HTN Flashcards
1
Q
Why do normotensitve adults at age 55, still have 90% change of developing HTN in life?
A
systolic BP continues to rise during lifetime.
dyastolic BP levels off around 50 years old.
2
Q
What factors affect cardiac output?
A
Heart rate
Myocardial contractility
Circulating volume, which affects myocardial stretch
3
Q
What factors influence peripheral resistance?
A
Vascular restriction and compliance
4
Q
How to correctly take BP?
A
- Patient sits with back against the chair, with feet on the floor for 5 minutes.
- Rest patient arm with cuff at heart level
- Use a cuff that bladder encircles 80% of arm
- No talking while measuring (i.e. inflated)
- No BP cuff over clothes or below pushed up sleeves
5
Q
How much should your BP drop in the middle of the night when you are sleeping?
A
10-20%
IF not, it signals possible increased risk for cardiovascular events.
6
Q
What is the BP goal for the JNC VIII for the general population over 60, without co- morbidities?
A
Over 60 yo, without other diseases, BP goal is under 150/90
7
Q
What is the BP goal for the JNC VIII for people 30-60 yo, without co- morbidities?
A
BP goal is 140/90 for 30-60 yo without co-morbidities
8
Q
What is the BP goal for the JNC VIII for people over 18 yo, with CKD?
A
BP goal iss 140/90 for 18+ with CKD
9
Q
What is the BP goal for the JNC VIII for people over 18 yo, with diabetes?
A
BP goal is 140/90 for 18+ with diabetes
10
Q
According to the JNC VIII, what is the initial treatment for nonblack population with HTN? (including DM)
A
Choose 1:
- thiazide diuretic
- CCB
- ACEI
- ARB
11
Q
According the JNC VIII, what is the initial treatment for the black population with HTN? (including DM)
A
Choose 1:
- thiazide diuretic
- CCB
12
Q
According to the JNC VIII, what is the initial treatment for the general population over 18 with HTN and CKD?
A
ACE or ARB to improve kidney function
- applies to all CKD, regardless of race or DM
13
Q
According to the JNC VIII, what should be done if the goal BP is not met within one month?
A
Increase dose or add on additional medication. Adjust until goal is met.
14
Q
Can an ACEI and ARB be used together?
A
NEVER
15
Q
When should a patient be referred to a specialist?
A
If they are unable to reach their goal within 3 meds.
16
Q
What the benefits of lowering your BP?
A
Reduces risk of stroke, MI and HF
17
Q
What are the targets of organ damage with HTN?
A
Cerebral- Stroke, TIA
Eyes- retinopathy
Heart- angina, MI, LVH, and HF
Kidneys- neuropathy and kidney disease
Vasculature- peripheral arterial disease
18
Q
What are the three essential components to HTN work up?
A
- Rule out secondary causes of HTN
- Assess the severity of the disease
- Identify concurrent CV risk factors
19
Q
What are major CV risk factors?
A
- HTN
- smoking
- age: Men >55 and Women >65
- Family history of premature CVD
- obesity
- physical inactivity
- DM
- dyslipidemia
- Microalbuminuria or estimated GFR
20
Q
What are some cardiopulmonary questions to asks HTN patients about?
A
Chest pain with or without exercise
Peripherial edema
Orthopnea
Paroxysmal nocturnal dyspnea
Dyspnea upon exertion
21
Q
What are some target organ system questions to ask HTN patients about?
A
- impotence, claudication
- dyspnea, chest pin, palpitations, syncope
- oliguria, hematuria, dysuria
- transient weakness or blindness, severe HA, confusion, seizures, lethargy w
22
Q
What are some secondary causes of HTN?
A
- sleep apnea
- pheochromocytoma (severe HA, diaphoresis, palpitations)
- aldosteronism (muscle cramps, weakness, polyuria, polyphasia, nocturia, rhabodo)
- renovascular condititon- hypokalemia
- mineralcorticoid alterations- from oral steroids, chewing tobacco, licorice
23
Q
What are some important diagnostic testing for HTN?
A
- ECG- 12 lead
- UA (proteinuria)
- blood glucose and hematocrit
- CBC with diff
- lipid profile
- CMP or BMP (complete metabolic panel)
24
Q
What is the normal decline of GFR?
A
In 60’s, declines 1-2mL/min/year
Will increase to 4-8 mL/min/year is systolic BP is uncontrolled
25
What does it mean if a declining GFR, also has proteinuria?
declining GFR + proteinuria is a significantly worsening prognosis
26
If a patient has CKD and albumin in their urine, what does that put them at higher risk for?
Microalbumin: 50% increased risk for CVD
Macroalbumin: 350% increase risk for CVD
27
How does is declined renal function indicated?
As renal function declines=>
- Cr increases (Men >1.5 and Women >1.3)
- eGFR declines (
28
How is albuminuria tested?
- Can do 24 hour collection, but hard for patients.
- Usually do a spot urine
- compare albumin/Cr ratio.
29
When should you refer to nephrology?
If sCr is above 1.5-2mg/dL
30
How is BP related to GFR?
In significant proteinuria, as BP declines
31
If an ECG is done on a patient with HTN, what can it tell us?
If increased QRS voltage, it can predict LVH, but it cannot exclude LVH.
A T wave inversion of V4-V6 can be labeled as a strain.
32
What are indications to screen for secondary HTN?
- abrupt onset of HTN under 35 yo
- malignant HTN >210/140 with target organ damage
- BP acceleration in previously controlled
- Newly diagnosed HTN with no response to meds
- S&S of secondary cause
33
What are some clues that secondary HTN is caused by RAS?
Renal artery stenosis:
- deterioration of renal function after ACEI
- refractory or sudden HTN
- High diastolic (>110) in
34
What are diagnostics for RAS?
- MRI or CT angiography ($$$, invasive)
| - duplex doppler US (non-invastive, less $) *most common
35
What does the DASH diet consist of?
- increase Ca, Mg, K and fiber.
Must be done together with high fruit and veggie diet to have any impact
- low fat diet (7-8% of total calories)
- low to moderate amount of sodium (2,400 to 3,000 mg/day)
36
What are the lifestyle modification recommendations to manage HTN?
- weight reduction
- DASH diet
- reduce dietary sodium
- increase physical activity regularly
- moderation of alcohol consumption
37
How does smoking affect HTN?
Smoking has pressor effect which increases the muscles need for oxygen by increasing the BP, HR and contractility. Also decreases the L ventricular function.
Smoking leads to a marked increase of CV complications and increase progression of renal insufficiency.
38
According to JNC VIII, how should you decided when to add a second drug?
Start one drug, titrate to max dose, then add second drug.
Titrate until BP goal is met.
39
What is the first step in treating HTN?
- lifestyle modifications
| - start with meds if: lifestyle modifications fail or BP is too high for lifestyle modifications alone
40
How do you start of HTN medication?
- begin with low dose of a long-acting, once daily med alone, with lifestyle modifications.
- Recheck in 3 months. If response is inadequate, go to second step.
41
What is the second step in treating HTN?
- if first drug is inadequate after 3 months, slowly increase the dose to the max, if there has been a good tolerance
- If bad reaction, switch to different class
- May add second agent after first drug is maxed out. (2 drugs can have synergistic effect)
42
What is the third step in treating HTN?
If after 3-6 month of med therapy, patient isn't controlled, and maxed out on three medications. Send to cardiologist.
43
What dosage of diuretics is best for reducing mortality and CV events?
low dose (high dose is same as placebo)
treatment of choice for ppl over 60 with isolated systolic HTN.
44
What needs to be monitored for patients on a diuretic?
electrolyte and kidney function
Avoid NSAIDS (they decrease effectiveness)
45
What type of diuretic is best?
Thiazide and loop
Aldosterone and K-sparing are for individualized tx.
46
How do thiazide diuretics work?
they inhibit the Na and Cl reabsorption in the distal convoluted tubules.
This decreases extracellular fluid vol and CO, which decreases peripheral vascular resistance, which lowers BP
47
Who are thiazide diuretics CI for?
First-line therapy unless, CHF or GFR
48
What are ADE for thiazide diuretics?
ADE usually dose related.
- Gout
- impaired glucose and lipid metabolism
- Erectile dysfunction
- Increase urinary loss of vitamin B1 (thiamine)
49
Name thiazide-type diuretics.
Cholorthiazide
hydrochlorothizide
methychloriazide
Polythiazide
Bendroflumethiazide
50
Name thiazide-like diuretics.
Chlorthalidone
Metolazone
indapamide
51
How the half-lives differ from thiazide type and like diuretics?
thiazide-type: short (3-13 hours) taken QD to BID
thiazide-like: long (40-60 hours) taken QD
52
Do thiazide type or like produce better BP lowering outcomes?
Type: less BP reduction
Like: better BP reduction, especially at night
53
What is the dosing equivalency between thiazide type: like?
HCTZ: Chlorthalidone
2:1
54
How does renal function affect the dosing or thiazide like and type diuretics?
Decreasing renal function, decreases efficacy in both types of diuretics
55
How do loop diuretics work?
Block the chloride reabsorption in the thick segment of the ascending loop of Henle, which looses sodium, chloride and K in the urine.
56
If a patients' GFR decrease, which diuretic is better to use?
Loop
57
What is the duration of action in a loop diuretic?
Short (3-6 hours)
Requires dosing Q6-8 hours
58
Which diuretic is more efficient in treating fluid overload?
Loop
59
What medications are CI with loop diuretics?
NSAIDS
60
Name some loop diuretics.
Furosemide (Lasix)
Torasemide
Bumetanide
Etacrynic acid
61
How do potassium sparing and aldosterone antagonists diuretics work?
Interferes with the ability of aldosterone to promote sodium reabsorption and potassium secretion.
Promotes sodium excretion with water and potassium retention.
62
Name some potassium sparing diuretics.
Amiloride
Triamterene
63
Name an aldosterone antagonist diuretic.
spironolactone
64
What conditions are helped by diuretics?
HF
isolated systolic HTN
Type II DM- at low doses
65
What conditions are diuretics not good for?
Type I and II DM- at high doses
Dyslipidmeia
Gout
Renal insufficiency
66
What are some major ADE with diuretics?
Increased blood cholesterol, glucose, uric acid, calcium, sodium and magnesium.
Hypokalemia
67
How do Beta-blockers work?
Blocking beta-adrenergic receptors decrease the HR and CO
-Selective and Non-selective
68
What is the difference between selective and non-selective beta-blockers?
Non-selective: first generation, block Beta-1 (heart) and Beta-2 (lungs, smooth muscle, heart) which can lead to bronchospasm
Selective: next generation, more Beta-1 selective, but can loose selectivity at higher doses. Decreased HR can lead to bradycardia, and decreased myocardial contractility
69
Name some selective beta-blockers
Propanolol
Nadolol
Carbedilol (coreg)
Labetalol
70
Name some selective beta-blockers
Metoprolol
Atenolol
Bisphorolol
71
What conditions will beta-blockers help?
MI, angina
Tachycardia, fibrilations
Essential tremor
Hyperthyroidism
Migraines
72
What conditions are not good to be taking beta-blockers with?
Bronchospastic disease
Depression,
DM
2/3rd degree heart block
HF
PVD
73
How do ACEI work?
Block the conversion of angiotension I to angiotension II (which is a potent vasoconstrictor)
74
How do ARBs work?
Block Angiotension II receptor, which causes vasodialtion.
75
What conditions are shown to improve with ACEI?
reduce CV events and slow renal disease progression
76
What condition is shown to improve with ARBs?
In patients with DM and microalumbinuria, adding an ARB slowed the progression from microalbuminuria to proteinuria.
77
What condition is shown to improve with ARBs?
In patients with DM and microalumbinuria, adding an ARB slowed the progression from microalbuminuria to proteinuria.
78
What coexisting conditions have ACEI and ARBs as their first line treatment?
coexisting CKD and diabetes
79
What conditions are ACEI and ARBs recommended for?
CVD, CHF, MI (remodeling) or LVH
80
Name some ACEI.
Enalapril
Lisinopril
Benzapril
Ramipril
81
Name some ARBs
Losartan
Valsartan
Irbesartan
Olmesartan
82
What do you need to monitor with ACEI and ARBs?
hypotension, renal function, hyperkalemia (safe with
83
What conditions are improved with ACE and ARBs?
DM with proteinuria, HF, MI with systolic dysfunction, and renal insufficiency
84
What conditions are CI with ACE?
pregnancy, renovascular disease
85
What are some ADEs for ACEI and ARBs?
hyperkalemia, rash and angioedema
Cough with ACEI, if so, switch to ARBs.
86
How do CCB work?
Dilate the coronary and peripheral arterial vasculature. Block Ca from entering smooth muscle and cardiac muscle, which produces arterial vasodilation.
Neg. inotropic aka decreases HR and slows AV conduction
87
What is the difference between dihyrdropyridines and non-dihydropyridines?
Dihydropyridines have less inotropic activity and greater selectivity for vascular smooth muscle
Non-dihydropyrines are a less selective vasodilator and have a direct effect on the myocardium causing SA and AV nodal conduction depression. Also, decreases O2 demand in the myocardium and causes peripheral vasodilation.
88
Name some dihydropyridines
Amlodipine
Nifedepine
*Use with thiazides
89
Name some non-dihydropyridines.
Verapamil
Calan
Diltiazem
Cardizem
90
What conditions are helped with CCB?
isolated systolic HTN
Angina
DM
arrhythmias
raynauld's syndrome
91
What conditions are CCBs used with caution?
HF (except amlodipine)
EF
92
What are ADEs of CCB?
hand and ankle edema
flushing
HA
93
How do antiadrenergic agents work?
reduce catecholamine release in smooth muscle which vasodilatates and reduces HR, CO, peripheral resistance and plasma renin.
94
What is a potential long term side effect of anti-adrenergic agents?
Fluid retention
| would add a diuretic
95
How would you stop an anti-adrenergic agent?
taper- if not, it could lead to rebound HTN and/or tachycardia.
96
What are central alpha-2 receptor agonists?
Stimulate Alpha-2 receptors in the brain
- can lead to rebound HTN if d/c abruptly
97
What is an example of a central alpha-2 receptor agonist?
catapress
98
What is a peripheral alpha-1 receptor agonist?
dont affect alpha-2, so don't worry about rebound HTN or reflexive tachycardia
Used in med with BPH
99
What are 3 examples of an alpha-1 receptor agonist?
Minipress (prazosin)
Hytrin (terazosin)
Caradura (doxzosin)
100
What is a direct vasodilator?
Usually 2nd or 3rd line therapy, prescribed by a specialist.
Usually post-MI, gives significant BP reduction
Can give in HTN emergency
101
What are examples of a direct vasodilator?
Nitrates (on venous level)
Minoxidil (on arterial level)
Hydraliazine (on arterial level)
102
What should you ask if patient seems like they have resistant HTN?
- How and what meds are you taking?
- Are you taking NSAIDs? (decreases efficiency of HTN medication)
- What are you eating?
- Any weight gain?
- Are there too many pills? Do you need reminders/simplification?
103
Who should be referred out for HTN?
- If HTN is really bad and there is end organ damage
| - BP not controlled with 3 medications
104
What is the difference between HTN emergency and urgency?
Emergency- malignant HTN, >180/120 with evidence of end organ damage. Send to ED.
Urgency- severe HTN >180/120 without signs of end organ damage. Monitor outpatient and use oral anti-HTN meds.
105
What are signs of HTN emergency?
Chest pain or back pain
Confusion or altered mental status
Blurry vision
HA
N/V
SOB
discrepancy between R and L arm
Abdominal bruits, or new heart murmur
Papilledema
106
How should you manage HTN urgency?
Use low dose oral anti-HTN
Initial goal is 160/110- avoid excessive drop in BP. Should no drop more than 25% in first 24 hours.
107
When do children start to get their BP taken?
Age 3 and up.
108
How is HTN diagnosed in children?
Based on chart that is defined by their age, height, weight and gender.
95th% or greater is HTN
90-95th% is pre-HTN
Must be elevated on 3 separate occasions.
109
How is HTN diagnosed in adolescents?
If >120/80 is pre-HTN
110
What is the treatment for pre-HTN in children/adolescents?
Lifestyle modifications
111
When should you add a HTN medication to treatment of HTN with children/adolescents?
only if:
| - end organ damage, symptomatic HTN, 2nd stage HTN, or HTN that doesn't respond to lifestyle changes.
