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Fall 2024 > Gentile - HTN packet > Flashcards

Gentile - HTN packet Flashcards

1
Q

What is the lifetime risk of HTN

A

> 90%

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2
Q

What fraction of US adults have HTN

A

1/3

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3
Q

What fraction of those diagnosed with HTN meet their BP goal

A

<50%

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4
Q

What fraction of people are unaware that they have HTN

A

1/6

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5
Q

What populations have worse outcomes with HTN control

A

African americans
Smokers

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6
Q

What are the risk factors for primary HTN (13)

A

Old age
Family history
Obesity
Insulin resistance/DM
Hyperlipidemia
Decreased nephron numbers: restricted intrauterine growth/prematurity
AA
Social determinants
Smoking
High sodium diet (>3g/day)
Excessive alcohol consumption
Physical inactivity
Insufficient sleep (<7hours)

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7
Q

How does someone get primary HTN

A

Multifactorial: genetics and environmental factors

Compounding effects on kidney structure and function

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8
Q

BP = __ x __

A

CO X SVR

Most patients have normal cardiac output but increased peripheral resistance

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9
Q

Where is the peripheral resistance most pronounced

A

small arterioles

Prolonged smooth muscle constriction = irreversible thickening of the vessel wall

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10
Q

What are the primary determinants of BP

A
  1. Sympathetic nervous system
  2. Renin-angiotensin-aldosterone system
  3. Plasma volume (largely mediated by kidneys)
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11
Q

Medications that can cause secondary HTN

A

Oral contraceptives
NSAIDs
Antidepressants: tricyclics, SSRIs, MAOIs
Corticosteroids
Decongestants (pseudoephedrine)
Some weight loss meds
Sodium-containing antacids
Erythropoietin
Cyclosporine/tacrolimus
Stimulants (methylphenidate/amphetamines)
Atypical psychotics - clozapine, olanzapine
Angiogenesis inhibitors - bevacizumab
Tyrosine kinase inhibitors - sunitinib, sorafenib

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12
Q

Causes of secondary HTN (not meds)

A

Illicit drug use
primary kidney disease
Primary aldosteronism
Triad - HTN, unexplained hypokalemia, metabolic acidosis
Renovascular HTN
Obstructive sleep apnea
Pheochromocytoma
Cushing’s syndrome
Endocrine disorders (hypothyroid, hyperthyroid, hyperparathyroid)
Coarctation of the aorta

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13
Q

Three general categories of HTN complications

A

CV
Neurovascular
Renal

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14
Q

CV complications of HTN

A

LVH
HF
Ischemic heart disease

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15
Q

Neurovascular complications of HTN

A

Ischemic stroke
Intracerebral hemorrhage

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16
Q

Renal complications of HTN

A

Chronic kidney disease
End stage kidney disease

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17
Q

HTN is the most prevalent modifiable risk factor for _______

A

premature CV disease

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18
Q

Risk doubles with __ mm Hg increase in systolic and __ mm Hg increase in diastolic

A

20
10

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19
Q

What parts of BP have the biggest influence on CV risk depending on age?

A

<50 years - diastolic
50-60 years - systolic pressure and pulse pressure

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20
Q

When should BP be taken?

A

Every clinical encounter

at minimum, annually and semiannually if risk factors or previous systolic BP was 120-129

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21
Q

In what case can HTN be diagnosed with one reading?

A

> =180/120 or >=160/100 with known end organ damage

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22
Q

What is the common scenario of HTN diagnosis?

A

elevated BP confirmed with average BP taken on >= 2 readings obtained on >= 2 occassions

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23
Q

What is the gold standard for HTN diagnosis?

A

Ambulatory 24 hour blood pressure monitoring

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24
Q

Self monitoring is especially useful in what cases?

A

White coat syndrome
Masked HTN

And to monitor response to treatment

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25
Q

What needs to be evaluated with HTN diagnosis?

A

Extent of target organ damage if any
Presence of established CV or kidney disease
Presence or absence of other CV risk factors
Potential lifestyle contributing factors
Potential interfering substances

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26
Q

What medical history much be taken with HTN diagnosis

A

Presence of precipitating/aggravating factors
Duration of HTN
Previous attempts at treatment
Extent of target-organ damage
Presence of other known CV disease risk factors

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27
Q

What must be assessed on physical exam for HTN diagnosis

A

Signs of end-organ damage or established CV disease
Evaluate for potential causes of secondary HTN
Fundoscopic exam for HTN retinopathy

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28
Q

What lab tests should be ordered for HTN

A

Electrolytes
Serum creatinine
Fasting glucose
Urinalysis
Complete blood count
Thyroid-stimulating hormone
Lipid profile
EKG
10-year ASCVD disease risk

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29
Q

In what patients should a urinary albumin to creatinine ratio be completed?

A

Diabetes and chronic kidney disease

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30
Q

In what patients should an echo be completed?

A

In patients you are evaluating for LVH (more sensitive than EKG)

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31
Q

In what patient should you test for secondary HTN

A

Unusual presentation - young age, abrupt onset, significant recent evaluation

Drug-resistant HTN

Presence of clinical clue for a specific cause of HTN - abdominal bruit, low serum potassium

32
Q

What is the general treatment approach for HTN in terms of lifestyle modifications

A

Address at least one aspect at every office visit:
Dietary salt restriction
Potassium supplementation (unless CI)
Weight loss (0.5-2 mmHg for each kg lost)
DASH diet
Exercise (3-4 sessions per week)
Limit alcohol intake
Smoking

33
Q

Describe the DASH diet

A

High in vegetables, fruits, low-fat dairy, whole grains, poultry, fish, and nuts

Low in sweets, sugar-sweetened beverages, and red meats

34
Q

Alcohol recommendations

A

Increased risk of HTN:
Women >= 2 drinks/day
Men >= 3 drinks/day

Diagnosed HTN:
Women: no more than 1/day
Men: no more than 2/day

35
Q

What are the proven risk reductions with HTN treatments (pharmacologic)

A

50% reduction in heart failure
30-40% reduction in stroke
20-25% reduction in MI

36
Q

Who should be treated pharmacologically?

A

> 135/>85 out of office OR
140/>90 in office OR
130/>80 and one of the following:
CV disease
T2DM
65 years old
10 year risk >=10%

37
Q

What is the biggest determinate of reduced CV risk?

A

Degree of blood pressure reduction; not the choice of med

38
Q

Most patients will need

A

More than 1 med

Multiple med classes = individualized therapy

39
Q

What are the 4 classes of first line meds?

A

Thiazide diuretics
ACE
ARB
Long-acting CCB

40
Q

Patients with nephropathy or CKD complicated by proteinuria should use what drug?

A

ACE or ARB

41
Q

What drug should not be used as monotherapy? What is the exception?

A

Beta blockers

ischemic heart disease or HFrEF

42
Q

Single agent therapy will not adequately control BP in most patient with systolic BP >= ___ mm Hg over goal

A

15

43
Q

At what point is it indicated to initiate with 2 first line agents

A

SBP >20
DBP >10

44
Q

What initial combo therapy is recommended

A

ACE/ARB + long-acting CCB
ACE/ARB + thiazide diuretic

No not combine ACE and ARB

45
Q

What should be done if 2 therapies not meeting goal?

A

ACE/ARB + long-acting CCB + thiazide diuretic

46
Q

What should be done if D-CCB not tolerated due to leg swelling?

A

Switch to ND-CCB

47
Q

What should be done if thiazide diuretic is not tolerated or CI?

A

Use mineralcorticoid receptor agonist (spironolactone or eplerenone)

48
Q

What should be done if 3 therapies are not enough, not tolerated, or CI

A

Beta blocker
Alpha blocker
Direct arterial vasodilator

49
Q

What combination should be avoided other than ACE + ARB

A

ND-CCB + BB
Could cause severe brady

50
Q

What can be done to increase adherence to BP meds

A

Use fixed-dose, single pill, combo meds when feasible to reduce pill burden

51
Q

What is actually the typical cause of drug resistant HTN

A

Often due to pseudoresistance:
inaccurate BP measurements
Poor adherence
No diet/lifestyle changes
Suboptimal therapy
White coat syndrome

52
Q

What could be causing true drug resistant HTN

A

Extracellular volume expansion (renal dz)
Increased sympathetic activation
Meds that elevate BP (NSAIDs, stimulants)

Always be sure to R/O secondary HTN

53
Q

What is the ultimate BP goal?

A

Reduction of CV events

54
Q

What is typically the BP goal?

A

<130/80

55
Q

In what groups is BP goal less aggressive at 135/80?

A

Labile BP or postural hypotension
Side effects w/ multiple meds
>75 years old with high burden of comorbidity or DBP<55

56
Q

How should BP goal be managed/assessed?

A

Determine if goal is met at every visit
Re-evaluate monthly after therapy is initiated
Once BP goal achieved, re-evaluate every 3-6 months to ensure maintenance of control

57
Q

What typically happens following discontinuation of therapy?

A

Substantial proportion remain normotensive for at least 1-2 years
Larger portion do well with dose reduction
More gradual tapering indicated in those well-controlled taking multiple drugs

58
Q

Which antihypertensive drugs should never be stopped abruptly?

A

Short-acting BB
Short-acting Alpha-2 agonists

Can cause fatal withdrawal syndrome; instead, gradually reduce over weeks

59
Q

Indicated med for HFrEF post MI

A

ACE or ARB, diuretic, AA

60
Q

Indicated med for chronic kidney disease with proteinuria

A

ACE or ARB

61
Q

Indicated med for angina pectoris

A

BB or CCB

62
Q

Indicated med for A fib with rapid ventricular response or A flutter

A

BB or ND-CCB

63
Q

Indicated med for BPH

A

Alpha blocker

64
Q

Indicated med for essential tremor

A

Noncardioselective BB

65
Q

Indicated med for Hyperthyroidism

A

BB

66
Q

Indicated med for migraine prophylaxis

A

BB and CCB

67
Q

Indicated med for osteoporosis

A

thiazide diuretic

68
Q

Indicated med for Raynaud phenomenon

A

D-CCB

69
Q

Contraindicated med for angioedema

A

ACEi

70
Q

Contraindicated med for bronchospastic disease

A

nonselective BB

71
Q

Contraindicated med for pregnancy

A

ACE, ARB, renin inhibitor

72
Q

Contraindicated med for second to third degree heart block

A

BB or ND-CCB unless pacemaker is present

73
Q

Which drug classes can cause depression

A

BB and central alpha-2 agonists

74
Q

Which drug classes can cause gout

A

Loop and thiazide diuretics

75
Q

Which drug classes can cause Hyponatremia

A

thiazide diuretics

76
Q

Which drug classes can cause Hyperkalemia

A

AA, ACE/ARBs, renin inhibitors

77
Q

Which drug classes can cause renovascular disease

A

ACE/ARB, renin inhibitor

Fall 2024 (34 decks)

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