A: HYPERTENSION Flashcards
Blood pressure is elevated enough to perfuse tissues and organs
Hypertension
High blood pressure
Hypertension
It is not a disease but an important risk factor for cardiovascular complications
Hypertension
It can be defined as a condition where blood pressure is elevated to an extent where clinical benefit is obtained from blood pressure
Hypertension
What are the Classification of Hypertension
Normal: < 120mmHg Systolic and < 80mmHg Diastolic
Pre hypertension or Elevated: 120-139 mmHg Systolic and 80-89mmHg Diastolic
HBP/HTN Stage 1: 140-159mmHg Systolic or 90-99mmHg Diastolic
HBP/HTN Stage 2: Greater than 160mmHg Systolic or Greater than 100mmgHg Diastolic
HTN Crisis: >180 mmHg or >120 mmHg
Blood Pressure Categories:
Normal
< 120mmHg Systolic and < 80mmHg Diastolic
Blood Pressure Categories:
Pre hypertension or Elevated
P120-139 mmHg Systolic and 80-89mmHg Diastolic
Blood Pressure Categories:
HBP/HTN Stage 1
140-159mmHg Systolic or 90-99mmHg Diastolic
Blood Pressure Categories:
HBP/HTN Stage 2
Greater than 160mmHg Systolic or Greater than 100mmgHg Diastolic
Blood Pressure Categories:
HTN Crisis
> 180 mmHg or >120 mmHg
Types, Causes, or Incidence of Hypertension
Primary Hypertension / Essential
Secondary Hypertension
No specific cause of Hypertension
Primary Hypertension / Essential
Identifiable cause
Secondary Hypertension
Physiology, or Formula of BP or HTN
BP = CO ✕ TPR
CO stands for
Cardiac Output
TPR stands for
Total Peripheral Resistance
Formula of CO
SV x HR
SV stands for
Stroke Volume
HR stands for
Heart Rate
Complications of HTN
1.) Cardiac Effects
a.) Left ventricular Hypertrophy
b.) Accelerated Atherosclerosis
2.) Renal Effects
3.) Cerebral Effects
4.) Retinal Effects
Blood pressure is measured using a
Sphygmomanometer
A device composed of an inflatable cuff to restrict the blood flow, and a mercury or mechanical manometer to measure the pressure
Sphygmomanometer
Blood Pressure is measured by
Sphygmomanometer
Manual (Mercury & Aneroid)
Digital
What is a present symptom in HTN
Headache
It is usually unclear if this is caused by hypertension or is an incidental finding
Headache
Predisposing Factors
- Family history
- Patient history
- Racial predisposition
- Obesity
- Smoking
- Stress
- Sedentary lifestyle
- Intake of fats and salts
Patient’s history and other physical findings suggest an underlying cause of hypertension
Secondary Hypertension
Diseases or Disorders that can cause High Blood Pressure
Primary aldosteronism
Pheochromocytoma
Renal artery stenosis
It is a clinical situation in which blood pressure is very high with minimal or no symptoms, and NO signs or symptoms indicating acute organ damage
Hypertensive urgency
Hypertensive emergency is also known as
Malignant hypertension or accelerated
A high blood pressure with potentially life-threatening symptoms and signs indicative of acute impairment of one or more organ systems
Hypertensive emergency
Diagnosis: Home or ambulatory blood pressure measurements is recommended to prevent
“white coat hypertension”
It is recommended to prevent “white coat hypertension”
Home or ambulatory blood pressure measurements
The number of times the heart beats in one minute
Cardiac Output
Diagnostics
CBC
Lipid Profile (HDL, LDL, Triglycerides)
SGOT
SGPT
Na
K
Ca
BUN
BUA
FBS & RBS
CREA
HBA1C
Urinalysis
What are the Lipid Profile
HDL, LDL, and Triglycerides
What are the electrolytes needed in Diagnostic
Na, K, and Ca
General Principle for the treatment of HTN
To lower blood pressure toward NORMAL with minimal side effects and to prevent or reverse organ damage
Candidates for the treatment of HTN
Patients with diastolic >90mmhg and systolic of >140mmhg
Non- specific measures / Non- Pharmacologic measures
- Weight loss results in reduction in BP of about 2.5/1.5 mmHg per kg (for overweight patients)
- Reduce salt intake (aim is <100 mmol daily sodium intake)
- Diet high in fruit and vegetables, legumes and whole grain cereal improves cardiovascular risk
- Regular dynamic exercise for at least 30 minutes on most days
- Alcohol intake should be restricted
- Quit smoking
Non-Pharmacologic Approaches: Weight loss results in reduction in BP of about __ (for overweight patients)
2.5/1.5 mmHg per kg
Non-Pharmacologic Approaches: Diet high in fruit and vegetables, legumes and whole grain cereal improves __
Cardiovascular risk
Non-Pharmacologic Approaches: Reduce salt intake (aim is __ daily sodium intake)
<100 mmol
Non-Pharmacologic Approaches: Regular dynamic exercise for at least __ on most days
30 minutes
AB/CD Algorithm by
Williams et al 2004
Initial choice of ACE inhibitor or angiotensin
receptor blocker and β blocker as first line
therapy in younger nonblack patients (<55
years)
Treatment A/B
Said patients often have hypertension associated with high concentration of renin. It is therefore logical to treat them with drugs that antagonize the renin-angiotensin system
Treatment A/B
In treatment A/B the initial choice as first line therapy are
ACE inhibitor or angiotensin
receptor blocker and β blocker
Treatment A/B is suitable for
younger nonblack patients (<55
years)
For elderly and black patients, who tend to have hypertension associated with low renin concentration, calcium channel blockers and thiazide diuretics are recommended
Treatment C/D
What is the recommended medicine in the treatment C/D
calcium channel blockers and thiazide diuretics
Treatment C/D is suitable for
elderly and black patients
What happens if initial drug therapy fails
A or B is combined with C or D
MOA: inhibition of the conversion of angiotensin 1 to angiotensin 2
Ace Inhibitors
Ace Inhibitors example
Captopril
Enalapril (enalaprilat)
Fosinopril
Lisinopril
Dolapril
Perindopril
MOA: works by blocking the binding of
Angiotensin 2 to the receptor
Angiotensin Receptor Blockers
ARBS stands for
Angiotensin Receptor Blockers
ACE inhibitors stands for
Angiotensin-converting enzyme
Angiotensin Receptor Blockers example
Telmisartan
Losartan
Olmesartan
Valsartan
MOA: Blocks Beta adrenergic system
Beta Blockers
Whites with high cardiac output, high heart rate and normal vascular resistance
respond the best with
Beta Blockers
In Beta Blockers the stimulation of renin secretion is
blocked
In Beta Blockers the cardiac contractility is
decreased
In Beta Blockers the reduction in heart rate
decreases cardiac output
In Beta Blockers the sympathetic output is
decreased
Beta blockers must be used cautiously in patients with
DM, Reynaud’s syndrome, & Neurological Disorder
NO beta blocker is safe with patients with
bronchospastic problem
What are the Beta-1 Selective Beta blockers
Metoprolol
Atenolol
Acebutolol
Esmolol
Betaxolol
Nebivolol
First B1 selective
Metoprolol
Have high intrinsic activity
Acebutolol
Shortest T1/2 (Half-life)
Esmolol
What are Non-Selective Beta blockers
Propranolol
Nadolol
Timolol
Pindolol
Penbutolol
Carvedilol ( with alpha blocking property)
Effective after Acute MI to prevent sudden death
Timolol
1st adrenergic to have high intrinsic activity
Pindolol
Significant Interaction in CCB
Beta blocker + Calcium Channel Blocker
MOA: Inhibits influx of calcium through slow channels in vascular smooth muscle and cause relaxation
Calcium Channel Blocker
These agents must be used with extreme caution or not at all in patient with conductive disturbances involving SA and AV node
Non-Dihydropyridine
Non-Dihydropyridine example
Verapamil
Diltiazem
Dihydropyridine example
Nifedipine
Amlodipine
Clevidipine
Isradipine
Felodipine
Nicardipine (2ND GENERATION )
To produce more selective effects on specific target tissues than the first generation agents
Dihydropyridine
Blocks the peripheral postsynaptic Alpha-1
adrenergic receptor
Peripheral Alpha-1 Adrenergic Antagonist
Given to HTN patients who have not responded to initial HTN therapy
Peripheral Alpha-1 Adrenergic Antagonist
Peripheral Alpha-1 Adrenergic Antagonist
terazosin
prazosin
doxazosin
Side effect of Zosin
may cause 1st dose phenomenon
MOA: act primarily within the CNS on alpha 2 receptors to decrease sympathetic outflow to the cardiovascular system
Centrally Active Alpha Agonist
Centrally Active Alpha Agonist Example
Methyldopa
Clonidine
Guanabenz
Guanfacine
Decrease TPR and CO
Methyldopa
Acts centrally , as well as peripherally, by depleting catecholamine stores in the brain and in the peripheral adrenergic system
Reserpine
Given in low doses to treat refractory hypertension
Reserpine
Contraindicated to patients with history of
depression
Reserpine
usual dose of Reserpine
0.1 to 0.25 mg per day
Second line agents in patients with refractory to initial therapy
Vasodilators
First line agents in patients with refractory to initial therapy
Reserpine
MOA: directly inhibits renin = reduction of production of Angiotensin 2
Aliskiren (Renin Inhibitor)
Vasodilators example
Hydralazine
Minoxidil
Nitroprusside
Arteriole relaxation & decrease of systemic vascular resistance
Hydralazine
decreases peripheral resistance
Minoxidil
releases nitric oxide
Nitroprusside
What forms in the blood vessel that causes HBP
Plaque