HTN Flashcards
1. Understand how a diagnosis of HTN is made 2. Illustrate the possible outcomes of uncontrolled HTN 3. Understand the differences between essential and secondary hypertension and know potential causes of secondary hypertension 4. Be able to discuss hypertensive emergencies and urgencies as well as possible medication and behavioral treatment options. 5. Select appropriate treatment options for hypertensive patients given compelling indications. 6. Compare various classes of drugs used to
Risk Factors that can worsen prognosis of HTN
- Youth
- Male
- Persistent DBP >115 mm Hg
- African Descent
- Smoking
- Diabetes
- Hyperlipidemia
- Obesity
- Excessive EtOH intake
- Evidence of End-Organ Damage
True or False: Most patients with hypertension have no specific symptoms and are diagnosed at time of physical examination.
TRUE
Starting from _________ mm Hg, heart disease risk DOUBLES with each increment of ______ mm Hg
115/75
20/10
What percent of adults >20 years have htn?
33%
_____% of deaths are related to HTN?
15%
Of the 33% of all adults with htn, how many are aware they have this condition?
83%
Of the 83% of adults who are aware they have htn, how many have it well controlled?
53%
What are some adverse effects that htn can have on the heart?
hypertrophy, HF, CAD, increased O2 demand
What are some adverse effects that htn can have neurologically?
retinopathy, headache, CVA (hemorrhagic or ischemic), encephalopathy
If you have encephalopathy from HTN, its probably pretty serious. 1) What is this called? and 2) What are some symptoms?
PRES–posterior reversible encephalopathy syndrome. Presents with malignant htn, AMS (altered mental status), papilledema, seizure
10% of death from HTN is caused by _______________
renal failure
Do you give medications for prehypertension?
Only if there is a “compelling indication”
What are the compelling indications for treating htn?
HF, MI, CAD, DM, CKD, CVA
Blood pressure > ___/___ typically requires multidrug therapy
160/90 (aka stage II htn)
Essential, or primary, hypertention accounts for ____% of all htn.
94%
Secondary hypertension could be caused by what other problems? (10)
smoking, ETOH, drugs (rx), thyroid/parathyroid, coarctation of aorta, OSA, Pheochromocytoma, aldosteronism, steroid problem/cushings, CKD
What presentation of hypertension would raise a red flag to consider a diagnosis of SECONDARY htn?
Patient INITIALLY presents with:
1) stage II htn
2) renal failure
3) abrupt increase in BP
4) onset younger than age 50
5) resistant htn (not responding to 3 drugs including a thiazide)
When should you start screening for htn?
Age 20
How often should you screen for htn for a patient whose BP is < 120/80? What about a patient whose pressure is borderline or higher?
2 years if normal, yearly if high
If there is a narrow pulse pressure, wait…what is a pulse pressure?
Ex: 120/80, pulse pressure is 120-80 = 40
If there is a narrow pulse pressure, what might that indicate?
valve problem, HF
Can you make a diagnosis of htn after a single BP reading if the reading is > 160/90?
No.
When can you make a dx of htn?
Minimum of 2 readings at a minimum of 2 office visits
After you make a Dx of htn, what is the NEXT thing you want to do?
eval for other cardiovascular risk factors. Identify cause of htn, eval for end organ damage
What organs are included in “end organ damage”?
eyes, heart, brain, kidneys
If a patient comes to your office for an eval of their BP, what should be included in the physical exam?
BP in both arms, eye exam, BMI, auscultation of carotid/femoral/abdominal arteries, thyroid palpation, cardio, resp, and neuro exams
What testing will you order for a patient newly diagnosed with htn?
1) UA (proteinuria = kidney damage)
2) uric acid = gout (in combo w/ htn = metabolic syndrome)
3) Hct = polycythemia indicates chronic hypoxia
4) BMP = K+, BUN, creat
5) Lipids
6) TSH
7) EKG = get baseline!
Your patient has an extremely high BP (230/140). What symptoms would take this pressure from an urgent situation to an emergent situation?
1) behavior change (encephalopathy)
2) vision change or headache
3) chest pain
4) paresthesias
5) end organ damage
What is your goal in treating a pressure of 230/140?
1) prevent end organ damage (or reverse it)
2) decrease pressure by 10-20% in first 24 hours
(Goal is same for urgent and emergent)
Should you ever try to reduce a BP by more than 20% per day?
No, could lead to stroke
What are the 2 emergent BP medications we are asked to know for this test?
Esmolol (a BB, like Labetolol) and Na Nitroprusside
Blood pressure targets vary based on risk, why is this?
If htn is uncomplicated, the multiple drugs that would be required to achieve “optimum” pressure may have more side effects than benefits. Whereas high risk patients need to be managed aggressively to prevent end organ damage
What is the target pressure for a patient with uncomplicated htn?
<140/90
What are the complicating factors of HTN?
cardiovascular disease and DM constitute an intermediate risk…..If diabetics have protein in the urine, that shows kidney damage and is high risk
What is the target pressure for a patient with intermediate risk (CVD/DM)
<130/80
What is the target pressure for a patient with high risk (DM+proteinuria)
<125/75
Good blood pressure control decreases risk for what 3 things specifically?
CVA, MI, HF
What types of lifestyle recommendations do we have for lowering blood pressure? What is there actual impact (how much can they reduce pressure?)
1) 10kg wt loss = 5-20mmHg drop
2) DASH diet = 8-14
3) low salt diet = 2-8
4) exercise = 4-9
5) less ETOH = 2=4
What medication is best for htn in patients with HF or MI?
BB
What medication is best for htn in patients with DM, CKD, HF?
ACE/ARB
What medication is best for htn in patients with Angina? (Or a secondary med for htn?)
CCB–dihydropyridine
What medication is best for htn in patients with tachycardia and htn?
CCB–non-dihydropyridine
ACE/ARB medications are best for patients with_______
DM, CKD, HF
non-dihydropyridine CCB are best for patients with _____________
tachycardia and HTN
BB’s are best for hypertensive patients with ___________
HF, MI
dihydropyridine CCB are best for patients with _________
angina (or as secondary htn med)
Your patient doesn’t have any “compelling indications” but they do have high BP that needs to be controlled with drug therapy. What is your first line treatment?
thiazide diuretics
What are the 3rd and 4th line BP meds? (classes only are fine)
Alpha blockers (“zosins”), Vasodilators (hydralazine, minoxidil), CNS acting (clonidine and a methyldopa)
Urgency or Emergency? 62 yo AA male comes to office with c/o dyspnea and cough. His BP is 180/110.
Urgency
Urgency or Emergency? A 55 yo white female comes into the office c/o occipital headache and BP of 180/110.
Emergency
Urgency or Emergency? An 89 yo female comes to the office oriented to self only. Son says this is unusual as she can typically answer routine questions easily. Her BP is 180/110
Emergency
Urgency or Emergency? A 32 yo Asian male comes into the office c/o chest pain that is reproducible with palpation of the sternum. His BP is 139/89.
Ehh, not really even urgent. Prehypertension. Reproducible chest pain indicates musculoskeletal problem, not cardiac.
The following: HF, MI, CAD, DM, CKD, CVA are considered?
Compelling indications!
Define compelling indication
A specific cause of htn that should be treated with a specific htn medication
When is Aldosterone blocker appropriate?
For patients with HF or MI who are already maximized on other therapy. (cannot have compromised renal fxn)
