Cardio-clinical-HTN-Bennet Flashcards
HTN is considered what bp level :
>130/80
HTN trends have increased/decreased just about everywhere.
increased
The number one modifiable risk to early death is :
High BP or HTN
What is the average pressure within the patient’s arteries through one cardiac cycle?
MAP
What is a better predictor of stress on arterial walls?
MAP
What is a normal MAP?
70-100
>60 needed to maintain cerebral/renal/cardiac; MAP >100 is high)
For every mmHg increase in SBP or a mmHg increase in DBP: the risk of death from heart attack & stroke, and the risk of heart failure and aortic aneurysm
20; 10; DOUBLES; DOUBLES
What 3 things can lead to HTN:
Too much volume, renin, catecholamines
Pheochromocytoma increases which catecholamine? which can increase BP?
Norepinephrine
Primary HTN causes include:
Genetics
Age
High salt,
low potassium diet
Insulin resistance/diabetes
Inactivity
ETOH
Obesity
Secondary HTN (known cause) which may be reversible causes include:
Meds/drugs
Chronic kidney disease (RAS, FMD, PKD)*
Endocrine causes
Coarctation of Aorta
Sleep Apnea
Major causes of HTN for 0-18:
Renal parenchymal disease
Aortic coarctation
Major causes for HTN for ages 19-39
Thyroid dysfunction
Fibromuscular dysplasia
Renal parenchymal disease
Endogenous Cushing’s Syndrome
major causes for HTN in ages 40-64
Hyperaldosteronism
Thyroid dysfunction
OSA
Exogenous (Iatrogenic) Cushing’s Syndrome
Pheochromocytoma
Major causes of HTN in ages >65
Renal Artery Stenosis
Chronic Kidney Disease (CKD)
Hypothyroid
Cushing’s (iatrogenic) is caused by which drug?
steroids
Testosterone supplements can increase EPO which can lead to slurrying of blood and lead to:
HTN
What is a cause for resistant HTN caused by low K+ levels?
Aldosteronism (Conn’s Syndrome)
- adrenal tumor
- bilateral adrenal hyperplasia
What is the most common cause of resistant HTN?
sleep apnea
Obstructive sleep apnea (OSA) is also a common cause of :
hypertension
Fibromuscular dysplasia (string of pearls narrowed renal arteries) and tortuosity is a cause of HTN in which population?
younger women
Diffucult to control HTN involving renal arteries in older age?
renal artery stenosis
If treating FMD or Renal artery stenosis with ACE inhibitors, what happens to Cr lab values?
Serum creatinine rises 30%, significantly
FMD (renal string of pearls) and renal artery disease both can compromise sufficient to the glomerular complex and lead to kidney injury.
blood pressure
Kidney’ s issues lead to HTN problems in what manner?
messing with Na+
altered RAS system
increased endothelin (vasoconsticor)
inhib NO
Endocrine disorders -Pheochromocytoma, Carcinoid and other neuroendocrine tumors producing excess:
and have what effect on BP
EPI/NE/DOPAMINE/ SEROTONIN; SSRI/SNRI/TCA (ie antidepressants)-can also raise BP
Coarctation is another cause of HTN , there is a 75% mortality by age
46
Where do you listen for a possible coarctation of the aorta?
posterior, L inferior scapula
What is endogenous cushing’s syndrome?
excess cortisol production (due to tumor on adrenal gland->10-15%); overproduction of ACTH by pituitary tumor ( ie Cushing’s Disease -70% or extra-pituitary, ACTH-producing tumor->10-15%)
Exogenous (iatrogenic Cushing’s): leading to resistant HTN, truncal obesity, striae, elevated glucose, easy bruising, osteoporosis at young age. is more or less common than endogenous Cushing’s and is caused by?
more common, steroids
Which top 3 diet involved issues can affect blood pressure (not including cholesterol)?
High salt, low potassium, and high ETOH
Alcohol has a biphasic affect with BP, how?
low BP ( vasodilation) for the first few hours, followed by vasoconstiction (while sleeping)
EPO is a treatment for chronic renal failure, however, it can worsen HTN in 2 ways:
increases blood viscosity
has direct pressor effect
Hyperthyroidism/hypothroidism can cause HTN?
both actually, via different mechanisms
Other endocrine issues that can cause HTN other than cushings and throid issues include:
hyperparathyroidism and acromegaly-growth hormones excess (fluid retention)
Normally, there is about a 10-20% drop of BP while you sleep which is called the nocturnal dip except which two populations:
of which both have a higher risk of HTN
African americans and those with sleep apnea
What are the things we do clinically when someone is diagnosed with HTN:
look at optic discs for HTN retinopathy
auscultate for cardiac murmurs or bruits
palpate thyroid
check peripheral pulses
directed neuro exam (visual and cognitive changes)
First choice antihypertensives include which 4?
and of those 4, are usually started first because of cost and they are highly tolerated
ace inhibitors (-pril)
angiotensin receptor blockers (-aratns)
CCBs
diuretics (thiazides)
diuretics are used
What diuretic is most commonly prescribed for treatment of HTN?
Hydrochlorothiazide
Though Hydrochlorothiazide is more often prescribed, which diuretic is most effective?
chlorthalidone
more expensive
Continually and repetitively emphasize which lifestyle changes for treatment of HTN:
a diet low in Na+ & high in K+ (DASH), aerobic exercise 3-5 x/wk, limit ETOH, stress management, sleep adequacy
Labs to check and why when diagnosed with primary HTN:
Chem panel: gluclose, electrolytes
CBC: polycythemia
lipids: hyperlipidemia
TSH: thyroid function
UA- leaking protein, renal dz
EKG
If you suspect secondary HTN, what are some important labs to consider:
- BNP (brain natriuretic peptide) and/or echo (ie heart failure)
- Aldosterone/Renin Ratio (hyperaldosteronism)
- Urinary catecholamines (pheo), 5-HIAA (carcinoid)
- Sleep study (OSA)
- AM Cortisol (Cushing’s)
- Magnetic Resonance Angiography of renal arteries (RAS, FMD)
What is the first line treatment for African Americans for HTN as they dont respond as well to ACE inhib, and angiotensin receptor blockers (ARBs)?
start off with diurectics and CCB
What is the first line therapy with diabetics?
ACE ihibs, and ARBs (especially with kidney disease)
Which first line therapy is not used for diabetics?
diuretics, as they can raise blood gluclose levels
Those with kidney disease (like many diabetics) we use:
ACEs and ARBs because they are renal sparing
What is first line HTN therapy for coronary artery disease sufferers:
BBlockers (especially after MI) , add ACE or ARB if BP not at goal, or have LV heart failure
What is the first line therapy for those with or without HTN for those with migraines?
BB and CCB, this can be with or w/o HTN
What first line HTN therapy is contraindicated for those with GOUT?
diuretics, as they can increase uric acid and worsen gout
At what age in kids should one follow ACC/AHA guidelines for treating HTN?
13
you should suspect secondary HTN if child has symptoms under the age of , with no fam hx of HTN, failure to , and thin body
6; thrive; habitus
Common conditions that cause HTN in kids under six with no fam hx of HTN are which 3 conditions:
Suspected or known kidney disease, endocrine disorder or congenital cardiac disorder
What end organ damage can be caused by poorly controlled or undiagnosed HTN?
Stroke or TIA
Vascular dementia (#2 cause of dementia)-“silent strokes”
Chronic kidney disease/renal failure
Myocardial infarction
Left ventricular hypertrophy
Heart failure (diastolic and systolic)
Aortic aneurysm
Retinopathy and retinal artery thrombosis
What do we consider HTN urgency (a type of HTN crisis)?
severe but asymptomatic HTN
SBP ≥ 180 OR DBP ≥ 110 mmHg
NO ACUTE, END-ORGAN INJURY
often caused by noncompliance
men 2:1
What do we consider a hypertensive emergency?
end organ damage
SBP ≥ 180 OR DBP ≥ 110 mmHg
severe chest pain, SOB, headache with confusion or blurred vision, severe back pain, nausea/vomiting, seizures, unresponsive, severe anxiety or sense of impending doom
What is malignant HTN?
subset of HTN Emergency with widespread arteriolar injury of at least 3 organs commonly involving retina, kidneys and brain —>death rates approach 100% if inadequately treated
worst hypertensive emergency
What end organ damage is most common?
cardiac then cerebral
if there is a 20mmhg difference in BP when measuring both arms, asymmetrical bilateral pulses, what pathology would you consider?
aortic dissection
What are some things to look for in a retinal exam with someone in HTN crisis?
(exudates, cotton wool spots
A new S3 sound during auscultation could indicate what?
Heart failure or torn chordae tendinae
How would you treat HTN urgency (no end organ failure, asymptomatic)?
compliance with medications and followup within 24 /48 hours
if compliant, increase dose and/or add another med and f/u
How would you treat a HTN emergency?
Lower BP SLOWLY by 25% in first 60min;
Then 10-15% more over next 6-23 hrs with the goal:
160/100-110mmHg) ICU admission
What are the 3 exceptions to the normal treatment of HTN emergency:
Lower BP SLOWLY by 25% in first 60min;
Then 10-15% more over next 6-23 hrs with the goal:
160/100-110mmHg) ICU admission
Aortic Dissection *
Stroke (Hemorrhagic or Ischemic) *
Eclampsia(HTN+Seizure+Pregnancy
How to treat the HTN emergency aortic dissection:
Lower HR to <60 bpm within
+
SBP to <120 mmHg within minutes
start on an IV
if BP still not at <120 add or nitroprusside or NTG
minutes; 20; BB (esmolol, labetolol); nicardipine
Why is it so important to focus on HR first if an aortic dissection is suspected/occuring?
slow down the amount of blood getting into the pocket to prevent tearing and/or occlusion
How do we treat hypertension emergency with acute ischemic stroke if using tPA?
If thrombolytics indicated (ie tPA) and BP is >220 mmHg:
then use
IV antihypertensives to lower BP to <185/110 before tPA and maintain BP <180/105 mmHg for 24 hrs after tPA
When do we not treat hypertensive emergent acute ischemic stroke with IV antihypertensives:
if not using tPA and BP less than 220/100
What is the BP range that we need to get to in order to treat ischemic stroke with tPA to lower risk of hemorrhagic stroke?
<180-185/110-105
If acute ischemic stroke with >220 mmHg and not using tPA, then tx to get a 15% reduction in 24 hours
slowly
What are the recommendations of high BP (over 220) with hemorrhagic stroke?
Aggressively lower SBP to between 140-160mmHg within first 2-4 hours, but not lower so as not to compromise perfusion
CV risks rise linearly/nonlinearly with BP elevations over 115/75 mmHg
linearly
What effect do NSAIDS have on BP?
they can elevate BP
In a HTN emergency, it is important to bring BP down slowly, with three exceptions:
stroke, eclampsia and aortic dissection
