HTN Flashcards
Primary HTN
general
Genetic predisposition
Onset is usually between ages 30 and 50 years
Environmental factors – overweight & obesity, OSA, diet (↑ salt intake, ↓ potassium intake), physical inactivity, excessive alcohol, smoking
Secondary HTN
general
Secondary may be curable…
Suspect if:
Onset of HTN at early age (< 30 yo)
Abrupt onset of HTN
Exacerbation of previously
drug resistant HTN
Stages of BP according to ACC
ACC/AHA
Normal < 120/80mmHg
Elevated 120-129/80mmHg
Stage 1 130-139/80-89mmHg
Stage 2 > 140/90mmHg
HTNs
First line med
ACE or ARB
Complications of HTN
Coronary heart disease, heart failure, LVH, ischemic and hemorrhagic stroke, CKD, end-stage renal disease, and acute hypertensive emergencies such as hypertensive encephalopathy and acute aortic dissection, etc.
Symptoms of HTN
Head ache, blurred vision, dizziness, nausea, fatigue, chest pain, shortness of breath, confusion
HTN
PE findings: (5)
abn eye exam, left ventricular heave, abdominal bruit, radial-femoral delay, pulsatile abd mass
What is the most frequent symptom of HTN?
A) nausea
B) headache
C) somnolence
D) chest pain
B) headache
HTN Diagnostic findings (2)
LVH on ECG or echocardiogram
proteinuria on UA
HTN nutshell
1- What is BP goal
Is this primary or secondary?
Goal < 130/80 unless hx Chronic Kidney Disease (then < 120/80)
Calculate 10-year risk (high-risk patients start rx BP > 130/80; lower-risk start rx BP > 140/90)
HTN
Work Up:
BMP (sodium/potassium/calcium)
Serum creatinine & GFR
Fasting glucose or A1C
Urinalysis (if + protein consider UACR)
CBC
Lipid profile
TSH
Calculate 10-year ASCVD risk
*consider sleep apnea
*consider echocardiogram
Secondary Hypertension
common causes(5)
secondary HTN
OCRAPH3
Fantastic 4 for HTN
1st line: ace or arb 2nd line: add on calcium channel blocker 3rd line: Thiazide diuretic 4th line: spironolactone; next step refer
Steps
1- check BP and define
2- if > 120/80 TLCs 3-6 months
3-if >130/80:
Calculate 10-year ASCVD risk
+ Dx: CAD, DM, CKD, PAD, CVA, age > 65?
If “yes” or > 10% risk 1-month, TLCs then Rx
If “no” or < 10% 3-6 months TLCs
4- >140/90 TLCs 3-6 months then Rx (2 drugs)
TLC
therapeutic lifestyle change
ACE/ARB compelling indications 4
DM, CKD, Cardiomyopathy, proteinuria
Beta Blockers compelling indications
post-ACS, Cardiomyopathy
HTN
Clonidine compelling indications
indicated for CKD and ESRD
can cause rebound HTN
Calcium Channel Blockers:
preferred for black pts, Raynaud’s, vasospastic angina
10 year risk
Very high Risk
10 year risk
High Risk
10 year risk
Moderate and Low Risk
38 yo Female
PMH: Type 2Diabetes, HTN presents for Office Visit.
What is BP goal?
10 year risk?
Drugs compelling indication?
< 130/80
High
Ace and arb
55 yo Male; 148/90
PMH: CAD, HTN, hyperlipidemia, presents in office.
What is his bp goal?
Do you need to calculate 10 year risk?
Drugs compelling indication?
What Rx consider?
Bp goal < 130/80
Do NOT need to calculate risk bc has ASCVD
Compelling indication for cad- ace/arb/bb
Consider he is > 140/90 so possible two drug tx
what is the benefit of Ca channel blocker
Contraindications
work well for black pts
Contraindicated In CHF
HTN
Lifestyle modifications
Initial monotherapy in uncomplicated HTN
What drugs what disease?
End Stage Renal Disease
HTN
Thiazide Diuretics meds
Hydrochlorothiazide (HCTZ)12.5-25 mg po daily
Chlorthalidone 12.5-25 mg po daily
Drug of choice: 1st line Tx HTN (if no compelling indications)
HTN
Thiazide diuretics MOA
Inhibits sodium reabsorption in distal renal tubules, resulting in increased excretion of water and of sodium, potassium, and hydrogen ions
HTN
Thiazide Adverse effects
Hypokalemia, Hyperglycemia, Hyperuricemia, Hypercalcemia, hypocalciuria, Hyponatremia, Hypomagnesemia
Do not use if GFR < 30, NA < 130, gout
ACE-Inhibitors MOA
Prevent the conversion of angiotensin I to angiotensin II (potent vasoconstrictor), inhibit bradykinin degradation, stimulate the synthesis of vasodilating prostaglandins, and can reduce sympathetic nervous system activity
ACE/ARB Adverse effects
Dry cough (↑ bradykinin levels) tickle in back of throat
Hyperkalemia
Skin rash, headache, renal impairment, angioedema
*contraindicated in pregnancy
ACE prefered for
prefered in heart failure, DM, CKD
Calcium Channel Blockers meds
For HTN use dihydropyridines!!
Amlodipine (Norvasc) 5-10 mg po daily
Nicardipine (adalact/Procardia) 15-180 mg po daily
Ca channel blocker MOA
Inhibits transmembrane influx of extracellular calcium that inhibits cardiac and vascular smooth muscle contraction
Ca channel blocker Adverse effects
Constipation
Peripheral edema
Headache, Heart block, Gingival overgrowth
Ca channel blockers are contra for
CHF
Beta-blockers MOA
Blocks response to beta-adrenergic stimulation; reduce cardiac output and decrease release of renin from kidney
Beta blockers drug of choice for
Drug of Choice: CM EF < 45%, aortic dissection, SVT, MI, hyperthyroid
Cardioselective (beta-1 receptors)
Atenolol 25-50 mg po BID
Metoprolol 12.5 -100 mg po BID (IV)
Bisoprolol 2.5-10 mg po BID
Nebivolol 5-20 mg po daily
Noncardioselective (beta-2 receptors)
Propranolol 40-180 mg po BID
Carvedilol 3.125-25 mg po BID
Labetalol 5-150 mg po BID (IV)- strongest for HTN
beta blockers do NOT use
Do NOT use cocaine MI or pheochromocytoma until alpha blockage established
beta blocker adverse effect
Fatigue
Can mask hypoglycemia S/Sx
Depression, sexual dysfunction, insomnia
Decreases HR
Special population Patient
Pregnancy
Drug of choice HTN: labetalol, nifedipine, HCTZ, methyldopa
Black patient
Respond more favorably to CCB and hydralazine/isosorbide than whites
Advance CKD ( hyperK, creatinine > 2.0)
Calcium channel blocker, clonidine, hydralazine, alpha blocker
when do you treat pregnant pts?
In pregnancy do not treat unless symptomatic or BP > 150/90
if you start pt on ACE or ARb and kidney function drops
think about renal artery stenosis
55 yo black male reports to office for primary HTN. No PMHX. What is most appropriate first line anti HTN for this patient?
A) metoprolol (BB)
B) valsartan (ARB)
C) amlodipine (CCB)
D) lisinopril (ACE)
C) amlodipine (CCB)
48 yo Female presents f/u HTN.
Meds:
lisinopril 20 mg po BID,
amlodipine 5 mg po daily
BP 138/88, HR 55
A) increase amlodipine 10 mg/d
B) continue current rx
C) add metoprolol 25 mg po BID
D) add HCTZ 25 mg qd
A) increase amlodipine 10 mg/d
BP goal < 130/80
Black patient withhyperkalemia and HTNpresents in office withelevated BP. What is mostappropriate add ontherapy?
A) diltiazem ( non-dihydropyridine ccb)
B) amlodipine ( dihydropyridine ccb)
C) spironolactone ( MRA)
D) atenolol ( bb)
Amlodipine- good bp reduction, will not affect K, counsel side effect edema
Diltiazem not good for BP reduction side effect GI
Spironolactone contraindicated hyperK
Atenolol poor choice for HTN esp in black patient
Resistant Hypertension possible causes
Hypertensive Crises
HTN crisis classification
Hypertensive Crises
In emergency ( + end-organ damage) Tx
admit and treat with IV rx goal reduce BP 10-20% first hour
In urgency ( no evidence end-organ damage) treat outpatient, close follow up, oral rx. Usually start/titrate “baseline” rx :
Amlodipine/HCTZ
Clonidine ( transdermal, po)
ACE/ARB
hydralazine (IV,PO)
A patient presents to EDwith agitation/HA bp210/110
a. What diagnosis is this ?
b. HTN urgency
c. HTN emergency
d. Malignant HTN
Pt has evid of end organ damage. This is htn emergency.
A patient presents to EDwith agitation/HA bp210/110
a.your goal is to reduce BP_ % in first hour
a.10%
b.10-20%
c.25%
Goal is to reduce BP 10-20% in 1 hour
A patient presents to EDwith agitation/HA bp210/110
Which of the following is best choice for this patient?
Clonidine 0.1 mg po
Amlodipine 10 mg po
Labetalol 10 mg IVP
Enalapril 5 mg IVP
Labetalol 10 mg IVP
Blood Pressure (BP) =
Blood Pressure (BP) = CO x SVR
Cardiac Output (CO)
Systemic Vascular Resistance (SVR)
BP considered elevated if
Elevated BP on three separate occasions ( > 120/80)
HTN Nutshell
4
1- What is BP goal
Is this primary or secondary?
Calculate 10 year risk
2- TLCs +/- Rx
3-Drugs w compelling indications
4-Drug/dose/side effects/follow up
