CHAPTER 25–27 HYPERTENSION

Question 1

5 ADVERSE EFFECTS OF HYPERTENSION

Answer 1

–acceleration of atherogenesis
–Elevated systolic and diastolic pressures are independent risk
–often occurs in combination with other risk factors such as dyslipidemia, glucose intolerance, hyperinsulinemia, obesity
–Association of hypertension and other risk factors is multiplicative rather than additive

Question 2

what is the increase in cardiovascular disease associated with elevated blood pressures

Answer 2

115/75, cardiovascular disease risk doubles with each increase of 20/10

Question 3

percent reduction in risk with blood pressure treatment

Answer 3

with drug therapy for hypertension:
–stroke decreases by 35%
–Myocardial infarction decreases by 20%
–Heart failure decreases by 50%

Question 4

classification of high blood pressure

Answer 4

<120 and <80 = normal
120–139 or 80–89 = pre-hypertension

140–159 or 90–99 = stage I hypertension
>160 or >100 = stage II hypertension

Question 5

prevalence of hypertension worldwide

Answer 5

–about 1 billion persons worldwide with hypertension
–About 70 million deaths per year worldwide
–Increased prevalence in developing countries
–#1 cause of preventable death in developing countries

Question 6

prevalence of hypertension in US adults

Answer 6

–30% of adults in US have hypertension

–30 million men
–35 million women

Question 7

percent of patients with hypertension who are aware of disease

Answer 7

76% are aware of disease

65% receiving medication

37% have controlled hypertension

Question 8

etiology of hypertension

Answer 8

–most often results from increased total peripheral vascular resistance
–Increased cardiac output places lesser part

Question 9

physiologic causes of hypertension

Answer 9

–inappropriate activation of renin–angiotensin system.
–Decreased renal sodium excretion.
–Increase in sympathetic nervous system activity

Question 10

environmental factors and hypertension

Answer 10

–excess sodium intake
–Obesity
–Stress

Question 11

discuss isolated systolic hypertension

Answer 11

–correlates with stiffening of large arteries
–Increase in systolic pulse-wave velocity
–Causes increase in systolic blood pressure and increased myocardial work with decrease coronary perfusion

Question 12

clinical presentation of hypertension

Answer 12

usually asymptomatic

Question 13

cardiac manifestations of hypertension

Answer 13

result from hypertrophic effects of increased afterload and acceleration of coronary atherosclerosis caused by hypertension

Question 14

left ventricular hypertrophy discussion

Answer 14

Left ventricular hypertrophy is powerful and independent risk factor for cardiovascular morbidity.
–Is usually concentric hypertrophy = increase in wall thickness relative to chamber dimensions

Question 15

myocardial fibrosis discussion

Answer 15

stimulated in part by angiotensin II and aldosterone levels
–Causes decreased ventricular compliance and diastolic dysfunction
–May result in congestive heart failure despite normal ventricular systolic function

Question 16

coronary artery disease and hypertension

Answer 16

hypertension is independent risk factor for coronary artery disease.
–LVH and accelerated atherosclerosis combine to greatly enhanced risk for congestive heart failure and cardiovascular death

Question 17

characteristics of patients with diastolic heart failure

Answer 17

–tend to be older, female and hypertensive
–Less mortality
–Normal left ventricular ejection fraction
–Typically long-standing hypertension and LVH

Question 18

malignant/accelerated hypertension

Answer 18

–very high systolic and diastolic pressures
–Severe neuroretinitis
–Proteinuria
–Microscopic hematuria
–Impairment of renal function
Other symptoms caused by proliferative endocarditis and fibroid necrosis and small arteries

Question 19

differential diagnoses of hypertension

Answer 19

–95% have essential hypertension.
–5% is secondary hypertension
–Obesity is contributing factor to essential hypertension.

Question 20

drugs causing secondary combined systolic and diastolic hypertension

Answer 20

–oral contraceptives
–Estrogens
–licorice
–Cyclosporine
–Cocaine
–Amphetamines
–Sympathomimetics
–Monoamine oxidase inhibitors

Question 21

secondary causes of isolated systolic hypertension

Answer 21

increased left ventricular STROKE VOLUME
–COMPLETE HEART BLOCK
–AORTIC REGURGITATION
–PATENT DUCTUS ARTERIOSUS
–HYPERTHYROIDISM
–ARTERIOVENOUS FISTULA
–SEVERE ANEMIA
–BERIBERI
–PAGET'S DISEASE OF BONE

Decreased aortic distensibility
–Aortic arteriosclerosis
–Coarctation of aorta

Question 22

indications for searching for secondary hypertension

Answer 22

–age of onset <20 years
–Age of onset >50 years
–target organ damage
–Serum creatinine >1.5 mL/deciliter
–Hypokalemia
–Abdominal bruit
–Labile pressures with tachycardia, sweating, and tremor
–Family history of renal disease
–Poor response to generally effective therapy

Question 23

DASH diet

Answer 23

= dietary approach to stop hypertension

–fruits, vegetables, low-fat dairy products,
–Rich in potassium, magnesium, and calcium

–Low in sugar, red meat, added fats,sodium

Question 24

first-line hypertension drugs

Answer 24

Dyazide diuretics
Beta-adrenergic receptor blockers
Angiotensin-converting enzyme inhibitors
Angiotensin receptor blockers
Calcium antagonists

Question 25

defining hypertensive crisis

Answer 25

acute organ dysfunction of the cardiovascular nervous system accompanying either by a marked absolute elevation of blood pressure 1 her blood increase in blood pressure in a previously normotensive individual

Question 26

antihypertensives contraindicated in pregnancy

Answer 26

ACE inhibitor, | angiotensin receptor blocker

Question 27

antihypertensive contraindicated in renal insufficiency

Answer 27

potassium sparing agents is a relative contraindication

Question 28

antihypertensives contraindicated in peripheral vascular disease

Answer 28

beta blocker

Question 29

antihypertensive contraindicated in gout

Answer 29

diuretic

Question 30

antihypertensives contraindicated in depression

Answer 30

–beta blocker | –Central alpha agonist

Question 31

common central alpha agonist medications

Answer 31

–clonidine –Guanfacine –Methyldopa

Question 32

percentage of middle-aged persons and United States with high blood pressure

Answer 32

20%

Question 33

common causes of secondary hypertensionin elderly

Answer 33

–renal parenchymal disease | –Atherosclerotic renal artery stenosis

Question 34

causes of renal artery stenosis

Answer 34

–atherosclerosis= 90% | –Fibromuscular dysplasia = 10%

Question 35

pathogenesis of renal artery stenosis

Answer 35

``` –same as generalized atherosclerosis obliterans –Smoking –Dyslipidemia –Hypertension –Glucose intolerance –Genetic predisposition ```

Question 36

definition of renal vascular hypertension

Answer 36

= secondary to atherosclerotic renal artery sclerosis or fibromuscular dysplasia, causing a decrease in renal perfusion pressure

Question 37

define high-grade renal artery stenosis

Answer 37

>60% of lumen of major renal artery –Accounts for 3% of cases of hypertension –Does not always cause hypertension

Question 38

smoking and renal artery stenosis

Answer 38

90% of older patients with renal artery stenosis are or have been heavy smokers –Usually Other atherosclerosis

Question 39

discussed renal artery stenosis caused by fibromuscular dysplasia

Answer 39

–presents at younger age –Common in women under 50 years old –Can occur in children +/- Abdominal bruit

Question 40

differential diagnosis of renal vascular hypertension and essential hypertension

Answer 40

–in older people with peripheral vascular disease, prevalence of atherosclerotic renal artery stenosis is high EKG up to 50%. –Prevalence of essential hypertension in this group is 60%. –Therefore difficult to separate

Question 41

diagnosis of renal artery stenosis

Answer 41

–Gold standard his renal arteriogram showing stenosis of proximal third of the renal artery –fibromuscular dysplasia shows characteristic areas of stenosis alternating with aneurysmal dilation dictation = "string of pearls" – Renal arteriogram is expensive, invasive, and does not provide information on function. –Doppler ultrasound of renal arteries is often used, but less predictable and more operator dependent

Question 42

treatment renal artery stenosis

Answer 42

–surgical revascularization with balloon angioplasty and/or vascular stent –Medical treatment= treatment of underlying causes and lifestyle

Question 43

mechanism of secondary hypertension caused by adrenal cortex

Answer 43

–overproduction of aldosterone –Overproduction deoxy corticalsterone –Overproduction of cortisol

Question 44

examples of mineralocorticoids versus glucocorticoids

Answer 44

mineralocorticoids –Aldosterone –desoxy corticosterone (DOC) glucocorticoids –Cortisol

Question 45

function of mineralocorticoids in secondary hypertension

Answer 45

increase salt and water retention by kidney

Question 46

function of glucocorticoids and secondary hypertension

Answer 46

marked hypersecretion of cortisol can stimulate mineralocorticoid receptors and cause a release of DOC and vasoconstrictors

Question 47

normal control of aldosterone secretion

Answer 47

by renin-angiotensin system –ACTH and serum potassium concentrations less important

Question 48

mechanism of hypertension caused by aldosterone

Answer 48

increased stimulation of mineralocorticoid receptors and a cortical collecting ducts of the kidney –Causes (of sodium channels leading to increased tubular reabsorption of sodium and secondary reabsorption of water –Also increased secretion of potassium and hydrogen ions

Question 49

idiopathic hyperaldosteronism

Answer 49

= 30% of patients with hyper aldosteronism –Surgically curable aldosterone producing adenoma Two thirds have bilateral adrenal gland hyperplasia

Question 50

clinical presentationof primary aldosteronism

Answer 50

``` –hypertension –Hypokalemia –Excessive urinary excretion of potassium –Suppressed plasma renin activity –Mild hyponatremia –Metabolic alkalosis ```

Question 51

symptoms of hypokalemia

Answer 51

``` –polyuria –Polydipsia –Muscle cramps –Muscle weakness –Glucose intolerance ```

Question 52

suspect primary aldosteronism when

Answer 52

–hypertension with spontaneous hypokalemia –Hypertension with severe and refractory diuretic induced hypokalemia –Family history of hyperaldosteronism –Unexplained hypertension, refractory to treatment –Unexplained hypertension in children and young adults –Incidentally discovered adrenal tumor

Question 53

testing for primary aldosteronism

Answer 53

measure plasma aldosterone concentration and plasma renin activity

Question 54

treatment of primary aldosteronism

Answer 54

–surgical adrenalectomy | –Spironolactone

Question 55

discuss pheochromocytoma

Answer 55

= a tumor arising from adrenal medullary chromaffin cells that produces excess secretion of catecholamines causing intermittent or sustained hypertension

Question 56

symptoms of pheochromocytoma

Answer 56

hypertension with triad of headache, sweating, palpitations ``` Other common symptoms –Pallor –Nausea –Tremor –Weakness –Anxiety –Epigastric pain –Chest pain –Flushing –Dizziness ```

Question 57

hypertension and Cushing's disease

Answer 57

–hypertension may be severe | –Target organ damages is common