Block I: HTN Flashcards
what is the definition of HTN?
130/80 (AHA)
OR
140/90
HTN is a silent disease until []
target organ damage is manifested
[] HTN is a more powerful predictor of complications
systolic (in comparison to diastolic)
what are some major complications of HTN
- CAD
- stroke
- cerebral infarction
- ESRD
- CHF
- aortic dissection
[] HTN is more pathological and more likely to lead to CAD or stroke
SBP
[] are major causes of morbidity and mortality in essential HTN
cardiac complications
preventing [] is the main goal in HTN therapy
cardiac complications
what is normal BP (ACC)
120/80 or less
what is elevated BP (ACC)
120-129/ < 80
what is HTN stage I (ACC)
130-139/80-19
what HTN stage II (ACC)
140/90 +
what is the BP goal
130/80
*waiting to hear back from prof. young about what we need to know
what is primary/essential HTN
95% of cases where no cause can be identified , idiopathic
what are important factors in primary/essential HTN
- age 22-55 ys
- genetics
- increased salt
- obesity
- alcohol
- cigarette smoking
- NSAIDS
- psuedoephedrine
- metabolic syndrome
pt. with high BP should consume no more than [] Na per day
2.4 g (some guidelines, 1.5)
how does obesity contribute to HTN
- increases cardiovascular volume
- elevates CO
- weight reduction lowers BP modestly
how does alcohol contribute to HTN?
by possibly increasing catecholamine release
how does smoking increase bp?
increases plasma NE
is it benifical to increase exercise in an already active HTN patient?
not very, no
NSAIDS can increase BP by [] mmHg
5
what 2 drugs should be avoided in borderline hypertensive patients
psuedoephedrine, nsaid
what is the most common cause secondary HTN
renal disease
what is another common cause of secondary HTN (other than renal diseasE)
- diabetic nephropathy
- renal vascular HTN
- excessive renin release due to reduction in renal blood flow and perfusion pressure
- estrogen use
- hyperaldosteronism
- pheocrhomocytoma
- coarctation of aorta
- thyroid disease
- prgnancy
[] will occur if there is a reduction in renal perfusion
renin release from kindey -> raas -> htn
what effect does estrogen have of HTN
can cause small increase in BP
will cause volume expansion and increased activity of RAAS
does estrogne effect postmenopausal women and their BP?
no
how does primary aldosteronism affect BP
can increase by retaining Na and water
how does pheochromocytoma affect BP
increase NE from tumor on adrenal gland
how does coarctation of aorta affect BP
increase BP
how does hypothyroidism affect BP
elevates diastolic BP
how does hyperthyroidism affect BP
elevates systolic BP
[] is most common cause of maternal and fetal morbidity and mortality
HTN
what are common target organs affected by HTN
- heart
- brain
- kidneys
- eyes
- peripheral arteries
what is the most frequent symptom of HTN?
HA (nos)
what HA is most assox. with HTN
sub, occipital pulsating HA,
normally during early morning and subsiding during the say
physical findings of HTN depend on []
cause HTN, duration & severity, degree of effect on target organs
how should BP be taken
in both arms and in legs (if lower extremity pulses are diminished or delayed) to exclude coarctation of aorta
what are some findings on fundoscopic exam that may indicate HTN
- narrowing arterial diameter to less than 50%
- copper/silver wiring
- exudates
- cotton-wool spots
- hemorrhages
- papilledema
what cardiovascular findings may be seen in a hypertensive patient
- left ventricular enlargement with left ventricular heave -> severe longstanding HTN
- presystolic S4 gallop due to decreased compliance of L ventricle
what heart sound may be present in a hypertensive patient
- presystolic s4 gallop due to decreased copmliance of L ventricle
- carotid, abdominal, femoral bruits
what EKG abnormlaities may be present in HTN patient
increased QRS interval from hypertrophied ventricle
what myocardial changes may occur in HTN
hypertrophied left ventricle, will increase QRS interval
what might you feel on abdominal palpation in a HTN patient
enlarged kidneys and abdominal anneurysm (pulsatile mass)
what are some diagnostic studies that can be done for HTN
- EKG (increased QRS interval)
- UA
- glucose
- hematocrit (increased)
- serum K (low)
- creatinine
- sodium
- calcium
- fasting lipids (HDL, LDL, tryglycerides)
what foods cause an increase soluble fiber and what is the goal?
25 g
- oats
- pears
- beans
- cantaloupes
describe the DASH diet
dietary approach to stop HTN
rich in fruit, veggies, calcium, low in saturated and total fat
what is proven to have a modest reduxtion in BP
- weight redux
- reduced alcohol
- reduced salt
- smoking cessation will reduce overall CV risk
what are 4 benefits of lifestyle modifications
- lower BP
- reduce dosage number antihypertensives
- minimize assoc. risk factors
- prevent progression to HTN from pre HTN
what are initial, single drug therapy option for HTN
- ACEI
- ARB
- CCB
- BB
how often should you f/u a patient on new HTN drugs
4-6 weeks to allow for full medication effects to be established before further titration or adjustment
patient has been titrated to usual dose, has shown incomplete response, what is the next step?
2nd medication
if first agent showed no efffect, what is the next step?
d/c and add new med
what happens to efficacy when 2 low dose drugs are used incstead of one large
better efficacy, more likely to offer better end-target organ protection and better clinical outcome than single agent
a patient has had excellent BP control over the years and is dedicated to continuing lifestyle modifications
can be considered for step down therapy, lower or d/c dose
what drugs are essential for a HTN patient with diabetic nephropathy and proteinuria
- ACEI/ARB
if DM ACEI first then ARB
what durgs are essential for HTN and stable engina
- BB
2. CCB
what drugs are essential for HTN and unstable angina or MI
- BB
2. ACEI
what drugs are essential for symptomatic ventricular dysfunction
- ACEI
- ARB
- BB
what are special considerations for black patients
- begin with diuretic
- bb less effective
- CCB more effective
- high risk angioedema ACEI/ARB
- can still be used in if CKD
describe a HTN urgency
- HTN in otherwise healthy individual
- > 220/115
- RARELY needs emergency therapy unless end organ damage is present
how to treat a HTN urgency (220/115)
lower over course 24 hours
what is a HTN emergency (diastolic)
DBP > 115-130
assoc. with evidence of end organ damage
what are examples of end-organ damage
- encephalopathy
- nephropathy
- myocardial ischemia or infarction
- HA
- irritability
- confusion
- altered mental status
- cerebrovascularspasm
these are signs of
encephalopathy
HTN emergencies require BP reduction in [] to avoid risk of serious morbidity and death
1 hours (remember 24 in ugency with no organ damage)
BP is [] in terms of end-organ damge
irrelevant, organ damage dictates seriousness of approach
- hematuria
- proteinuria
- pregressive renal dysfunction
indicative of []
hypertensive nephropathy
what are some other HTN emergencies
- intracranial hemorrhage
- aortic dissection
- pre-eclampsia
- eclampsia
- pulmonary edema
- unstable angina
- MI
- malignant HTN
- severe HTN with papilledema
2. rapid course, can cause necrosis of arterial walls in kidney, retina, and brain
malignant HTN
death my malignant hypertension occurs most frequently by []
uremia or rupture of cerebral vessel
initial goal in parenteral treatment of HTN emergency is to []
reduce by no more than 25% within minutes 1-2 hrs
-move forward 160/100mmHg within 2-6 hours
excessive reduction in pressure during hypertensive emergency may lead to
coronary, cerebral, or retinal ischemia
what are common IV meds for HTN emergencies
- nitroprusside
- nicardipine
- hydralazine
- labetalol
- metoprolol
what is the def. orthostatic hypotension
- decrese in systolic BP of 20mmHG or decrease in diastolic BP of 1o mmHG within 3 minutes of standing when compared with BP from sitting/supine position
what are some causes orthostatic hypotension
- hypovolemia
- drugs
- autonomic conditions
what can cause hypovolemia
- hemorrhage
- burn
- spesis
- dialysis
- sweating
- hyperglycemia
- DI
- addison’s
- anorexia
- Na wastin
what are drugs that can cause orthostatic hypotension
- diuretics
- alpha blockers
- antidespressants
- sildafenil
- nitrates
- alcohol
- narcotics
- sympatholytics
what would a good workup of orthostatic hypotension include
- CBC
- CMP
- INR/PTT
- fecal occult blood
- EKG
- orthostatic vital signs
- +/- head CT
