Exam 2: Management of hypertension

Question 1

Identify the pertinent physical findings in a hypertensive pt

Answer 1

• Retinal exam: (fundoscopy)
  
  • arteriolar narrowing (grade 1)
  • arteriovenous compression (grade 2)
  • hemorrhage or exudate (grade 3)
  • and papilledema (grade 4)
• Neck:
  
  • thyroid enlargement
• Cardiovascular:
  
  • S₄, LV enlargement (displaced PMI); may indicate end-organ cardiac damage
• Renal:
  
  • palpable kidneys (polycystic kidney disease)
  • abdominal bruit (renal artery stenosis)
• Extremities:
  
  • ABI of ≤ 0.7

Question 2

Identify the lab / imaging studies that may indicate underlying hypertension in a pt who is being evaluated for any reason

Answer 2

• Labs:
  
  • Complete Blood Count (CBC)
    
    • Elevated hemoglobin
      
      • (numerous causes) may be indicative of increased viscosity, which can cause HTN
    • Low serum potassium
      
      • aldosterone excess
  • Complete Metabolic Profile (CMP) & TSH
    
    • Including glomerular filtration rate (gfr)
      
      • Decreased gfr
        
        • most common cause is HTN
  • Fasting lipid Profile
  • Fasting Glucose
    
    • Increased fasting glucose
      
      • metabolic syndrome (glucose resistance) and or “pre-diabetes”
  • Urinalysis
    
    • Proteinuria
      
      • reliable target in prevention of end-organ damage to the kidney
  • EKG
    
    • ST “strain” in anterolateral leads (V5-6)
    • LV hypertrophy (severe)
    • Left atrial abnormality (prolonged conduction)
• Imaging:
  
  • CT scan: (head)
    
    • Lacunar infarct or “white matter” disease on radiology

Question 3

Be able to identify and distinguish hypertensive urgency from hypertensive emergency

Answer 3

• Hypertensive urgency
  
  • BP > 160/110 (in this lecture, others have 180/120)
  • No end organ damage
• Hypertensive emergency
  
  • acute increase in BP which leads to (new) or progressive end-organ damage

Question 4

How to manage Hypertensive urgency

Answer 4

• Goal:
  
  • to gradually reduce BP to physiologically safe level over 24-48 hours (160/95)
• Short-acting medications:
  
  • clonidine, captopril, labetalol and nicardepine.
• Followed by re-assesment and change of chronic medications
• Discuss medication compliance, home monitoring, diet/sodium restriction and F/U

Question 5

How to manage Hypertensive emergancy

Answer 5

• ER transfer for:
  
  • any BP >160/110 for more than 10 minutes with evidence of end-organ damage
• Goal:
  
  • approximately 10% reduction in the first hour
  • and 25% is the first six hours (at the most)
    
    • Autoregulation mechanism
    • “threshold” for hypo-perfusion is 25% of baseline or existing BP
    • to avoid inadvertent worsening of ischemia
• Exception is for this goal:
  
  • Aortic dissection:
    
    • Reduce BP to 120 systolic and HR to 60 bpm ASAP
  • Ischemic CVA in the setting of tPA administration:
    
    • Decrease to 185/110 ASAP and maintain BP at 180/105mmHg for the first 24 hours following administration

Question 6

Recognize and utilize the most current evidence based HTN guidelines

JNC 8 (older guidelines)

Answer 6

• Focuses on 3 main questions:
  
  1. when to begin treatment
  2. how low to aim for
  3. which antihypertensive medications to use
• For patients 60 and older
  
  • start Tx for BP >150/90mmHg w/ a goal of 150/90
• For everyone else (including diabetic and CKD patients)
  
  • the threshold is 140/90 and goal is the same
• For non-black patients without** CKD**
  
  • the initial therapy should be either:
    
    • thiazide diuretic, calcium channel blocker (CCB), angiotensin-converting enzyme (ACE) inhibitor or antiotensin receptor blocker (ARB)
• For black patients
  
  • the initial choice should be diuretic or CCB
• For those with CKD
  
  • an ACE inhibitor or ARB should be the initial choice

Question 7

Recognize and utilize the most current evidence based HTN guidelines

ACC (“newest” guidelines)

Answer 7

• goals of 130 / 80 for most people

(This is newest guideline. Was emphasized in TBL!!!)

Question 8

Tips for taking BP in a patient with suspected hypertension

Answer 8

• Have the patient relax (feet on floor, back supported)
• Check BP in both arms and use the higher of the two
• Use the bell (not the diaphragm) of your stethoscope and use as your reference the readings from the beginning of the first sound and the end of the second sound to report systolic and diastolic BP, respectively
• Patient resting for 5 minutes with feet flat on the floor prior to measurement
• Appropriate sized cuff over bare arm
• Arm rested on a flat surface at the level of the heart
• Be aware of “terminal digit bias” (extrenal variability)
• Other caveats include : numerous internal factor like white coat effect and bladder phenomenon ( a full bladder has been shown to increase BP by 15/10 mmHg over the determined baseline for a given pt)

Question 9

Medications / OTC’s are not associated with hypertension

Answer 9

• Aspirin is not an NSAID. (what the?!? just go with it i guess?)
• Licorice (European Black)
  
  • enhances mineralicorticoid activity / sodium retention.
• Alcohol, SSRI/SNRI, Caffeine, cocaine
  
  • adrenergic stimulation
• NSAIDs and steroids
  
  • salt retention
• VEGf inhibitors (chemotherapy) i.e. bevacizumab, sympathomimetics, erythropoetins & calcineurin inhibitors (cyclosporine)
  
  • all cause vasoconstriction due to endothelial dysfunction

Question 10

Historical & Lab associations

Excess daytime somnolence

Answer 10

Obstructive Sleep Apnea

Question 11

Historical & Lab associations

Palpitations, tremors and sweating in a patient with a TSH = 0.002

Answer 11

Hyperthyrodism

Question 12

Historical & Lab associations

A 25 y/o Female w/ no significant history and sudden-onset, severe HTN and an epigastric bruit

Answer 12

Renal artery stenosis (RAS)

from

Fibromuscular dysplasia

Question 13

Physiology of Renin-angiotenisn system (RAS):

Only 20% of patients have elevated renin levels, 30% have suppressed renin levels and 50% have normal renin levels.

Answer 13

• Juxtaglomerular apparatus (JG)
  
  • in the kidney
  • releases renin in response to decreased BP, sodium or volume
• Angiotensinogen
  
  • prod of the liver
  • cleaves it to produce angiotensin I (A1).
• Angiotensin Converting Enzyme (ACE)
  
  • then converts A1 into A2.
• A2
  
  • potent vasoconstrictor
  • powerful stimulator for aldosterone production
• Aldosterone
  
  • retains salt and water
  • excretes potassium

Question 14

Steps to reduce BP in an overweight patient

Answer 14

• HTN diagnosis
  
  • should be reserved for, at a minimum, the second OV
• Lifestyle
  
  • The most effective measure to reduce BP in an overweight patient is weight loss
  • The next most effective treatment is reduction of sodium to less than 2000mg/day
  • Equally effective is increasing aerobic physical activity to at least 30 min /day – three days per week.
  • Lastly, reducing alcohol consumption helps lower BP
• Pharmacotherapy
  
  • Thiazide diuretics, CCB’s, beta-blockers, ACE inhibitors, ARBs, Aldosterone agonists and Alpha-blockers all interfere with some point in the defined process involved in BP control

Question 15

HTN drugs generally considered safe in pregnancy

Answer 15

• Labetolol
• Methyldopa
• Hydralizine
• Nifedipine

Question 16

choice of medication is based on which organ you are hoping to prevent damage to as well as existing co-morbid disease:

1. CHF or CAD ?
2. Refractory chest pain due to stable ischemic CAD ?
3. Renal protection ?

Answer 16

1. CHF or CAD:
   
   • B-blocker, aldactone, ACE/ARB
2. Refractory chest pain due to stable ischemic CAD:
   
   • Nitrates
3. Renal protection:
   
   • ACE/ARB

Question 17

Emergency HTN - History

Answer 17

• Illicit drug / stimulant use
  
  • urine drug screen
• Rebound hypertension
  
  • abrupt d/c of certain BP meds (clonidine or minoxidil)
• Compliant with BP medications?
• EtOH withdrawl
• Preeclampsia, HELLP syndrome (hemolysis, elevated liver enzymes and low platelets)

Question 18

Emergency HTN - End-Organ Damage

Neurologic End-Organ Damage

Answer 18

• New focal neurologic deficits
• AMS

Question 19

Emergency HTN - End-Organ Damage

Cardiovascular End-Organ Damage

Answer 19

• Acute CHF
  
  • JVD, rales, S3, edema
• Acute MI
  
  • ST elevation / TWI, elevated troponins in the context of chest pain
• Aortic Dissection
  
  • “tearing” or “ripping”chest pain that radiates to the back and is sudden in onset

Question 20

Emergency HTN - End-Organ Damage

Renal End-Organ Damage

Answer 20

• Oligura / anuria, AMS, pericarditis (uremic) and peripheral edema
• Labs :
  
  • acute decline in gfr
• UA:
  
  • blood and protein on UA (particularly fragmented RBCs)
• Renal Artery Stenosis / blockage:
  
  • Young pt may have fibromuscular dysplasia
  • Renal artery ultrasound is test of choice