6. HTA Flashcards
population in which to suspect 2nd hyperTA (eg given in objective) (3)
young patients requiring multiple medications,
patients with an abdominal bruit,
patients with hypokalemia in the absence of diuretics
Definition hypertensive urgency
dBP≥130mmHg
definition hypertensive emergency
Severe elevation of BP (no cut off)
AND presence of any of these sx manifesting target organ damage
CNS
headache,
dizziness,
altered mental status,
changes in vision
CARDIO/resp
SOB, CP
Vo
Acute renal failure
decreased urine output
Target organ damage
Cerebrovascular
- Hypertensive encephalopathy (mental status change)
- Intracranial hemorrhage (stroke)
- vascular dementia
Hypertensive retinopathy
Cardiac
- Acute aortic dissection
- Acute LV failure: dysfunction / chronic hypertrophy
- Acute coronary syndrome
Renal
- Acute kidney injury
- CKD - albuminuria
PAD (claudication)
Visit 1 BP measurement, gold standard, how many readings
Min 3 readings
(discard first reading)
gold standard is automated office blood pressure (AOBP)
When to perform out of office BP
If AOBP (office) ≥ 135/85
or non-AOBP ≥ 140/90,
out-of-office BP should be performed before Visit 2
Hypertension diagnosis out of office
1) Daytime ambulatory BP ≥ 135/85
2) 24h ambulatory BP (ABPM) ≥ 130/80
3) 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)
Visit 2 mean OBPM HTA diagnosis
≥140/90 with
macrovascular target organ damage,
diabetes mellitus or
CKD (eGFR<60)
VIsit 3 mean OBPM HTA diagnosis
Mean OBPM ≥160/100
VIsit 4-5
Mean OBPM ≥140/90
Accurate BP Measurement - things to not forget (4 categories)
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
take BP in children above what age
3 yo
whn to diagnose HTA in children or ado (how many readings)
auscultatory-confirmed BP readings ≥95th percentile at 3 different visits
target organ dammage
Cerebrovascular
Stroke
Dementia (Vascular)
Hypertensive retinopathy
Cardiac
LV dysfunction
LV hypertrophy
CHF
CAD (MI, angina, ACS)
Renal (CKD, albuminuria)
PAD (claudication)
Target TA in db pt
Diabetes <130/80
Target TA
All (including elderly)
<140/90
Target TA SPRINT
SPRINT population ≥ 50yo
CV disease
CKD
FRS ≥15%
Age ≥75yo
HTA follow up global risk (11 ish)
Assess global cardiovasc risk
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
HTA labs (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
Adjusting antihypertensive drug therapy
q1-2 months
Modify health behaviours q 3-6 mo
exercise
weight loss
ROH
tobacco cessation
Diet - DASH/ Mediterranean
Sodium <2000mg (1 tsp salt) per day
Potassium increase dietary intake to reduce BP (if no risk of hyperkalemia)
stress mgmt
R/A rx (R/O obvious rx that can increase BP/ should not be taken when increased BP)
NSAIDs
Contraceptives
steroids,
licorice
some OTC meds
When to suspect RENOVASCULAR
secondary hyperTA
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
what rare disease could cause HTA and which pop expecially
younger women and accounting for 10% to 20% of the cases of renal artery stenosis
Consider r/o fibromuscular dysplasia if you think about 2ndary hyperTA
+ unexplained asymmetry of kidney sizes (>1.5cm)
2 big categories of secondary hyperTA
renovascular hypertension
endocrine hypertension
endocrine hypertension - 2 big causes
1) Hyperaldosteronism
2) Pheochromocytoma/paraganglioma
Hyperaldosteronism - investigations
Plasma aldosterone and renin/renin activity
Pheochromocytoma/paraganglioma - investigations
24h urinary total metanephrines and catecholamines
or 24h urine fractionated metanephrines, plasma free metanephrine/normetanephrines)
What makes you suspect Hyperaldosteronism (3)
K<3.5mmol/L or marked diuretic-induced hypokalemia (K<3)
HTN resistant to ≥3 drugs
Incidental adrenal adenoma
What makes you 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)
what is Pheochromocytoma
rare tumor of the adrenal medulla that causes excess secretion of catecholamines (epinephrine and norepinephrine)
what is Hyperaldosteronism
Excess production of aldosterone,
a hormone produced by the adrenal cortex that regulates sodium and potassium balance
Type of meds that exist for BP control
ACE-i (nonblack) or ARB
Long-acting CCB (eg. Amlodipine)
Long-acting Thiazide diuretic (eg. Chlorthalidone, indapamide)
BB (<60yo)
Rx for blood control to AVOID in black ppl
ACE-I !!!
11% increase in CVA events
Examples of ACE i
perindopril
ramipril
Examples of ARB / ARA
Candesartan (Atacand)
Irbesartan (Avapro)
Losartan
valsartan
règle de 10-5 pour les rx de TA
on peut débuter 1 classe de Rx PAR
10mmHg au-dessus de la cible syst
5mm Hg au-dessu cible diast
initier 2 rx cpmme premier tx si cible est >20/10
examples rx combinés
effets secondaires CCB amlodipine à surveiller
effets secondaires ACE i à surveiller
effets secondaires ARB à surveiller
