Essential Hypertension

Question 1

when does cough related to ACEi start?

Answer 1

within 1-2 weeks after starting but can start up to 6 months later. Non productive

Question 2

how does the cough happen?

Answer 2

ACE metabolizes kinins and substance P and so ACEi will increase kinins and substance P which possibly induces bronchial irritation and cough.

Question 3

How to stop the cough related to ACEi?

Answer 3

Stop ACE and takes 1 -4 weeks for cough to resolve. Changing to different ACEI will still cause cough to continue.

Question 4

What if cough doesn’t go away after stopping ACEi?

Answer 4

need to look at other causes.

Question 5

Goal BP for ppl >60

Answer 5

<150/90 and start therapy if above (per JNC 8)

Question 6

Age <60 or CKD or DM2 BP goals

Answer 6

<140/90 or initiate therapy if above

Question 7

Initial HTN treatment choice for blacks

Answer 7

thiazide or CCB alone or in combination. Acei/ARB not first line

Question 8

initial HTN treatment choice for all ethnicities except black

Answer 8

thiazide, ACEi, ARB or CCB alone or in combo

Question 9

All ethnicities w/ CKD, initial HTN tx choice

Answer 9

ACE or ARB alone or in combo with other classes

Question 10

When to start combination therapy to treat HTN?

Answer 10

if pt’s BP is >160/100 or 20/10 above target or do not achieve goal on monotherapy need combo therapy.

Question 11

FOR BOARDS: chlorthalidone may be preferred over HCTZ due to higher potency and longer duration of action

Answer 11

True (FOR boards) but be aware of chlorthalidone causing hyponatremia in real life.

Question 12

When is spironolactone helpful

Answer 12

when pts have uncontrolled HTN despite 3 BP drugs and relatively contraindicated in men with potential antiandrogenic effects.

Question 13

When can angioedema occur as a side effect of ACEi?

Answer 13

can occur anytime and this can happen 0 .5% IT is not dependent on dosage or type of ACEi.

Question 14

what are the risk factors for angioedema related to ACEi?

Answer 14

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

Question 15

Does angioedema present with itching or urticaria?

Answer 15

NO. Can see hoarseness and strider if upper airways are affected.

Question 16

why does angioedema happen with ACEI

Answer 16

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

Question 17

What to do if someone needs to be on the cardioprotective effects of ACE and get angioedema

Answer 17

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.

Question 18

how much does DASH DIET lower BP

Answer 18

8-14 SBP

Question 19

weight loss helps HTN how?

Answer 19

reduction of BMI<25 and this can lower SBP by 5-20 per 10 kg loss

Question 20

how much exercise does help HTN?

Answer 20

30/min day for 5-6 days/week lowers by 4-9 SBP

Question 21

pts who have HTN >20/10 above goal should

Answer 21

have combination antihypertensive therapy started with 2 or more medications to reach their goal BP

Question 22

Drugs that elevate BP?

Answer 22

NSAIDS Antidepressants (TCAs, doxepin) Steroids (prednisone) oral contraceptives decongestants (pseudoephedrine) Migraine medications (triptans and ergotamines) erythropoietin

Question 23

what herbal supplement elevates BP

Answer 23

licorice (mimics aldosterone)

Question 24

NSAIDS can cause injury

Answer 24

enhances renal vasoconstriction, induces interstitial nephritis, or causes glomerulonephritis (minimal change or membranous nephropathy).

Question 25

NSAIDS can also raise blood pressure due to

Answer 25

sodium retention and attenuate the effect of diuretic agents (leading to increased BP) and blunt the blood pressure lower effects of several antihypertensive agents.

Question 26

peripheral edema from CCB is seen in

Answer 26

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

Question 27

What helps prevent the development of CCB induced edema

Answer 27

ACE i and CCB Accomplish trial showed that starting both ACEi and CCB better with lower ASCVD events compared to ACEi and thiazide.

Question 28

beta blockers side effects on prediabetic pts?

Answer 28

increased risk for developing diabetes or glucose intolerance (not carvedilol) benefit for pts with recent MI or CHF

Question 29

calicum channel blockers side effects on prediabetic pts?

Answer 29

little effect on glucose metabolism

Question 30

thiazide side effects on prediabetic ps?

Answer 30

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.

Question 31

adverse side effects of thiazides

Answer 31

see hypokalemia, hyponatremia, hyperuricemia and elevated TG’s. Increased risk for developing diabetes.

Question 32

What to be done with someone has a new diagnosis of HTN?

Answer 32

get EKG, UA, and maybe TTE need to screen for HLD and A1c.

Question 33

Guidelines for BP JNC 8

Answer 33

Question 34

when to get ambulatory BP monitoring

Answer 34

evaluate for white coat sydrome

episodic HTN

resistant HTN

hypotensive symptoms on antihypertensive therapy

Question 35

If suspecting “white coat” hypertension what do we order?

Answer 35

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

Question 36

Criteria for HTN based on 24 hr BP monitoring

Answer 36

24 hr average>125/75

Daytime (awake) >130/80

Nighttime (asleep) >110/65

Question 37

masked hypertension

Answer 37

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.

Question 38

treating african american people with HTN. first line medications should be:

Answer 38

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,