HTN and HTN urgency/emergency Flashcards
what are the modifiable risk factors of HTN?
current cigarette smoking secondhand smoke DM HLD obesity low physical activity unhealthy diet
what are the fixed risk factors of HTN?
CKD family history increased age low SES male obstructive sleep apnea psychosocial stress
what are the cardiac consequences of HTN?
LVH HF atherosclerotic CAD microvascular dz arrhythmias (Afib)
what are the cerebral consequences of HTN?
CVA
dementia
HTN-encephalopathy
what are the renal consequences of HTN?
renal injury
ESRD
what are the arterial consequences of HTN?
PAD
what is primary/essential HTN?
elevated BP with no specific underlying disorder
80-90% of cases
what is secondary HTN?
elevated BP with a specific underlying disorder
what is hypertensive urgency?
severe BP elevation (>180/110) without symptoms of end organ damage
what is a hypertensive emergency?
severe BP elevation (>180/110) WITH symptoms of end organ damage
what physiological factors raise blood pressure?
Na retention vasoconstriction endothelin 1 activation of SNS pro-inflammatory Th1 cells
what is normal BP?
<120/80
what is elevated BP?
120-129/<80
what is stage 1 HTN?
130-139/80-89
what is stage 2 HTN?
≥ 140/90
what are signs of secondary HTN?
features of Cushing syndome neurofibromatosis enlarged kidneys abdominal bruits precordial murmurs
what are signs of target-organ damage?
motor or sensory deficit retinopathy Afib/arrhythmia pulmonary edema/congestion absent, reduced or asymmetrical pulses ischemic skin lesions carotid murmurs
what lab tests need to be ordered when primary HTN is suspected?
CBC CMP lipid panel TSH UA EKG
what is the treatment for elevated BP?
nonpharmacologic therapy (lifestyle changes)
what is the treatment for stage 1 HTN in patients without other risk factors for CVD?
nonpharmacological therapy (lifestyle changes)
what is the treatment for stage 1 HTN in patients WITH other risk factors for CVD? (HLD, DM, CKD, old)
nonpharmacologic therapy
AND
BP lower medication (RAS inhibitor or diuretic)
what is the treatment for stage 2 HTN?
nonpharmacologic therapy
AND
BP lower medication (RAS inhibitor or diuretic)
what are the nonpharmacological therapies?
weight reduction salt reduction DASH diet alcohol reduction increase physical activity
which nonpharmacological therapy can most significantly lower BP?
DASH diet
what are the first line anti-HTN?
RAAS inhibitors
CCBs
thiazide diuretics
what anti-HTN is best for white ppl?
ACEI or ARBs
what anti-HTN is best for black ppl?
CCBs or diuretics
what anti-HTN is best for patients with DM2?
ACEI or ARBs
what anti-HTN is best for patients with CHF?
ACEI or ARBs or B-blockers
what anti-HTN is best for patients with BPH?
a-blockers
what anti-HTN is best for patients with Afib?
CCBs or B-blockers
what factors are important when reassessing BP?
detection of orthostasis ID white coat syndrome document adherence monitor response reinforce importance of treatment
what is the protocol for HTN urgency?
BP should be lowered gradually <160/100 but not acutely >20-25% of MAP over several days-weeks
what are the most common presentations of HTN emergency?
cerebral infarction
pulmonary edema
what labs/imaging should be ordered for suspected HTN emergency?
EKG CXR UA serum electrolytes creatinine
what is the protocol for HTN emergency?
lower MAP gradually:
10-20% in 1st hour
5-15% over next 24 hours
in primary htn what is the source of the HTN
increase in total peripheral resistance
How does limit of Na intake influence a decrease in blood pressure
reduction in salt intake reduces fluid retention which lowers BP. In addition, lack of salt will activate RAAS which can be blocked pharmacologically.
Why are ACE inhibitors less likely to work in African Americans with primary HTN
they have low renin primary HTN so there is nothing to block (in addition, allergies)
What conditions are likely to indicate secondary HTN
Abrupt onset
HTN <30 y/o
Accelerated/malignant HTN
What are the categories of the first line drugs used to treat HTN
Thiazides
ACEi
ARBs
CCB dihydropyridines or nondihydropyridines
What is the mechanism of the thiazide diuretics?
block Na-Cl cotransporters in the distal convoluted tubule
A low GFR would make what class of drugs less effective?
Thiazides
What drug is long lasting and used by many HTN experts for this reason?
Chlorthalidone
what is the mechanism of action of furosemide
blocks Na-K-Cl cotransporter in the thick ascending loop of henle
What are loop diuretics indicated for
HF
Pulmonary Edema
HTN
What are notable toxicities of furosemide
Hypo-“saltemia” lose all salts
ototoxic
You need a loop diuretic but cyka blyat your patient has a sulfa allergy because they are weak. what loop diuretic can you give your weak baby patient
ethacrynic acid
how do potassium sparing diuretics work?
block Na the ENaC channel or Aldosterone at the collecting duct after K+ has been reabsorbed
What are the Potassium sparing diuretics
Amiloride - blocks ENaC
Spironolactone - Blocks aldosterone
What is the clinical indication of Amiloriode
Offsets K+ loss from other diuretics
hyperkalemia risk
What is the clinical application of spironolactone?
counteracts K+ loss from other diuretics
reduce fibrosis in HFrEF post MI
Where does aliskirin work on the RAAS
blocks renin
what is a universal process that occurs in people recently put on ACE inhibitors
Decrease in GFR -> increase in serum creatinine
What is the clinical application of captopril and other ACEi
HTN
Acute HTN/Emergency
HFrEF
Diabetic nephropathy
What are two notable side effects of ACEi
cough
angioedema
What is the mechanism of the -sartan drugs
block angiotensin II receptors
What is candesartan notable for
irreversible binding and longer half life.
Which AT receptors do -sartan drugs have a higher affinity
AT1
What is the mechanism of action of aliskirin
blocks direct effects of renin
What is a disadvantage of aliskirin
its new and expensive but does have few toxicities
You have a pregnant lady with HTN, what will you not giver her 100 percent
ACEi
What are the dihydropyridine CCB
Nifedipine
Amlodipine
What are the uses Amlodipine is limited to
CAD
HTN
Which category of CCB is cardioactive
non-dihydropyridine - verapamil; diltiazem
When taking dihydropyridine CCB what interaction is important to look for
CYP3A4 active drugs
What is the key difference between Nifedipine and Verapamil
nifedipine at therapeutic doses exerts smaller direct ionotropic effects and no chronotropic, but DOES have large vasodilation, HR, and CO because of reflex SNS
What a-blockers were used early but not tolerated due to their extensive adverse effects
Phentolamine
Phenoxybenzamine
What is the mechanism of action for propranolol
nonselective beta blockers (class II antiarrhythmic)
what is the mechanism of action of atenolol or metoprolol
B1 selective blocker
What is the risk of abruptly stopping a or B blockers
Tachycardia and HTN spike -> death
why are B blockers no longer a first line therapy for HTN
dont prevent MI, HF, or death
higher incidence of stroke
What is the clinical use of hydralazine
hypertensive emergency in pregnancy
HFrEF
What is the mechanism of action of nitroprusside
venous and arteriolar dilation
How does renal HTN affect systemic hypertension
stenosis decreases renal perfusion which activates RAAS
Presence of what effects indicated BL renovascular HTN
Flash Pulmonary Edema
Progressive Renal Failure
Refractory Congestive Cardiac Failure
What drug is classically used for IV HTN emergency
Sodium Nitroprusside