HTN 3 Flashcards
Hypertensive Urgency
Severe elevations in BP (SBP >180 and/or DBP >120) in
otherwise stable pts without target organ damage (TOD).
Symptoms: None or minimal
Cause: Usually related to nonadherence
Goal: Lower BP gradually (hours to days); decreasing BP
too quickly can cause CVA, MI
Things to do
Sit there and wait 5 minutes
Restart or titrate therapy
Pt should follow in 1 week
If there is still the same, then ask if they have symptoms.
Make sure they have taken their medicines.
Symptoms of TIA or heart attack. (difficult breathing, visual call 911)
If someone says they have a headache but not a vision issue they are cleared
Start taking your medication and it will take 2-3 days and weeks
Hypertensive Emergency
Severe elevations in BP (SBP >180 and/or DBP >120) in otherwise stable pts with target organ damage (TOD).
Symptoms: Yes
Goal: Lower BP minutes to hours by no more than 25%, and then lowered to 160/100-110 within the next 2-6 hours
This is only when people feel their blood pressure, there is target organ damage,
There will be headaches and vision changes
There can be drug-induced causes but usually, it is non-adherence.
MAKE SURE DO NOT lower their blood too much that it will be very low. Lower it by 25% and then work on it more
What is Resistant Hypertension
Office B.P above goal and _>3 antihypertensives (if pt is taking 3-4 meds and HTN is not controlled it is resistant HTN.
Risk factors are: older age CKD, black race, DM
Medication adherence, Whitecoat HTN, and POOR blood pressure technique
Risk factors of resitant HTN are
: older age CKD, black race, DM
How to improve resistant HTN?
Removing contributing lifestyle factors are: Obesity, Physical activity, Excessive ETOH, High salt, low fiber diet.
Discontinue interfering substances such as NSAIDS, SYMPATHOMEMATICS, stimulants, Oral contraceptives, Licorice, Ephedra
Optimize current drugs and doses → ARB/ACE AND CCB. If PT is taking HTCZ change to chlorthalidone for better outcomes.
For pt not controlled on 3 drugs consider adding add spironolactone ( aldosteorne antagonist)
pt on resistant HTN and not controlled with three drugs consider
adding spironolactone ( aldosterone antagonist)
Removing contributing lifestyle factors for resistant HTN ARE
Obesity, Physical activity, Excessive ETOH, High salt, low fiber diet.
FOR resistant HTN Discontinue interfering substances such as
NSAIDs, SYMPATHOMEMATICS, stimulants, Oral contraceptives, Licorice, Ephedra.
WHITE COAT HTN
Some patients can get REALLY nervous before their blood pressure is taken. They can have high BP readings taken at the clinic than when taken outside of the clinic.
20/10 INCREASE IN WHITE coat HTN
SOltuon to White coat HTN
24hr Ambulatory BP monitoring (ABPM)
Monitor the blood pressure at home (HBPM or SMBP)
Home blood pressure monitoring provides a “truer” blood pressure reading
Special Populations Race AND Ethnicity
Black pt has a higher prevalence of htn , lower control rates, and higher rates of mortality.
Initial therapy Thiazide-type diuretic or CCB the best choice for single-drug therapy
Most pt will require 2 or more meds to reach the goal → ACE inhibitor or ARB is recommended as an add-on or used when compelling indication.
Special Populations Race AND Ethnicity Initial therapy
Thiazide-type diuretic or CCB (verapamil/diltiazem) the best choice for single-drug therapy
Special Populations Race AND Ethnicity with 2 or more meds
Most pt will require 2 or more meds to reach the goal → ACE inhibitor or ARB is recommended as an add-on or used when compelling indication.
Elderly people with ISH regimens are
Often have ISH Isolated systolic HTN
After age 60 DBP gradually decrease while SBP continues to rise
BP-lowering decreases the risk of fatal and non-fetal stroke and CV events and death
Dihydropyridine CCBs (amlodipine, nifedipine) are effective in older patients with ISH
Elderly people HTN recommendations are
Dihydropyridine CCBs (amlodipine, nifedipine) are effective in older patients with ISH
Elderly people: Treatment can have challengeS THAT ARE
Polypharmacy
Frailty
Cognitive impairment
Variable life expectancy
Elderly people: Higher risk for B.P Med side effect
Orthostatic hypotension
Risk of syncope/falls
Volume depletion
Electrolyte problems
Special Population Men’s
68 % of men with HTN have erectile dysfunction
Worse: Thiazide-diuretics Beta blockers
Neutral: ACEI’s CCBs
erectile dysfunction in men can be addressed by
Phosphodiesterase-5 inhibitors can be co-administered
with antihypertensive medications with the benefit
Pregnancy Special populations:
Pt who are pregnant and develop high blood pressure should be monitored closely also known as PRE eclampsia
Medications used during pregnancy
▪ Hydralazine & labetalol is good to manage severe elevations of B.P
Nifedipine
Methyldopa is
Medications that are contraindicated during pregnancy are
ACEIs, ARBs, aliskiren, and spironolactone
The optimal goal for HF PT IS _____. types of heart failure
The optimal goal for BP: <130/80
Two heart failure are one with reduced ejection fraction and preserved ejection fraction
Medications for HF with REF are
Reduced ejection fractions have more data and symptoms Medications that lower BP and have compelling indications to be used in HF (GDMT). GDMT Beta Blocker + diuretic + ACEI/ARB/ARNI +/- aldosterone antagonist
Patients with HFpEF who present with symptoms of volume overload,
diuretics should be prescribed to control hypertension.
Adults with HFpEF and persistent hypertension after the management of volume overload
should be prescribed ACE inhibitors or ARBs and beta-blockers
DRUGS NOT TO BE USED IN heart failure are
non-DHP CCB (diltiazam and verapamil)
POST MI: blood goal
BP GOAL <130/80 ;
First-line therapy for POST MI are
First-line therapy → ACEI/ARB and BB
BB→BB WITHOUT intrinsic sympathomimetic activity (usually start with metoprolol)
in POST MI ACE AND ARB
DECREASE CARDIAC REMODELING
SIHD: CHD, CAD, Chronic stable angina) FIRST LINE therapy are
BB and ACEI/ARB
SIHD: CHD, CAD, Chronic stable angina) if after adding first-line therapies there is Angina we Use
DHP-CCB (AMLODIPINE , NIFEDAPINE)
SIHD: CHD, CAD, Chronic stable angina) if after adding first-line therapies there is no Angina we Use
DHP-CCB or thiazide or aldosterone antagonist
If someone has kidney disease EGFR less than 60 and or UACR greater than 30 means there is some kidney disease happening we use
ACE/ARB
Pt with CKD stage 1 or 2 will be using _____ according to ACCA
ACE/ARB
It pt is having higher than 300 UACR
ACE will be used
Management of HTN in Pts with a previous history of stroke:
Optimal BP goal <130/80
The prevalence of HTN in patients who experience a recurrent stroke is 70%
An individual who experiences an initial stroke or TIA: will have another chance of stroke
Case mortality rate is 41% after a recurrent stroke (versus 22% after an initial stroke)
ACEI/ARB thiazide diuretic are the fist line
First-line therapy for Management of HTN in Pts with a previous history of stroke or recurrent stroke:
ACEI/ARB thiazide diuretic or combination of 2
According to the Systolic blood pressure intervention Trial the first-line therapy
First line Tx: combination of ACEI/ARBs, thiazides, CCBs
Drugs to be approved for heart failure are
Metoprolol succinate
Bisoprolol
Carvedilol
Spironolactone should be given with caution due to low K+
Second-Line Therapy for Management of HTN in Pts with a previous history of stroke or recurrent stroke:
CCB, mineralcorticoid receptor antagonist
