Gen Med Unit 7: Cardio > HTN: Essential and Secondary > Flashcards

HTN: Essential and Secondary Flashcards

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1
Q

What is the optimal SBP/DBP?

A

<120/80

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2
Q

What are the JNC BP recommendations for pts >60?

A

<150/90

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3
Q

What are the JNC BP recommendations for pts <60?

A

<140/90

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4
Q

What are the JNC BP recommendations for pts with CKD under 18?

A

<140/90

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5
Q

What are the JNC BP recommendations for pts with diabetes under 18?

A

<140/90

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6
Q

What is the most common cause of HTN?

A

Primary/Essential
Most common (90-95%)
Etiology unknown

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7
Q

What are some common causes of secondary HTN?

A
  1. Renal disease (most common)
  2. Obesity
  3. Sleep apnea
  4. Pregnancy
  5. Endocrine abnormalities
  6. Arterial narrowing
  7. Medications & substance abuse
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8
Q

What endocrine disorders can cause HTN?

A
  1. Cushing’s syndrome
  2. Hyperthyroidism
  3. Hypothyroidism
  4. Acromegaly
  5. Hyperaldosteronism(Conn’s syndrome)
  6. Hyperparathyroidism
  7. Pheochromocytoma
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9
Q

What arterial narrowing disorders can cause HTN?

A
  1. Coarctation of the aorta

2. Renal artery stenosis

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10
Q

What medications and substance abuse disorders can cause HTN?

A

Alcohol excess, oral contraceptives, NSAID’s, corticosteroids, cocaine, amphetamines

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11
Q

What sxs are asst with renal artery stenosis?

A

Abdominal bruits

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12
Q

What sxs are asst with coarctation of the aorta?

A
  1. ↓ BP in the lower extremities

2. Delayed or absent femoral arterial pulses

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13
Q

What sxs are asst with pheochromocytoma?

A

Labile or paroxysmal HTN w/ h/a, palpitations, pallor, & hyperhidrosis

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14
Q

What sxs are asst with Cushing’s syndrome?

A
  1. Truncal obesity
  2. Glucose intolerance
  3. Moon face
  4. Buffalo hump
  5. Striae
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15
Q

What sxs are asst with Hypothyroidism?

A
  1. Dry skin, alopecia

2. Slow DTR’s

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16
Q

What sxs are asst with Hyperthyroidism?

A
  1. Enlarged thyroid

2. Exophthalmos

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17
Q

What renal diseases can cause HTN?

A
  1. Chronic glomerulonephritis
  2. Chronic pyelonephritis
  3. Polycystic kidney disease
  4. Connective tissue disorders
  5. Obstructive uropathy
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18
Q

What asst. morbidities/mortalities are asst. with HTN?

A 
Stroke
MI
CHF
LVH
PVD
Aortic dissection
Ventricular arrhythmias
Renal failure
Retinopathy
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19
Q

What stage of HTN may be asymptomatic? When do symptoms start?

A

Early stage, symptoms may start when target organ damage begins

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20
Q

What are the complications asst. with asymptomatic HTN?

A

Requires a lot of patient education about long term risks

Lifestyle modification

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21
Q

What are the criteria for metabolic syndrome?

A
  1. Truncal obesity
  2. ↑ triglycerides
  3. ↓ HDL
  4. HTN
  5. Hyperglycemia
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22
Q

What are the criteria for metabolic syndrome?

A
  1. Truncal obesity
  2. ↑ triglycerides
  3. ↓ HDL
  4. HTN
  5. Hyperglycemia
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23
Q

What information is needed from the pt history?

A
  1. Known duration of HTN
  2. Previously recorded levels
  3. Meds
  4. Evaluate for history or symptoms of
    A. CAD
    B. HF
    C. TIA/Stroke
    D. Peripheral vascular disease
    E. Renal dysfunction
    F. Dyslipidemia
    G. DM
    H. Sleep apnea
    I. FH any of above
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24
Q

What information is needed from the pt social history?

A
  1. Exercise level
  2. Tobacco use
  3. Alcohol use
  4. Stimulant drugs
  5. Diet
    A. Salt
    B. Stimulants
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25
What is the proper way to take a blood pressure?
Avoid caffeine, smoking & exercise 30 min. prior Seat pt. quietly X 5 min Use appropriate sized cuff Two measurements at least 5 min. apart Do not check BP in limb used for IV infusion or where circulation is potentially compromised Check both arms “White Coat HTN”
26
What is the proper blood pressure cuff size criteria?
1. Inflatable part (bladder) of the BP cuff should cover about 80% of the circumference of the upper arm 2. The cuff should cover 2/3 of the distance from the elbow to the shoulder
27
Define grade 1 hypertensive retinopathy
Arterial constriction/sclerosis -`silver or copper wiring`
28
Define grade 2 hypertensive retinopathy
1. Arterial constriction/sclerosis -`silver or copper wiring` 2. `AV nicking`
29
Define grade 4 hypertensive retinopathy
1. Arterial constriction/sclerosis -`silver or copper wiring` 2. `AV nicking` 3. Retinal edema, cotton wool spots and flame-shaped hemorrhages 4. Grade 3 + swelling of optic disc (papilledema)
30
Define grade 4 hypertensive retinopathy
1. Arterial constriction/sclerosis -`silver or copper wiring` 2. `AV nicking` 3. Retinal edema, cotton wool spots and flame-shaped hemorrhages 4. Grade 3 + swelling of optic disc (papilledema)
31
How are renal causes of HTN screened for?
1. UA for proteinuria 2. Serum BUN & Creatinine 3. Hb & Hct
32
How are metabolic causes of HTN screened for?
1. FBS | 2. Lipid panel
33
What are other HTN screening mechanisms?
1. EKG | 2. +/- CXR
34
What are other HTN screening mechanisms?
1. EKG | 2. +/- CXR
35
When is a renal artery US/renal artery doppler/MRA indicated in a pt with HTN?
``` 1. BP difficult to control A. Enlarged kidneys B. Renal bruit C. UA with protein D. ↑ Serum creatinine E. Young w/ severe HTN (<40 yr) ```
36
If BP is difficult to control, and hypokalemia, what other tests are indicated?
1. PRA (Plasma Renin Activity) test 2. Serum aldosterone level A. R/O Cushing’s Dz, Primary Aldosteronism, Steroid abuse
37
If BP is difficult to control, and hypercalcemia, what other tests are indicated?
1. Repeat serum Ca, Albumin, Mg, Alk. Phos, Cr 2. PTH, BMP 3. 24-hr urine Ca A. R/O Neoplasms, hyperparathyroidism
38
If BP is difficult to control, and abnormal TSH what other tests are indicated?
1. Free T4, Free T3, Thyrotropin-receptor Ab | A. R/O Grave’s Dz
39
What can decreased renin levels indicate?
1. Hypervolemia due to a high-sodium diet 2. Salt-retaining steroids 3. Primary aldosteronism 4. Cushing's syndrome 5. Licorice ingestion syndrome 6. Essential hypertension w/ low renin levels
40
What can increased serum aldosterone levels with decreased renin levels (PRA) indicate?
Confirms primary aldosteronism
41
What can cause increased renin (PRA plasma renin activity) levels?
1. Essential HTN (uncommon) 2. Renovascular Dz 3. Cirrhosis 4. Renin-producing renal tumors (Bartter's syndrome) 5. Adrenal hypofunction (Addison's disease) 6. Chronic renal failure 7. Transplant rejection
42
What other dx studies can be performed for pts with HTN based on H&P findings?
``` 1. 24 hr urine for metanephrines A. R/O pheochromocytoma 2. Sleep studies A. R/O sleep apnea 3. Dexamethasone suppression test A. R/O Cushing’s syndrome ```
43
What lifestyle changes are indicated in HTN treatment?
1. Wt reduction to BMI 18.5 – 24.9 kg/m² 2. Aerobic exercise 30 min/day most days 3. Smoking cessation 4. Dietary changes: increase fruits and vegetables (↑ K+), ↓ salt (<2400mg), reduce saturated and total fats 5. Moderate ETOH consumption A. Men ≤ 2 drinks/day B. Women ≤ 1 drink/day
44
What are the indications for pharmacologic tx for HTN pts?
BP initially > 160/100 or unresponsive to lifestyle changes needs pharmacologic Tx
45
What is the BP goal for pts over 60 w/out DM or CKD?
< 150/90 mmHg
46
What is the BP goal for pts over 60 w/ DM or CKD, or pts 18-59 w/out major comorbidities?
< 140/90 mmHg
47
What are the 4 first line HTN treatment options?
1. Thiazide-type diuretics 2. Calcium channel blockers (CCBs) 3. ACEIs 4. ARBs
48
What are the 2nd and 3rd line HTN alternatives?
↑ Doses or combinations of ACEIs, ARBs, Thiazide-type diuretics, & CCBs
49
What are the later line alternative treatments for HTN?
1. Beta-blockers 2. Alpha-blockers 3. Alpha1/beta-blockers 4. Vasodilating beta-blockers 5. Central alpha2-adrenergic agonists 6. Direct vasodilators 7. Loop diuretics 8. Aldosterone antagonists 9. Peripherally acting adrenergic antagonists
50
What is the first line treatment for HTN pts who are african american?
First-line Tx in pt of African descent w/out CKD should use CCBs and thiazides instead of ACEIs
51
What is the first line treatment for all pts with CKD?
Use of ACEIs and ARBs is recommended in all patients with CKD regardless of ethnic background
52
What is the MOA of loop diuretics and what are some examples?
1. Inhibit Na/K/Cl co-transporters in thick ALH 2. Furosemide (Lasix), bumetadine (Bumex),torsemide (Demedex) 3. Often add on therapy, not first line
53
What is the MOA of Thiazide diuretics and what are some examples?
1. Inhibit NaCl transporter in early distal tubule 2. HCTZ (Microzide, Esidrix), indapamide (Lozol), triamterene/HCTZ (Maxzide, Dyazide), chlorthiazide (Diuril), metolazine (Zaroxolyn), chlorthalidone 3. Often 1st line unless pt has renal dysfunction
54
What is the MOA of ACEi and what are some examples?
1. Inhibits conversion of angiotensin I to angiotensin II (vasoconstrictor) A. Preventing vasoconstriction 2. Prevents bradykinin (vasodilator) degradation A. Maintaining vasodilation 3. Lisinopril (Zestril, Prinivil), benzapril (Lotensin), captopril (Capoten), enalapril (Vasotec), ramipril (Altace)
55
What is the first line treatment for HTN in pts with diabetes?
ACE inhibitors or ARBs bc renally protective and pts with dm are at risk for kidney disease
56
What is the most common se for ACE inhibitors?
↑ Bradykinin build-up → cough
57
What is the MOA of ARBs and what are some examples?
1. Selectively blocks Type I angiotensin II receptors 2. Relaxes smooth muscles → vasodilation 3. Promotes renal excretion of Na & H2O 4. Valsartan (Diovan), irbesartan (Avapro), olmesartan (Benicar),telmisartan (Micardis), losartan (Cozaar)
58
Why don't ARBs cause cough?
No effect on bradykinin degradation → no cough
59
What is first line treatment for pts who are african american or elderly?
CCB
60
What is the MOA of CCBs and what are some examples?
1. Inhibits Ca ion influx into vascular smooth muscle & myocardium 2. Relaxes smooth muscle, ↓ peripheral resistance, dilates coronary arteries 3. Cause peripheral vasodilation 4. Prolongs AV node refractory period 5. Diltiazem (Cardizem, Cartia, Taztia), verapamil (Calan, Verelan, Isoptin, Covera), amlodipine (Norvasc), nifedipine (Procardia, Adalat), nicardipine (Cardene)
61
What is the MOA of beta 1 blockers and what are some examples?
1. B1 receptor blockade (cardio-selective) A. ↓ Heart rate & contractility → ↓ cardiac output B. ↓ Myocardial oxygen demand C. Slows AV node conduction D. ↓ Renin release E. Dilates coronary arteries 2. Metoprolol (Toprol, Lopressor), atenolol (Tenormin), bisoprolol (Zebeta), nebivolol (Bystolic)
62
What is esmolol (Brevibloc) used for?
AV node blocker-used in SVT
63
What is the MOA of beta 2 blockers and what are some examples?
1. B2 receptor blockers A. Vasoconstriction initially B. Total peripheral resistance returns to normal or ↓ with long term use C. Not cardio-selective 2. Propranolol (Inderal), nadolol (Corgard) *Sotalol (ventricular anti-arrhythmic as well, slows action potential)
64
If a diabetic pt is on an ACE, and starts to develop hyperkalemia, what do you do?
Switch to an ARB
65
What is the MOA of alpha antagonists (peripheral) and what are some examples?
1. Relaxes arteriole smooth muscle 2. ↓ Vascular resistance and BP 3. Relaxes prostate and bladder smooth muscle and facilitates bladder emptying 4. Doxazosin (Cardura), prazosin (Minipress), terazosin (Hytrin)
66
What is the drug of choice in pts with BPH and HTN (not diabetic)?
Alpha antagonists
67
What is the MOA of direct vasodilators and what are some examples?
1. Nitrate relaxes smooth muscle → dilates peripheral vessels 2. Used in HTN emergencies, advanced CHF, not a first line BP agent! 3. Hydralazine (Apresoline), Minoxidil
68
What drug is also used for Reynaud's disease?
Nifedipine (procardia, Adalat)
69
What are the special considerations for Minoxidil?
1. Usually used with beta blocker to prevent tachycardia | 2. Used with loop diuretic to prevent fluid accumulation
70
What is the MOA of adrenergic antagonists and what are some examples?
1. Direct renin inhibitor 2. Interferes w/ conversion of angiotensin to angiotensin I 3. Reserpine, aliskiren (Tekturna) 4. Used when everything else is faliling
71
What is the MOA of alpha1/beta blockers and what are some examples?
1. Selectively blocks alpha-1 adrenergic receptors 2. Blocks beta-1 & beta-2 receptors 3. Indicated for HTN & CHF; HTN emergencies, post MI protection 4. Carvedilol (Coreg), labetolol (Trandate)
72
What is the MOA of alpha 2 adrenergic agonists and what are some examples?
1. Activates central alpha 2 receptors → ↓ central adrenergic outflow 2. Used in refractory HTN 3. Clonidine (Catapres), methyldopa (Aldomet)
73
What is the MOA of aldosterone receptor antagonists and what are some examples?
1. Antagonizes aldosterone receptors in distal convoluted tubule → ↓ Na & H2O reabsorption, ↑ K retention 2. Used in refractory HTN (and acne) 3. Spironolactone (Aldactone)
Gen Med Unit 7: Cardio
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