Clinical Key Htn Flashcards
Definition of Htn
Office blood pressure ≥140 and/or ≥90 Home blood pressure ≥135 and/or ≥85 Ambulatory blood pressure • Daytime (or awake) ≥135 and/or ≥85 • Nighttime (or sleep) ≥120 and/or ≥70 • 24 hour ≥130 and/or ≥80
Risk factors for Htn
- Male
- Age (men ≥55”yr, women ≥65”yr)
- Smoking
- Dyslipidemia
- Impaired fasting glucose (100-125”mg/dL)
- Obesity (BMI ≥ 30”kg/m 2 or waist circumference: men, ≥102”cm, women, ≥88”cm)
- Family history or premature cardiovascular disease (men aged
Asymptomatic Target organ damage of Htn
- Left ventricular hypertrophy by ECG or transthoracic echocardiography
- Chronic kidney disease (eGFR ≤ 60”mL/min/1.73”m 2 )
- Microalbuminuria (albumin-to-creatinine ratio, 30-300”mg/g)
- Ankle-brachial index 10”m/sec
Diabetes Mellitus diagnosis
(fasting plasma glucose ≥126”mg/dL × 2; or hemoglobin A 1C ≥ 7%; or postload plasma glucose >
198”mg/dL
Established cardiovascular or renal disease
- Stroke or TIA
- CAD: myocardial infarction, angina, myocardial revascularization
- Heart failure (with decreased or preserved ejection fraction)
- Intermittent claudication (symptomatic peripheral artery disease)
- Chronic kidney disease with eGFR
Chronic kidney disease
clinical clues
diagnostic testing
Estimated GFR
Renovascular disease
clinical clues
diagnostic testing
New elevation in serum creatinine, marked elevation in serum creatinine with ACE inhibitor or ARB, drug-resistant hypertension, flash pulmonary edema, abdominal or flank bruit
Renal sonography (atrophic
kidney), CT or MR
angiography, invasive
angiography
Coarctation of the aorta
clinical clues
diagnostic testing
Arm pulses > leg pulses, arm BP > leg BP,
chest bruits, rib notching on chest
radiography
MR angiography, TEE,
invasive angiography
Primary aldosteronism
clinical clues
diagnostic testing
Hypokalemia, drug-resistant hypertension
Plasma renin and aldosterone, 24-hour urine aldosterone and potassium after oral salt loading, adrenal vein sampling
cushing Syndrome
clinical clues
diagnostic testing
Truncal obesity, wide and blanching purple
striae, muscle weakness
1”mg dexamethasonesuppression
test, urinary
cortisol after
dexamethasone, adrenal CT
Pheocromocytoma
clinical clues
diagnostic testing
Paroxysms of hypertension, palpitations,
perspiration, and pallor; diabetes
Plasma metanephrines, 24-
hour urinary metanephrines
and catecholamines,
abdominal CT or MR imaging
Obstructive sleep apnea
clinical clues
diagnostic testing
Loud snoring, large neck, obesity,
somnolence
Polysonography
Diet for Htn
- Adopt a diet that is:
• High in vegetables, nuts, fruits, grains, low-fat dairy products, fish, poultry, etc.
• Low in sweets, sugar-sweetened beverages, and red meats
Adapt this dietary pattern to calorie requirements, personal/cultural food preferences, and
medical conditions such as diabetes. - Lower sodium intake
Physical activity for Htn
- Engage in three to four 40-minute sessions of moderate-to-intense aerobic physical
activity per week.
thiazide contraindication
gout
loop diuretics contraindications
hepatic coma
potassium sparing diuretics contraindications
Serum potassium
concentration > 5.5”mEq/L
GFR
ACE inhibitor contraindication
pregnancy
bilatereral renal artery stenosis
hyperkalemia
Dihydropyridine CCB contraindication
as monotherapy in chronic kidney disease with proteinuria
nonidhydropyridine CCB contraindication
heart block
Systolic heart failure
ARBs, DRI contraindications
Pregnancy
bilateral renal artery stenosis
B adrenergic blockers contraindications
heart block
asthma
depression
cocaine and meth abuse
A adrenergic blockers Contraindication
orthostatic hypotension
systolic heart failure
left ventricular dysfunction
Central sympatholytics contraindications
orthostatic hypotension
directi vasodilators contraindication
orthostatic hypotension
thiazide side effects
Insulin resistance, new-onset type 2 diabetes
Hypokalemia, hyponatremia
Hypertriglyceridemia
Hyperuricemia, precipitation of gout
Erectile dysfunction (more than other drug classes)
Potentiate nondepolarizing muscle relaxants
Photosensitivity dermatitis
Loop diuretics side effects
Interstitial nephritis
Hypokalemia
Potentiate succinylcholine
Potentiate aminoglycoside ototoxicity
K sparing diuretics side effects
Hyperkalemia
ACE inhibitor side effects
Cough Hyperkalemia Angioedema Leukopenia Fetal toxicity Cholestatic jaundice (rare fulminant hepatic necrosis if the drug is not discontinued)
Dihydropyridine CCB side effects
Headaches Flushing Ankle edema Heart failure Gingival hyperplasia Esophageal reflux
Nondihydropytidine CCB Side effects
Bradycardia, AV block (especially with verapamil)
Constipation (often severe with verapamil)
Worsening of systolic function, heart failure
Gingival edema or hypertrophy
Increase cyclosporine blood levels
ARBs, DRI side effects
hyperkalemia
angioedema (rare)
B adrenergic blockers side effects
New-onset type 2 diabetes (especially in combination with a thiazide)
Heart block, acute decompensated heart failure
Bronchospasm
Depression, nightmares, fatigue
Cold extremities, claudication (β 2 effect)
Stevens-Johnson syndrome
Agranulocytosis
A adrenergic blockers side effects
Orthostatic hypotension
Drug tolerance (in the absence of diuretic
therapy)
Ankle edema
Heart failure
First-dose effect (acute hypotension)
Potentiate hypotension with PDE-5 inhibitors (e.g., sildenafil)
central sympatholytics side effects
Depression, dry mouth, lethargy
Erectile dysfunction (dose dependent)
Rebound hypertension with clonidine withdrawal
Coombs test–positive hemolytic anemia
and elevated liver enzymes with α-methyldopa
Direct Vasodilators side effects
Reflex tachycardia
Fluid retention
Hirsutism, pericardial effusion with minoxidil
Lupus with hydralazine
Blood pressure treatment goals
Preferred first-line htn treatment
Three choices: calcium channel blocker, ACE inhibitor or ARB, or thiazide diuretic (chlorthalidone preferred)
Combination treatment htn
Good option for stage 1 hypertension
ACE inhibitor + calcium channel blocker preferred over an ACE inhibitor + thiazide-type diuretic
prehypertenstion
ARB
htn in general
CCB, ACE-I or ARB, D
htn in elderly pts
CCB, ACE-I or ARB, D
HTN WITH LEFT VENTRICULAR HYPERTROPHY
ARB, D, CCB
htn in pts with dibatees mellitus
CCB, ACE-I or ARB, D
htn in pts with diabetic nephropathy
ARB, D
htn in nondiabetic chornic keney disease
ACE-I or ARB, BB, D
bp reduction for secondary prevention of coronary events
ACE-I, CCB, BB, D
BP recution for secondary prevention of stroke
ACE-I + D, CCB
bp management for patient with heart failure
D, BB, ACE-I or ARB, aldosterone antagonist
Gestational hypertension (stage 2, without preeclampsia)
Labetalol, nifedipine, methyldopa
thoracic aortic aneurysm
BB, ACE-I or ARB, D
Atrial fibrillation (ventricular rate control)
BB, nondihydropyridine CCB
psuedoresistant htn
Inadequate medical regimen Pressor substances (e.g., nonsteroidal anti-inflammatory drugs [NSAIDs], calcineurin inhibitors such as cyclosporine or tacrolimus, or sympathomimetics such as cocaine or methamphetamine) White coat reaction, improper blood pressure measurement Medication nonadherence
Truly resistant htn
Chronic kidney disease Primary aldosteronism Other secondary hypertension (e.g., pheochromocytoma, Cushing syndrome, atherosclerotic renal artery stenosis, fibromuscular renal artery stenosis, Takayasu arteritis, coarctation of the aorta, hyperthyroidism, hypothyroidism, hyperparathyroidism) Difficult primary hypertension
Hypertensive crisis with
retinopathy,
microangiopathy, or acute
renal insufficiency
Labetalol
Hypertensive
encephalopathy
Labetalol
Acute aortic dissection
Nitroprusside plus
metoprolol
Acute pulmonary edema
Nitroprusside with loop
diuretic
Acute coronary syndrome
Nitroglycerine
Acute ischemic stroke and
BP > 220/120”mm”Hg
Labetalol
Cerebral hemorrhage and
Systolic BP > 180”mm”Hg
or MAP > 130”mm”Hg
Labetalol
Acute ischemic stroke with
indication for thrombolytic
therapy and BP >
185/110”mm”Hg
Labetalol
Cocaine/XTC intoxication
Phentolamine (after
benzodiazepines)
Pheochromocytoma crisis
Phentolamine
Perioperative
hypertension during or
after CABG
Nicardipine
During or after craniotomy
Nicardipine
Severe
preeclampsia/eclampsia
Labetalol (plus MgSO 4 and oral antihypertensive medication such as nifedipine with or without methyldopa)
Contraindications and side effects
Labetalol
Second- or third-degree
AV block; systolic heart
failure, COPD (relative);
bradycardia
Contraindications and side effects
nicardipine
Liver failure
Contraindications and side effects
nitroprusside
Liver/kidney failure
(relative), cyanide
toxicity
Contraindications and side effects
nitroglycerine
none
Contraindications and side effects
Urapadil
none
Contraindications and side effects
Esmolol
Second- or third-degree
AV block, systolic heart
failure, COPD (relative);
bradycardia
Contraindications and side effects
Phentolamine
Tachyarrhythmia,
angina pectoris
Health system
- Standardized medication intensification protocol
- Team-based approach involving clinical pharmacists
- Pay providers for performance
Drug Treatment
- Low-dose combination therapy
- Best-tolerated drug classes
- Fixed-dose single pill combinations
- Long-acting once daily drugs
- Low-cost generics
Patient Engagement
- Low-dose combination therapy
- Best-tolerated drug classes
- Fixed-dose single pill combinations
- Long-acting once daily drugs
- Low-cost generics
