Essential Hypertension Flashcards
Look for secondary HTN evaluation in Nephrology for secondary work up.
when does cough related to ACEi start?
within 1-2 weeks after starting but can start up to 6 months later. Non productive
how does the cough happen?
ACE metabolizes kinins and substance P and so ACEi will increase kinins and substance P which possibly induces bronchial irritation and cough.
How to stop the cough related to ACEi?
Stop ACE and takes 1 -4 weeks for cough to resolve. Changing to different ACEI will still cause cough to continue.
What if cough doesn’t go away after stopping ACEi?
need to look at other causes.
Goal BP for ppl >60
<150/90 and start therapy if above (per JNC 8)
Age <60 or CKD or DM2 BP goals
<140/90 or initiate therapy if above
Initial HTN treatment choice for blacks
thiazide or CCB alone or in combination. Acei/ARB not first line
initial HTN treatment choice for all ethnicities except black
thiazide, ACEi, ARB or CCB alone or in combo
All ethnicities w/ CKD, initial HTN tx choice
ACE or ARB alone or in combo with other classes
When to start combination therapy to treat HTN?
if pt’s BP is >160/100 or 20/10 above target or do not achieve goal on monotherapy need combo therapy.
FOR BOARDS: chlorthalidone may be preferred over HCTZ due to higher potency and longer duration of action
True (FOR boards) but be aware of chlorthalidone causing hyponatremia in real life.
When is spironolactone helpful
when pts have uncontrolled HTN despite 3 BP drugs and relatively contraindicated in men with potential antiandrogenic effects.
When can angioedema occur as a side effect of ACEi?
can occur anytime and this can happen 0 .5% IT is not dependent on dosage or type of ACEi.
what are the risk factors for angioedema related to ACEi?
African descent, female gender, smoking, use of NSAIDs. affects lips, tongue and face and upper airways. can affect intestines and result in abdominal pain and swelling and ascities
Does angioedema present with itching or urticaria?
NO. Can see hoarseness and strider if upper airways are affected.
why does angioedema happen with ACEI
because they inhibit ACE and so there’s elevated levels of bradykinin and so this is not histamine mediated. so fresh frozen plasma may be used since it contains ACE which degrades bradykinin but also may have a paradoxical effect too
What to do if someone needs to be on the cardioprotective effects of ACE and get angioedema
stop the ACEI and can start them on ARBS but there is a 1.5-10% rate of recurrence with angioedema in pts who were switched to ARBs. Recurrent angioedema is seen within 1 month of discontinuation of ACE i so may have a residual effect of ace i rather than ARB use.
how much does DASH DIET lower BP
8-14 SBP
weight loss helps HTN how?
reduction of BMI<25 and this can lower SBP by 5-20 per 10 kg loss
how much exercise does help HTN?
30/min day for 5-6 days/week lowers by 4-9 SBP
pts who have HTN >20/10 above goal should
have combination antihypertensive therapy started with 2 or more medications to reach their goal BP
Drugs that elevate BP?
NSAIDS Antidepressants (TCAs, doxepin) Steroids (prednisone) oral contraceptives decongestants (pseudoephedrine) Migraine medications (triptans and ergotamines) erythropoietin
what herbal supplement elevates BP
licorice (mimics aldosterone)
NSAIDS can cause injury
enhances renal vasoconstriction, induces interstitial nephritis, or causes glomerulonephritis (minimal change or membranous nephropathy).
NSAIDS can also raise blood pressure due to
sodium retention and attenuate the effect of diuretic agents (leading to increased BP) and blunt the blood pressure lower effects of several antihypertensive agents.
peripheral edema from CCB is seen in
5-10% of pts and results from preferential arterial dilation which increases the pressure gradient between the capillaries and interstitium leading to extravasation of intravascular fluid
What helps prevent the development of CCB induced edema
ACE i and CCB Accomplish trial showed that starting both ACEi and CCB better with lower ASCVD events compared to ACEi and thiazide.
beta blockers side effects on prediabetic pts?
increased risk for developing diabetes or glucose intolerance (not carvedilol) benefit for pts with recent MI or CHF
calicum channel blockers side effects on prediabetic pts?
little effect on glucose metabolism
thiazide side effects on prediabetic ps?
greatest effect on glucose and lipid metabolism of all antihypertensive pts and favorable cardiovascular out comes esp in CHF and stroke and favorable cost profile especially effective in AA and older women.
adverse side effects of thiazides
see hypokalemia, hyponatremia, hyperuricemia and elevated TG’s. Increased risk for developing diabetes.
What to be done with someone has a new diagnosis of HTN?
get EKG, UA, and maybe TTE need to screen for HLD and A1c.
Guidelines for BP JNC 8
when to get ambulatory BP monitoring
evaluate for white coat sydrome
episodic HTN
resistant HTN
hypotensive symptoms on antihypertensive therapy
If suspecting “white coat” hypertension what do we order?
get 24 hr ambulatory blood pressure monitoring- measures and records pulse and BP at 15 to 20 minutes during the day and at 30 to 60 minute intervals at night.
ABPM more closely predicts the future cardiovascular events and all cause mortality than either physician office or home blood pressure measuremetns. if ABPM are normal, then pt has no evidence of end organ damage and so no need for anti hypertensive meds
be careful. “white coat” hypertension pts are at risk for developing sustained HTN and so need close monitoring.
I
Criteria for HTN based on 24 hr BP monitoring
24 hr average>125/75
Daytime (awake) >130/80
Nighttime (asleep) >110/65
masked hypertension
normal BP in the office but elevated in ambulatory setting
needs to be confirmed with ambulatory BP monitoring or 24 hr home blood pressure monitoring.
treating african american people with HTN. first line medications should be:
calcium channel blockers and thiazides
not ACEi. ALL HAT showed thiazide diuretic was more effective in improving cardiovascular outcomes compared to ACE i and higher risk of stroke with ACEi as initial therapy compared to CCB,
