HTN, CVD, Parkinsons, Polymyalgia Flashcards
What is HTN? ISH?
- Systolic over 140 or diastolic over 90
- isolated systolic HTN (ISH) is common form of HTN in elderly, systolic over 140 and diastolic below 90
- for most elderly pts, HTN doesn’t have a reversible cause and is asx
What should eval of HTN include? Tx?
- eval should include detection of other cardiovascular risk factors and end organ damage and a seach for secondary causes when appropriate
- tx w/ lifestyle modifications and drugs, often starting w/ thiazide diuretic
How common is HTN in people older than 80?
- 65%
What are the major mechanisms of BP regulation?
- volume of blood pumped into arterial tree - this is determined by
A: vol of blood w/in the heart
B: vigor of heart’s contraction
C: kidneys - stiffness of the arteries - this is determined by:
A: vascular smooth muscle cell contractile tone
B: endothelial cell fxn
C: matrix that embeds the vascular smooth muscle cells
What are assoc conditions of HTN?
- MI
- CVA
- PVD
- CHF
- Renal Failure
Risk of CVD and relationship w/ BP?
- independent of other risks
- if 115/75 is ideal - each 20/10 mmHg rise doubles risk of CVD
What is preHTN?
- SBP: 120-139
or - DBP: 80-89
What are the benefits of lowering BP?
- stroke incidence: reduction of 35-40%
- MI: 20-25%
- Heart failure: 50% (long standing HTN is MC cause of diastolic heart failure)
Dementia relationship w/ HTN?
- cognitive impairment more common w/ HTN
- reduced progression of dementia occurs w/ effective antiHTN therapy
Causes of secondary HTN?
- sleep apnea
- drug induced
- chronic kidney disease
- primary aldosteronism
- renovascular disease
- chronic steroid therapy or cushing’s syndrome
- pheochromocytoma
- coarctation of the aorta
- thyroid or parathyroid disease
- think about a secondary cause if uncontrollable still w. meds or in younger pt
What are CVD risk factors?
- HTN
- cigarette smoking
- dyslipidemia
- obesity (BMI greater than 30 kg/m2)
- physical inactivity
- DM
- microalbuminuria or est GFR of less than 60ml/min
- age: 55+ for men and 65+ for women
- family hx of premature CVD )(men younger than 55 and women less than 65)
Target organ damage - from HTN/CVD?
- heart: LVH angina or prior MI prior coronary revascularization CHF - CVA/TIA - renal disease - PAD - retinopathy
Assoc of LVH and CVD? How can we stop this from progressing?
- LVH is an independent RF for CVD
- regression of LVH occurs w/ aggressive BP management: wt loss, Na restriction, and tx w/ all classes of drugs except the direct vasodilators hydrazine and minoxidil
Lab tests for HTN?
always: EKG UA Chem fasting lipid panel H/H, TSH
optional:
microalbumin
Diff lifestyle modifications for HTN?
- wt reduction 5-20 mmHg/10kg wt loss
- DASH eating plan 8-14 mmHg
- Na restriction 2-8mmHg
- physical activity: 4-9 mmHg
- moderation of ETOH consumption: 2-4 mmHg
Initial drug choices in HTN?
w/o compelling indications:
- stage 1: SBP 140-159 or DBP 90-99 mmHg - thiazide type diuretics, may consider ACEI, ARB, BB, CCB or combo
- stage 2: SBP over 160 or DBP over 100 - 2 drug combo for most: usually thiazide and ACEI or ARB, BB or CCB
w/ compelling indications:
other antiHTN drugs - diuretics, ACEI, ARB, BB, CCB as needed
84 yo shows up to Urogyn clinic for appt and has BP of 190/100 and is asx- what should you do?
- send her to ER
- ask if she has HA, blurry vision, sxs of MI
What could a lack of BP drop of 10-20% during the night indicate?
- possible increased risk for CV events
What home BP measurement is considered HTN?
- over 135/85
What should you do if BP is over 20/10 mmHg above goal?
- start w/ 2 agents
- one should be thiazide
- most will reqr more than 1 drug to achieve goal BP
Initial therapy for HTN w/ heart failure?
THIAZ, BB, ACEI, ARB, ALDO ANT
Initial therapy for HTN w/ S/P MI?
- BB, ACEI, ALDO ANT
Initial therapy for HTN w/ high risk of CAD?
- THIAZ, BB, ACEI, CCB
Initial therapy for HTN w/ diabetes?
- THIAZ, BB, ACEI, ARB, CCB
Initial therapy for chronic renal disease and HTN?
- ACEI and ARB
Initial therapy for recurrent stroke prevention in pt w/ HTN?
- THIAZ, ACEI
What other diseases are thiazides therapeutic for?
- osteopenia/osteoporosis
Other uses for BBs?
- atrial tachycardias, migraine, thyrotoxocosis, essential tremor, perioperative period, peformance anxiety
Other use for CCBs?
- raynauds
Other use for Alpha-blockers?
- useful in BPH
Relative CIs for antiHTN drugs?
- thiazides: gout, hx of hyponatremia
- BB: RAD or 2nd/3rd degree Heart block
- ACEI/ARBs: risk of preg
- Aldosterone antag/K sparing diuretics: hyperkalemia
What is postural hypotension? When should orthostatics be checked?
- drop in standing SBP of over 10 mmHg, assoc w/ dizziness/fainting
- always check these when adjusting meds
- avoid vol depletion and excessively rapid titration
What are HTN emergencies?
- marked BP elevations and acute TOD:
encephalopathy, TIA/CVA, papilledema, MI or unstable angina, Pulmonary edema, life threatening arterial bleeding or aortic dissection, renal failure - this reqr hospitalization and parenteral drug therapy
What are HTN urgencies?
- marked BP elevation but no acute TOD
- usually doesn’t reqr hospitalization
- does reqr immediate combo oral antiHTN therapy
MC HTN in geri population? Cause of this?
- ISH: more than 2/3 of cases
- caused primarily by an increase in arterial stiffness due to increased collagen deposition and cross linking, degeneration of elastin fibers, atherosclerotic changes, and age related endothelial dysfxn
When would BP reading be falsely elevated in elderly pts?
- if they have really stiff, calcified arteries - known as pseudoHTN
