10/21 Flashcards
HTN
persistently elevated arterial BP
one of the most important preventable contributors to disease and death
pulmonary HTN
abnormal elevation or artery pressure
may be the result of left heart failure, pulmonary parenchymal or vascular disease, thromboembolism or a combination of these factors
essential (primary) HTN:
90% HN patients
unknown etiology, genetics may play a role
secondary HTN
one or more factors contributing to the development of HTN
epidemiology
1/3 american adults (~78 million) adults have HTN
race: AA
Age: common in the elderly
risk factors: old age, male, AA, obesity, high Na intake, low K intake, excess alcohol intake, FH
normal BP
> 120/>80
preHTN
120-139/80-89
stage 1 HTN
140-159/90-99
stage 2 HTN
> 160/>100
CVD risk
the BP relationship to risk of CVD is continuous, consistent and independent of other risk factors
every increment of ___ mmHg doubles risk of CVD starting at ___ mmHg
20/10
115/75
-preHTN signals the need for increased education to reduce BP and prevent HTN
pathophys of primary HTN
abnormalities with: humoral (RAAS, natiuretic hormone, insulin resistance, hyperinsulinemia) vascular endothelial mechanisms neuronal mechanisms peripheral autoregulation defects electrolyte disturbances
likely multiple mechanisms contribute
causes of secondary HTN
sleep apnea, drug/food induced (NSAIDs, CS, estrogen, OC, sympathomimetic amines, erythropoetin, ketoconazole), CKD, primary aldosteronsim, renovascular disease, steroids (cushing’s), thyroid disease
primary aldosteronism
prevalance: 0.5-2%
adrenal adenoma
clinical: asymptomatic, HA, muscle cramps, retinopathy, hypokalemia, metabolic acidosis, norm-high Na
test individuals w treatment-resistant HTN (>140/90 w 3 meds), mod/severe HTN, adrenal tumor, FH
tx: surgically remove
mean arterial pressure (MAP)
=1/3 (SBP) + 2/3 (DBP)
represents average pressure exerted on arterial walls during 1 cardiac cycle
normal: 70-11
target organ damage:
stroke, TIA (transient ischemic attack), retinopathy, AAA (abdominal aortic aneurysm), renal failure, CKD, LVH (left ventricular hypertrophy), CHD, CHF
etiology of BP
BP = CO x TPR CO = SV x HR meds to control? SV = diuretics HR = BB, some CCBs TPR = ACEIs, ARBs, hydralazine, sympatholytics
goal in pt over 60 yo
goal in pt 60 or younger
train of thought for working up a case
classification?
goal BP?
special factors/considerations?
optimal therapy?
JNCs overview
systematic review w randomized controlled trials only, graded recommendations: no specific lifesytle recommendations, initial therapy, racial CKD and DM subgroups addressed
3 key questions addressed in JNC8
therapy at specific BP thresholds
specified BP goal and improved outcomes
benefits of various antihypertensive drugs over others
first-line treatments
thiazides, CCB, ACE, ARB
treatment in black population
thiazides, CCBs
treatment in CKD patients
goal
treatment in DM
goal
JNC8 preferred agents
thiazide: chlorthalidone - more potent (2x HCTZ), longer half life HCTZ - inexpensive ACEI: enalapril: BID lisinopril: QD
JNC8 treatment strategies
- add 1 drug (or inc initial dose) if BP goal not met in 1 month
- if goal not met, add and titrate a 3rd med
- other classes may be used if goal BP not met w 3 meds or CI w thiazide, ACE/ARB, CCB
do not use ___ and ___ together
ACE and ARB
dosing antihypertensive drugs
- titrate to max dose, then add 2nd drug
- add a 2nd drug before achieving max dose of initial
- start w 2 drugs at the same time if BP>160/100 or BP >20/10 above goal
non-pharm treatment
weight reduction, DASH diet, Na reduction, physical activity, alcohol moderation, smoking cessation
DASH diet
vegetables, fruits, whole grain, fish, poultry, beans, seeds, limit Na and sweets
