HTN Flashcards
1
Q
Increases risk for HTN
A
older age, obesity, sedentary, high fat high sodium diet, family history, race, type A/depression, dyslipidemia, alcohol, smoking
2
Q
Secondary Caues of HTN
A
chronic NSAID use, birth controll pills, renal artery stenosis, pheochromocytoma, illegal drug use, cushings syndrome, coarction of aorta, primary hyperaldosteronism, OSA, SSRIS and tricyclic antidepressants, decongestants, weight loss meds, endocrine disorders, low vitamin D
3
Q
Target Organ Damage from HTN
A
Heart: CHF, MI, LVH, angina. Stroke. CKD. Retinopathy. PAD.
4
Q
Screening
A
120 annual
5
Q
PAD s/s
A
BP >15 in arms d/t subclavian stenosis
6
Q
Postural hypotension
A
20 or > drop from supine to standing
7
Q
Diagnosis of HTN
A
> 140/>90 on repeated exam, 3 readings at least 1 week apart
8
Q
prehypertension
A
120-139/80-89
9
Q
stage 1
A
139-159/89-90
10
Q
stage 2
A
> 160/>100
11
Q
HTN History
A
Duration: when was your last known normal blood pressure? Prior treatment? Any intake causing this like NSAIDs, estrogen, adrenal steroids, cocaine, high na. Family History: HTN, pheochromocytoma, cardiac disease, DM, kidney disease. S/S secondary causes: muscle weakness, headache, palpitations, fatigue, sleeping through out the day. S/S Target organ damage: decreased vision, headache, chest pain, dyspnea, claudication. Psychosocial: family, work, stress Risk: smoking, drinking, inactivity, diet
12
Q
Physical Exam HTN
A
General: fatigue, body fat, strength, alertness.
Palpate pulses femoral and brachial same time to r/o COA.
Eyes: fundoscope - hemorrhage, papilledema, cotton wool spots
Neck: listen and palpate carotid. Thyroid.
Heart. Lungs.
Abdomen: renal masses, bruits
Extremities: edema
13
Q
Labs HTN
A
CBC, Lipids, TSH, UA, ECG, Plasma Renin Activity, Albuminuria, BUN, Serum Creatinine, fasting blood glucose, electrolyte panel
14
Q
Treat - Black
A
Thiazide, CCB
15
Q
Treat - not black
A
ACE/ARB
16
Q
Treat not black > 60
A
thiazide, CCB. If
17
Q
CKD and HTN
A
ACE ARB
18
Q
Renal Artery Stenosis, what it causes, how to control it, how to diagnosis it
A
blocked renal artery –> renin angiotensin system –> increased bp. treat w/ angioplasty. control with beta blockers. dx abdominal bruits
19
Q
Pheochromocytoma: s/s, treatment, diagnosis
A
tumor on adrenal gland. Bilateral headache, hypertension, hyperhydrosis, hyperglycemia. Need alpha blocker and surgery. dx w CT scan.
20
Q
Primary Aldosteronism: s/s, treatment
A
caused by adrenal adenoma symptoms are muscle cramps and fatigue. can be surgically corrected.
21
Q
COA: s/s, diagnosis
A
claudication, pulse delay brachial and fem, lower blood pressure in lower extremities. Need CXR.
22
Q
Cushings
A
hirutism, edema, buffalo hump, moon face, truncal obesity. Adrenal cortex hypersecretion of glucocorticoids leading to HTN.
23
Q
OSA
A
Morning headache, daytime sleepiness, snoring, gasping
24
Q
HTN treatment w Renal or Heart Failure
A
loop diuretics
25
Monitor these labs after starting BP mgmt
glucose, k, lipids, renal function
26
treatment with CAD and HTN
beta blockers, cardioprotective post MI, good with anxiety
27
Beta Blockers contraindicated in
asthma and bronchocontriction
28
good for DM with HTN
ace/arb/ccb
29
amlodipine s/e
leg edema
30
LDL goal
if DM, ACS, CVD less than 70.
31
LDL does
brings cholesterol into the plasma
32
HDL does
prevents the oxidation of the LDL into the arterial wall. Brings the free cholesterol to the liver to be reprocessed
33
how to decrease LDL and increase HDL
weight reduction, diet, exercise
34
Saturated fats lead to
increased lipids
35
Physical Exam with Hyperlipidemia
height/weight BMI. heart rate and rhythm. BP. Xanthomas fatty deposits. Corneal arcus white ring.
36
Labs with Hyperlipidemia
fasting: full lipid profile. not fasting: total cholesterol, HDL-C.
Total > 240 high
200-239 borderline
HDL 200 high
37
Before starting a statin need these labs
need liver enzymes d/t may lead to hepatic impairment. draw CK if c/o myalgias.
38
if myalgias
use bile acid sequestrants or cholesterol absorption inhibitors
39
treat hypertriglyceridemia
fibric acid, tri > 400. must monitor LFTs.
40
TDAP
one dose then q10years
41
varicella
2 doses four weeks apart
42
HPV
3 doses through age 26. 2 through 21 for males, 3 for gay men
43
pneumonia
>65
44
hep a
two doses 6 months apart
45
hep b
3 doses. 2nd one months after 1st, third is 2 months after second
46
HR for Hep C
1945-1965. injection drug users, blood transfusions
47
HIV screening
drug use, gay, STIs, unprotected sex, HIV partners, exchange sex for money
48
Causes of Renal Artery Stenosis
fibromuscular dysplasia causing tight renal bands usually found in those younger than 30. atherosclerosis in those greater than 50
49
hyperaladosteronism symptoms
weakness, headache, fatigue, hypertension, hypokalemia
50
neurovascular s/s of target organ damage
transient weakness, blindness, loss of vision, severe headache, confusion, lethargy, seizures
51
vascular target organ damage
COA, impotence, claudication
52
cardiovascular target organ damage
chest pain, dyspnea, palpitations, syncope
53
renal s/s target organ damage
oliguria, hematuria, dysuria
54
peripheral circulatory changes w HTN
thinning skin, loss of extremity hair, decreased or absent pulses
55
eye changes with HTN
arteriolar narrowing, av nicking, hemorrhages, papilledema
56
CAD markers
c reactive protein, interleukin6, monocyte-macrophage colony stimulating factor
57
s1
heard at apex. systole. mitral and tricuspid are closed, semilunar are open, blood is flowing through during contraction
58
s2
closure of aortic and pulmonic, mitral and tricuspid are open and filling during diastole best heard at base
59
s3
rapid filling of left ventricle. heard in CHF, normal in pregnancy
60
s4
found in MI, LVH, chronic HTN
61
Systolic HF
decreased ability to contract --> decreased EF and decreased cardiac output. caused by left ventricular dilated cardiomyopathy
62
Diastolic HF
cant relax and fill, caused by LVH from uncontrolled HTN. EF normal.
63
L sided HF
sob, wheezing, frothy cough, S3, coarse rales
64
R sided HF
jvd, hepatomegaly, splenomegaly, dependent edema
65
triglyceride range
>150 high
66
hdl range
>40 good
67
cholesterol total level range
>200 high
68
ABI normal range
0.9-1.3 -- abnormal = PVD
69
Risk factors for atherosclerotic disease
smoking, htn, low HDL, family history of CHD, male >45, female >55 if two or more need 10 year risk
70
Labs to draw with HTN
UA, CBC, serum K, BUN, Cr, fasting blood glucose, lipoprotein, serum uric acid, calcium
71
bladder of BP cup is this % of arm & where
80, 1 cm above AC fossa, support level with heart, average of at least two measures, feet on the floor,
72
peripheral circulatory impairment
pulses diminished or absent, skin thinning, loss of extremity hair
73
how many office visits to diagnose htn
3
74
cant give diuretics with these comorbidities
dm and renal insufficiency
75
diuretics good if pt also has...
CHF
76
beta blockers good if pt also has..
MI, angina, migraines, hyperthyroidism, tachycardia or a fib, CAD, anxiety
77
ace/arb good for...
chf, dm, renal insufficiency
78
can't do calcium channel blockers with
CHF
79
Why we should not lower blood pressure in hypertensive crisis too quickly
loss of autoregulation, decreases cerebral perfusion
80
triglycerides > 500 risk for
acute pancreatitis. treat with niacin or a fibrate, once controlled move to lowering LDL
81
Risk factors of heart disease
HTN. Family hx of young age MI. DM. Dyslipidemia. *Low HDL*. Age. Cigarettes. Obesity. Microalbuminuria. CAD. PVD.
82
Lifestyle changes for Hyperlipidemia
Weight loss, exercise, low sat fat diet
83
best agents to decrease LDL
Statins.
84
Statin drug interactions
Graperfruit juice, fibrates, antifungal, macrolide antibiotics, amiodarone, caridem, norvasc, verapamil
85
Fibric acid
Gemfibrozil, Fenofibrate, reduces production of triglyceridese by the liver and increases HDL. Side effects dyspepsia, gallstones, myopathy
86
Pt education: high triglycerides
Reduction of simple carbs, junk food and fried food
87
Pt education: low HDL
increase exercise, OTC niacin
88
Bile Acid Sequestrants
Questran Light. Colestid, Welchol. Works in the intestines to interfere with fat absorpion. Good if can't tolerate statin. Take w a multivitamin. Side effects bloating, abd pain, gas. Start at low dose.
89
Zetia
Combo of simvastatin and vytorin. Can cause rhabdo. Side effects diarrhea, joint pain, tired
90
When to recheck lipids levels
3 months then every 6 months during first year also check LFTs
91
S/s Rhabdo
muscle pain, weakness, dark urine. Will cause renal failure. Ck markedly elevated 10,000-25,000. Urine red brown from myoglobinuria, proteinuria
92
Dietary sources of calcium
low fat dairy
93
Potassium sources
fruits and veggies
94
Mg sources
dried beans, whole grains, nuts
95
Obesity waist circumference
men 40 women 35
96
Medicare wellness visit
BMI, full physical exam, visual acuity
97
Colorectal cancer screening
Start at age 50. flex sigmoid every 5, colonoscopy every 10. FOBT annual. If HR begin age 40. If you have significant polyps colonoscopy is annual
98
Prostate exam
annual digital rectal exam
99
Mammogram
every other year starting at age 50
100
Breast exam
yearly at age 40, every 3 years 20-30s
101
Cervical Ca
Start at 21. Pap q3years
102
Gonorrhea and Syphilus
start screen at age 18 if sexually active
103
Chlamydia
start at 24 if sexually active
104
Bp screening if 120/80
every 2 years
105
Bp screening if >120
every year
106
BP if >140
discuss treatment
107
Comprehensive Geriatric Assessment
Medical: medications, hearing and vision, contence, nutrition, intregrity, pain, abuse. Psychosocial: depression, social support, home environment. Cognitive w mini mental exam. Functional: ADLs, falls, time up and go test
108
BEERS criteria
age 65+ screen of medications that may be inappropriate
109
Herpes Zoster
1 dose > 60 years
110
Tetanus
booster every 10 years
111
BP 160/100 or greater
combo with CCB/Thiazide + ACE/ARB'
112
Resistant
add aldoactoe, beta or alpha or vasodilator
113
ace and arb together causes
decreased GFR, hypotension, hyperkalemia
114
needs hospitalization
180/120 and s/s target organ damage - retinopathy, dizzy, AMS, blurry vision, chest pain, SOB, oliguria
115
statin w liver disease
pravastatin
116
statin w kidney disease
lipitor
117
labs before starting a statin
LFTs, CK, TSH
118
Therapeutic Inertia
failure of providers to increase therapy in the setting of identified poor blood pressure control
119
Top two causes of HTN prevalence
age and obesity also main reason is high salt
120
BP =
systemic vascular resistance x cardiac output
121
factors determining blood pressure
sympathetic nervous system, renin angiotensin aldosterone system, plasma volume (mediated by the kidneys) -- feelings,, patho process, blood
122
Aging and blood pressure
systolic rises, diastolic decreases after age 50. from progressive arterial stiffing. major risk factor for cardiac, stroke, and kidney disease in the older population
123
EF dialstolic v systolic
diastolic preserved, decreased ef in systolic, HF increases w increased blood pressure.
124
risk for htn complications is lowest at this blood pressure
115/75. for every 20mm in systolic or 10mm diastolic above this the risk for cardiac/stroke events doubles
125
to diagnosis htn
140/90 on at least two visits over a period of at least 1 week apart.
126
nonpharm therapy to decrease blood pressure according to US Preventative Task Force
1) Decrease sodium
2) Supplement K
3) Increase activity/lose weight
4) Mgmt stress
5) Decrease alcohol
127
USPSTF other guidelines with screening for htn pts
also screen for DM, hyperlipidemia, smoking, aspirin prevention for those at increased risk.
128
bp screening in >65... who else needs this evaluated?
include orthostatic hypotension. 20mm or greater fall in systolic pressure from rising from supine. Also needs to be screened in diabetic and those w complaints of dizziness, weakness. 5 minutes supine then immediately and 2 mins after standing.
129
Mild hypertension
no end organ damage. need 3 readings >140 or/
130
advise patients not to do this before taking blood pressure
have coffee 1 hr before, smoke 1/2 hour before, no decongestants or pupillary dilators before,
131
length/width of bladder of bp cuff
L 80/ W 40. 20mm above systolic pulse as estimated from loss of radial pulse. deflate 3mmhg per second
132
blood pressure in african americans
occurs 1) younger age and 2)more severe. salt increases more than white people. more vulnerable to strokes and hypertensive kidney disease. 3-5x more likely to have kidney complications and CKD.
133
Common finding with COA
brachial-femoral delay
134
Differential pressure
brachial bp (arm) vs popliteal pressure (leg)
135
blood work to evaluate cardiac risk, s/s organ damage, underlying causes of htn
blood chemistry: blood glucose, cr/bun/gfr, electrolytes
lipid profile
UA for hematuria, albumin/cr ratio
ECG
serum uric acid -- pathogenic factor of htn
plasma renin -- for those with mineralocorticoid excess causing htn
albumineria -
136
Best test for LVH
2d echo
137
When to do a ekg
htn w CHF, Left vent dysfunction, CAD
138
> 60 goal HTN w/ out DM/CKD
139
>18 goal HTN
140
goal HTN w DM/CKD
141
60 and not black use CCB/thiazide and add ace/arb if not at goal.
142
black htn for stage 1/stage 2
stage 1 - 140-159, ccb or thiazide, add an ace or arb or combine ccb with thiazide. stage 2 >160, combine both ccb and thiazide and add ace or arb
143
CKD bp mgmt
ace or arb add ccb/diuretic if not at goal
144
DM bp mgmt
ace or arb - if black use ccb thiazide -- add opposite if not at goal.
145
CAD and bp mgmt
beta blocker AND ace or arb add ccb or thiazide if not at goal
146
Stroke Hx w HTN mgmt
ace or arb, add thiazide or ccb if not at goal
147
CHF hx w htn mgmt
ace or arb plus a beta blocker plus diuretic and aldactone, add CCB if needed
148
Resistant htn
need to add spironolactone, beta or alpha, or direct vasodilator
149
Why you can't combine ace/arb
hypotension, hyperkalemia, decreased GFR
150
If unable to acheive bp goals
refer to htn specialist
151
only 51% of htn are adequately mgmt because
1) access to care/meds 2) resistence to meds because they are asymptomatic, immediate benefits are not obvious 3) therapeutic inertia
152
180/110
the history of prior treatment for hypertension and nonadherence to antihypertensive medications is a common finding
153
"when was the last time you were told your bp was normal" will tell you
how long the pt has had undiagnosed htn
154
ace+arb -->
angioedema
155
cholesterol % by liver
| cholesterol % from food
75 - liver
| 25 - food
156
causes of dyslipidemia
diet - will increase LDLs w transfats, weight gain, anorexia nervosa.... increase tris with weight gain, low fat diets, high carbs, excessive alcohol. certain drugs like diuretics, cylosporins, glucocorticoids, amoidarone, estrogen, bile acid sequestrants, PIs. Liver and kidney disease. Hypothyroid. Obesity. Pregnancy. Poorly controlled DM.
157
Who gets treated for hyperlipidemia
1) ASCVD 2) LDL > 190 3) DM 40-75 w LDL 70-189 w/ pit ASCVD 4) 70-189 10 year risk 7.5 5) family hx of young ASCVD dad
158
Statin for DM and 10 year risk
moderate intensity
159
seen in those with insulin resistance
skin tags, acanthosis nigricans
160
ATP III
1) Determine labs 2) determine ASCVD risk 3) Risk factors: smoking, low hdl, age >45m >55w, family hx CHD, htn 4) if 2+ risk factors get 10 year risk 5) determine risk 6) TLC 7) after 3 months get drug 8) id metabolic syndrome 9) treat high tris
161
myopathy
any disease of the muscle
162
myalgia
muscle ache or weakness w out CK elevation
163
myositis
muscle ache w increased CK
164
rhabdo
10x normal ck w muscle ache
165
conditions that can increase risk for myopathy
hypothyroidism, vitamin D insufficiency, kidney or hepatic dysfunction, rheumatologic disorders such as polymyalgia rheumatica, corticosteroid myopathy, or primary muscle disease
166
statin therapy w renal impairment
atorvastatin or fluvastatin
167
liver disease and a statin
low dose pravastatin
168
least likely to cause myalgia
pravastatin and fluvastatin
169
hypothyroid and dyslipidemia
can cause it. can lead to worse myopathy. need tsh before starting a statin
170
metabolized by CYP3A4 should not give w fibrates (gemfibrozil) , dilatazem, verapamil, amlodipine, HIV PI, amiodarone, grapefruit juice, niacin
simvastatin, lovastatin, atorvastatin
