Cardiology: Hypertension

Question 1

how is HTN defined?

Answer 1

systolic BP>140mmHg and or a diastolic BP >90mmHg based on 3 measurements separated in time.

Question 2

how is essential HTN defined? what percentage of HTN does this represent?

Answer 2

HTN with no identifiable cause

represents 95% of cases of HTN

Question 3

what is risk factor of essential HTN? (7)

Answer 3

family history of HTN or heart disease, a high sodium diet, smoking, obesity, ethnicity (blacks>whites), and advanced age

Question 4

name some signs and symptoms of HTN?

Answer 4

asymptomatic until complications develop

Question 5

what end organ damage should you evaluate for in HTN? in 
brain
eye
heart
kidney

Answer 5

brain (stroke, dementia),
eye (cotton wool exudates, hemorrhage),
heart (LVH),
kidney (proteinuria, chronic kidney disease, renal bruits)

Question 6

what labs should be ordered to evaluate for HTN?

Answer 6

obtain a UA, BUN/creatinine, a CBC, and electrolytes

Question 7

what is first step in treating HTN? wht is most effective?

Answer 7

lifestyle modifications, weight loss is the single most effective lifestyle modification

Question 8

what should BP goal be in healthy pts? for pts with diabetes or renal disease with proteinuria?

Answer 8

BP <130/80mmHg

Question 9

name 3 first line agents used to treat HTN and that have been shown to decrease mortality?

Answer 9

diuretics, ACEIs, and beta-blockers

Question 10

what routine test should be done to test for complications?

Answer 10

renal complications (BUN,creatinine, urine protein-to-creatinine ratio)
cardiac complications (ECG evidence of hypertrophy)

Question 11

a 40 year old male presents for a routine examination. his examination is significant for BP 145/75 mmHg but is otherwise unremarkable, as are his labs. What is the next best step?

Answer 11

with a single BP recording and no evidence of end-organ damage, the next best step should consist of a repeat BP measurement at the end of the examination with a return visit if BP is still high

Question 12

name treatment for HTN using ABCD mnemonic?

Answer 12

ACEIs/ARBs
Beta-blockers
CCBs
Diuretics

Question 13

name causes of 2ndary HTN? using CHAPS as a mnemonic

Answer 13

Cushing's syndrome
Hyperaldosteronism (Conn's syndrome)
Aortic coarctations
Pheochromocytoma
Stenosis of renal arteries

Question 14

how is systolic and diastolic BP defined when normal, prehypertension, stage 1 HTN, stage 2 HTN? according to the JNC7

Answer 14

normal: 160/100

Question 15

what drug therapy according to JNC7 for normal, preHTN, stage 1 HTN, and stage 2 HTN?

Answer 15

normal: encourage lifestyle modification
preHTN: no antihypertensive drug indicated
stage 1 HTN: thiazide diuretics for most pts, ACEIs, ARBs, beta-blockers, CCBs or a combination may be considered
stage 2 HTN: two-drug combination for most pts (usually a thiazide diuretic plus an ACEI, and ARB, a beta-blocker, or a CCB)

Question 16

name 3 medications to treat BP in pts with uncomplicated medical history

Answer 16

diuretics, beta-blockers, ACEIs

Question 17

name 5 medications to treat BP in pts with CHF

Answer 17

diuretics, beta-blockers, ACEIs, ARBs, aldosterone antagonists

Question 18

name 5 medications to treat BP in pts with DM

Answer 18

diuretics, beta-blockers, ACEIs, ARBs, CCBs

Question 19

name 4 medications to treat BP in pt post MI

Answer 19

beta-blockers, ACEIs, ARBs, aldosterone anatagonists

Question 20

name 2 medications to treat BP in chronic kidney disease

Answer 20

ACEIs, ARBs

Question 21

name 2 medications to treat BP in pts with BPH

Answer 21

diuretics and alpha adrenergic blockers

Question 22

name 3 medications used to treat BP in pts with isolated systolic HTN

Answer 22

diuretics, ACEIs, CCBs (dihydropryridines)

Question 23

name etiology of HTN in primary renal disease?

Answer 23

often unilateral renal parenchymal disease

Question 24

how is primary renal disease that causes HTN managed?

Answer 24

treat with ACEIs, which slow the progression of renal disease

Question 25

what is etiology of renal artery stenosis. (2) name common age group (2)

Answer 25

especially common in pts 50 yrs of age with recent onset HTN. etiologies include fibromuscular dysplasia (younger pt) and atherosclerosis (older pts)

Question 26

how is renal artery stenosis diagnosed?

Answer 26

MRA or renal artery Doppler ultrasound

Question 27

how is renal artery stenosis managed? unilateral, bilateral, what is second option

Answer 27

angioplasty or stenting consider ACEIs in unilateral disease in bilateral disease (ACEIs can accelerate kidney failure by preferential vasodilation of the efferent arteriole) open surgery is a second option if angioplasty is no effective or feasible

Question 28

in what pt population can OCP cause HTN

Answer 28

common in women >35 yrs of age, obese women, and those with long standing use

Question 29

how is HTN caused in OCPs managed?

Answer 29

discontinue OCPs (effect may be delayed)

Question 30

how does pheochromocytoma cause HTN? what is triad of symptoms?

Answer 30

an adrenal gland tumor that secretes epinephrine and norepinephrine, leading episodic HA, sweating, and tachycardia

Question 31

how does Conn's syndrome (hyperaldosteronism) cause HTN? name triad of symptoms

Answer 31

an most often 2ndary to an aldosterone-producing adrenal adenoma. causes triad of HTN, unexplained hypokalemia, and metabolic alkalosis

Question 32

name diagnosis and management of HTN in pt with pheochromocytoma?

Answer 32

diagnose with urinary metanephrines and catecholamine levels or plasma metanephrine. surgical removal of tumor after treatment with both alpha and beta blockers

Question 33

name diagnosis, expected lab results, and treatment of HTN caused by Conn's syndrome.

Answer 33

metabolic workup with plasma aldosterone and renin level; increased aldosterone and decreased renin levels suggest primary hyperaldosteronism. surgical removal of tumor

Question 34

name etiology of Cushing's syndrome

Answer 34

due to an ACTH-producing pituitary turmor, an ectopic ACTH-secreting tumor, or cortisol secretion by an adrenal adenoma or carcinoma. also due to exogenous steroid exposure

Question 35

Name management of Cushing's syndrome

Answer 35

surgical removal of tumor; removal of exogenous steroids

Question 36

name management of coarctation of the aorta

Answer 36

surgical repair

Question 37

define hypertensive crises?

Answer 37

a spectrum of clinical presentations in which elevated BPs lead to end organ damage

Question 38

how does hypertensive crises present?

Answer 38

``` renal disease chest pain (ischemia or MI) back pain (aortic dissection) changes in mental status (hypertensive encephalopathy) ```

Question 39

how to diagnose hypertensive urgency

Answer 39

elevated BP with mild to moderate symptoms (HA, chest pain) without end organ damage

Question 40

how is hypertensive emergency diagnosed?

Answer 40

elevated BP with signs or symptoms of impending end organ damage such as acute kidney injury, intracranial hemorrhage, papilledema, or ECG changes suggestive of ischemia or pulmonary edema

Question 41

how is malignant hypertension diagnosed?

Answer 41

progressive renal failure and/or encephalopathy with papilledema

Question 42

how is hypertensive urgency treated?

Answer 42

oral antihypertensives (beta blockers, clonidine, ACEIs) with the goal of gradually lowering BP over 24-48 hrs

Question 43

hypertensive emergencies are treated how?

Answer 43

IV medications (labetalol, nitroprusside, nicardipine) with the goal of lowering MAP by no more than 25% over the first 2 hrs to prevent cerebral hypoperfusion or coronary insufficiency