Resistant Hypertension in Adults
What is the definition of resistant hypertension?
BP above goal (140/90) despite max/optimal dosage of 3 antihypertensives, including a diuretic
- making sure to rule out comorbid conditions, medication nonadherence, white coat HTN, secondary HTN, or suboptimal therapy
Fill in the blank for this Class A clinical recommendation:
Guideline directed medical therapy should be titrated to target dosing within *_ to **____ weeks of heart failure diagnosis to improve symptoms and reduce mortality and heart failure readmissions.
6- 12
Reduces risk of 180 all cause mortality or HF readmission
Another class A recommendation for HFrEF:
- a SGLT-2 inhibitor is recommended in patient who have HFrEF to reduce risk of HF related hospitalization or cardiovascular death
Pt's with arrhythmogenic cardiomyopathy, what kind of workouts are associated with disease progression and increased arrhythmia risk?
high intensity and prolonged endurance exercises
Limited low intensity activity may be appropriate
Arrhythmogenic CM - auto dom d/o (fibrofatty replacement of normal myocardium -> progressive thinning and ballooning of ventricular wall -> arrhythmias)
When a patient starts taking amiodorone and they are already taking warfarin, are they at higher risk of supratherapeutic INR if they have normal or severe renal function?
Normal
Amiodorone inhibits warfarin's metabolism. Amiodarone’s effect on warfarin response varied threefold across the renal function range, increasing WSI (wafarin sensitivity index) by 36% in patients with normal renal function (CrCl 115 mL/minute), but by only 11.8% in patients with severe renal dysfunction (CrCl 15 mL/minute). Similarly, amiodarone had a strong effect in patients with normal renal function (hazard ratio (HR) 1.80; 1.23, 2.64), but a negligible effect on supratherapeutic INR hazard in patients with severe renal dysfunction
Dronedarone has less risks of this bc it has less iodine
Name 2 indications for cardiac rehab:
CABG surgery , heart cath, heart transplant, stable angina, stable chronic HF, STEMI in last 12 months, symptomatic peripheral artery disease, unstable angina or nSTEMI in past 12 months, valve disease/replacement
Ideally, you want to start within 1-2 weeks of sentinel cardiac event
How much does a full bladder increase the systolic blood pressure (mmHg)?
10-25 mmHg increase
other errors that affect systolic bp: cuff too small or over clothing, acute pain, not resting 3-5 min, talking, back/feet unsupported, labored breathing, legs cross, arm below/above heart level (below, increases 2 per inch; above, decreases 2 per inch)
If you can't use ACE-I/ARB or ARNi due to patient intolerance (adverse effects or hyperkalemia or eGFR decline >30%), what can you use instead?
Isosorbide dinitrate AND hydralazine
(direct acting vasodilators - decrease preload and afterload, decrease left ventricular end-diastolic diameter and the volume of MR, reduce left atrial and left ventricular wall tension, decrease pulmonary artery pressure and pulmonary arterial wedge pressure, increase stroke volume, and improve LVEF , as well as induce left ventricular reverse remodeling)
or if they "self-identify as black"
What class evidence rating does this clinical recommendation have? (A, B, C, D, I)
All patients with hypertrophic cardiomyopathy, regardless of age, should undergo risk assessment for sudden cardiac death and need for implantable cardioverter-defibrillator placement. Validated risk assessment tools can aid in decision making but should not be the sole deciding factor.
Class C (The USPSTF recommends selectively offering or providing this service to individual patients based on professional judgment and patient preferences. There is at least moderate certainty that the net benefit is small.)
Other Class C evidence ratings:
- Beta blockers and nondihydropyridine calcium channel blockers are first line therapy for symptomatic patients with obstructive hypertrophic cardiomyopathy and for symptomatic patients with nonobstructive hypertrophic cardiomyopathy with preserved EF.
- heart transplantation should be considered if cardiomyopathy is refractory to medical therapy
- patients with cardiomyopathy should be referred for genetic testing
- exercise recs in cardiomyopathy should be individualized by type, with most patients safely participating in recreational activity
What is amiodorone FDA approved for?
Life threatening ventricular arrhythmias (pulseless vtach & vfib)
Using it for supraventricular tachyarrthymias (i.e. afib) and preventing ventricular tachyarrhthmias are off label uses! Amiodarone is a versatile treatment option for managing various supraventricular tachyarrhythmias, including atrial flutter, refractory atrioventricular (AV) nodal tachycardia, and AV nodal re-entrant tachycardia, which is often referred to as SVT. Amiodarone is also indicated for the treatment of ventricular arrhythmias, including monomorphic VT, non-Torsades polymorphic VT (secondary to myocardial ischemia and not linked to prolonged QTc), and pulseless VF and VT unresponsive to CPR, defibrillation, and epinephrine administration.
Current medicare coverage of cardiac rehab includes:
__ 1-hour sessions per day for up to ___ sessions
two 1-hour sessions per day for up to 36 sessions over a 36 week period with the option of an additional 36 sessions if medically necessary
six 1-hour sessions per day for up to 72 sessions during an 18-week period for those who qualify for intensive rehab services
What evidence rating is this clinical recommendation? (A, B, C, D, I)
For accurate office and home BP measurement, ensure use of proper technique.
Class C ( low-quality evidence, often derived from observational studies, case series, or expert opinion rather than robust randomized controlled trials. It signifies that the evidence is weak, inconsistent, or limited, suggesting that the recommendation for a specific action or treatment is not strongly supported)
Class A - screening for HTN with office BP measurement in adults 18+ is recommended. confirmation of BP outside of office is recommended prior to starting treatment
another surprising class c - before diagnosing resistant HTN, exclude medical nonadherence, substance induced causes for elevated BP, suboptimal antiHTN tx
When starting diuresis in HFrEF (specifically loop diuretics), what creatinine pattern should you start considering alternate causes of kidney dysfunction (decreased UOP, still congested)?
Doubling or increase >1mg/dL
Mild transient increases of creatinine (0.3-0.5 mg/dL) during effective diuresis are associated with better outcomes
Initial therapy for furosemide - twice the previous oral dose or 20-40mg for pts not on diuretics. Outpatient self-titration based off of >3lbs weight gain in 1 day or >5 lbs in 1 week.
What is the classic finding for hypertrophic cardiomyopathy? (murmur and what increases the murmur?)
systolic murmur (btwn apex & left sternal border), increases with valsalva or squatting->standing (decreases preload, increases afterload)
95% of HCM EKG's will have LVH and q waves (increased R wave amplitude in the left-sided ECG leads (I, aVL and V4-6) and increased S wave depth in the right-sided leads (III, aVR, V1-3)
Amiodorone MOA:
Inhibits potassium channels. Extends action potential duration and refractory period in myocardial cells
involves the inhibition of potassium rectifier currents responsible for repolarizing the heart during phase 3 of the cardiac action potential. Myocyte excitability is reduced, thus hindering the continuation of tachyarrhythmias by preventing reentry mechanisms and ectopic foci.
What evidence rating is this clinical recommendation? (A, B, C, D, I)
Cardiac rehabilitation programs, along with mental health therapies, may improve mental health among patients with coronary heart disease
Grade B - Grade B recommendation signifies that the United States Preventive Services Task Force recommends a preventive service with high or moderate certainty that the net benefit is moderate to substantial. Clinicians are encouraged to offer or provide these services to eligible patients, and they are typically covered by insurance
Other recs:
A - cardiac rehab should be recommended in pt with coronary heart disease to reduce mortality, MI, hospitalization, and improve exercise tolerance, quality of life
B - cardiac rehab recommended with hx of CHF to lower risk of hospitalization and improve quality of life / functional capacity
B - post coronary heart disease, patients benefit from virtual, hybrid, or in person cardiac rehab programs
what is an interventional option you can refer to IR for if they continue to have inadequate BP control or can't tolerate meds?
renal sympathetic denervation (min invasive catheter - radiofrequency/us energy, ablates sympathetic nerve fibers in the wall of renal artery)
carotid baroreceptor amplification (reduces sympathetic response, neg feedback loop)
what is the target dose for farxiga / jardiance for GMDT?
10mg daily ; starting dose is 10mg daily
BB: Coreg 80mg daily, Met Succ 200mg daily, bisoprolol 10mg daily
MRA: Spironolactone 25-50mg daily, kerendia (finerenone) 20mg daily, eplerenone 50mg daily
ARNI/ACEi/ARB: entresto 97-103mg BID, lisinopril 20-40mg daily, losartan 150mg daily, valsartan 160mg BID, enalapril 10-20mg BID
What modifications do you make to GDMT for peripartum cardiomyopathies?
No ACEi or ARBs, spironolactone during pregnancy. Can use captopril/enalapril/candesartan postpartum). NO research on SGLT-2inhibitors - don't use
Metoprolol and spironolactone preferred in breastfeeding. Can use bisoprolol during preg
Bromocriptine (d2 agonist) promising option for improving LVEF (although suppresses prolactin so not great for breastfeeding)
Diuretics used cautiously to prevent hypotension and uterine hypoperfusion
BNP level in normal pregnant woman is about twice that in non-pregnant women, rising early in pregnancy and remaining high throughout gestation until about 72 h after delivery. It has good negative predictive value though
What are the pediatric FDA approved indications for amiodorone?
None! All are off-label : supraventricular arrhthymias, PALS involving VF/pulseless VT, SVT, VT
POEM question (not cardiac rehab) : does anticoagulation decrease mortality in patients hospitalized with COVID - 19 ?
yes - in pt with little to no o2 treatment, therapeutic dose anticoagulation with LMWH or unfractionated heparin reduced 28 day mortality compared to prophylactic dose anticoagulation
Optimial first line pharmacotherapy for HTN consists of : dihydropyridine CCB, an ARB or ACEi, and thiazide diuretic. What would be the preferred fourth line option for resistant HTN?
mineralocorticoid receptor antagonist (spironolactone) - direct RAAS effect . make sure to check baseline CKD and serum potassium
other considerations: beta blockers, nondihydropyridine CCBs, direct vasodilators, alpha 2 agonist, alpha blockers
Tryvio - dual endothelin receptor antagonist aprocitentan - approved by FDA for resistant htn - potent vasodilator (may be alt. if they have hyperkalemia and can't do MRA's)
____, when added to optimized GMDT, decreased HF hospitalization with no effect on mortality and should be considered in patients with HFrEF and afib with inadequate rate control or persistent symptosm despite maximally tolerated BB therapy
Digoxin
Digoxin or Ivrabadine - also indicated in pt's with normal sinus rhythm with persistent symptoms, despite GDMT
Vericiguat (verquvo) - oral soluble guanylyl cyclase stimulator promoting vasodilation and myocardial remodeling
for asymptomatic first degree relatives of patients with HCM, how often should you screen adults?
3-5 years for adult (ekg, serial echos, genetic testing)
1-2 years in children with genotype positive relatives
every 2-3 years for all other children
relatives of pt with arrhythmogenic CM should be screened every 2-3 years
What is the most prevalent adverse effect in patients who take amiodorone?
Corneal microdeposits, happens in at least 90% of pt's on amiodorone
This occurrence is believed to result from amiodarone being secreted in the lacrimal gland and subsequently taken up by the corneal epithelium. However, only about 10% of these patients will develop actual visual symptoms. Can also lead to corneal opacities, lenticular changes, loss of eyelashes or eyebrows, papilledema, photosensitivity, scotoma, macular degeneration and optic neuropathy or optic neuritis
honorable mentions for adverse affects: cardiac toxicity, GI upset, pulmonary toxicity (pul. fibrosis/restrictive lung dz) , hypo/hyperthyroidism, liver toxicity, blue-skin discoloration, neurologic toxicity (cog impair to peripheral neuropathy)
what percentage of eligible people actually participate in cardiac rehab?
20-30%
significant reduction in mortality. currently, one person in the US dies every 24 seconds due to cardiovascular disease