Case 8: Hypertension Flashcards
USPSTF screening recommendation for hypertension
Screen in patients with no known HTN starting at 18
Normal blood pressure
SBP: <120
DBP: <80
Prehypertension
SBP: 120-139
DBP: 80-89
- technically a higher subset of normal blood pressure
- used to identify pts in whom early intervention of healthy lifestyles could reduce blood pressure
HTN (<60 yrs old)
SBP: >140
DBP: >90
HTN (>60 yrs old)
SBP: >150
DBP: >90
JNC8 update
Updated EBM recs for management of high BP
Defaulted recommendations for Dx and prevention of high BP to earlier JNC7 report
3 questions to ask someone with new diagnosis of hypertension
- Presence of end organ damage (brain, heart, kidneys, vasculature, eyes)
- Presence of cardiovascular risk factors or other co-morbid conditions
- Reveal potential causes of hypertension
Also can ask
- Family hx of diabetes, hypercholesterolemia
- pt’s diet history
- review of psychosocial stressors (stress causes direct release of Ag2 and norepi)
Signs of end organ damage due to hypertension (brain, heart, kidneys, vasculature, eyes)
Heart
- LVH, angina, prior MI, prior coronary revasc, CHF
Brain
- stroke, TIA
Kidney
- chronic renal failure
Vasculature
- peripheral artery disease
Eyes:
- retinopathy
Patient with X number of years of HTN probably already has end organ disease
10
Major cardiovascular RFs or concomitant disorders that affect prognosis/treatment of HTN (11)
- diabetes
- high cholesterol
- obesity
- family Hx of premature CV disease or death (<55 in men, <65 in women)
- smoking
- alcohol
- cocaine, ketamine, narcotic withdrawel
- age (>55 in men, >65 in women)
- physical inactivity
- microalbuminuria
- GFR = 60
Causes of high blood pressure
- sleep apnea
- renovascular disease
- CKD
- primary aldosteronism
- pheochromocytoma
- coarctation of aorta
- thyroid disease
- parathyroid disease
- OCPs, amphetamines, steroids
- pseudophedrine, NSAIDs, appetite suppressants
- St John’s Wart, ginseng, licorice, ma huang, bitter orange, ginkgo
- smoking, alcohol, cocaine, ketamine, narc w/drawal
Causes of hypertension
Essential hypertension (95%) Secondary hypertension (5%): sleep apnea, CKD, renovascular, drug, pheo, aldosteronism, chronic steroids, Cushings, thyroid/parathyroid dz, coarc of aorta
How to accurately dx HTN
2 elevated measurements 5 minutes apart, one in each arm on 2 or more visits (can’t be Dx if acutely ill or in pain)
- pt should be seated quietly for at least 5 min
- support back, arm at heart level
- need correct size cuff: length should be 80% arm circumference and width should be 40% arm circumference (bc cuff that is too small will give erroneously high BP) – with obese - need to use XL or thigh cuff instead of adult sized cuff
BMI Underweight
<18.5
BMI Normal
18.5-24.9
BMI Overweight
25.-29.9
BMI Obese
30-40
BMI Extreme obesity
> 40
People with white coat HTN should..
- check BP at home
2. still receive ongoing surveillance for development of essential HTN
Hypertensive retinopathy fundoscopy
Cotton wool spots
Flame hemorrhages
Exudates
Hypertensive emergency fundoscopy
Papilledema
Signs on PE that point to progression of HTN
- carotid, abdominal, femoral bruits
- crackles, diminished breath sounds (CHF)
- AAA pulsation
- enlarged PMI
How to monitor HTN
Only need ONE measurement in ONE arm for ongoing monitoring
Patient’s explanatory model of illness/health may overlap or diverge from…
Physician’s biomedical model of disease
What tests are indicated in the initial workup of HTN?
- EKG
- UA
- Blood glucose
- Blood hematocrit
- Serum potassium
- Serum calcium
- Serum creatinine and corresponding GFR
- urine albumin/creatinine
- Fasting lipids
(do not need TFTs, echo, LFTs, Na, Cl)
EKG for initial evaluation of HTN
To assess rate and rhythm
- beta blockers and CCBs are contraindicated in people with abnormal R/R
To assess LVH
- 2nd indicator of death prognosis (first is age)
UA for initial evaluation of HTN
To assess glucosuria (look for diabetes as co-morbid)
To assess proteinuria (evidence of HTN nephropathy)
Blood glucose for initial evaluation of HTN
To assess for diabetes as co-morbid condition
Blood hematocrit for initial evaluation of HTN
To assess for anemia
- anemia makes major CV events (MI, stroke) more likely
- can also be product of end organ damage in moderate/severe renal disease
Serum K for initial evaluation of HTN
Obtain baseline because several anti HTN make pts hyperkalemic (ACEIs, ARBs, K sparing diuretics)
Also some secondary causes of HTN cause hyperK: primary aldosteronism, Cushings
Serum Ca for initial evaluation of HTN
33% of pts with hyperparathyroidism + HTN have illness that can be attributed to renal parenchymal damage due to nephrolithiasis
Serum creatinine and GFR for initial evaluation of HTN
Can point to hypertensive nephropathy
Also some anti HTN raise serum creatinine (ACEIs, ARBs, diuretics)
Urine albumin/creatinine ratio for initial evaluation of HTN
To assess for microalbuminuria
Fasting lipids (total cholesterol, HDL, LDL, triglycerides) for initial evaluation of HTN
Look for lipid co-morbidities
Management of HTN involves (4)
- Lifestyle modifications
- Pharmaceutical management according to JNC 8 guidelines, all which apply to pts > 18 - choose agent based on age, diabetes status, CKD status
- If BP not at goal, max first or add second
- If BP not at goal w 2 meds maxed out, continue adding from other classes (but never ACEI + ARB together)
Age < 60
General non black population
ACEI
ARBs
CCBs
Thiazide diuretics
Goal: 140/90
Age < 60
General black population
CCBs
Thiazide diuretics
Goal: 140/90
Age > 60 General population (non black or black)
ACEI
ARBs
CCBs
Thiazide diuretics
Goal: 150/90
Any age + any race + CKD
ACEI
ARBs
Goal: 140/90
Any age + any race + diabetes
ACEI
ARBs
CCBs
Thiazide diuretics
Goal: 140/90
Are beta blockers and alpha blockers first line therapies for HTN?
No
Poor support in clinical trials
Thiazide diuretics
Most cost effective anti HTN drug
- marked reduction in M/M from HTN in comparison to never, more expensive anti HTN medications
- diminished returns when increase dose to 50 mg (low dose inexpensive thiazide diuretics are the best and should be used as first choice drug in most HTN pts except those with CKD)
- may slow demineralization in osteoporosis
Thiazide complications
- can cause hyponatremia: monitor electrolytes
- can precipitate gout flares: avoid in pt w Hx of gout
- can exacerbate urinary incontinence
- can cause elderly to be hypotensive if used at too high doses
Starting dose for thiazides in normal adult
25 mg
Starting dose for thiazides in elderly
6.25 or 12.5mg and then titrate up
Lifestyle modifications that lower BP in order of increasing SBP reduction range
Weight reduction DASH eating plan Physical activity Sodium restriction Moderation of alcohol consumption
Sodium restriction is defined by
<100 mmol/day = 2.4 Na or 6 g NaCl
Moderation of alcohol consumption is defined by
no more than 2 drinks/day for men
no more than 1 drink/day for women
USPSTF aspirin recommendations
Start aspirin to reduce risk of MI in
a) men 45 to 79
b) women 55 to 79
JNC7 aspirin recommendations
In pts with HTN, only judiciously prescribe aspirin when BP in normal range (otherwise, risk of hemorrhagic stroke)
Alpha blockers in management of HTN
- no evidence that shows the decrease M/M
- only utilized as adjunct in hart to control blood pressure
- often prescribed in prostatism but shouldn’t be used as first line anti HTN in pts w BPH
In which ethnicities are BP control rates the lowest?
Native Americans
Mexican Americans
African Americans and HTN
- reduced BP responses to monotherapy with ACEIs, ARBs, and BB (but still reduce M/M in AA)
- 2-4x more likely to develop angioedema from ACEIs
- ACEIs/ARBs only recommended as first line treatment in blacks if they have CKD (can be used as third, fourth line treatment in general black population however)
Beta blockers special considerations
- check EKG and pulse prior to starting because should be avoided in patients with third degree heart block
- avoid in asthma patients
- do not mask hypoglycemic episodes in diabetics (myth)
- good for use in pts with tachy/fibrillation, migraines, essential tremor, perioperative HTN
ACEIs special considerations
- first line in diabetics and CKD pts (renal protective)
- monitor Na, K, creatinine (rise above 35% baseline in creatinine is acceptable)
- Category C drug in pregnancy: avoid
- have direct heart remodeling effects
- Cough common side effect (bradykinin)
- Angioedema is serious side effect)
- reduces microalbuminuria
ARB special considerations
- Category C drug in pregnancy: avoid
- have direct heart remodeling effects
- Cough common side effect (bradykinin) but less
- reduces microalbuminuria and macroalbuminuria
CCB special considerations
- useful in Raynauds and certain arrhythmias
- can cause leg edema
- only use long acting (short acting contraindicated)
Loop diuretic special considerations
- monitor electrolytes
- start at lower doses in elderly
Aldosterone antagonist and K sparing diuretic special considerations
- can cause hyperkalemia so avoid in pts with K>5
- low dose aldo antagonist reduces M/M in CHF
but high dose aldo antagonist increases sudden death
Alpha blocker special considerations
- not mentioned in JNC for Tx of HTN - only useful as adjunct in hard to control BP
- can be used in prostatism but not as first line anti HTIN in pts with BPH
Refer to specialist when…
Fail to control BP in pts maxed out on 3 drug regimen that includes a diuretic
