Fm 8 Flashcards
When to screen for htn
The USPSTF recommends screening for high blood pressure in adults aged 18 years or older. The USPSTF recommends obtaining measurements outside of the clinical setting for diagnostic confirmation before starting treatment.
In adults 60 years and older, a systolic blood pressure > 150 or a diastolic blood pressure > 90 is defined as hypertension.
In adults younger than 60 years old, a systolic blood pressure > 140 or a diastolic blood pressure > 90 is defined as hypertension.
Causes of Hypertension
95 - 98% of the hypertension in the United States is essential hypertension - chronically higher blood pressure readings than normal with no underlying identifiable cause.
Identifiable causes of hypertension are far less common and are known as secondary hypertension. Causes of secondary hypertension include sleep apnea, chronic renal disease, renovascular causes, drug-induced causes, pheochromocytoma, primary aldosteronism, chronic steroid use, Cushing’s syndrome, thyroid and parathyroid disease, and coarctation of the aorta.
Technique for Taking Blood Pressure
Monitoring Hypertension
The patient should be seated quietly for at least five minutes in a chair with their back supported, rather than on an examination table. The arm should be supported at heart level. You want to auscultate the blood pressure with your stethoscope using a properly calibrated and validated instrument.
The most important point is using an appropriately sized cuff to ensure accuracy. The length of the bladder of the cuff should be at least 80% of the arm circumference, and the width of the cuff must be at least 40% of the arm circumference. A cuff that is too small will give you an erroneously high blood pressure reading. With increasing prevalence of obesity, most adults no longer will fit into an “adult” cuff, but may require an “extra large” or “thigh-sized cuff.
Remember, you only need one measurement on one arm for ongoing monitoring, as you are no longer screening for hypertension or an aortic anomaly.
Important Elements of the Physical Exam in Patients with Hypertension 9
Look for identifiable causes of hypertension and evidence of end organ damage and coronary vascular disease.
Body mass index (BMI)
Assess if the patient is underweight, normal weight, overweight, or obese. Being overweight or obese is a risk factor for hypertension, cholesterol, diabetes, and many other diseases.
Funduscopic eye examination
Assess for arteriovenous nicking, cotton-wool spots, flame hemorrhages, exudates, and other changes associated with hypertensive retinopathy (see diagram) or papilledema associated with hypertensive emergencies.
Auscultate for carotid, abdominal, and femoral bruits
Assess for the presence of peripheral vascular and cardiovascular disease, which can occur as a result of hypertension.
Palpation of the thyroid gland
Assess for nodules, tenderness, or thyromegaly, which might indicate hyperthyroidism, one of the causes of secondary hypertension.
Lung examination
Assess for signs of congestive heart failure, such as crackles or diminished breath sounds. Congestive heart failure can occur with long-standing hypertension, usually over many years.
Heart examination
Assess the heart rate, rhythm, presence of murmurs, or an enlarged point of maximal impulse which may indicate cardiovascular disease, valvular disease, or cardiomegaly.
Abdominal examination
Look for abdominal aortic pulsation, bruits, or masses.
Lower extremity examination
Assess for the presence of cardiovascular disease or peripheral vascular disease in the lower extremities such as diminished pulses, loss of extremity hair, thick toenails, cold or red skin.
Conduct a baseline neurologic assessment
Assess for neurologic changes from ischemic or hypertensive brain disease. It is important to get a baseline neurologic exam even if the findings are normal because subtle changes can happen over time. Ex is hypertensive encephalopathy
Pharmaceuticals by age and bp for htn
Age Population BP Goal Recommended Agents Age < 60 years old General non-black population <140/90 ACE Inhibitor, ARB, calcium channel blocker, or thiazide diuretic General black population <140/90 Calcium channel blocker or thiazide diuretic Age ≥ 60 years old General population <150/90 ACE Inhibitor, ARB, calcium channel blocker, or thiazide diuretic All ages With Chronic Kidney Disease <140/90 ACE Inhibitor or ARB With Diabetes mellitus <140/90 ACE Inhibitor, ARB, calcium channel blocker, or thiazide diuretic
Target bp goals 3
Age Population BP Goal Age < 60 years old General population < 140/90 Age > 60 years old General population < 150/90 All ages With Chronic Kidney Disease
or Diabetes mellitus
< 140/90
Thiazides diuretics
A. Hydrochlorothiazide is the most cost-effective antihypertensive drug.
C. Thiazides may affect electrolyte levels.
D. Thiazide diuretics should be avoided in patients with a history of gout bc can cause hyperuricemia.
F. Thiazide diuretics may cause elderly patients to become incontinent of urine.
doses of hydrochlorothiazide above 25 mg have not demonstrated improved blood pressure measurements nor decreased morbidity and mortality.
Lifestyle Changes to Decrease Blood Pressure (most change to least change)
Weight reduction: Maintain normal body weight (body mass index 18.5-24.9 kg/m2).
Adopt DASH eating plan: Consume a diet rich in fruits, vegetables, and lowfat dairy products with a reduced content of saturated and total fat. You can read more about the DASH eating plan by clicking here.
Dietary sodium reduction: Reduce dietary sodium intake to no more than 100 mmol per day (2.4 g sodium or 6 g sodium chloride).
Physical activity: Engage in regular aerobic physical activity such as brisk walking (at least 30 min per day, most days of the week).
Moderation of alcohol consumption: Limit consumption to no more than 2 drinks (e.g., 24 oz beer, 10 oz wine, or 3 oz 80-proof whiskey) per day in most men, and to no more than 1 drink per day in women and lighter weight persons.
When to Initiate Aspirin in Hypertensive Patients
The USPSTF recommends initiating low-dose aspirin use for the primary prevention of cardiovascular disease (CVD) and colorectal cancer (CRC) in adults aged 50 to 59 years who have a 10% or greater 10-year CVD risk, are not at increased risk for bleeding, have a life expectancy of at least 10 years, and are willing to take low-dose aspirin daily for at least 10 years.
Hypertension Management: When to Refer to a Nephrologist or Cardiologist
Generally, failure to achieve blood pressure goal in patients who are adhering to full doses of an appropriate three-drug regimen that includes a diuretic would warrant referral to a nephrologist or cardiologist.
