7.1.1.1. do not use with beta blockers
8.7.1.2. cardio selective (drop HR)
8.7.1.3. tx angina
8.7.1.4. IR: 80-120mg PO TID
8.7.1.4.1. start 80mg PO TID
8.7.1.4.2. MAX: 480mg/day
8.7.1.5. 12hER: 120-480 mg/day divided into QD-BID
8.7.1.5.1. start 180mg ER PO qAM
8.7.1.5.2. MAX: 480mg/day
8.7.1.6. 24hER:
8.7.1.6.1. AM start 240mg ER PO qAM
8.7.1.6.2. PM start 200mg ER PO qPM
8.7.2. DILTIAZEM (Cardizem)
8.7.2.1. both dihydro/non dihydro
8.7.2.2. for AFIB + HTN
8.7.2.3. 12hER - 120-180mg ER PO BID
8.7.2.3.1. start 60-120mg, titrate over 7-14 days
8.7.2.3.2. MAX: 360mg/day
8.7.2.4. 24hER - 180-480mg ER PO qd
8.7.2.4.1. start 120-240mg ER PO qd, titrate over 7-14 days
8.7.2.4.2. MAX: 540mg/day ER
8.7.3. AMLODIPINE (Norvasc)
8.7.3.1. dihydropyridine
8.7.3.2. start 5mg PO qd
8.7.3.2.1. 2.5mg PO qd if elderly or second agent
8.7.3.2.2. increase after 1-2 weeks
8.7.3.2.3. MAX: 10mg/day
8.7.3.3. CI: simvastatin, griseofulvin, ceritinib, dangtrolene, elglustat, oxcarbazepine
8.7.3.4. AE: angina, MI, hypotension, hepatitis, edema, fatigue, palpitations, nausea, flushing
8.8. SECOND LINE
8.8.1. NIFEDIPINE (Procardia)
8.8.1.1. dihydropyridine
8.8.1.2. raynaud's
8.8.1.3. start 30-60mg ER PO qd
8.8.1.3.1. increase dose q7-14 days
8.8.1.3.2. MAX: 120mg/day
8.8.1.4. CI: HTN, elderly, hepatic impairment, CHF, aortic stenosis, hypotension, sartans, barbitals, -nibs, rifampin
8.8.1.5. AE: CHF, MI, hypotension edema, HA, dizziness, flushing, weakness, nausea, constipation, palpitations, dyspnea
9. CENTRAL SYMPATHOLYTICS
9.1. FIRST LINE
9.1.1. CLONIDINE (Catapres)
9.1.1.1. alpha 2 selective
9.1.1.2. for anxiety, panic, withdrawl, substance abuse +HTN
9.1.1.3. START: .1mg BID
9.1.1.3.1. rebound HTN
9.1.1.3.2. increase by .1mg/day qwk
9.1.1.3.3. MAX: 2.4mg/day
9.1.1.3.4. taper over 2-4 days to D/C
9.1.1.4. CI: abrupt withdrawal, elderly, renal impairment, CV dx, hypotension, MI, CAD, dehydration, depression, etoh, BETA BLOCKERS, -GILINE,
9.1.1.5. AE: hypotension, syncope, bradycardia, AV block, HA, fatigue, nightmares, URI, irritability, otalgia, sexual dysfunction
9.1.1.6. MONITOR: Cr, VS, HR, BP
9.2. SECOND LINE
9.2.1. METHYLDOPA (Aldomet)
9.2.1.1. HTN control in pregnancy
9.2.1.2. START: 250mg PO BID-TID
9.2.1.2.1. adjust q2 days
9.2.1.2.2. MAX: 3g/day
9.2.1.3. CI: Hepatitis, cirrhosis, elderly, renal impairment, -zines, -giline,
9.2.1.4. AE: Myocarditis, leukopenia, bradycardia, sedation, HA, weakness, CHF, angina, V/D/C, hyperprolactinemia,
9.2.1.5. MONITOR: CBC, HR, LFT
10. RENIN INHIBITOR
10.1. ALISKIREN
10.1.1. new - $$$
10.1.2. Start: 150 mg PO qd
10.1.2.1. MAX: 300mg/day
10.1.3. decreases AGT I & II
10.1.4. OK with HCTZ
10.1.5. CI: ACE/ARB, PREGNANCY, renal dx, volume depletion, hyponatremia, CHF, post MI,
10.1.6. AE: angioedema, hypotension, renal failure, diarrhea, hyperkalemia, BUN/Cr elevation
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. POSTASSIUM SPARING DIURETICS
12.1. TRIAMTERENE/HYDROCHL. (Maxzide)
12.1.1. add on for loop diuretics
12.1.2. 37.5mg/25mg PO qd
12.1.2.1. MAX: 75mg/50mg/day
12.1.3. CI: hyperkalemia, PREGNANCY, anuria, renal impairment, hepatic impairment, arrhythmias, gout, SLE, amiloride, dofetilide, other K sparings,
12.1.4. AE: Electrolyte disorders, jaundice, cramps, N/V, rash, impotence, blurred vision, HA, anorexia
12.2. ALDOSTERONE ANTAGONISTS
12.2.1. CHF > HTN use
12.2.1.1. SPIRONOLACTONE
12.2.1.1.1. Hyperaldosteroneism
12.2.1.1.2. Hirsuitism
12.2.1.2. EPLERENONE