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Résidence - FM Learner > 49. Hypertension > Flashcards

49. Hypertension Flashcards

1
Q

When to suspect secondary hypertension ? (3)

A
  • young patients requiring multiple medications
  • patients with an abdominal bruit
  • patients with hypokalemia in the absence of diuretics
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2
Q

Describe : Hypertensive urgency

A

dBP≥130mmHg

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3
Q

Describe hypertensive emergency (5)

A

severe elevation of BP in the setting of any below
* Cerebrovascular
(1) Hypertensive encephalopathy
(2) Intracranial hemorrhage

  • Cardiac
    (1) Acute aortic dissection
    (2) Acute LV failure
    (3) Acute coronary syndrome
  • Renal : Acute kidney injury
  • Pre-eclampsia/eclampsia
  • Catecholamine-associated HTN
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4
Q

Describe diagnosis HTA during visit 1 (3)

A
  • Require minimum of 3 readings during same visit (discard first reading) - gold standard is automated office blood pressure (AOBP)
  • History and Physical (cardioresp, fundoscopy, bruits, peripheral pulse) +/- Labs
  • If AOBP ≥ 135/85 or non-AOBP ≥ 140/90, out-of-office BP should be performed before Visit 2
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5
Q

Describe Out-of-office BP measurements (3)

A

can diagnose if any:

  • Daytime ambulatory BP ≥ 135/85
  • 24h ambulatory BP (ABPM) ≥ 130/80
  • Daytime home BP (7d) ≥ 135/85
    2 readings before breakfast, 2 readings 2h after dinner, eliminate day 1 readings and average other 6 days (total 24 readings)
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6
Q

Describe diagnosis HTA during visit 2,3,4,5

A
  • Visit 2 : Mean OBPM (office BP measurement) ≥140/90 with macrovascular target organ damage, diabetes mellitus or CKD (eGFR<60)
  • Visit 3 : Mean OBPM ≥160/100
  • Visit 4-5 : Mean OBPM ≥140/90
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7
Q

Describe how to accurately measure BP (4)

A
  • Cuff with appropriate bladder size (Bladder width 40% of arm circumference and length 80-100% of arm circumference)
  • Nondominant arm, unless SBP difference >10mmHg (use higher value arm)
  • Rest comfortably for 5 minutes in seated position, back support, arm supported at heart level
  • No caffeine/tobacco 1h, no exercise 30mins preceding
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8
Q

Describe BP measurement in children (2)

A
  • Consider BP measured annually in children and adolescents ≥3 y of age.
  • Diagnosis of HTN if a child or adolescent if auscultatory-confirmed BP readings ≥95th percentile at 3 different visits. (c.f. Blood Pressure Table Pediatrics)
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9
Q

Name Target Organ Damage (5)

A
  • Cerebrovascular
    (1) Stroke
    (2) Dementia (Vascular)
  • Hypertensive retinopathy
  • Cardiac
    (1) LV dysfunction
    (2) LV hypertrophy
    (3) Insuffisance cardiaque congestive
    (4) Coronary artery disease (MI, angina, ACS)
  • Renal (CKD, albuminuria)
  • Peripheral artery disease (claudication)
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10
Q

Name BP targets in HTA

A
  • Diabetes <130/80
  • All (including elderly and CKD) <140/90
  • High risk consider ≤120
    (1) SPRINT population ≥ 50yo
    (2) CV disease
    (3) IRC
    (4) Framingham Risk Score (FRS) ≥15%
    (5) Age ≥75yo
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11
Q

What to discuss during follow-ups ?

A

Assess global cardiovascular risk (site nice)
* Age ≥55yo
* Male
* Family Hx CAD (Age <55 in men, <65 in women)
* Sedentary lifestyle
* Poor dietary habits
* Abdominal obesity
* Dysglycemia
* Smoking
* Dyslipidemia
* Stress
* Nonadherence

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12
Q

Name routine labs HTA (5)

A
  • FBG and/or HbA1C
  • Lipid profile (serum total cholesterol, LDL, HDL, non-HDL, TG) fasting or non-fasting
  • K, Na, Cr
  • UA (r/o albuminuria which would guide treatment, eg ACEi/ARB)
  • EKG
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13
Q

Name health behaviours to change (7)

A
  • Exercise
  • Weight loss (dietary education, physical activity, behaviour modification)
  • Alcohol consumption (≤2 drinks per day (Men <14/week, women <9)
  • Diet
  • Stress management (cognitive behaviour interventions with relaxation techniques)
  • Smoking cessation
  • Re-assess habits (steroids, licorice), meds (NSAIDs, OCP), OTC meds
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14
Q

Describe exercise recommendaitons

A

30-60 mins of moderate-intensity dynamic exercise (walking, jogging, cycling, swimming)
** 4-7 days per week ** in addition to routine ADLs

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15
Q

What’s the weight loss goal ? (BMI, waist circumference)

A
  • BMI 18.5-24.9
  • waist circumference <102cm for men <88cm for women
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16
Q

Describe diet for BP (3)

A
  • Dietary Approaches to Stop Hypertension [DASH]
    (1) Reduce saturated fat, cholesterol
    (2) Emphasis on fruits, vegetables, low-fat dairy products, dietary and soluble fibre, whole grains, and protein from plant sources
  • Sodium <2000mg (1 tsp salt) per day
  • Potassium increase dietary intake to reduce BP (if no risk of hyperkalemia)
17
Q

What to R/O in HTA ? (3)

A
  • Renovascular hypertension
  • Endocrine hypertension
    (1) Hyperaldosteronism
    (2) Pheochromocytoma/paraganglioma
18
Q

How to R/O renovascular hypertension ?

A

with imaging eg.
* Duplex ultrasound of renal arteries
* Computed Tomography Angiography (CTA)
* Magnetic Resonance Angiography (MRA)
* Captopril-radioisotope renal scan

19
Q

Name criterias for imaging in HTA

A

Rule out renovascular hypertension with imaging if ≥2 of below
* Sudden onset, worsening HTN and age >55 or <30*
* Abdominal bruit*
* HTN resistant to ≥3 drugs*
* Serum creatinine ≥30% increase with ACE-I or ARB
* Atherosclerotic vascular disease (smoke/DLP)
* Recurrent pulmonary edema with hypertensive surges
* Consider r/o fibromuscular dysplasia with CTA/MRA if any of three above* or unexplained asymmetry of kidney sizes (>1.5cm), family history of FMD, or FMD in other territory

20
Q

How to R/O Hyperaldosteronism? (2)

A

Plasma aldosterone and renin/renin activity

21
Q

When to suspect Hyperaldosteronism ? (3)

A
  • K<3.5mmol/L or marked diuretic-induced hypokalemia (K<3)
  • HTN resistant to ≥3 drugs
  • Incidental adrenal adenoma
22
Q

How to R/O Pheochromocytoma/paraganglioma ? ()

A
  • 24h urinary total metanephrines and catecholamines
  • or 24h urine fractionated metanephrines, plasma free metanephrine/normetanephrines
23
Q

When to suspect Pheochromocytoma/paraganglioma ? (5)

A
  • Paroxysmal, unexplained, labile, severe (≥180/110) HTN refractory to usual therapy
  • Symptoms of catecholamine excess (headache, palpitations, sweating, panic attacks, pallor)
  • HTN triggered by BB, MAO-i, micturition, changes in abdominal pressure, surgery, anesthesia
  • Incidental adrenal mass
  • Hereditary (MEN2A/B, neurofibromatosis type 1, Von Hippel-Lindau)
24
Q

Describe initial tx HTA if no other indicaitons (5)

A
  • Long-acting Thiazide diuretic (eg. Chlorthalidone, indapamide)
  • BB (<60yo)
  • Inhibiteur de l’enzyme de conversion (nonblack) : IECA, -pril
  • Long-acting CCB (eg. Amlodipine)
  • Les antagonistes des récepteurs de l’angiotensine (ARA, - sartan)
25
Q

Describe initial tx HTA if : DB (2)

A
  • IECA
  • ARA
26
Q

Describe initial tx HTA if : Coronary artery disease (2)

A
  • IECA, ARA
  • BB or Calcium channel blockers in stable angina
27
Q

Describe initial tx HTA if : Recent MI (2)

A
  • IECA (ou ARA)
  • BB
28
Q

Describe initial tx HTA if : Heart failure (3)

A
  • IECA (ou ARA)
  • BB
  • Les antagonistes de l’aldostérone in recent CV hospitalization, acute MI, elevated BNP or NYHA class II-IV -> Monitor potassium
29
Q

Describe initial tx HTA if : LV hypertrophy (3)

A
  • IECA, ARA
  • Long-acting CCB
  • Thiazide
30
Q

Describe initial tx HTA if : Previous stroke/TIA (2)

A

IECA + thiazide combination

31
Q

Describe initial tx HTA if : Non-diabetic IRC (2)

A

ACE-i (or ARB) if proteinuria, Diuretics as additional therapy

32
Q

Name E2 : IECA/ARA (4)

A
  • Tératogène
  • Toux
  • HyperK
  • Anigodème
33
Q

Name E2 : BB (3)

A
  • Dysfonction sexuelle H
  • Effet sur SNC
  • Hyperglycémie
34
Q

Name E2 : BBC (dihydropyridiue) à effet prolongé (3)

A
  • Bouffés vasomotrices
  • Céphalée
  • OMI (si OMI, avisé de prendre le soir)
35
Q

Name E2 : Diurétiques thiazidiques (indapamide, chlorthalidone) (5)

A
  • Dysfonction sexuel
  • HypoK
  • HypoNa
  • HypoMg
  • Hyperuricémie

Résidence - FM Learner (26 decks)

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