Evaluation and Treatment of HTN

Question 1

What is primary/essential hypertension?

Answer 1

> 140/90 idiopathic without secondary cause. This is 95% of all cases of HTN. 2x increase in african americans.
Typical age of onset= 25-55.

Question 2

What is secondary hypertension?

Answer 2

hypertension with secondary cause

Question 3

What is resistant HTN?

Answer 3

BP >160 despite 3 or more medications, including diuretic in which all drugs are dosed at least 50% or more of max dose, or BP that requires 4 drugs to control.

Question 4

What is malignant/accelerated hypertension?

Answer 4

HTN with grade 3 or 4 HTN retinopathy, TMA, and evidence of acute tissue injury (brain, kidney or heart).

Question 5

What are the joint national committee (JNC) reports/guidelines?

Answer 5

committee established in the 70s to provide an overview of recent scientific evidence ad unify positions of member organizations and send a clear message to the practicing community that lowering high BP is very important.

Question 6

** What does the JNC 8 recommend for treating HTN of the general population OVER 60 years old?
(TEST QUESTION)

Answer 6

lower BP to less than 150/90

Question 7

** What does the JNC 8 recommend for treating HTN of the general population UNDER 60 years old?
(TEST QUESTION)

Answer 7

lower BP to less than 140/90

Question 8

** What should initial treatment in the white population, including those with DM include?

Answer 8

initially a thiazide diuretic, calcium channel blocker, ACE inhibitor, or ARB.

Question 9

** What should initial treatment in the black population, including those with DM include?

Answer 9

initially a thiazide diuretic or calcium channel blocker

Question 10

What are some secondary causes of HTN?

Answer 10

• CKD
• renovascular parenchymal disease (atherosclerotic renal artery stenosis)= MOST COMMON CAUSE
• sleep apnea
• drug induced
• primary aldosteronism

Question 11

What drugs can cause secondary HTN?

Answer 11

• oral contraceptives
• NSAIDs
• antidepressants
• glucocorticoids
• decongestants (pseudoephedrine)
• weight loss medications
• EPO
• cyclosporine
• amphetamines
• cocaine

Question 12

What are the 3 objectives when evaluating a pt with HTN?

Answer 12

1. lifestyle, CV risk factors, concomitant disorders
2. reveal identifiable causes of high BP (secondary causes).
3. evaluate for evidence of target organ damage and CVD.

Question 13

What are the big CVD risk factors?

Answer 13

• HTN
• smoking
• obesity
• dyslipidemia
• DM
• all modifiable

Question 14

What does each increment of 20/10 mm HG do to your risk of developing CVD?

Answer 14

doubles it

Question 15

What is ambulatory BP monitoring?

Answer 15

monitoring BP at different intervals, indicated for evaluation of “white coat” HTN. May also reveal absence of 10-20% decrease of BP during sleep, which may indicate increased CVD risk.

Question 16

What is important to have a pt do prior to taking BP?

Answer 16

no caffeine and no smoking 1 hr prior to visit

Question 17

What are the routine laboratory tests for HTN?

Answer 17

• EKG
• urinalysis
• glucose and hematocrit
• BMP (serum K+, creatinine, and calcium)
• lipid profile

Question 18

What are the lifestyle modifications suggested for pts with HTN?

Answer 18

• weight reduction
• DASH eating plan= whole grains, poultry, fish, and nuts
• dietary sodium reduction (2.5 g)
• physical activity
• moderation of alcohol consumption

Question 19

How often do you follow up with a pt once they have reached their goal BP?

Answer 19

3-6 months

Question 20

What is important to remember about treating with certain medications, especially in the city?

Answer 20

make sure an insurance company will cover the drug you choose.

Question 21

What drugs should be used to control HTN in women who are pregnant?

Answer 21

methyldopa, BBs, and vasodilators for the safety of the fetus.
*ACE inhibitors and ARBs are contraindicated.

Question 22

What population has the lowest rates of BP control?

Answer 22

people over age 65

Question 23

** How should you think about hypertensive EMERGENCY?

TEST QUESTION

Answer 23

SYMPTOPMATIC hypertension. These are pts with marked BP elevations and acute target organ damage (encephalopathy, myocardial infarction, unstable angina, pulmonary edema, eclampsia, stroke…). These pts require hospitalization and parental drug therapy.

Question 24

** What is hypertensive URGENCY?

TEST QUESTION

Answer 24

ASYMPTOMATIC hypertension. These are pts with markedly elevated BP but WITHOUT acute target organ damage. They do not require hospitalization but should receive immediate combination oral antihypertensive therapy.

Question 25

What is autoregulation?

Answer 25

• ability of blood vessels to constrict or dilate in response to changes in perfusion pressure and maintain normal organ perfusion.
• When a person is in hypertensive emergency, bring them down slowly so as not to take them into a hypotensive state (even though they are at 120/80, their body is used to the high pressures and must adjust slowly).

Question 26

How slowly should BP be reduced for hypertensive emergency?

Answer 26

• reduce 25% over 2-3 hours

- oral anti-hypertensive medications after 6-12 hours of parenteral therapy.

Question 27

Why is nonadherance a problem?

Answer 27

bc patients don’t feel ill, so they don’t feel like they need to take their medications.

Question 28

When do we consider work up for secondary HTN?

Answer 28

resistant HTN despite compliance with all other modalities.

Question 29

Where is renal artery disease (typically atherosclerosis) most commonly seen?

Answer 29

caucasians, smokers, and hyperlipidemics

Question 30

What is fibromuscular dysplasia?

Answer 30

form of renal artery disease but happens in younger pts (females). Will see medial fibrosis (looks like beads on a string).

Question 31

Is stenting an atherosclerotic renal artery better than medical management (controlling BP and lipids)?

Answer 31

NO they are equal

Question 32

What is underdiagnosed and an important common cause of secondary HTN?

Answer 32

sleep apnea. Ask about excessive daytime sleepiness, witnessed apneic events during sleep, tired after a “good night’s sleep.”
*Treat with c-pap and this helps tremendously!

Question 33

What is the most common endocrine associated cause of HTN?

Answer 33

primary aldosteronism. Pts will also have HYPOkalemia and a metabolic alkalosis.
This is usually due to adrenal hyperplasia or adrenal adenoma.
*Treat with spironolactone or epleronone (K+ sparing diuretics) and this gets them off of all other medications.

Question 34

What do projections show about decreasing salt intake?

Answer 34

reduction in annual number of deaths

Question 35

** What hypertensive drugs are contraindicated in pregnancy?
(TEST QUESTION)

Answer 35

ACE inhibitors and ARBs