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Foundations II > HTN > Flashcards

HTN Flashcards

1
Q

HTN is a precursor to many systemic disease including…

A
  • hypertensive retinopathy
  • cerebrovascular disease
  • renal failure
  • Cardiovascular disease
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2
Q

Beginning at __/__ mmHg, CVD risk ____ for each increment of __/__mmHg

A

115/75
doubles
20/10

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3
Q

What is the MOA of Primary (essential) HTN?

A
  • overactive SNS
  • Renal sodium retention
  • inflammation, oxidative stress, vascular remodeling
  • aldosterone, angiotensin II, renin, prorenin activate pathways damaging vascular health

Note: unknown but…90-95% of HTN cases

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4
Q

What are some risk factors for HTN?

A

Non-reversible: age, race, fam hx

Reversible: obesity/weight gain, physical inactivity,

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5
Q

What is secondary HTN?

A
  • HTN caused by underlying cause: renal dz, para/thryoid dz, obstructive sleep apnea, pheochromocytoma, cushing’s dz, renovascular dz, primary aldosteronism, coarctation of the aorta
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6
Q

Describe clinical presentations of secondary HTN.

A
  • diastolic HTN onset 50+ y/o
  • p/w target organ damage
  • signs of secondary causes: hypokalemia, abd bruit, fam hx of kidney dz, labile pressures w/tachy
  • poor response to effective therapy
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7
Q

Give examples of target organ damage in secondary HTN.

A
  • Heart dz: MI, angina, coronary revascularization, heart failure
  • cerebrovascular dz: ischemic stroke, cerebral hemorrhage, TIA
  • retinopathy
  • renal dz
  • Peripheral arterial dz
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8
Q

What hx is relevant to HTN and to secondary causes?

A

HTN hx: BP trends, prior treatment

Secondary hx: meds, illicit drug use

  • signs of sleep apnea: early am ha’s, erratic sleep
  • thinning skin, myalgias, tachy, diaphoresis

Social hx: diet (Na, sat fat), school, work

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9
Q

List some secondary HTN target organ damage sxs.

A

Ha’s, transient weakness/blindness, loss visual acquity, CP, dyspnea, claudication sexual dysfunction

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10
Q

What are secondary HTN physical exam findings.

A

VS: BMI, waist circumference (indications of metabolic syndrome)
Gen: body fat distr, skin lesions, muscle strength
HEENT: fundoscopy for grades of hypertensive changes:
Neck: thyroid, carotid,
resp: rhonchi, rales
abd: renal masses, bruites, femoral pulses
neuro: focal weakness, visual disturbance, confusion
cardio: extremity edema, PMI (LVH), brachial/femoral aa., S4 gallop murmur

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11
Q

What screening recommendations does the USPSTF suggest?

A
  • all adults 18+ screened
  • every 3-5 yrs if age 18-39, normal BP, no risk factors
  • annually 40+ or if at increased risk
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12
Q

Diagnostic criteria for HTN for JNC-7, JNC-8,

A

JNC7: gen pop goal 140/90; pt’s w/ dm or renal dz goal is 130/80
JNC8: all adults <60, BP goal is <140/90 (includes pt’s w/ CKD, DM); adults 60+
y/o <150/90
ACC/AHA: goal is 130/80

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13
Q

What tests would you order if you were trying to diagnose HTN?

A

Order: CBC, TSH, EKG, UA, blood chemistries (glu, Ca, Cr, electrolytes, GFR), Lipid profile
+/-: urine albumin excretion, Echo, sleep study

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14
Q

What are treatment goals of ACC/AHA 2017 for HTN?

A

initiate anti-hypertensives in…

  • all pt’s w/stage 2 HTN
  • pt w/stage 1 HTN w/ 1 or more of the following…est. ASCVD, T2DM, CKD, 10yr ASCVD risk of at least 10%
  • <130/80 if on meds and <140/90 for low risk, who don’t qualify for meds
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15
Q

What are the non-pharmacologic treatment options for HTN?

A

dietary modifications: salt restriction, DASH diet (low fat, lots of veggies/fruits), Alcohol reduction
- also weight loss, exercise, smoking cessation

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16
Q

What are the pharmacologic treatment options for HTN?

A

Diuretics, CCB, ACE-I, ARB, BB’s, direct renin inhibitor, central alpha agonists, alpha blockers

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17
Q

What types of diuretics are available and what is the MOA?

A

MOA: inhibits sodium reabsorption in the nephron, increasing Na+ and H2O excretion

  • Thiazide-type diuretics
  • loop diuretics
  • Potassium Sparing Diuretics
  • Aldosterone antagonists

Note: use in combo w/all other agents, will control in 50% of pt’s

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18
Q

Thiazide type diuretics: example, side effects, contraindications?

A
  • Hydrochlorothiazide (hydrodiuril)
  • SE: hypokalemia, hyponatremia, glucose disturbance, dyslipidemia, gout
    CI: sulfonamide, but still give unless severe allergy
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19
Q

Loop diuretics: example, side effects, which pt’s?

A
  • Furosemide (Lasix), hypokalemia, glucose disturbance
  • supplement potassium
  • reserved for pt’s w/kidney dz and fluid retention, but otherwise poor antihypertensive
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20
Q

Potassium Sparing Diuretics: example, side effects?

A
  • Triamterene (Dyrenium)
  • SE: hyperkalemia (esp. w/CKD or DM), nephrolithiasis, renal dysfunction
  • weak antihypertensives
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21
Q

Potassium Sparing Diuretics: contraindications?

A
  • Caution combining w/ACE-I, ARB, DRI, K supplements

- hepatic dz, renal failure, hyperkalemia

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22
Q

Aldosterone Antagonists: examples, side effects?

A
  • Spironolactone (Aldactone, Aldactazide)
  • hyperkalemia & gynecomastia
  • technically K+ sparing diuretic but more potent as an antihypertensive
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23
Q

Aldosterone Antagonists: contraindications?

A
  • renal impairment, DM w/proteinuria, hyperkalemia
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24
Q

Calcium Channel Blockers: MOA?

A
  • inhibition of calcium influx into myocardial/vascular smooth muscle cells –> contractile process inhibited –> vasodilation
  • Effect: reduced peripheral vascular resistance
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25
Q

Calcium Channel Blockers: Types and examples?

A
  • Non-dihydropyridine: cardiac depresent
    – Verapamil (Calan) & Diltiazem (Cardizem, Cartia)
    Dihydropyridine: selective vasodilators
    – DIPINE’s….Amlodipine (Norvasc), Felodipine (Plendil), Isradipine (Dynacirc), Nicardipine (Cardene), Nifedipine (Adalat, Procardia), Nisoldipine (Sular)
    *Note: these have increased efficacy in blacks, elderly
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26
Q

Calcium Channel Blockers: Side effects (non-DHP) and (DHP)

A

Non-DHP: bradycardia, constipation, gingival hyperplasia, worsening heart failure
DHP: peripheral edema, headache, flushing

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27
Q

Calcium Channel Blockers: non-DHP (dihydropyridines) contraindications?

A

Acute MI, AV block, Cardiogenic shock, hear failure, hypotension, sick sinus syndrome, ventricular dysfunction or V-tach, WPW syndrome
(non-DHP’s are cardiac depressants = heart contraindications)

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28
Q

Calcium Channel Blockers: dihydropyridines (DHP)

A
  • Acute MI

- in urgent/emergent HTN, immediate release Nifedipine is contraindicated

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29
Q

ACE- Inhibitors: suffix and examples?

A

-PRIL
Lisinopril (Prinvil, Zestril), Quinapril (Accupril), Enalapril (Vasotec), Ramipril (Altace), Captopril (Capoten), Benzepril (Lotenisin), Trandolapril (Mavik)

30
Q

ACE-inhibitors: MOA?

A
  • inhibit the RAAS system, and stimulate bradykinin (which has a vasodilator effect)
31
Q

ACE-inhibitors: when are the helpful and what are the side effects?

A
  • in pt’s w/ CKD, DM, heart failure, post MI

- SE: *Cough, hyperkalemia, angioedema, acute renal failure

32
Q

ACE-Inhibitors: when is it less effective and what contraindications are there?

A
  • in blacks, elderly, or when predominant systolic HTN

- CI: pregnancy, angioedema, renal artery stenosis

33
Q

ARBs: suffix and examples?

A
  • SARTAN
  • i.e. Losartan (Cozaar), Valsartan (Diovan), Olmesartan (Benicar), Telmisartan (Micardis), Candesartan (Atacand), Irbesartan (Avapro)
34
Q

ARBs: MOA?

A
  • inhibits the RAAS system
35
Q

ARBs: when are they helpful, side effects, contraindications?

A
  • helpful in pt’s w/ CKD, DM, and heart failure
  • SE: hyperkalemia, angioedema, acute renal failure
  • contraindications: pregnancy, renal artery stenosis
36
Q

Direct Renin Inhibitors (DRI): example, MOA?

A
  • Aliskiren (Tekturna)

- inhibit enzyme activity of renin, reducing the activity of angiotensin I and II and aldosterone

37
Q

DRI - Aliskiren (Tekturna): side effects?

A
  • SE: hyperkalemia, renal impairment, hypersensitivity reactions (anaphylaxis, angioedema)
38
Q

DRI - Aliskiren (Tekturna): contraindications?

A
  • avoid combining w/ACE-I or ARB in setting of kidney impairment
  • pregnancy
39
Q

Beta Blockers: types, examples?

A
    • LOL
  • Cardioselective (beta1 receptors): Atenolol (Tenormin), Metoprolol (Lopressor, Toprol XL), Nabivolol (Bystolic)
  • Noncardioselective (beta1 & beta2 receptors): Propranolol (Inderal), Nadolol (Corgard), Combo alpha and beta blockers include Labetolol (trandate) and Carvedilol (Coreg)
40
Q

Beta Blockers: MOA?

A

blocks activity of catecholamines at beta adrenoreceptors –> decreased cardiac output, some decreased PVR, and decreased renin activity (Propranolol)

41
Q

Betablockers: side effects? important notes to remember?

A
  • exercise intolerance, fatigue, depression, bradycardia, exacerbate reactive airway dz, exacerbate peripheral vascular dz
42
Q

Betablockers: take caution w/…? avoid? what does it reduce?

A
  • caution w/ DM, depression, NOT for unstable HF
  • avoid abrupt cessation
  • reduced mortality after MI and w/ HF
43
Q

Betablockers: contraindications:

A

AV block, cardiogenic shock, heart failure, hypotension, asthma, COPD

44
Q

Central Alpha Agonists: example? MOA?

A
  • Clonidine (Catapres), Methyldopa
  • MOA: stimulate alpha2 adrenergic receptors in the brain which reduces CNS sympathetic outflow
  • RARE, last resort med
45
Q

Central Alpha Agonists: avoid? when to use? side effects?

A
  • avoid abrupt cessation
  • is OK in pregnancy
  • SE: anticholinergic side effects, bradycardia, orthostatic hypotension, dizziness, rebound HTN
46
Q

Which HTN medication is okay to use during pregnancy? drug class? side effects?

A
  • Methyldopa
  • central alpha agonists
  • Hepatitis, hemolytic anemia, fever
47
Q

Central Alpha Agonists: Contraindications?

A

Methyldopa in liver disease

48
Q

Alpha Blockers: examples? MOA?

A

– ZOSIN….Doxazosin (cardura), Terazosin (Hytrin), Prazosin (minipress)

MOA: targets alpha1 receptors on vascular smooth muscle, causing peripheral vascular resistance to decrease –> decreasing BP

49
Q

Alpha Blockers: when to use? side effects?

A
  • in mild-mod HTN and NOT for monotherapy
  • showed increased risk of HF w/ doxazosin
  • SE: orthostatic hypotension (esp. w/1st use), reflex tachycardia, dizziness
50
Q

What is the first clinical intervention to initiate to treat HTN? How long before f/u?

A
  • lifestyle interventions

- 3-6 months f/u if non pharmacologic therapy

51
Q

You have started a pt on a HTN med. They are still not at BP goal after 1 month reassessment. What should you do next?

A
  • up the dose or add 2nd medication
  • consider consult w/ HTN specialist
  • continue f/u every 3-6 months, once BP is controlled
  • Monitor serum potassium and Creatinine 1-2 x annually
52
Q

Treatment strategies: JNC7, JNC8, AHA/ACC 2017

A
  • JNC 7: choose diuretic 1st; following compelling indications
  • JNC 8: choose either THIAZ, ACEI, ARB, or CCB 1st; in AA pt’s choose THIAZ or CCB; in CKD pt’s ACE or ARB
  • AHA/ACC: first line agents: TZD, CCB, ACE -I, ARB
53
Q

ACC/AHA guidelines for HTN for patients w/ stable ischemic heart dz.

A
  • BP goal <130/80
  • use beta blockers, ACE-I, ARBs; if they do not meet goal they get different drugs depending on if they have angina or not
54
Q

ACC/AHA guidelines for HTN for patients w/ heart failure w/ reduced ejection fraction.

A

BP goal is <130/80

- no CCB

55
Q

ACC/AHA guidelines for HTN for pt’s with CKD.

A

BP goal is <130/80

  • with albuminuria –> use ACE-I
  • w/out albuminuria- use usual 1st line med
56
Q

ACC/AHA guidelines for HTN for secondary stroke prevention (>72 hrs s/p stroke & stable or TIA.

A
  • different goals if they had HTN diagnosis prior to stroke or not
57
Q

ACC/AHA guidelines for HTN for pt’s with DM.

A

BP goal is <130/80

- w/ albuminuria, consider ACE-I or ARB

58
Q

ACC/AHA guidelines for HTN for pt’s with A. fib, valvular heart dz, & thoracic aortic dz.

A
  • A. fib: ARBs helpful for preventing a fib recurrence
  • VHD: chronic aortic insufficiency - avoid slowing heart rate (BBs)
  • Thoracic aortic: beta blockers preferred
59
Q

ACC/AHA guidelines for HTN medications safe for pregnant patients.

A
  • Methyldopa
  • acceptable: Nifedipine, Labetalol

-NO ACE-I, ARB, or DRI

60
Q

What are some poor indicators for prognosis of HTN?

A

1) cardiovascular dz: LVH, smoking, dyslipidemia, impaired fasting glu
2) cerebrovascular dz: carotid wall thickening or plaque
3) kidney disease: low eGFR or Microalbuminuria
4) retinopathy
5) vascular disease: ABI < 0.9

61
Q

What are some poor outcomes of HTN?

A
  • premature cardiovascular dz, heart failure, LVH, ischemic stroke, intracerebral hemorrhage, CKD/ESRD, PAD, retinopathy
62
Q

What are some benefits of therapy for HTN?

A

lowering BP significantly reduces the risk of:

  • MI by 20-25%
  • CVA by 35-40%
  • HF by +50%
  • CKD
63
Q

What is resistant HTN?

A
  • Failure to achieve goal BP in pt who fully adhering to full dose treatment of a 3-drug regimen, including a thiazide diuretic, or at goal (but requiring >4 antihypertensives
64
Q

What causes resistant HTN? What approach should you take?

A 
Causes: 
- improper BP measurement
- volume overload/retention
- medication/drug induced
- obesity
- excess alcohol
Approach: address possible causes and reassess for secondary HTN and or send to HTN specialist
65
Q

What BP is considered a hypertensive emergency? Difference between hypertensive urgency vs. emergency?

A
  • urgency: asxs, etiology- nonadherence to med or to low sodium diet and/or high salt load
  • emergency: associated w/ acute end-organ damage
66
Q

What is end-organ damage related to Hypertensive emergencies?

A
  • cerebrovascular: encephalopathy, brain infarct, hemorrhage
  • cardiac: dissection, LV failure, MI
  • renal: acute glomerulonephritis
67
Q

What conditions are associated with Hypertensive emergencies?

A
  • Post CABG, post-kidney transplant, eclampsia, severe body burns or epistaxis, surgical (post-op HTN, post-op bleeding), excessive circulating catecholamines (Pheo, cocaine, rebound HTN)
68
Q

What is the overall goal of a hypertensive urgency?

A
  • gradual reduction to safe levels <160/100

- too rapid reduction –> cerebral or myocardial ischemia or infarct

69
Q

What is the treatment strategy for a pt undergoing a hypertensive urgency?

A
  • rest (can drop 10-20mmHg)
  • est. pt’s: increase dose current meds, add diuretic, adhere to sodium restriction
  • new occurrence of HTN… BP reduction over several hours
70
Q

What is the treatment strategy for a pt undergoing a hypertensive emergency?

A
  1. hospitalized in ICU
  2. reduction of BP
    - no more than 25% w/in minutes to 1 hour;
    - if stable –> BP goal is 160/100 over 2-6hrs then decrease to norm BP goal over 24-48hrs

Foundations II (3 decks)

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