49. Hypertension (50%) Flashcards
When to suspect secondary hypertension ? (3)
- young patients requiring multiple medications
- patients with an abdominal bruit
- patients with hypokalemia in the absence of diuretics
Describe : Hypertensive urgency
dBP≥130mmHg
Describe hypertensive emergency (5)
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
Describe diagnosis HTA during visit 1 (3)
- 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
Describe Out-of-office BP measurements (3)
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)
Describe diagnosis HTA during visit 2,3,4,5
- 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
Describe how to accurately measure BP (4)
- 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
Describe BP measurement in children (2)
- 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)
Name Target Organ Damage (5)
- 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)
Name BP targets in HTA
- 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
What to discuss during follow-ups ?
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
Name routine labs HTA (5)
- 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
Name health behaviours to change (7)
- 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
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
What’s the weight loss goal ? (BMI, waist circumference)
- BMI 18.5-24.9
- waist circumference <102cm for men <88cm for women
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)
What to R/O in HTA ? (3)
- Hypertension rénovasculaire
- Hypertension endocrinienne
(1) Hyperaldostéronisme
(2) Phéochromocytome/paragangliome
How to R/O renovascular hypertension ?
with imaging eg.
* Duplex ultrasound of renal arteries
* Computed Tomography Angiography (CTA)
* Magnetic Resonance Angiography (MRA)
* Captopril-radioisotope renal scan
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
How to R/O Hyperaldosteronism? (2)
Plasma aldosterone and renin/renin activity
When to suspect Hyperaldosteronism ? (3)
- K<3.5mmol/L or marked diuretic-induced hypokalemia (K<3)
- HTN resistant to ≥3 drugs
- Adénome surrénalien accidentel
How to R/O Pheochromocytoma/paraganglioma ? ()
- 24h urinary total metanephrines and catecholamines
- or 24h urine fractionated metanephrines, plasma free metanephrine/normetanephrines
When to suspect Pheochromocytoma/paraganglioma ? (5)
- 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)
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)
Describe initial tx HTA if : DB (2)
- IECA
- ARA
Describe initial tx HTA if : Coronary artery disease (2)
- IECA, ARA
- BB or Calcium channel blockers in stable angina
Describe initial tx HTA if : Recent MI (2)
- IECA (ou ARA)
- BB
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
Describe initial tx HTA if : LV hypertrophy (3)
- IECA, ARA
- Long-acting CCB
- Thiazide
Describe initial tx HTA if : Previous stroke/TIA (2)
IECA + thiazide combination
Describe initial tx HTA if : Non-diabetic IRC (2)
ACE-i (or ARB) if proteinuria, Diuretics as additional therapy
Name E2 : IECA/ARA (4)
- Tératogène
- Toux
- HyperK
- Anigodème
Name E2 : BB (3)
- Dysfonction sexuelle H
- Effet sur SNC
- Hyperglycémie
Name E2 : BBC (dihydropyridiue) à effet prolongé (3)
- Bouffés vasomotrices
- Céphalée
- OMI (si OMI, avisé de prendre le soir)
Name E2 : Diurétiques thiazidiques (indapamide, chlorthalidone) (5)
- Dysfonction sexuel
- HypoK
- HypoNa
- HypoMg
- Hyperuricémie
