HTN Flashcards
What is the formula for BP?
BP = CO x Peripheral resistance CO = Preload x contractility
Primary care recommendations for HTN
Most common condition in primary care
screen everyone 18+
Failure to detect early and adequately treat can lead to myocardial infarction, stroke, renal failure, and death.
What is Primary HTN?
Also known as “Essential hypertension”
True cause is not entirely known, but thought to be most likely result of numerous genetic and environmental effects on the cardiovascular and renal structure and function
Risk Factors for Primary HTN?
Age Rage Family History (Genetics) Obesity Diet: ETOH, sodium
What is secondary HTN?
Medical problems (common and uncommon) that may contribute to elevated blood pressure May co-exist with primary hypertension, but be a barrier to control of blood pressure
What are common causes of secondary HTN?
A-Apnea, Aldosteronism B-Bruit, Bad kidney C-Catecholamine, Coarctation, Cushing D-Drugs (EtOH) E-Endocrine disorders
What is isolated systolic BP?
Isolated elevation in systolic blood pressure (>140 mmHg) is related to significant cardiac risk.
Widening pulse pressure is a significant risk factor for CV event, specifically in older adults
An elevated SBP is a much more important CV risk factor than elevated DBP
Most common form of high blood pressure in older Americans
What is white coat HTN? What does that mean for patient health?
“Labile” hypertension
BP persistently > 120/80 at the provider’s office, but not on home measurements
Systolic BP is especially elevated
Cardiovascular risks appear to be less than persons with sustained hypertension, but white-coat hypertension may increase risk of stroke and LV remodeling.
How should you prepare a patient to get their blood pressure taken?
Prepare patient
Relax, sitting in chair, feet on floor, > 5 min
Avoid caffeine, exercise, smoking for at least 30 min
Empty bladder
No talking
No clothes under cuff
Technique
Support patient’s arm
Use correct cuff
Measurements
At first visit, records bilateral readings
Note blood pressure medications taken before reading
How does the JNC8 classify HTN?
Normal: <120 and < 80
Prehypertension 120-139 or 80-89
stage 1 HTN 140-159 or 90-99
Stage 2 HTN >160 or >100
JNC 8 recommendations, go!
> 60 yo - 150/90
< 60 yo gen pop 140 and 90
Kidney disease any age 140 and 90
DM any age 140 and 90
2017 AHA/ACC classifications
normal : <120 and <80
elevated 120-129 and <80
Stage 1 : 130-139 or 80-89
Stage 2: 140+ or 90+
According to JNC 8, when do we treat?
JNC 8: Treat with BP lowering medication:
> 60 years old: >150/90
< 60 years old: > 140/90 (regardless of comorbidities)
Lifestyle modifications for ALL
According to 2017 guidelines, when do we treat?
2017 Guidelines: Treat with BP lowering medication:
>130/80 (STAGE 1): Assess 10 year ASCVD risk
< 10%, lifestyle changes and reassess in 3-6 months
> 10% or CVD, DM, CKD, start BP-lowering medication
>140/90 (STAGE 2): BP-lowering medications (2)
Lifestyle modifications for > 120/80
Diagnostic tests for HTN, initial visit
12 lead ECG Blood glucose (FBG) Fasting cholesterol panel GFR Serum calcium Serum potassium Urinalysis TSH CBC
Echo, uric acid, urinary albumin to creatinine ratio
How to evaluate for 2/2 HTN
Sleep study
Hormone levels (Aldosterone, Cortisone)
Urine drug screen
Renal Ultrasound
What are “lifestyle modifications?”
Exercise DASH diet Salt Restriction (“No salt added” vs “Low salt”) Weight Reduction Reduction in excess Alcohol Consumption Limiting NSAIDs Stress Reduction
Whats the difference between “low salt” and “not salt added?”
“No added salt” diet - 4g daily
“Low salt” diet - 2g daily
Who appears to benefit most from “lifestyle modifications?”
AA and elderly patients appear to benefit the most from Na restriction
Specifically important for patients with central adiposity
Most important for young and middle-aged patients
What comprises the DASH Diet?
Standard- 2,300 mg Lower sodium- 1,500 mg Goals: 2,000-calorie-a-day DASH diet. Grains: 6 to 8 servings a day Vegetables: 4 to 5 servings a day Fruits: 4 to 5 servings a day Dairy: 2 to 3 servings a day Lean meat, poultry and fish: 6 servings or fewer a day Nuts, seeds and legumes: 4 to 5 servings a week Fats and oils: 2 to 3 servings a day Sweets: 5 servings or fewer a week
What does DASH stand for?
Dietary Approaches to Stop HTN
What does JNC recommend for first line medication treatment for HTN for white folks?
In the general nonblack population, including those with diabetes, initial antihypertensive treatment should include:
thiazide-type diuretic
calcium channel blocker
angiotensin-converting enzyme inhibitor or angiotensin receptor blocker (grade B)
What does JNC recommend for first line medication treatment for HTN for black folks?
In the general black population, including those with diabetes, initial antihypertensive treatment should include a thiazide-type diuretic or calcium channel blocker.
JNC 8 recs for folks with CKD?
In the population aged ≥ 18 years with CKD, initial (or add-on) antihypertensive treatment should include an ACEI or ARB to improve kidney outcomes. (grade B)
This applies for all CKD patients with hypertension, regardless of race or diabetes status.
What is use for thiazides?
First line in many patients, comparable to all other first line agents
Safe and low cost
Commonly used in combination
MOA of thiazides
Enhance Sodium excretion -> reduce intravascular volume -> reduce peripheral resistance
Side effects of thiazides
Potassium wasting Hyperglycemia / Hypercalcemia*/ Hyperuricemia Sexual dysfunction Urinary frequency Transient increase in LDL
CAUTION WITH THIAZIDES
Sulfa allergy (?)
Gout
Monitor hypokalemia, uric acid, calcium
discuss chlorthalidone vs HCTZ
Chlorthalidone has twice the potency as HCTZ. Most studies with thiazide-type diuretics, that showed promising results, used Chlorthalidone
Use CCBs
AA patients (specific focus when single agent)*
Nondihydropyridines: (Verapamil, Diltiazem) used to rate control in patients with Afib or for control of angina.
Preferred over BB for treatment in patients with airway disease
CCB may improve GFR in patients with renal insufficiency. May be helpful with patients who have DM/CKD with history of angioedema with ACEI/ARB
There have been studies that showed increase risk of MI and sudden death.
MOA CCBs
Block entry of calcium in the heart and vascular smooth muscle -> reduces smooth muscle contraction -> reduce peripheral vascular resistance
SE CCBs
Edema * Reflex tachycardia/Bradycardia Headache Constipation Dizziness
CAUTION CCBS
Not recommended first line after MI
ACE-I USE
First line in CKD, DM
Specific use after MI, to reduce heart failure and mortality
Reverse LVH and remodeling due to HTN (post MI*)
Low cost
There are different dosage recommendations for ACEI use (HTN vs renal protection).
MOA ACE-Is
Block conversion of renin-activating angiotensin I to angiotensin II -> reduces vasoconstriction -> also reduces Aldosterone
Inhibit breakdown of bradykinin (vasodilator)
SE ACE-Is
Dry cough (benign) Hyperkalemia Elevated Crt (AKI)
CAUTION ACE-Is
Angioedema (critical)
Must avoid in pregnancy
Can you take ACE-I’s during pregnancy?
NO WAY!
ARBs Use
Same indications as ACEI
Comparable to ACEI in blood pressure control
Do NOT use ACEI and ARB together
ARBs MOA
Same as ACEI, without the effect on bradykinin (which removes the risk for cough)
CAUTION ARBS
Angioedema (critical)
Must avoid in pregnancy
If ARBs are just as good as ACEIs, without the cough (and a decreased risk of angioedema), why would you start someone on an ACEI?
Price, ACE-Is are older and been around longer
Ways to titrate BP meds according to JNC8
- Start one drug, titrate to maximize dose, then start second agent
If there is partial response to the initial therapy, the agent should be increased.
If there is no response to the initial therapy, switch to another first-line agent. - Start one drug then add a second drug, before achieving maximum dose of the initial drug.
- Begin with two drugs at the same time, either as two separate pill or as a single pill combination.
How to titrate BP meds according to 2017 guidelines
- Stage 1: (ASCVD risk is > 10% or known clinical CVD, DM, CKD) start 1 BP lowering medication
If goal is met after 1 month, titrate medication, reassess in 3-6 months
If goal is not met after 1 month, consider different medication or titration
Continue monthly follow up until control is achieved. - Stage 2: start 2 BP lowering medication of different classes.
Follow titration scheduled above
Lifestyle modifications for all
Things to consider with BP meds and older adults
Caution with older patients (>65 yo): Start low, go slow. Carefully consider diuretics. Monitor renal function closely. Review risk of postural hypotension
What should you do with resistance HTN?
Confirm resistance, exclude environmental factors, screen for secondary causes, maximize pharmacologic therapy, refer to specialist.
Arrange by cost: Losartan HCTZ Lisinopril Amlodipine
HCTZ $4
Lisinopril $4
Amlodipine $40-50
Losartan $40-60
drugs safe for pregnancy?
labetalol, nifedipine
Considerations for pregnancy?
Women who are pregnant or are planning to become pregnant:
Use methyldopa, nifedipine, or labetalol
Should NOT be treated with ACEI or ARB
How does this affect the care of women who are NOT pregnant? (age 13-55)
What wouldn’t your first choice med be hydralazine for outpatient BP management?
very frequency dosing
What are important steps to helping patients maintain good BP control?
Requires partnership of patient/ provider to improve adherence
Education is key
Medication Regimen
Goals of treatment
Encourage patient to check BP at home and bring back number to follow up appointment
Bring medications to each visit
Increase frequency of follow up on blood pressure with office visits or phone calls
Common barriers to care/adherence to treatment
Lack of understanding of disease
Lack of access
Side effects
Cost
Lack of appropriate f/u by provider, including not f/u on missed apts
Confusion regarding medications, language/reading barriers, pharmacy confusion
Therapeutic / clinical inertia
What should you include in HPI for HTN?
HPI for Hypertension: Diet Exercise Weight loss Medication adherence Home blood pressure measurements
What ROS should be included for HTN?
HEENT: Vision changes
Heart: Chest pain, palpitations
Lungs: Shortness of breath, cough, orthopnea
Abdomen: Abdominal pain
Neuro: Dizziness, lightheadedness, weakness
Peripheral vascular: Edema, leg pain
Physical exam for HTN?
HEENT: Fundoscopic exam, thyroid, carotids Heart: Rate, rhythm, murmurs Lungs Abdomen: HSM, aorta Neuro: Cranial nerves, strength Peripheral vascular: Pulses, edema
What is the ultimate goal of antihypertensive therapy?
The ultimate goal of antihypertensive therapy is to reduce cardiovascular morbidity and mortality
