HTN Flashcards
What is BP?
Cardiac Output
x
Peripheral Resistance
Who should you screen for HTN and why?
All adults >18 y/o
If you don’t detect early, can lead to MI, stroke, renal failure, death
What is primary HTN?
“essential HTN”
Unknown cause, likely the result of genetic and environmental effects on CV and renal structure and function
What are risk factors for primary HTN?
Age Race Family history (genetics) Obesity Diet: ETOH, sodium
What is secondary HTN?
Medical problems may contribute to elevated BP and may also co-exist with primary HTN
What are causes of secondary HTN? (ABCDE)
A - Apnea, Aldosteronism B - Bruit, Bad kidney C - Catecholamine, Coarctation, Cushing D - Drugs (ETOH) E - Endocrine disorders
What is Isolated Systolic HTN?
> 140 mmHg systolic elevation that is related to significant cardiac risk
Why is Isolated Systolic HTN bad?
- Widening pulse pressure is a significant risk factor for CV event (esp in older adults)
- Elevated SBP is a much more important risk factor for CV events than elevated DBP
- Most common form of high BP in older Americans!
What is White Coat HTN?
“Labile” HTN
- BP is persistently >120/80 at Dr’s office, but normal on home measurements
- SBP is especially high
What are the risks with White Coat HTN?
CV risks are less than people with sustained HTN, but may increase risk of stroke and LV remodeling
I10 Essential (primary) HTN Diagnoses
I11 - Hypertensive heart disease (w/wo HF)
I12 - Hypertensive CKD (what stage)
I13 - Hypertensive heart and CKD
I15 Secondary HTN Diagnoses
I15.0 Renovascular HTN I15.1 HTN 2/2 renal disorders I15.2 HTN 2/2 endocrine disorders I15.8 Other secondary HTN I15.9 Secondary HTN, unspecified
How do you take an accurate BP?
Prepare patient:
-Relaxed in chair with feet on floor for >5 min
-No caffeine, exercise, smoking for at least 30 min
-Empty bladder
-No talking
-No clothes under cuff
Technique:
-Support pt’s arm and use correct size cuff
Measurements:
-At first visit, record b/l findings
-Note BP meds taken before reading
What are the BP Ranges according to 2017 ACC/AHA Guideline?
Normal: <120/80
Elevated: 120-129/<80
Stage 1: <120/80-89 or 120-129/80-89 or 130-139/<80 or 130-139/80-89
Stage 2: everything else
What do you do when BP >130/80 (Stage 1)?
1) Assess ASCVD 10-year risk
2) If <10%, lifestyle changes and reassess in 3-6 months
3) If >10% or CVD, DM, CKD –> start BP-lowering medication
What do you do when BP >140/90 (Stage 2)?
Begin 2 BP-lowering medications
What do you do when BP >120/80?
Lifestyle modifications
What is the diagnostic workup for HTN?
CMP (liver fxn, glucose, kidneys/GFR, BUN, potassium, calcium) - repeat q3-6 mos
12 lead EKG (electrical changes and ischemia)
FBG
Fasting cholesterol panel (to assess ASCVD 10 year risk)
Urinalysis (proteinuria? in AKI?)
TSH
CBC (anemia?)
Consider: Echo (structural heart), uric acid (increased levels in HTN), urinary albumin to creatinine ratio
What is a normal and abnormal urinary albumin to creatinine ratio?
<30 is normal
Ratio of 30-300 indicates microalbuminuria, which is sometimes present in DM and HTN
How do you evaluate secondary HTN?
Sleep study (for OSA) Hormone levels (aldosterone, cortisone) Urine drug screen (cocaine?) Renal ultrasound (polycystic, blood flow, obstruction)
What are lifestyle modifications?
Exercise DASH diet Salt restriction (no salt added <4 grams; low salt <2 grams) Weight reduction Reduce excess ETOH consumption Limit NSAIDs Stress reduction
What is the DASH diet?
Dietary Approaches to Stop HTN
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 are first line BP meds for the general (non-black) population (including those with DM)?
- Thiazide-type diuretic
- CCB
- ARB or ACEi
What is the first-line tx in the general black population (including those with DM)?
- Thiazide-type diuretic
- CCB
In >18 y.o with CKD, what is the first-line initial or add-on treatment?
Should include an ACEi or ARB to improve kidney outcomes
REGARDLESS of race or DM
What is the MOA of thiazide-like diuretics?
Enhance sodium excretion –> reduce intravascular volume –> reduce peripheral resistance
What are side effects of thiazide-type diuretics?
Potassium-wasting (hypokalemia?) Hyperglycemia/hypercalcemia/hyperuricemia Sexual dysfunction Urinary frequency Transient increase in LDL
What are all the anti-HTN meds?
Centrally Acting Alpha Agonists: Clonidine
Vasodilators: Hydralazine, Monoxidil
Loop Diuretics- Furosemide, Bumetanide
Potassium-Sparing Diuretics: Spironolactone, Amiloride
Beta Blockers: Atenolol, Metoprolol, Nadalol
Alpha-Adrenergic blockers: Terazosin, Prazosin, Doxazosin
Alpha/Beta Blocker: Carvedilol, Labetalol
Nitrates: Nitroglycerin, Isosorbide dinitrate
Considerations with thiazide-type diuretics
- Sulfa allergy cautions (ok to use if sulfa allergy is mild)
- Gout (can increase uric acid levels so d/c if recurrent gout flares)
- Monitor hypokalemia, uric acid, and calcium
- Chlorthalidone is 2x more potent than HCTZ but much more expensive
When to use CCBs?
- AA patients (specific focus when single agent)
- Nondihydropyridines: (verapamil, diltiazem) used to rate control in patients with A fib or for control of angina
- Preferred over BB for tx patients with airway disease
What is the MOA of CCB?
Block entry of Ca in the heart and vascular smooth muscle –> reduces smooth muscle contraction –> reduces PVR
What are SE of CCBs?
Edema!! (Not a sign of HF and may be immediate or delayed sx) Reflex tachycardia/bradycardia Headache Constipation Dizziness
When should you not use CCB?
NOT recommended first-line after MI
When are CCBs good?
May improve GFR in pts with renal insufficiency
May be helpful in pts who have DM/CKD and history of angioedema with ACE/ARB
When and why to use ACE inhibitors?
First line in CKD and DM
Use after MI to reduce HF and mortality
Reverse LVH and remodeling due to HTN (post MI)
Low cost
Different dosages for use in HTN vs. renal protection (renal protection 2.5-5 mg and HTN 10-40 mg)
What is the MOA of ACEis?
Block conversion of angiotensin I to angiotensin II –> reduces vasoconstriction –> reduces aldosterone
Inhibits breakdown of bradykinin (vasodilator)
What are SE of ACEis?
Dry (benign) cough (because of inhibition of bradykinin breakdown in lungs) Hyperkalemia Elevated Creatinine (AKI)
What are dangers of ACEis?
Angioedema (can’t use ARB either if this occurs)
Must be avoided in pregnancy
When and why to use ARBs?
Same indications as ACEis
Comparable to ACEis in BP control (but no cough!…but more expensive)
Do NOT use ACEi with ARB together
What anti-HTN med would you use in a black patient?
CCB or thiazide diuretic
What anti-HTN med would you use in a nonblack patient <60?
ARB or ACEi
What anti-HTN med would you use in a nonblack patient >60?
CCB, thiazide, ARB, or ACEi
What anti-HTN med would you use in CKD?
ARB or ACEi
What anti-HTN med would you use in CAD?
BB and ARB or ACEi
What anti-HTN med would you use in DM?
ARB or ACEi
What anti-HTN med would you use in HF?
ARB or ACEi and BB
What anti-HTN med would you use in patient with hx of CVA?
ARB or ACEi
What does angiotensin II do?
Vasoconstriction
What does aldosterone do?
Acts on the renal tubules and influences sodium and water reabsorption
What are examples of the first-line anti-HTN meds?
Thiazide-type diuretics: HCTZ, chlorthalidone
CCBs: amlodipine, diltiazem, nifedipine
ACEis: lisinopril, enalapril
ARBs: losartan, valsartan (not now, has NMDA)
What are the titration guidelines for stage 1 HTN with >10% ASCVD risk or known clinical CVD, DM, or CKD?
Lifestyle modifications (for all)
Start 1 BP lowering med…
(Most meds take 2 weeks to begin working)
If goal is met after 1 month, titrate medication, reassess in 3-6 months
If goal is not met after 1 month, consider different med or titration
Continue monthly follow-up until control is achieved
What are the titration guidelines for stage 2 HTN?
Lifestyle modifications for all
Start 2 BP lowering medications of different classes
If goal is met after 1 month, titrate medications, reassess in 3-6 months
If goal is not met after 1 month, consider different med or titration
Continue monthly follow-up until control is achieved
What are some standard practices in HTN treatment?
- Do not use an ACEi and ARB together
- If BP goal can’t be reached 2/2 contraindications or the need to use >3 drugs, anti-HTN drugs from other classes can be used
- Referral to specialist may be indicated for pt if goal BP can’t be achieved
What do you do for resistant HTN?
Confirm resistance, exclude environmental factors, screen for secondary causes, maximize pharmacologic therapy, and refer to specialist
What are some considerations in treating HTN in the older adult (>65)?
Start low and go slow
Carefully consider diuretics
Monitor renal function closely
Review risk of postural hypotension and patient teach (slow to get out of bed)
Affordability of HTN meds
HCTZ $4 (thiazide-type diuretic)
Lisinopril $4 (ACEi)
Amlodipine $40-50 (CCB)
Losartan $40-60 (ARB)
Safest to least safe for pregnancy:
Labetalol (BB)
Nifedipine (CCB)
HCTZ (thiazide-type diuretic)
Lisinopril (ACEi)
How do you treat HTN in pregnancy?
Use methyldopa, nifedipine, or labetalol
No ACEs or ARBs
Easiest to hardest dosing regimen:
Chlorthalidone
Benzapril HCT- combo med
Metoprolol
Hydralazine (QID dosing!)
What are considerations in maintaining BP control?
- Requires partnership to improve adherence
- Education is key! (Med regimen, goals of treatment)
- Encourage pt to check BP at home and write down numbers
- Bring meds to each visit
- Increase frequency of f/u on BP with visits or phone calls
- Assess barriers to care
What are potential barrier to care?
Lack of understanding of the disease
Lack of access (transportation, etc.)
Side effects
Cost
Lack of appropriate f/u by provider, like not following up on missed appointments
Confusion re: meds, language/reading barriers, pharmacy confusion
Therapeutic/clinical inertia
