8/13- Hypertension: A Case Discussion Flashcards
Case 1)
- 55 yo man in for check-up
- BP 120/76 one year ago
- Smoker (40 pack years)
- No medications; no other coronary risk factors
- FHx: father died suddenly and unexpectedly at 42 yo; mother died of breast cancer
PE:
- Mildly overweight; no acute distress
- WT = 210 lbs, HT = 5’6”
- BP = 136/88 (confirmed)
- HR = 62/min
Labs:
- High fasting blood sugar (FBS): 180 mg%
- High HbA1c =9
- High BUN = 24 (nL 8-20)
- High serum creatinine: 1.5mg% (0.7-1.1mg%)
- Last yr, his BUN and creatinine were normal
- High total cholesterol: 250mg%
- High LDL cholesterol: 180mg%
- Low HDL: 35mg%
- Urinalysis: 1 + proteinuria (by dipstick); no hematuria
Which of the following risk factors does this pt have?
A. DM & HT
B. DM & high LDL
C. DM, high LDL, low HDLD, FH of CAD
D. Male > 45, DM, smoking, high LDL, low HDL, FH CAD
E. Male > 45, DM, smoking, high LDL, low HDL, FH of CAD and FH of HT
Which of the following risk factors does this pt have?
A. DM & HT
B. DM & high LDL
C. DM, high LDL, low HDLD, FH of CAD
D. Male > 45, DM, smoking, high LDL, low HDL, FH CAD
E. Male > 45, DM, smoking, high LDL, low HDL, FH of CAD and FH of HT
D- family history of HT not relevant
What is normal fasting blood sugar?
100-125 mg%
What is normal value for HbA1C?
Under 7%
How do we diagnose people with diabetes (lab-wise)?
- High HbA1C
or
- High FBC
Does accurate measurement of HbA1C require fasting? Does FBS?
HbA1C- no
FBS- yes
What does HbA1C measure?
Glycosylated Hb; a measure of the average blood sugar over about 2 months
Case 1)
How would you best characterize the pt’s BP (BP = 136/88)?
A. Normal
B. Isolates systolic HT
C. Pre-HTN
D. HTN
E. Optimal BP
How would you best characterize the pt’s BP (BP = 136/88)?
A. Normal
B. Isolates systolic HT
C. Pre-HTN
D. HTN
E. Optimal BP
(between 120/80 and 140/90)
Which of the following strategies would you recommend?
A. Salt restriction and weight reduction
B. Drug therapy to lower BP despite BP < 140/90
C. Exercise, salt restriction & wt reduction
D. Stop smoking, exercise, salt restriction & wt reduction
E. B and D
Which of the following strategies would you recommend?
A. Salt restriction and weight reduction
B. Drug therapy to lower BP despite BP < 140/90
C. Exercise, salt restriction & wt reduction
D. Stop smoking, exercise, salt restriction & wt reduction
E. B and D
When it comes to pre-HTN, pharmacologic treatments are only given for diabetics/chronic kidney disease so that it incentivizes lifestyle changes)
Assuming his BP is confirmed on two other occasions, is he at a higher risk for CVA or CHD, despite a normal diastolic BP?
A. Yes
B. No
A. Yes
Systolic and diastolic HTN are independent risk factors
Assuming BP lowering drugs are appropriate, which would you recommend?
A. Diuretic (HCTZ)
B. Beta blocker (atenolol)
C. Alpha blocker (prazosin)
D. ACEI (lisinopril)
E. Centrally acting sympatholytic (clonidine)
Assuming BP lowering drugs are appropriate, which would you recommend?
A. Diuretic (HCTZ)
B. Beta blocker (atenolol)
C. Alpha blocker (prazosin)
D. ACEI (lisinopril)
E. Centrally acting sympatholytic (clonidine)
Specific risk factors:
- Diabetes
- Chronic renal disease (as long as not end-stage)
So need ACEI or ARB
The most important reason for selection of an ACEI in a diabetic as the preferred anti-HT is:
A. ACEI reduce CAD
B. ACEI reduce stroke
C. ACEI reduce LVH
D. ACEI reduce end-stage renal failure
The most important reason for selection of an ACEI in a diabetic as the preferred anti-HT is:
A. ACEI reduce CAD
B. ACEI reduce stroke
C. ACEI reduce LVH
D. ACEI reduce end-stage renal failure
Case 1)
If this pt develops cough after starting lisinopril, which anti-HT drug would you now recommend?
A. Diuretic (HCTZ)
B. Beta blocker (atenolol)
C. Alpha blocker (prazosin)
D. ARB (valsartan)
E. Centrally acting sympatholytic (clonidine)
If this pt develops cough after starting lisinopril, which anti-HT drug would you now recommend?
A. Diuretic (HCTZ)
B. Beta blocker (atenolol)
C. Alpha blocker (prazosin)
D. ARB (valsartan)
E. Centrally acting sympatholytic (clonidine)
Like ACEI but without the cough.
Preferred in:
- Diabetes
- Renal failure
- Heart failure
Case 1)
Have ARB’s been demonstrated to delay progression of renal failure in diabetics?
A. Yes
B. No
C. Not really but they work so much like an ACEI that we think they probably should
Have ARB’s been demonstrated to delay progression of renal failure in diabetics?
A. Yes
B. No
C. Not really but they work so much like an ACEI that we think they probably should
- 3 different ARBs have been proven to delay the development of the endpt (end stage kidney dz requiring transplant/dialysis, doubling the creatinine, or –)
If creatinine levels are around what, you would not give them an ACEI or and ARB? What would you give them instead?
If creatinine > 3 or 4 (“severe” or advanced renal failure), can’t give ACEI or ARB
- Instead, use any other BP lowering drug (like CCB)
BP ~ 125/75 on a low dose anti-HT drug; what do you now advise?
A. Uptitrate to target normal BP
B. Discontinue the drug
C. Uptitrate to max dose
D. Add a diuretic or BB to target normal BP
E. Continue same Rx
BP ~ 125/75 on a low dose anti-HT drug; what do you now advise?
A. Uptitrate to target normal BP
B. Discontinue the drug
C. Uptitrate to max dose
D. Add a diuretic or BB to target normal BP
E. Continue same Rx
- must continue treatment
What is the goal BP in this pt?
A. 120/80
B. 130/80
C. 130/85
D. As low as tolerated
What is the goal BP in this pt?
A. 120/80
B. 130/80
C. 130/85
D. As low as tolerated
140/90 is the goal for uncomplicated HT pts 130/80 is the goal for any pt with:
- Diabetes
- Chronic kidney disease 120/80 is optimal BP 115/75 is associated with the lowest risk of CV and renal complications (observational studies)
Does targeting systolic blood pressure under 120 reduce CVD events compared to targeting SBP under 140 in pts with type 2 DM at high risk for CVD events?
No! no difference in CV complications between BP under 120 and 140 in diabetics (in terms of CVD events)
- SBP under 120 is NOT recommended in diabetics and is being tested in older pts +/- renal disease
BP Goal for:
- Uncomplicated HTN pts:
- Diabetics:
- Chronic kidney disease:
- “Optimal” for lowest risk:
BP Goal for:
- Uncomplicated HTN pts: under 140/90
- Diabetics: under 130/80
- Chronic kidney disease: under 130/80
- “Optimal” for lowest risk: 115/75(?)
What is the single most important risk factor for death in the world?
Hypertension!
Then:
- Tobacco
- High cholesterol
- Underweight
- Unsafe sex
- High BMI
- Physical inactivity
- Alcohol
Which anti-HT drugs are preferred as initial therapy in an uncomplicated HTN with a BP of 146/90?
A. Diuretics
B. Beta blockers
C. Alpha blockers
D. ACEI or ARB
E. CCBs
Which anti-HT drugs are preferred as initial therapy in an uncomplicated HTN with a BP of 146/90?
A. Diuretics
B. Beta blockers
C. Alpha blockers
D. ACEI or ARB
E. CCBs
Why are thiazide diuretics preferred as initial therapy in HT?
- Thiazide diuretics are effective in reducing a variety of CV hypertensive complications such as stroke, CHD and CHF by about 30-40% and to reduce all cause and cardiovascular mortality by about 10-25%.
- Beta blockers while usually effective in reducing CV events appear to be inferior to diuretics, especially in elderly hypertensive patients and unlike diuretics do NOT significantly reduce mortality or CV mortality.
What is the ALLHAT hypothesis/conclusion?
Among antihypertensive drugs, thiazide diuretics are unsurpassed in:
- Controlling elevated blood pressure
- Preventing cardiovascular complications
- Since they are also least expensive, diuretics should be used as INITIAL anti-hypertensive drug therapy (alone or in combination with another drug class)
Case 2)
- 74 yo Af Am woman in previous good health
- Referred for BP evaluation
- Repeated BP msmts of 168/82 in last 3 mo
- Normal PE except anxious and concerned about BP
ECG:
- Sinus bradycardia
- Normal QRS axis
- Mild LVH voltage (R in V5 + S in V1 = 35 mm)
CXR: No cardiomegaly; clear lung fields
This pt has which of the following?
A. Normal BP for her age
B. Isolated systolic HT
C. Pre-HTN
D. Hypertension
E. Optimal BP
This pt has which of the following?
A. Normal BP for her age
B. Isolated systolic HT
C. Pre-HTN
D. Hypertension
E. Optimal BP
Case 2) (BP = 168/82)
Which of the following best appliies to this pt?
A. SBP 168 is normal for a 74 yo woman
B. Pulse pressure is normal despite mildly elevated SBP
C. Higher risk of CVA/CHD despite DBP 82
D. Reducing SBP is potentially harmful in this elderly asymptomatic woman
Which of the following best appliies to this pt?
A. SBP 168 is normal for a 74 yo woman
B. Pulse pressure is normal despite mildly elevated SBP
C. Higher risk of CVA/CHD despite DBP 82
D. Reducing SBP is potentially harmful in this elderly asymptomatic woman
Case 2)
Which of the following is the BEST mgmt approach (isolated systolic HTN)
A. Salt restriction
B. Anti-HTN drug(s) and salt restriction
C. Reassurance
D. Anxiety relieving drug
Which of the following is the BEST mgmt approach (isolated systolic HTN)
A. Salt restriction
B. Anti-HTN drug(s) and salt restriction
C. Reassurance
D. Anxiety relieving drug
Case 2)
Assuming single drug therapy is recommended, what is your recommended initial anti-HTN drug in this pt?
A. Diuretic
B. Beta blocker
C. ACEI
D. CCB
E. Direct acting vasodilator such as hydralazine
Assuming single drug therapy is recommended, what is your recommended initial anti-HTN drug in this pt?
A. Diuretic
B. Beta blocker
C. ACEI
D. CCB
E. Direct acting vasodilator such as hydralazine
Diuretic recommended first in uncomplicated HTN pt (Chlorthalidone was shown in the Systolic Hypertension in the Elderly Program “SHEP” in 1991 to REDUCE STROKE by 40%!!!! In patients with Isolated Systolic Hypertension!!)
Case 2)
BP 156/78 (from 168/82) in your first anti-HT drug for this pt; what do you recommend now?
A. Uptitrate to target normal BP
B. Discontinue since DBP is under 80
C. Uptitrate to target BP under 140/90
D. Add a CCB to achieve better BP control
E. Either C or D
BP 156/78 (from 168/82) in your first anti-HT drug for this pt; what do you recommend now?
A. Uptitrate to target normal BP
B. Discontinue since DBP is under 80
C. Uptitrate to target BP under 140/90
D. Add a CCB to achieve better BP control
E. Either C or D
What is unique about a CCB in regards to this case (2)?
CCB (Amlodipine) was shown in the systolic HTN in trial to reduce stroke by over 40% in pts with isolated systolic hypertension!
Case 2)
Which initial drug(s) is/are preferred in a diabetic hypertensive with BP 170/92?
A. Hydrochlorothizide 25 mg every morning
B. Amlodipine 5 mg every morning
C. Lisinopril 10 mg every morning
D. A + C
E. B + C
Which initial drug(s) is/are preferred in a diabetic hypertensive with BP 170/92?
A. Hydrochlorothizide 25 mg every morning
B. Amlodipine 5 mg every morning
C. Lisinopril 10 mg every morning
D. A + C
E. B + C
- Stage 2, so need to start 2 drugs initially
- CCB not initially preferred for HTN in diabetic pt
What is the preferred initial therapy option for the following compelling indication: heart failure?
1. ACEI/ARB!!!
(2. BB)
(3. Aldo antagonist)
What is the preferred initial therapy option for the following compelling indication: post MI?
1. BB or ACEI
(2. Aldo antagonist)
What is the preferred initial therapy option for the following compelling indication: High CAD risk?
Thiazide
Beta Blocker
ACEI
CCB
What is the preferred initial therapy option for the following compelling indication: diabetes?
- ACEI, ARB
- CCB
What is the preferred initial therapy option for the following compelling indication: chronic kidney disease?
ACEI ARB
What is the preferred initial therapy option for the following compelling indication: recurrent stroke prevention?
Thiazide ACEI
What is the preferred initial therapy option for the following compelling indication:
- Heart failure:
- Post MI:
- High CAD risk:
- Diabetes:
- Chronic kidney disease:
- Recurrent stroke prevention:
- Heart failure: ACEI/ARB (then BB)
- Post MI: BB/ACEI
- High CAD risk: Thiazide, BB, ACEI, CCB
- Diabetes: ACEI/ARB (then CCB)
- Chronic kidney disease: ACEI/ARB
- Recurrent stroke prevention: Thiazide/ACEI
Basically:
ACEI or ARB in DM or renal failure;
ACEI or ARB in systolic CHF;
BB or CCB in CAD
65 yo woman with acute dyspnea and this EKG
A. CHF
B. ACS
C. Pericarditis
D. Acute MI
65 yo woman with acute dyspnea and this EKG
A. CHF
B. ACS
C. Pericarditis
D. Acute MI
- Acute ST segment elevation
- Semi-interoseptal b/c changes in V1, V2 and ST elevation in V3, V4
32 yo man with 2 days sharp chest pain with this EKG
A. AMI
B. ACS
C. Pericarditis
D. Spasm
32 yo man with 2 days sharp chest pain with this EKG
A. AMI
B. ACS
C. Pericarditis
D. Spasm
Asymptomatic BCM MS 2 with this EKG
A. NSR
B. LVH
C. RVH
D. WPW
Asymptomatic BCM MS 2 with this EKG
A. NSR
B. LVH
C. RVH
D. WPW
- Delta wave and prolonged QRS segment
-
-
What is the rhythm in this smoker?
A. PAT
B. VT
C. AVRT
D. MAT
What is the rhythm in this smoker?
A. PAT
B. VT
C. AVRT
D. MAT
What is the cardiac rhythm?
A. AFib
B. Aflutter
C. MAT
D. VT
What is the cardiac rhythm?
A. AFib
B. Aflutter
C. MAT
D. VT
- Narrow QRS complex
- Regular rhythm
- Atrial activity present and in characteristic pattern
What is the QRS axis?
A. RAD
B. LAD
C. Normal
D. NW Axis (indeterminate)
What is the QRS axis?
A. RAD
B. LAD
C. Normal
D. NW Axis (indeterminate)
- Lead I is negative
- aVF is positive
Measure the PR interval in s:
A. >0.2
B. Under 0.2
C. 0.16-0.2
D. 0.04
Measure the PR interval in s:
A. >0.2
B. Under 0.2
C. 0.16-0.2
D. 0.04
(more than 5 mm)
Measure the QRS interval?
A. Normal
B. Long
C. Short
Measure the QRS interval?
A. Normal
B. Long
C. Short
Examine the P wave in 2, 3, and aVF. What is this?
A. Ectopic atrial rhythm
B. NSR
C. LAE
D. RAE
Examine the P wave in 2, 3, and aVF. What is this?
A. Ectopic atrial rhythm
B. NSR
C. LAE
D. RAE
What is the heart rate?
A. 60/min
B. 100/min
C. 75/min
D. 50/min
What is the heart rate?
A. 60/min
B. 100/min
C. 75/min
D. 50/min
HR = 300/(no. big boxes)
