49. Hypertension (50%) Flashcards
1
Q
Posez le diagnostic d’hypertension seulement après des lectures répétées de la TA (c.-à-d. à différents moments lors de visites différentes).
A
2
Q
Chez qui soupconner une HTA secondaire ?
A
- jeunes patients nécessitant de multiples médicaments
- souffle abdominal
- hypokaliémie en l’absence de diurétiques
3
Q
Nomme conseils concernant modificaiton des habitudes de vie
A
- perte de poids
- exercice
- limitez la consommation d’alcool
- habitudes alimentaires
4
Q
Lorsque le diagnostic d’hypertension est posé, traitez-la en utilisant la pharmacothérapie appropriée en tenant compte de quoi ?
A
- âge du patient
- autres troubles concomitants
- autres facteurs de risque cardiovasculaire
5
Q
Chez tous les hypertendus, lors des visites de suivi, évaluez quoi ?
A
- la réponse au traitement
- la compliance médicamenteuse
- les effets indésirables.
6
Q
Describe workup : HTA
A
- Profil lipidique (réponse accepté)
- K
- N
- Creat
- Urinalysis
- HbA1c
- ECG
- Albumine urinaire si DB
- B-HCG
7
Q
Nommez des causes 2nd HTA
A
ABCDEs
* A - Atherosclerose
* B - Bruit / Bad kiney / Big belly
* C - Catecholamines (phéochromocytome)
* D - Drug (Acetaminophen. diet)
* E - Endocrine (Thyroïde, aldostérone), EtOH
* S - Sleep apnea, Stress
8
Q
Name anti-HTA RX to avoid
A
- alpha blocker : alone or 1st line
- BB if >= 60
- IECA if black or pregnant
9
Q
Describe tx : Hypertensive emergency
A
- Nifedipine
- Labetalol
- Captopril
- Hydralazine
- Clonidine
10
Q
Describe consideration for HTA tx in pregnancy / breastfeeding
A
- AVOID : IECA, ARA
- AIM : < 140/90
- Breasteeding : Labetalol, methyldopa, nifedipine
11
Q
When to measure HTA in children ?
A
- Measure if >= 3
- Vérifiez dans le bras DROIT, car si coarctation de l’aorte, faussement bas dans le bras GAUCHE
12
Q
Describe workup : HTA in children
A
- Échocardiographie
- Évaluation du risque de maladie cardiovasculaire
- Prématurité, poids corporel faible = HTA secondaire probable; rechercher une autre cause
13
Q
Describe : Hypertensive urgency
A
dBP≥130mmHg
14
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
15
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
16
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)
17
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
18
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
19
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)
20
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)
21
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
22
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
23
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
24
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
25
Describe exercise recommendaitons
30-60 mins of moderate-intensity dynamic exercise (walking, jogging, cycling, swimming)
**4-7 days per week** in addition to routine ADLs
26
What's the weight loss goal ? (BMI, waist circumference)
* BMI 18.5-24.9
* waist circumference <102cm for men <88cm for women
27
Describe diet for BP (3)
* Dietary Approaches to Stop Hypertension [DASH]
(1) Réduire les gras saturées, le cholestérol
(2) L'accent est mis sur les fruits, les légumes, les produits laitiers faibles en gras, les fibres alimentaires et solubles, les grains entiers et les protéines d'origine végétale.
* Sodium <2 000 mg (1 tsp) par jour
* Potassium increase dietary intake to reduce BP (if no risk of hyperkalemia)
28
What to R/O in HTA ? (3)
* Hypertension rénovasculaire
* Hypertension endocrinienne
(1) Hyperaldostéronisme
(2) Phéochromocytome/paragangliome
29
How to R/O renovascular hypertension ?
avec imagerie, par exemple :
* Échographie duplex des artères rénales
* Angioscanner (ATDM)
* Angiographie par résonance magnétique
* Scintigraphie rénale au captopril
30
Name criterias for imaging in HTA
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
31
How to R/O Hyperaldosteronism? (2)
Aldostérone plasmatique et rénine
32
When to suspect Hyperaldosteronism ? (3)
* K<3.5mmol/L or marked diuretic-induced hypokalemia (K<3)
* HTN resistant to ≥3 drugs
* Adénome surrénalien accidentel
33
How to R/O Pheochromocytoma/paraganglioma ? ()
* Métanéphrines et catécholamines urinaires totales sur 24 h
* ou métanéphrines fractionnées urinaires sur 24 h, métanéphrine/normétanéphrines libres plasmatiques
34
Quand suspecter un phéochromocytome/paragangliome ? (5)
* Hypertension paroxystique, inexpliquée, labile, sévère (≥ 180/110), réfractaire au traitement habituel
* Symptômes d'excès de catécholamines (maux de tête, palpitations, sueurs, crises de panique, pâleur)
* Hypertension déclenchée par la cyclosporine, les IMAOs, la miction, les variations de la pression abdominale, la chirurgie, l'anesthésie
* Masse surrénalienne accidentelle
* Héréditaire (MEN2A/B, neurofibromatose de type 1, syndrome de Von Hippel-Lindau)
35
Describe initial tx HTA if no other indicaitons (5)
* 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)
36
Describe initial tx HTA if : DB (2)
* IECA
* ARA
37
Describe initial tx HTA if : Coronary artery disease (2)
* IECA, ARA
* BB or Calcium channel blockers in stable angina
38
Describe initial tx HTA if : Recent MI (2)
* IECA (ou ARA)
* BB
39
Describe initial tx HTA if : Heart failure (3)
* IECA (ou ARA)
* BB
* Les antagonistes de l'aldostérone in recent CV hospitalization, acute MI, elevated BNP or NYHA class II-IV -> Monitor potassium
40
Describe initial tx HTA if : LV hypertrophy (3)
* IECA, ARA
* Long-acting CCB
* Thiazide
41
Describe initial tx HTA if : Previous stroke/TIA (2)
IECA + thiazide combination
42
Describe initial tx HTA if : Non-diabetic IRC (2)
ACE-i (or ARB) if proteinuria, Diuretics as additional therapy
43
Name E2 : IECA/ARA (4)
* Tératogène
* Toux
* HyperK
* Anigodème
44
Name E2 : BB (3)
* Dysfonction sexuelle H
* Effet sur SNC
* Hyperglycémie
45
Name E2 : BBC (dihydropyridiue) à effet prolongé (3)
* Bouffés vasomotrices
* Céphalée
* OMI (si OMI, avisé de prendre le soir)
46
Name E2 : Diurétiques thiazidiques (indapamide, chlorthalidone) (5)
* Dysfonction sexuel
* HypoK
* HypoNa
* HypoMg
* Hyperuricémie
