High Yield Clinical HTN

Question 1

For HTN, screen for it every

Answer 1

2 years is <120/80 mmHg; ANNUALLY if less than 139/89

Question 2

PreHTN is; drug therapy is

Answer 2

BP of 120/80 to 139/89 mmHg; NOT RECOMMENDED for preHTN (lifestyle mod better)

Question 3

What is important on initial evaluation?

Answer 3

1. accurate BP
2. White coat HTN
3. 24 HR ABP MONITORING!!!
4. stress
5. preHTN
6. long term implications of the label

Question 4

Problems seen with taking BP?

Answer 4

1. Failure to have patient sit quietly for 5 min before reading
2. Failure to support limb
3. Using a cuff that is too small or deflating cuff too rapidly;
   for pseudoHTN, use Osler’s maneuver (feel for stiff tube-like structure, when the healthy arteries should not be felt when empty!!)

Question 5

How can one deal with white coat HTN? How do they compare with normotensive and actual HTN?

Answer 5

Lifestyle mods and regular follow-up (don’t dismiss it: they have lower BP at home or with 24 HR ambulatory BP monitor at home);
LV mass is somewhere in b/w

Question 6

Masked HTN is; how do we look for it?

Answer 6

Patient normotensive in office, but elevated outside; do home readings and ABP monitoring!!!!

Question 7

ABP monitoring good for?

Answer 7

1. white coat HTN
2. BP variable
3. Nocturnal HTN (should be lower)
4. Drug-resistant HTN
5. HTN in preg
6. Maybe masked HTN

Question 8

Underlying causes of HTN?

Answer 8

OSA, OTC, OCPs, CKD, hyperaldo, RAS, Cushings, Pheo, coarc, thyroid and PTH, tobacco, illicit drugs, EtOH

Question 9

Some essential elements of PE for HTN?

Answer 9

1. Fundoscopy
2. look at neck
3. cardiopulm exam
4. abdo exam
5. neuro exam
6. peripheral pulses

Question 10

Tests done for newly diagnosed HTN? Some special tests?

Answer 10

1. Hg, Hct; serum electrolytes, creatinine, glucose, fasting lipids
2. UA
3. EKG;
   Echo for LVH, serum uric acid (gout maybe), microalbuminuria

Question 11

Important parts of history:

Answer 11

past treatment, current meds, lifestyle factors

Question 12

Rising creatinine with abd bruit is; hypokalemia is; arm HTN but legs normal; HA, swweating, palpitations; intermittant severe HTN; snoring daytime sleepiness

Answer 12

RAS; hyperaldo; coarc;
pheo, maybe hyperthyroid;
drugs; OSA

Question 13

Goal is to get pt below

Answer 13

140/90 if less than 60; 150/90 if greater than 60 ideally!!

Question 14

Some recommended lifestyle mods for treating HTN?

Answer 14

1. Na restriction
2. weight loss
3. Exercise (>30 min aerobic exercise most days)
4. Smoking cessation
5. EtOH intake limited to no more than 2 drinks daily

Question 15

Major cause of treatment failure is; people usually need

Answer 15

noncompliance;

three drugs with a bunch of complications

Question 16

How to treat different conditions related to HTN?

Answer 16

1. Heart failure: diuretic, beta-blocker, ACE inhibitor, ARB, aldosterone antag
2. Post-MI: beta blocker, ACE inhibitor, aldo antagonist
3. High coronary disease risk: diuretic, beta blocker, ACE inhibitor, ARB + CCB
4. Diabetes: diuretic, beta blocker, ACE inhibitor, ARB, CCB
5. Chronic kidney disease; ACEi and ARB
6. Recurrent stroke prevention: diuretic, ACEi

Question 17

Good combo therapies? Some not so good? Advans?

Answer 17

Good: ACEi/ARB and HCTZ; ACEi/ARB + nonhydropyridine CCBs to avoid edema;
not so good: ACEi/ARB combo;

better adherence and could cost less than individual prescriptions

Question 18

When BP doesn’t look well-controlled:

Answer 18

1. consider ABP monitoring!!!
2. ask about co-med that increases BP (NSAID)
3. ask about excessive EtOH or salt intake
4. Consider secondary cause
5. Evaluate adherence
6. Treat uncontrolled HTN with different drugs using different mechs

Question 19

How often should you see HTN patients?

Answer 19

1. Stable, well-controlled: 6-12 mos
2. BP in stage I: 2 months
3. BP in stage 2: 1 mo or less;
   allow 2-4 weeks for BP to stabilize

Question 20

Severe HTN requires urgent treatment if:

Answer 20

1. acute cardiovascular or neuro events are present
2. patient is pregnant
3. severe catecholamine excess is present