HTN Flashcards
What is a lipid profile? Why is it important in HTN?
-Measure cholesterol, triglycerides + lipoproteins to see risk of atherosclerotic disease or to diagnose specific lipoprotein abnormality
Signs + Symptoms of HTN
Raised BP
Late: dizziness, fatigue, palpitations, AM headaches, blurred vision
from patho
Important diagnostics for HTN?
**
Lipid Profile Urinalysis Electrolytes Fasting Blood Glucose CBC BUN &Creatinine Lipid Profile (Total Chol, HDL, LDL, Triglyceride) CRP 12-lead ECG Echocardiogram
(BP, HR)
Pharmacological interventions for HTN?
**
Thiazide/Loop Diuretics Beta Blockers ACE Inhibitors, ARB’s Calcium Channel Blockers Vasodilators
3 step approach to managing HTN?
**
1) Lifestyle modifications
2) Start with one drug at low dose and increase if necessary
3) Addition of a 2nd anti-hypertensive
medication until results are achieved
Recommended lifestyle changes for those with HTN
**
Smoking Cessation Alcohol use - 1-2 standard drinks/day Diet/Weight loss - DASH diet Exercise: light weights/aerobic (tight) Blood glucose control for people with Diabetes
Differentiate between CHEP guidelines and AHA as teaching/learning resources
x
4 systems of BP regulation in body:
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Arterial Baroreceptors/ Chemoreceptors
Regulation of body fluid volume
Renin-angiotensin aldosterone system
Vascular autoregulation
Name 7 kinds of HTN
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Primary hypertension Secondary hypertension “White coat” hypertension Isolated systolic hypertension Malignant (persistent severe) hypertension Pregnancy Induced Hypertension (PIH)
SBP = ?
DBP = ?
**
Systolic BP
pumping pressure
Distolic BP
filling pressure
Ranges for stages of HTN?
**
High Normal: 130-139 S or 85-89D
Stage 1: ≥140-159 S or ≥90-99D
Stage 2: 160-179S or 100-109D
Stage 3: ≥= 180S or ≥=110D
How do we diagnose HTN?
- Conventional route for diagnosis = 6 measures over 6 months…unrealistic + high risk of complciations
- Urgent cases (BP needs to be lowered within few hours) can be diagnosed on initial visit – BP taken every 5 min, monitor for rapid drop
From class: 2 BP readings are taken 5 minutes apart
no caffeinated drinks
no smoking
no alcohol
Possible adverse effects of HTN? Why is this condition such a concern?
- Target Organ Damage
- Stress on the heart L ventricular hypertrophy
- HF
- Stress on blood vessels atherosclerosis, CVA
- Renal disease (hypertensive nephropathy)
Non-modifiable risk factors for HTN? *From class PP's
Age
Family hx
Gender: men over women until age 55; over 74 women
Ethnicity
Insulin resistance syndrome/Metabolic Syndrome
hyperinsulinemia + obesity + Type 2 Diabetes + hyperlipidemia
Modifiable risk factors for HTN?
Stress fight/flight Obesity: BMI > 25 Nutrition: Na+ diet; high fat Substance abuse smoking, alcohol, cocaine, caffeine Oral contraceptives Sedentary lifestyle
Risk factors for primary HTN?
genetic heritage( African descent, First nations, Inuit, Metis, South Asians, Chinese) excess sodium intake alcohol intake body weight physical inactivity lipid levels personality traits (those with hostile attitudes) vitamin D deficiency
What is the biggest risk factor for CVD?
HTN
Conditions that lead to secondary HTN?
o Primary renal disease (acute + chronic)
o Oral contraceptives
o Pharmaceuticals
o Chronic alcohol intake
o Pheochromocytoma (a small vascular tumor of the adrenal medulla, causing irregular secretion of epinephrine and norepinephrine, leading to attacks of raised blood pressure, palpitations, and headache)
o Primary aldosteronism (excess aldosterone secretion)
o Renovascular disease
o Cushing syndrome (htn major cause of death in those with this condition)
o Other endocrine disorders: hypothyroidism, hyperthyroidism, hyperparathyroidism
o Obstructive sleep apnea
o Coarctation of the aorta
How frequent are follow-ups with patients with diagnosed HTN?
q1-2months for those on antihypertensives until 2 readings find below target values(more frequent for symptomatic patients, severe cases, intolerance to antihypertensives, those with organ damage), then seen q3-6months
How does the outcome of a lipid profile relate to risk of CAD?
-Risk of CAD inc as ratio of LDL to HDL or total cholesterol (HDL + LDL) to HDL increases
When is a lipid profile measured?
-Obtained after 12 hour fast (though lipid levels remain quite constant)
What is cholesterol required for? High in what tissues?
oRequired for hormone synthesis + cell membrane formation
oHigh in brain + nervous tissue
HDL’s:
- Relationship with CAD risk?
- fx
- Dec with?
o inverse relationship between inc + risk of CAD → have protective quality, transport cholesterol away from tissues + cells of arterial wall, bring to liver
• Dec with smoking, diabetes, physical inactivity
Triglycerides:
- Made up of (2)?
- Blood levels inc when?
- Correlative relationship between triglycerides and LDL and HDLs?
o Composed of fatty acids + glycerol
o Stored in adipose, source of energy
o Levels inc after meals, affected by stress
o Inc with diabetes, alcohol use, obesity
o Direct correlation w LDL, inverse with HDL
What factors determine which antihypertensive is used?
•In choosing drug, will consider general health, sex, age, race, severity of BP, any additional underlying medical conditions, and whether particular drugs should not be used
Is the kind of antihypertensive used important in reducing risk of CVD? What is?
• Amount of BP reduction is major determinant of reduction in CVD, not choice of antihypertensives
To increase effectiveness, is an antihypertensive dose typically increased?
•Typically begin with one drug, then add a second if not managing (rather than inc dose – but can do this too) → using combo drug therapy usually more effective than inc dose + has less side effects
Without a specified determination in HTN, which kind of antihypertensives are NOT typically used?
beta blockers not typically used as initial therapy in absence of specific determination
In absence of particular determination, which 3 kinds of drug classes are typically used with HTN?
1) thiazide diuretics
2) long-acting Ca channel blockers
3) ACE inhibitors or ARB’s
What is “nondipping” HTN and how to manage this pharmacologically?
= failure of BP to fall at least 10mmHg during the night;
= a stronger predictor of adverse CVD effects than daytime pressure → shifting one drug to nighttime may help this
Goal of HTN phamacologic therapy (target BP range)?
for noncomplicated cases, to get below 140/90 or 150/90 (for those >60)
For systolic HTN, why do you need to be careful not to push diastolic P too low?
…r/t MI + stroke
What is “resistant HTN”? What is it due to?
DBP of >90mmHg despite taking 3 drugs; could be d/t suboptimal therapy, extracellular volume expansion, poor compliance, secondary htn, office or white coat htn, ingestion of substances that elevate BP
In HTN treatment, When are the following drugs recommended?
1) ACE inhibitors
2) Beta blockers
1) for DM with proteinuria, HR or prior MI
2) HF or prior MI
Which drugs are recommended for control of symptoms of angina pectoris?
Beta blockers or calcium channel blockers
Which antihypertensives are NOT recommended during pregnancy?
ACE inhibitors + Angiotensin II receptor blockers (ARB’s)
What does the DASH diet include?
General recommendations for diet in HTN?
- DASH = high in fruits + veggies & low fat dairy products
- Choose diet low in meats, sweets, refined grains, high in vegs + fruit
- Dietary salt restriction
- Vitamin D supplementation
Exercise recommendations for HTN?
Do something active for at least 30 mins a day on most days of the week; aerobic exercise has benefit on systolic BP
Limit alcohol intake to?
1 drink for women, 2 for men/day (5oz wine, 1 beer, 1.5oz hard)
General approach to lifestyle modifications in treatment of HTN?
(what “moto” is used?)
“Start low and go slow” – don’t have to change everything at once, choose one thing first and try until becomes habit
Limiting intake of what drugs is recommended in lifestyle changes for HTN?
NSAIDS + acetaminophen
At what BP should antihypertensives be held?
Bottom line systolic P (when to not administer antihypertensive) = 100mmHg
90mmHg needed to perfuse organs
Approach for Angina?
M- Morphine O- Oxygen N- Nitroglycerine A- ASA (plavix) - First have sit down, give O2 and see if this is enough - IF pain doesn’t subside, start Nitro
Pulse pressure reflects?
force of heart each time it contracts
What is attributed with an inc in HTN in children?
Rising obesity rates
Relationship between sex and BP?
Women: lower sys BP than men until 50, then rises significantly to surpass that of men
(women have overall higher risk of developing HTN)
What is CHEP?
Canadian Hypertension Education Program - evidence informed guidelines for the accurate measurement of and treatment of HTN
o CHEP’s intent is to edu HCW and the public abt the consequences of HTN and the imp of adequate prevention and Tx in order to reduce the burden of CVD
Major points in CHEP?
- Encourage pts to use approved BP measuring devices + proper technique when measuring at home (home measurements highly encouraged)
- Adults with high normal BP require annual assessment
- All Canadian adults need to have BP assessed at all appropriate clinical visits
- Optimal management requires assess of overall cardiovascular risk
- Lifestyle modifications important - introduce small managemable changes
- Treat to target
Managment recommendations:
- Healthy diet w reduced cholesterol, saturated fat, dec sodium
- Inc fruits, veggies, low fat dairy products, dietary fibre, whole grains, proteins from plant products
- Inc physical activity to prevent childhood obesity
Which is a stronger predictor of CV evets, that done at home or in a clinical setting?
Home
Idiopathic HTN aka?
Essential
Primary
Secondary HTN generally results from?
Other disease such as adrenal tumour, pre-eclampsia, or renal artery disease
May also be result of medications
Normal CO?
BP =
4-8L/min
BP = CO + SVR (systemic vascular resistance)
What is SVR?
Systemic Vascular Resistance
= the forece (resistance) the left ventricle has to overcome to eject its volume of blood
How is HTN drug tx determined?
Very individualized
Must think about whether patient has other medical problems and impact of drug tx on pt quality of life
What is a common side effect of antihypertensives in men?
sexual dysfunction…leads to noncompliance (why must choose drug carefully, taking into account how it will affect quality of life)
How is HTN defined in terms of percentiles?
o HTN is defined as BP > or = to the 95 percentile for age gender and height on 3 sep occasions
o PreHTN=90-95th percentile
What is “masked” HTN?
•normal when in DRs office and high when at home
General guidelines for when a patient will be on one or two drugs?
If pt has stage HTN 140-159/90-99 theyre most likely given thiazide diuretic; may consider ACE I, ARB, BB, CCB or combo
If pt has stage II HTN theyre most likely on two drug combo
Where do adrenergic drugs work on?
o Have either central action in brain or peripheral action in the heart and blood vessels
How do vasodilators work?
Act directly on smooth muscle cells, not through alpha or beta receptors
What is a more reliable indicator of long term effectiveness of antihypertensives than BP?
looking at fundus of eye
