HTN Flashcards
1
Q
New Diabetes Guidelines from American Diabetes Association
A
- Less strict SBP target
- New Target–> SBP <140 SBP
- Lower target may be achieved if w/out undue burden
- Does NOT mean HTN is not important for DM
2
Q
JNC 7 Classification of HTN
A
- Normal: SBP 159 or DBP >99
3
Q
CV Mortality Risk
A
- Doubles with each 20/10 mmHg increase in BP
4
Q
BP Goals by Category
A
- Essential HTN: <140/80
5
Q
BP Measurement Techniques
A
- In office: 2 readings (average), 5 minutes apart, sitting. Confirm elevated reading in contralateral arm
- Ambulatory BP monitoring: Indicated for evaluation of ‘white-coat” HTN; Absence of 10-20% BP decrease during sleep may indicate increased CVD risk
- Home BP: Provides information on response to therapy. May help improve adherence to therapy & evaluate “white-coat.” Avoid finger/wrist cuffs.
6
Q
Home BP Measurements: Why & How
A
- Better predictor of cardiovascular risk, target organ damage
- Helps reduce “white coat” effect & determine the presence of masked HTN
- Should be a routine component of BP measurement for monitoring someone with known or suspected HTN
- Use upper arm, appropriate sized cuff, seated, in AM & PM for 1-week
7
Q
Home BP Measurement: Who & What
A
- Most patients are suitable for HBPM, except those with A-Fib or other cardiac rhythm disturbances which make automatic BP monitoring unreliable
- Need 12 readings on average to make clinical decisions
- Average usually considered normal if majority of findings are SBP <135/85
8
Q
HBPM: Protocol
A
- 5 consecutive days (minimum)
- perform 3 measurements, 5min apart, in the AM and PM
- Toss the first 2 days and the first measurement each days thereafter
- Average remaining measurements
- Average the 2nd and 3rd measurements of each triplicate set
- Bring all recordings to HCP
9
Q
Systolic Blood Pressure
A
Increases with age
10
Q
Measuring BP in Elderly
A
- An auscultatory gap is more common in elders
- Period during which sounds of the true SBP fade away and reappear at a lower pressure point
- Usually occurs with vascular disease
- Often a common reason for inaccurate BPs (underestimates SBP)
11
Q
HTN and Elders
A
- HTN affects most elders
- More likely to have organ damage
- Optimal BP in HTN pts. NOT definitely established
- Proven benefits of treating HTN in >70yrs
- Risk of adverse outcomes by age & BP vary:
- 140 increases risks
- > 69: J Curve effect; risk of adverse events increase at SBP below upper 130s and above upper 140s
12
Q
BP Goals for the Very Elderly
A
- GOAL = 79 is beneficial:
- Decreases BP (~15/6mmHg)
- Decreases fatal and non-fatal stroke by 30%
- Decreases death from stroke by 39%
- Decreases death from any cause by 21%
- Decreases death from CV cause by 23%
- Decreases rate of HF by 64%
- ** No significant difference in K, uric acid, glucose, and creatinine
13
Q
JNC 7 Treatment Algorithm Stage 1
A
1) Lifestyle modifications
14
Q
Stage I HTN (Without compelling indications)
A
- SBP 140-159 or DBP 90-99
1) Thiazide diuretic
2) May consider ACE-I, ARB, BB, CCB, or combo
15
Q
Stage II HTN (without compelling indications)
A
- SBP >159 or DBP >99
1) 2 drug combo (usually thiazide diuretic + ACE-I or ARB, BB, or CCB)
16
Q
HTN Treatment with compelling indications
A
- Diuretics, ACE-I, ARB, CCB, and BB as needed
17
Q
Lifestyle modifications
A
- Weight reduction: SBP -5-20mmHg/10kg
- DASH diet: -8-14mmHg
- Na Reduction: -2-8mmHg
- Physical activity: -4-9mmHg
- Moderate ETOH Consumption: -2-4mmHg
18
Q
ETOH Consumption
A
- Guidelines for men: 24oz beer, 10oz wine, 3oz liquor
- Guidelines for women: 1/2 of men
- Average BP reduction: SBP -4mmHG; DBP -2.5mmHG
19
Q
Compelling indications per JNC 7
A
- High CVD risk: thiazide, ACE-I, CCB
- Post-MI: BB, ACE-I, aldosterone antagonist
- HF: Thiazide, BB, ACE-I, ARB, Aldosterone antagonist
- DM: Thiazide, BB, ACE-I, ARB, CCB
- CKD: ACE-I, ARB
- Recurrent stroke prevention: Thiazide, ACE-I
20
Q
C.R.A.P - Secondary HTN
A
- Congenital Heart Disease
- Renal Disease
- Aldosterone problem
- Pregnancy
21
Q
HTN: Choosing the right med
A
- If no compelling indications: thiazide diuretic
- If particular compelling indications: use list from JNC7
- Choose one of “5i important classes”: ACE, ARB, BB, CCB, Diuretic
- Simple A/CD strategy per Canadian study: ACE/ARB, CCB, & Diuretic
- Combo agent:
- 1 is diuretic
- 1 is RAAS blocker
- 1 is CCB
22
Q
HTN: ESH and AHA Guidelines
A
- No 1 choice for BP reduction
- Goal <130/80 for CHD, DM, and CKD
- 5 important classes: ACE, ARB, BB, Diuretic, CCB
23
Q
HTN: Using combo meds
A
- double combo:
- Dual RAAS blocker (ARB/DRI): Only use for severe HF, advanced chronic renal disease w/ heavy proteinuria
- RAAS blocker + HCTZ
- RAAS blocker + CCB (amlodipine)
- Triple combo (2 available): ARB, CCB (amlodipine), + HCTZ
24
Q
Uncontrolled HTN
A
- 2 categories:
- Difficult-to-treat HTN: Issues w/measurement and adherence, suboptimal therapy, white coat HTN
- Truly resistant HTN: Volume overload, interfering substances, associated factors, secondary HTN
25
Evaluating White Coat HTN
- Validate office measurement w/HBPM
- 24hr monitoring:
* Continue current therapy if 135/85 then increase therapy
26
Resistant HTN
- BP remains elevated despite 3 anti-HTN agents
| - 1 agent should be diuretic
27
Resistant HTN: Volume Overload
- Expansion of ECV is contributing factor (relative or absolute)
- May NOT show up as peripheral edema
1st Step) Increase thiazide diuretic
2nd step) Convert to more potent diuretic
3rd Step) Loop diuretic: if creatinine >1.5-1.8 or GFR <30
28
Resistant HTN: Interfering Substances
- Common: ETOH; NSAIDs and COX-2 inhibitors; OCs; some antidepressants; sympathomimetics; stimulants
- Less common: steroids; cyclosporine; erythropoietin; natural licorice; chewing tobacco; MAOIs; Ginseng, Ephedra, Ma huang, bitter orange; tacrolimus
29
Resistant HTN: Associated or Contributing Factors
- Older patient: isolated systolic HTN; Tx goals based on age
- Heavy ETOH
- Obesity: Issues of increased Na and fluid retention; Stimulation of SNS and RAAS; Higher doses of meds often needed; Impact of weight loss; Weight loss strategies (caloric restriction, Orlistat, bariatric surgery)
30
Secondary HTN: Chronic Kidney Disease
- Tx should include:
* Dietary Na restriction
* Diuretic; RAAS blocker
* Monitor labs w/in 2wk and q6mo
* Increase of <5.5 is OK
31
Secondary HTN: Primary hyperaldosteronism
- Clues:
* Fatigue; hypokalemia; not responsive to K supplementation
* Many will have NL K levels
- Diagnostic: Plasma aldosterone/renin ratio
* Ratio 20 w/ aldosterone level >15 ng/dL suggests primary hyperaldosteronism
- Need Dx confirmed by another test to distinguish bilateral adrenal hyperplasia from adrenal adenoma
* Abnormal response to sodium loading
* CT or MRI
- Tx for Prim. hyperaldosteronism 2/t bilateral adrenal hyperplasia: aldosterone antagonist, ACE, or ARB
* Spironolactone/Eplerenone (if gynecomastia develops
- Surgery if adrenal adenoma
32
Secondary HTN: OSA
- Clues: Hx of snoring, witnessed apnea, excessive daytime sleepiness
- Referral: polysomnography
- Tx: CPAP, BiPAP
33
Secondary HTN: Other causes
- Cushing's disease
- Coarctation of aorta
- Renal artery stenosis
- Thyroid Dz
- Hyperparathyroidism
- Pheochromocytoma
34
HTN: Intensification of Meds
1) optimize diuretic therapy
2) add spironolactone
3) add: alpha-blocker, combined alpha/beta-blocker, or clonidine, guanfacine, or hydralazine
4) Add 4th agent by compelling indications
35
HTN: When to refer to specialist
- When secondary cause of HTN is suspected
| - If BP remains elevated after 6mo of therapy
36
HTN: Pearls
- Lifestyle modifications for ALL
- If on 3 meds, need a balance of: vasodilator (ACE, ARB, DH-CCB), negative chronotrope (BB or NDH-CCB), & diuretic
- For those with resistant HTN: screen for common causes of HTN; consider adding spironolactone (-20/10)
