HTN Flashcards
HTN is most prevalent in which race
blacks > whites > hispanics
normal blood pressure values
- systolic pressure < 120 mmHg
- diastolic pressure < 80 mmHg
what blood pressure values classify as pre-hypertension
- systolic pressure 120-139 mmHg OR
- diastolic pressure 80-89 mmHg
what blood pressure values classify as stage 1 HTN
- systolic 140-159 mmHg OR
- diastolic 90-99 mmHg
what blood pressure values classify as stage 2 HTN
- systolic > or = 160 mmHg OR
- diastolic > or = 100 mmHg
equation for blood pressure
BP = CO x systemic vascular resistance
what are the major factors that determine BP
- sympathetic nervous system
- Renin angiotensin aldosterone system
- plasma volume
what are the modifiable risk factors for primary HTN
- smoking
- high sodium diet
- excess alcohol intake
- obesity/weight gain
- physical inactivity
- dyslipidemia
- vitamin D deficiency
primary HTN accounts for what percentage of diagnosed HTN
90-95% of all HTN
what is secondary HTN
- increased BP resulting from an identifiable medication or medical condition
- must be addressed to achieve adequate BP control
- 5-10% of all HTN
what are the major conditions that are associated with secondary HTN
- renal disease
- medication induced: estrogen, NSAIDS, steroids
- Thyroid, Parathyroid disease
- Coarctation of aorta
- primary hyperaldosteronism
- Cushing’s syndrome
- Pheochromocytoma (hypertensive emergency: HA, sweating, tachycardia)
- obstructive sleep apnea
united states preventive services task force recommendation for screening for HTN
- all individuals 18 or older should be screened
- adults 40 yo or older should be measured at least annually
- adults betwwen 18-39 should be screened annually if they have risk factors or previously measured BP was elevated
- adults betwwen 18-39 without risk ractors and high BP should be screened at least every 3 years
gold standard for diagnosing HTN
- ambulatory blood pressure monitoring
- if BP elevated at screening, the diagnosis should be confirmed using out of office BP measurement
general principles you should tell patient when having them check BP outside of office
- serial measurements required
- measure on both arms
- comfortable, quiet setting
- avoid eating, exercise, smoking, and caffeine
Physical exam for a person who is hypertensive
- vitals
- BMI, waist circumference
- BP both arms
- pulses
- general
- body fat distribution
- skin lesions
- muscle strength
- alertness
- HEENT
- fundoscopy for hemorrhage
- cotton wool spots
- Neck
- carotids, thyroid
- Respiratory: rales
- Cardiac
- displaced PMI or new murmur
- Abd
- renal masses
- abdominal aorta
- Neuro
- visual disturbance
- focal weakness
- confusion
what tests should you always order when evaluating for HTN
- LUBE
- Lipid panel
- UA
- Basic metabolic panel
- fasting glucose
- creatinine, electrolytes, GFR
- EKG
what is the first line treatment for all patients with essential HTN
Lifestyle modifications
- Diet
- lower sodium intake
- DASH diet
- alcohol reduction
- Exercise
- 3-4x/week (40 min, mod-vigorous)
- healthy weight
- smoking cessation
What are the BIG FOUR medications when it comes to treating HTN
- Diuretics
- Angiotensin Converting Enzyme inhibitors (ACE-I)
- Angiotensin II receptor blockers (ARB)
- calcium channel blockers
What other four medications can be used to treat HTN if the BIG FOUR aren’t working
- beta blockers
- alpha blockers
- central alpha agonist
- direct renin inhibitor
What is everybody’s treatment threshold/goal for BP. What is the exeption
- 140/90
- exception is people over 60 yo who don’t have kidney disease or diabetes, in which case their goal is 150/90
In the general nonblack population, including those with diabetes, initial antihypertensive treatment should include
- One of BIG FOUR
- thiazide type diuretic
- calcium channel blocker
- angiotensin-converting enzyme inhibitor
- Angiotensin II receptor blockers
In the general black population, including those with diabetes, initial antihypertensive treatment should include
- thiazide-type diuretic OR
- Calcium channel blockers
Adults with chronic kidney disease should be put on which drugs regardless of race or diabetes status
- angiotensin II receptor blocker (ARB)
- angiotensin converting enzyme inhibitor (ACE-I)
Medication recommendation summary (put CKD, race recommendations all together)
- if you have CKD, start with ACEI or ARB
- if you are black, start with thiazide or CCB
- neither? start with any one of BIG FOUR
if a single antihypertensive drug doesn’t work, what should you do
- add a second drug from another class
- if that doesn’t work, add another from one of the remaining classes
- **Don’t use ACEI and ARB together
- ex:
- ACE, thiazide, CCB
- ARB, thiazide, CCB
If the patient is taking three out of the four BIG FOUR classes of antihypertensives and still hasn’t reached the target goal, what should you do
- consider other classes of medications or refer to specialist
what is resistant hypertension. How should you manage it
- blood pressure that is not controlled despite adherence to an appropriate three drug regimen or requires at least four medications to achieve control
- ensure adherence to lifestyle changes, medication regimen, and accurate measurement
- consider referral
How would you treat
- 65 yo white male with BP 170/90
- lifestyle management
- target goal BP: < 150/90
- place him on ACEI, ARB, CCB, or Thiazide
How would you treat
- 65 yo black female with DM and BP 162/98
- lifestyle modification
- target BP: < 140/90
- CCB or Thiazide
What are the side effects of Thiazide type diuretics
- Hypokalemia
- Gout
- Dyslipidemia
Contraindication to taking Thiazide type diuretics
sulfa sensitivity
MOA of Thiazide type diuretics
- decrease body’s sodium stores by inhibiting sodium reabsorption in the nephron
- reduces plasma volume and peripheral vascular resistance
Name the four types of Diuretics
- Thiazide type diuretics
- Loop diuretics
- Potassium sparing diuretics
- aldosterone antagonist
Hydrocholorthiazide (HCTZ) is a part of which class of drugs
Thiazide-type diuretics
Side effect of ACE inhibitors
- hyperkalemia
- acute renal failure
- angioedema
Which patient populations greatly benefit from being put on an ACE inhibitors
- DM
- CKD
- post MI
- Heart failure
contraindications to give ACE inhibitors
- renal artery stenosis
- pregnancy
- angioedema
The “Pril”s (e.g. lisinopril, enalapril) are a part of which drug class
ACE inhibitors
MOA of ACE inhibitors
- inhibit the RAAS system and stimulate bradykinin (which has a vasodilatory effect)
MOA of angiotensin II receptor blockers
inhibit the RAAS system
The “..sartan”s (e.g. Losartan, valsartan etc..) fall into which drug class
angiotensin II receptor blockers
Side effects of angiotensin II receptor blockers
- hyperkalemia
- acute renal failure
- angioedema
which patient populations greatly benefit from being placed on an angiotensin II receptor blocker
- CKD
- DM
- heart failure
contraindications to give angiotensin II receptor blockers
- pregnancy
- renal artery stenosis
- angioedema
What are the two types of calcium channel blockers. Which is used to treat HTN?
- Non-dihydropyridine
- dihydropyridine: more selective as vasodilators, less cardiac depressant effect
”..pine”s (e.g. amlodipine, felodipine..etc) are a part of which drug class
dihydropyridine
side effects of calcium channel blockers
- cardiodepressant -> bradycardia
- dizziness
- HA
which patient populations greatly benefit from being put on a calcium channel blocker
black population
contraindications to give calcium channel blocker
- several types of cardiac dysfunction
- acute MI
MOA of calcium channel blocker
inhibit calcium influx into arterial smooth muscle cells, which reduces peripheral vascular resistance
What are the types of Beta blockers
- cardioselective (B1 receptors)
- Noncardioselective (B1 and B2 receptors
”..olol”s (e.g. propranolol, nadolol etc) are in which drug class
beta blockers
side effects of beta blockers
- bradycardia
- bronchospasm
which patient populations benefit from being on beta blockers
- post MI
- stable heart failure
- high CAD risk
- often used in pregnancy
contraindications for beta blockers
- bronchospastic disease
- heart block
- acute decompensation heart failre
- **avoid abrupt cessation
side effect of central alpha agonists
- hepatitis
- hemolytic anemia
- anticholinergic effects
clonidine and methyldopa are a part of which drug class
central alpha agonists
MOA of central alpha agonists
- stimulate a2 adrenergic receptors in the brain which reduces CNS sympathetic outflow
what is the most commonly used anti-HTN in pregnancy
Methyldopa: central alpha agonists
contraindications for central alpha agonists (specifically methyldopa)
liver failure
“zosin” (e.g. doxazosin, terazosin, etc) are a part of which drug class
alpha blockers
MOA of alpha blockers
targets alpha 1 receptors on vascular smooth muscle, causing peripheral vascular resistance to decrease, thus decreasing BP
side effects of alpha blockers
- orthostatic hypotension
- reflex tachycardia
which patient population benefits from being on a alpha blockers
BPH
aliskiren (tekturna) is a part of which drug class
direct renin inhibitors
side effects of direct renin inhibitors
- hyperkalemia
- renal impairment
- hypersensitivity reaction (anaphylaxis, angioedema)
contraindications for direct renin inhibitors
- with ACE-I or ARB in diabetics
- pregnancy
Hypertensive urgency
-
asymptomatic severe HTN (diastolic > 120 mmHg) and NO evidence of end organ damage
- usually nonadherence to chronic antihypertensive medication
- nonadherence to low sodium diet and/or high salt load
hypertensive emergency
severe HTN (diastolic > 120 mmHg) and evidence of acute end-organ damage
Causes of hypertensive crisis (urgency and emergency)
- abrupt d/c of BP meds
- high salt load
- neurological emergencies (stroke, trauma)
- cardiac emergencies (HR,MI)
- vascular emergencies (aortic dissection)
- pregnancy
- renal emergencies
Treatment for hypertensive urgency
- Goal: reduce BP < 160/120 mmHg (achieved over hours-days)
- treatment
- rest
- increase dose of current meds
- add meds
- f/u
treatment for hypertensive emergency
- hospitalized in ICU
- address underlying cause
- reduce BP
- no more than 25% within minutes to 1 hour
- BP goal, 160/100-110 mmHg over 2-6 hours
- *sublingual nefidipine is contraindicated
