8-19 Hypertension CIS - Pales Flashcards
What are the different stages of HTN? Numbers for each?
Normal:
Systolic <120 AND Diastolic <80
Prehypertension
Systolic 120-139 OR Diastolic 80-89
Stage 1 hypertension
Systolic 140-159 OR Diastolic 90-99
Stage 2 hypertension
Systolic ≥160 OR diastolic ≥100*
What are the criteria for determining HTN based on readings? Is it based on 1 reading?
Calculation of seated blood pressure is based on the mean of two or more readings on two separate office visits.
If a patient has checked their blood pressure several times and reported the following numbers to you: 135/92, 145/90, 128/86, 152/85; do they have HTN?
Yes, mean is roughly stage 1 HTN, checked at least two separate times
What are the contributing/risk factors for developing essential HTN?
Genetic predisposition
Abdominal Obesity
Salt intake
Alcohol intake
Age
A patient with essential HTN has c/o headaches. Is this due to elevated BP?
HA are probably coexisting, not directly due to HTN
What pathologies is HTN a risk factor for?
Stroke
Myocardial Infarction
Heart Failure
ESRD
Atrial Fibrillation
Aortic Dissection
PVD
What is the likely mechanism of increased BP with essential HTN?
Vasospasm is main cause of elevated BP
– RAS activation leading to vasoconstriction of small vessels
What is the mechanism for the gradually increasing BP seen with older adults?
decreased vascular compliance in larger vessels, esp aorta
What are some lifestyle modifications that can reduce essential HTN?
Weight reduction
DASH diet
Dietary Na+ reduction
Physical activity
Moderation of EtOH consumption
Stop smoking
For a patient with essential HTN, should you start patient on a medication or should you wait for life-style modifications to take an effect
Start meds, tell them to start lifestyle changes immediately
What is the initial recommended HTN Tx for non-black patients?
ACE Inhibitors
ARB
CCB
Thiazide diuretics
What is the initial recommended HTN Tx for black patients?
CCB
Thiazide diuretics
26 year old female with no medical history presents with 30 lbs weight gain over 2 mo time, headaches, increased thirst and urination, muscle weakness. Patient has abdominal striae, moon face, fat deposition between shoulder blades.
VS: T: 97, BP 165/105, P: 60
Lab: Glucose 350 (normal 60-100)
No family History of HTN or DM
What is the cause of this patient’s HTN?
Patient has Cushing’s Syndrome
- oversecretion of cortisol by adrenal glands
- Cortisol-mediated enhancement of epinephrine vasoconstriction
What diagnostic tests are appropriate to check for Cushing’s Syndrome?
24 hours urinary catecholamines
dexamethosone suppression test
When should you suspect secondary HTN?
Compelling finding on initial evaluation
Hard to control HTN (either new onset or well controlled HTN becoming hard to control)
Atypical age of diagnosis (less than 30)
Absence predisposing factors
89 year old male with h/o HTN for 40 years usually well controlled on amlodipine, HCTZ, and losartan presents with worsening blood pressure control. Home BP measurements: 170/100, 155/95, 190/110
On exam: bilateral abdominal bruits.
What diagnostic test would you like to order for this patient?
renal arteriogram, check creatine to make sure contrast doesn’t kill him;
or use US or renal AA Doppler
CT angiogram a possibility too
What diagnostic tests are helpful with renovascular HTN?
- Captopril Test (reactive rise in renin and large fall in BP after administration)
- DSA
- MRI – angiography
- Arteriography
- Renal vein renin ratio (ratio of 1.5 or greater)
What are the 2 main causes of renovascular HTN?
atherosclerosis
fibromuscular dysplasia
Compare and contrast atherosclerosis vs. fibromuscular dysplasia in regards to:
age
sex
b/l
progressive
response to angioplasty
associated risks
Atherosclerosis
Age >50
Sex Male
Bilaterality 33%
Progressive +++
Response to Angioplasty +
Fibromuscular dysplasia
<40, Female, 60%, +, +++
What medications should you be careful in prescribing to a patient with renovascular HTN?
Do not prescribe ACE inhbitors – can cause renal failure if b/l
54 year old African-American male presents with anxiety, tremors, weight loss. Despite his weight loss, he is having a hard time buttoning the top button on his shirt. His wife also said that he was looking “weird” (NEW COMPLAINT)
VS: T 100, BP 165/100, P 119
Patient has exopthalmos
What is causing his elevated BP?
Hyperthyroid disease – Grave’s disease
What tests would you like to order for his BP?
Test with TSH levels -> should be low due to suppression due to high T4
can also do radioactive iodine scan
What treatment would you like to do for high BP related to Grave’s disease?
Treat with beta blockers
-propranolol until underlying disease treated
55 year old male with no previous history of HTN (last check was 3 mo ago at PCP office) presents to ER with severe muscle weakness without focal deficit. No Chest pain or SOB. Patient is on no medications. BP 210/120. Potassium is 1.9 (normal 3.5-5.3). Creatinine is normal. Urine is negative for protein.
Does this patient has a hypertensive emergency (hypertensive crisis)? Why or why not?
What is the most likely cause of this patient’s HTN?
No –> no end organ damage
primary hyperaldosteronism – Conn’s disease
What are the definitions for HTN urgency and emergency?
Urgency
A systolic BP > 180 or a diastolic BP > 130 and NO evidence of end organ damage.
Emergency
May occur at any BP, but involves ACUTE DAMAGE to at least one organ system.
What are the signs of HTN on the heart?
MI (A),
Angina (A),
Aortic dissection (A),
Aneurysmal dilatation of large vessels (C),
LVH (C),
CHF (A)
What are the signs of HTN on renal system?
Hematuria (C),
Proteinuria (C),
ARF (A)
What are the signs of HTN on the CNS?
Cerebral edema (A),
Altered mental status (A),
Bleed (A),
Stroke (A) or
TIA (A)
What are the signs of HTN with the eyes?
Retinal hemorrhages or exudates (A or C),
Papilledema (A)
A-V nicking (C)
What are some consequences of secondary hypoaldosteronism?
Causes are:
- Diuretics
- CHF
- Cirrhosis
- Ascites
- Nephrosis
- Others
What is the difference in renin and aldosterone levels with primary and secondary aldosteronism?
primary:
Elevated aldosterone and low renin levels < Potassium
secondary:
Elevated aldosterone and elevated renin levels
Why is someone with primary hyperaldosteronism weak?
due to hypokalemia
What medication would you choose to treat Conn’s Disease?
Treat with spironolactone, or aldosterone antagonist
Other than hyperaldosteronism, what other adrenal condition can cause secondary hypertension?
- Sleep apena
- Drug induced causes
- Chronic kidney disease
- Primary aldosteronism
- Renovascular disease
- Steroid therapy or Cushing’s syndrome
- Pheochromocytoma
- Coarctation of the aorta
- Thyroid disease
- Parathyroid disease
- Pain induced
What other (not hyperaldosteronism) adrenal conditions can cause secondary HTN?
Pheochromocytoma
What is coarctation of the aorta?
Narrowing of medial layer of aorta.
Commonly at ligamentum arteriosum
What are the 3 types of coarctation of the aorta?
Interrupted
Preductal
Postductal
How do you Dx a coarctation of the aorta?
1.Differences in upper and lower extremities
- Blood Pressure
- systolic hypertension in an infant
- 20mm hg between arms
3.Heart Sounds – if isolated a systolic ejection murmur in the aortic outlet and between scapulae.
- Radiology –
- Cardiomegaly
- Rib notching
Match the following suffixes to the appropriate class of medications:
- pril
- lol
- pine
- sartan
- zosin
HCTZ, Chlorthalidone
Hydralazine, Minoxidil
Clonidine, Methyldopa
Aliskiren
Verapamil, Diltiazem
ACE Inhibitors -pril
b-Blockers (and a-b)-lol
Dihydropyridine CCB –pine
ARBs -sartan
Alfa Blockers -zosin
Thiazide Diuretics - HCTZ, Chlorthalidone
Direct Vasodialators - Hydralazine, Minoxidil
Central Sympatholytics - Clonidine, Methyldopa
DRI - Aliskiren
Non-Dihydropyridine CCB - Verapamil, Diltiazem
