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HTN Flashcards

1
Q

What is HTN a precursor to

A

systemic dx like hypertensive retinopathy, cerebrovascular dz, renal failure, and CVD

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2
Q

What is the #1 attributable risk factor for death world wide

A

Suboptimal BP

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3
Q

What is the epidemiology of HTN

A

1/3 adults have HTN

1/3 have pre-HTN

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4
Q

Why does incidence of HTN increase in women around 55 y/o

A

Menopause! estrogens not there to protect anymore

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5
Q

What races have a higher prevalence of HTN

A

African American
White
Mexican American

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6
Q

What happens when BP hits 115/75

A

CVD risk DOUBLES for each 20/10 mmHg increase

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7
Q

What is the MOA of primary essential HTN

A

Overactive SNS
Renal Na+ retention
Inflammation, oxidative stress, vascular remodeling
RAAS damaging vascular health

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8
Q

What controls BP

A

SNS, RAAS, plasma volume mediated by kidneys

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9
Q

What are the types of HTN

A 
Primary essential HTN (90-95% of cases)
Secondary HTN (younger onset)
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10
Q

What are risk factors for Primary HTN

A

*Smoking
*Diet (high Na intake)
*Excess alcohol intake
*Obesity
*Physical inactivity
Age, race, FHx, dyslipidemia, DM

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11
Q

What disorders can cause Secondary HTN

A 
Renal disease
Meds (adderall, NSAID, OCP, steroid, decongestant)
Hypo/Hyperthyroid/parathyroid
Obstructive sleep apnea
Pheochromocytoma 
Coarctation of aorta
Primary Aldosteronism
Reno vascular dz
Cushing's
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12
Q

When should you suspect secondary HTN

A

Young onset
Diastolic HTN >50 y/o
Target organ damage at presentation (SrCr >1.5, LVH)
Secondary causes
-Hypokalemia, abdominal bruit, Labile pressure w/ tacky diaphoresis or tremor, FHx renal dz
Poor response to generally effective therapy

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13
Q

How is HTN and age related

A

Young patient= DIASTOLIC

Older pt= SYSTOLIC

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14
Q

What are positive findings for end organ damage

A

MI, Angina, coronary revascularization, HF
Ischemic stroke, cerebral hemorrhage, TIA
Retinopathy
Renal dz
PAD (claudication)

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15
Q

What symptoms during Hx should make you think of HTN

A

muscle weakness, tachycardia, sweating, tremor, thinning skin, flank pain
Sleep apnea signs (early morning HA, day time somnolence, loud snoring, erratic sleep)

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16
Q

What can increased waist circumference be indicative of

A

Cushing’s disease (Dexamethasone test)

Metabolic syndrome

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17
Q

What could you see on HTN HEENT PE

A 
Arterial diameter narrower than 50% of venous  (A:V 2:#)
Copper/silver wire appearance 
exudates
Cotton wool spots
hemorrhaged (flame hemorrhage)
Papilledema
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18
Q

What could you see on remaining HTN PE

A

Rhonchi, rales
Renal mass/bruit
Visual disturbance, focal weakness, confusion

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19
Q

What could you see on CV HTN PE

A

LVH (displaced PMI, ECG evidence)
S4 (pre systolic) gallop (decreased LV compliance)- A-Stiff—wall
Carotid, abd, femoral bruits
Extremity edema

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20
Q

USPSTF guideline for HTN

A

Screen all 18+
Every 3-5 years in 18-39, normal BP, no RF
Annual if 40+ or increased risk for HTN

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21
Q

What is required to diagnose HTN

A

2+ properly measured, seated BP readings on 2 or more office visits

  • legs uncrossed, rested, proper cuff size, arm at heart level
  • High caffeine drinker not at risk for HTN dx because HTN comes in waves for them, not steady
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22
Q

What is the JNC7 HTN goal

A

Gen. pop: 140/90

DM or renal Dz: 130/80

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23
Q

What is the JNC8 HTN goal

A

<140/90 for ALL adults (including CKD/DM)
<150/90 in adults 60+
-ACC/AHA said continue with JNC-7

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24
Q

What is the ADA target BP (diabetics)

A

<140/90

risk-based individualization to lower targets 130/80

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25
Q

What diagnostic tests are important o order in HTN eval

A 
CBC 
Urinalysis
Blood chemistry (glucose, Ca, Cr, GFR, electrolytes)
TSH (new HTN pt)
Lipid profile
ECG
-Maybe: urine albumin, echo, sleep study
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26
Q

What patients did the ACC/AHA study say to initiate anti-HTN meds in

A

All with stage 2 HTN

Pt with Stage 1 and 1+ of following (ASCVD, T2DM, CKD, 10 year ASCVD risk 10%+)

27
Q

What are non-pharm Diet Modification treatment options for HTN

A

Salt restriction= 5/3 mmHg decrease
DASH diet= 6/4 mmHg decrease
–High fruit/veg, then grain. low fat dairy
Alcohol reduction= 2-4 decrease in SBP

28
Q

What are other non-pharm treatment options

A

Weight loss (1mmHg per 1 lb lost)
Exercise (4-6/3 mmHg)
Smoking cessation

29
Q

What are pharm treatment options for HTN

A 
Diuretics
CCB
ACE-I
ARB
BB
DRI
Central alpha 2 agonist
Alpha 1 blockers
30
Q

Who do diuretics work better in

A

Black, elderly, obese, smokers

31
Q

What are side effects/CI of diuretics (HCTZ)

A 
Hypokalemia, Mg, Na
Hypercalcemia
Hyperurecemia 
Dyslipidemia
Hyperglycemia**

-Contraindicated with Sulfa drugs

32
Q

What are side effects in loop diuretics (Furosemide)

A

Hypokalemia/Na/Mg/Ca
Hypercholesterolemia
Glucose disturbance
–Supplement potassium!

33
Q

What is special about loop diuretics

A

Poor anti-HTN med, much better as diuretic

Reserved for patients with renal dz of fluid retention

34
Q

What are side effects/CI of K Sparing diuretics (Triamterene)

A

Hyperkalemia
Nephrolithiasis
Renal dysfunction

-Contraindicated in hyperkalemia, renal failure, liver Dz

35
Q

What should you use caution combining K sparing diuretics with

A

Ace, Arb, DRI, K supplement

-Weak anti-HTN

36
Q

What are side effects/CI of Aldosterone Antagonists (spironolactone)

A

Hyperkalemia, Gynecomastia

-Contraindicated in renal impairment, DM, hyperkalemia

37
Q

What are the types of CCB and how do they work

A

Non-DHP (cardiac depressants, verapamil/Diltiazem) and DHP (selective vasodilator, nifedipine, amlodipine)

  • Inhibit the influx of calcium into myocardial and smooth muscle cells= less contractile= vasodilation
  • Reduce PVR
38
Q

Who should and shouldn’t use CCB

A

-Very effective in african american
DHP Contraindicated in acute MI or emergent HTN release
Non-DHP contraindicated in acute MI, AV block, HF, WPW, V-tach, etc

39
Q

What are side effects of CCB

A

DHP- Peripheral deems, HA, flush

Non-DHP- brady, gingival hyperplasia, HF, constpation

40
Q

What are side effects/CI of ACE inhibitors

A

Cough!
Hyperkalemia, angioedema, acute renal failure

  • Less effective in african americans
  • Contraindicated in pregnancy, angioedema, renal artery stenosis
41
Q

Who are ACE inhibitors especially good for

A

patients with CKD, DM, HF, post-MI

42
Q

What are the side effects/CI of ARB’s

A

hyperkalemia, angioedema, acute renal failure

-Contraindicated in pregnancy and renal artery stenosis

43
Q

What are the side effects/CI of Direct Renin Inhibitors (Aliskiren)

A

Hyperkalemia, hypersensitivity reactions, renal impairment

-DO NOT combine with ACE or ARB
Don’t use in pregnancy

44
Q

What are the types of BB

A

Cardioselective (Metoprolol, atenolol)
Non-cardioselective (Propranolol, Nadolol)
Combination non-selective: Carvedilol, Labetolol

45
Q

What are side effects/CI of BB

A

-Exercise intolerance, bradycardia, fatigue, sexual dysfunction
-Do Not use in AV block, cariogenic shock, unstable HF, hypotension
Do not use if with COPD or asthma
-Caution with depression/DM
-AVOID abrupt cessation

46
Q

What are side effects/CI in Central alpha-2 bockers

A

anticholinergic effects, bradycardia, dizziness
Clonidine: constipation, blurry vision
Methyldopa: hepatitis, fever, anemia

-DO NOT use methyldopa in liver disease
Avoid abrupt cessation (rebound HTN)

47
Q

What are side effects of alpha-1 blockers

A

Reflex tacky, Dizzy, orthostatic hypotension

  • First Dose Effect- give at night time for elderly
  • Doxazosin=increased risk of HF
48
Q

What can alpha-1 blockers be used for

A

treatment of BPH!

Also HTN, PTSD, Raynauds

49
Q

How should you initiate treatment always

A

Lifestyle interventions (f/u 3-6 months depending on their numbers)

50
Q

What treatment should you start if lifestyle modifications don’t work

A 
Pharm therapy (f/u at 1 mo)
Continue med if at goal. If not at goal, increase dose or add 2nd med
If 3+ meds don't work, consider HTN specialist referral
51
Q

How should you monitor HTN once BP goal is met

A

every 3-6 months

Monitor SrCr and K+ 1-2x annually

52
Q

What are the treatment strategies for JNC7, JNC8, and AHA/ACC

A

JNC7: Diuretic first, then follow indications
JNC8: THIAZ, ACE, ARB, or CCB first line (in Af. Am. Thiaz or CCB first) (In CKD, ACE or ARB first)
AHA/ACC: First line agents same as JNC8

53
Q

What are first line pregnancy drugs

A

Methyldopa (central alpha agonist)
Nifedipine (CCB)
Labetolol (BB)

-Avoid ACE, ARB, DRI; known teratogenic effects

54
Q

What CVD indicators have a poor prognosis

A

**LVH
Men >55, Women >65
smoking, dyslipidemia, DM, FHx premature CVD, Abd. obesity, high pulse pressure

55
Q

What other indicators have poor prognosis

A

**Carotid wall thickening or plaque
**Low GFR, Microalbuminemia
**ABI <0.9 (mild marker for PAD)
Retinopathy

56
Q

What comorbid conditions have poor outcomes

A 
Premature CVD
HF
LVH
Ischemic stroke
Intracerebral hemorrhage
CKD/ESRD
PAD
Retinopathy
57
Q

How can therapy benefit prognosis

A

Lowering BP reduces risk of:

MI, stroke, HF, CKD

58
Q

What is Resistant HTN

A

failure to achieve BP goal in compliant patient with 3 drugs, including a thiazide
OR
at goal but requiring 4+ anti-HTN meds

59
Q

What are causes of resistant BP

A 
improper BP measurement
volume overload/retention
Med induced
obesity
excess alcohol
60
Q

What is Hypertensive Urgency

A

SBP 180+ and/or DBP 120+
May be asymptomatic
Can be due to non-adherence to anti-HTN med or non-adherence to low sodium diet

61
Q

What is a Hypertensive Emergency

A

SBP 180+ and/or DBP 120+
Associated with acute end organ damage (Encephalopathy, brain infarct, hemorrhage, dissection, LV failure, MI, acute glomerulonephritis)

62
Q

What is the goal of Hypertensive Urgency

A

GRADUAL reduction to safe level (<160/100)
Not too rapid or will cause MI or cerebral infarct
-Sublingual Nifedipine contraindicated

63
Q

How can you reduce BP in hypertensive urgency

A

rest (10-20 mmHg drop)
If HTN pt: increase current med dose, add med (diuretic), adhere to Na restriction
If new HTN: need more aggressive treatment, several hours to reduce

64
Q

How do you treat a hypertensive Emergency

A

ICU- hospitalization*
Reduce no more than 25% in the first hour
<160/110 in 2-6 hours
Back to normal in 24-48 hours

Nayla Foundations (18 decks)

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