Ambulatory Med Flashcards
Hypertension
- defined as blood pressure more than 140/90
- most often essential hypertension with renal artery stenosis the most common cause of secondary HTN and OCPs are the most common cause of secondary HTN in young women
- increases the risk for LVH, MI, CHF, CVA, chronic kidney disease, peripheral arterial disease, AAA, aortic dissection, and retinopathy
- goal for therapy is to reduce blood pressure below 140/90 in those less than 60 and below 150/90 in those over 60
- initial monotherapy can include a thiazide, long-acting CCB, or ACEI/ARB; then try in combination; finally add beta-blockers, a-blockers, and vasodilators like hydralazine for refractory cases
What are possible causes of secondary hypertension?
- the most common is renal artery stenosis
- OCPs are the most common cause of secondary HTN in young women
- chronic renal failure and polycystic kidney disease
- hyperaldosteronism, hyperthyroidism, Cushing syndrome
How does hypertension impact the heart?
- hypertension increases after load, which leads to concentric LVH
- this reduces LV function and as a result, the chamber dilates, eventually leading to heart failure
- hypertension also accelerates atheroscolerosis, contributing to CAD and ischemic disease
Describe the staging system for hypertension.
- normal BP is less than 120/80
- pre-hypertension is less than 140/90
- stage I hypertension is less than 160/100
- stage II hypertension is greater than 160/100
- HTN urgency is greater than 180/120
What is the difference between HTN urgency and HTN emergency?
- HTN urgency is a blood pressure greater than 180/120 in a patient with no signs of end organ damage
- HTN emergency is hypertension with signs of organ damage such as neurologic changes, MI, aortic dissection
What are possible complications of HTN?
HTN predominately affects the brain, eyes, heart, and kidneys
- HTN is a risk factor for CAD and therefore ACS, CHF secondary to LVH, peripheral artery disease, AAA, and aortic dissection
- in the eye, early changes include AV nicking due to thickened arterial walls, cotton wool spots indicative of nerve fiber infarction which can cause visual disturbances and scotomata, hemorrhages and exudates, papilledema
- intracerebral hemorrhage and other stroke subtypes as well as hypertensive encephalopathy
- arteriosclerosis of afferent and efferent arterioles called nephrosclerosis and decreased GFR or tubular dysfunction eventually leading to renal failure
What is the proper way to take blood pressure and to diagnose hypertension?
- blood pressure should be taken with the patient seated comfortably after 5 minutes of sitting quietly, the arm at the level of the heart, without any caffeine or cigarette use in the past 30 minutes
- requires two elevated pressures more than 4 weeks apart
What is the target blood pressure goal when treating hypertension in the following?
- general population under 60
- general population over 60
- diabetics without CKD
- those with CKD
- general population under 60: less than 140/90
- general population over 60: less than 150/90
- diabetics without CKD: less than 140/90
- those with CKD: less than 140/90
What two populations are thiazide diuretics a good option for in the treatment of hypertension?
- African Americans who are more salt sensitive
- and those with osteoporosis since thiazides increase calcium reabsorption
Through what mechanism do beta-blockers reduce blood pressure? Who are they a good option for and who are they a bad option for?
- they decrease HR, cardiac output, and renin release
- they are a good option in those with CHF, CAD, or afib
- they are a bad option in those with obstructive lung disease, heart block, or depression
What is the normal action of angiotensin II?
it causes vasoconstriction, aldosterone release, and ventricular remodeling
ACE inhibitors are the preferred antihypertensive in which population of hypertensives?
those with diabetes or CKD because they have a protective effect on the kidneys
How does hydralazine function as an antihypertensive?
it is a vasodilator
What side effects are associated with dihydropyridine CCBs and with nondihydropyridine CCBs?
- dihydropyridines like amlodipine increase the risk for peripheral edema
- nondihydropyridines verapamil and diltiazem increase the risk for heart block
Which antihypertensives are considered first-line mono therapy?
- thiazide diuretics
- long-acting calcium channel blockers
- ACEI/ARBs
