HTN Guidelines Flashcards
What is the proper patient position for BP reading?
Sitting position, back supported, arm bare and supported at heart level, legs uncrossed and feet flat on the floor
How should the cuff be positioned for BP reading? How do you know the right size of cuff?
Middle of cuff at heart level, lower edge of cuff 3 cm above elbow crease
Cuff bladder width should be close to 40% of arm circumference and length should cover 80-100% of arm circumference
T/F: Resistant hypertension is defined as BP above target despite 2 or more BP lowering drugs at optimal doses.
False, Resistant hypertension is BP above target despite 3 or more BP lowering drugs at optimal doses
Which three class of drugs would likely be prescribed for resistant hypertension?
usually a diuretic, RAAS blocker and Ca Channel blocker
What is the purpose of out-of –office BP measurements?
To rule out white-coat hypertension
Also to diagnose suspected masked hypertension
Single-pill combination (SPC) are recommended where possible, why?
To improve treatment efficacy, adherence and tolerability
AOBP. What does it stand for and how is it done?
Automated Office BP. Automated device takes a series of BP measurements without the provider or others present. Patient is left unattended in a private area while 3-6 readings are taken. First reading discarded, others averaged.
OBPM. What does it stand for and how is it done?
Office blood pressure measurement. BP measured using upper arm device with provider in the room.
Electronic or oscillometric devices are preferred to auscultatory devices
ABPM. What does it stand for and how is it done?
Ambulatory BP monitoring. Using a validated oscillometric device worn for 24 hours. BPs taken at 20-30 minute intervals
HBPM. What does it stand for and how is it done?
Home BP monitoring. Self-monitoring, patient measures BP for 7 days, twice in the morning and twice in the evening
Which method of BP monitoring is preferred for in-office measurement?
AOBP – Automated office BP
Which method of BP monitoring is preferred for diagnosis?
ABPM – Ambulatory BP monitoring
BP should be taken in both arms on at least one visit, if one arm has consistently higher pressure, which arm should be used for BP measurement?
The arm with higher BP should be used
How long should a patient rest before BP is measured?
Should rest comfortably for 5 minutes prior to BP measurement
What is the threshold for diagnosis of hypertension using OBPM?
SBP greater than or equal to 140
And/or
DBP greater than or equal to 90
What group of patients has a different threshold for diagnosis of hypertension? What is the threshold?
Patients with Diabetes
SBP greater than or equal to 130
And/or
DBP greater than or equal to 80
What is the threshold for diagnosis of hypertension using HBPM?
Using home BP monitoring, the threshold changes to
SBP greater than or equal to 135
And/or
DBP greater than or equal to 85
What is the threshold for diagnosis of hypertension using ABPM?
Using ambulatory BP monitoring, the threshold changes to
Mean 24 hour
SBP greater than or equal to 130
And/or
DBP greater than or equal to 80
OR
Mean daytime
SBP greater than or equal to 135
And/or
DBP greater than or equal to 85
When would you do a seated vs. Standing BP
Seated used to determine and monitor treatment decisions
Standing used to examine for postural hypotension, which may modify treatment
Do you recall how to auscultate a BP?
Inflate to 30mmHg above loss of radial pulse
Listen over brachial artery
Deflate slowly
Systolic = appearance of first Korotkoff sound
Diastolic = point when sounds disappear
An office BP of ___/___ or greater allows for immediate diagnosis of HTN
180/110
What preliminary investigations are indicated for patients with hypertension?
Urinalysis
Blood chemistry (K, Na, creatinine)
Fasting glucose or A1c
Serum total cholesterol, LDL, HDL, non-HDL, triglycerides, lipids
12 lead ECG
T/F: diabetes develops in 1-3% per year of those with drug-treated HTN
True!
Screen adults with HTN with annual fasting plasma glucose testing
Target organ damage (TOD) should be assessed in patients with HTN, presence of any TOD puts patient in medium-high or high risk category for therapy. What are some TOD examples?
Cardiovascular disease: CAD, HF, left ventricular hypertrophy
Cerebrovascular disease: aneurysms, hemorrhages, ischemic stroke, TIA, etc.
Hypertensive retinopathy
Peripheral Artery Disease
Renal disease: albuminuria, CKD
Another tool for risk assessment is the Global Cardiovascular Risk Assessment
HTN Canada stratifies patients by risk level and threshold for treatment and BP treatment targets depend on the risk level…
For high-risk patients what is the threshold for initiation of treatment and what is the BP treatment target?
Threshold for treatment: SBP greater than or equal to 130
BP target: SBP<120
For diabetic patients what is the threshold for initiation of treatment and what is the BP treatment target?
Threshold for treatment: SBP greater than or equal to 130, DBP greater than or equal to 80
BP target: SBP<130, DBP<80
For medium-risk patients what is the threshold for initiation of treatment and what is the BP treatment target?
Threshold for treatment: SBP greater than or equal to 140, DBP greater than or equal to 90
BP target: SBP<140, DBP<90
For low-risk patients what is the threshold for initiation of treatment and what is the BP treatment target?
Threshold for treatment: SBP greater than or equal to 160, DBP greater than or equal to 100
BP target: SBP<140, DBP<90
What are some health behavior recommendations for HTN?
Being more physically active
Weight reduction
Moderation in alcohol intake
Healthy eating
Relaxation/stress management
Smoking cessation
What are helpful dietary recommendations for prevention and management of HTN?
DASH-like diet – high in fresh fruits and vegetables, dietary fiber, non-animal protein (ex. Soy), and low-fat dairy products. Low in saturated fat and cholesterol.
To decrease BP in hypertensive pts consider increasing dietary potassium (!?)
What is first-line therapy for HTN?
After health behavior management, lists all of the things as first line: thiazide/thiazide-like diuretic, ACE-I, ARB, long-acting CCB, B-Blocker, single-pill combination
** There are some more specific recommendations for first line drugs in certain situations, but even then there are often multiple choices.
Hint: ACE-I are almost always on the list of first line drugs! (except in pregnancy/lactation and isolated systolic HTN without other compelling indications)
T/F: it is ok to prescribe your patients multiple drugs for HTN
True!
May require multiple drugs, especially in T2DM
Low doses of multiple drugs may be better tolerated than higher doses of fewer drugs
Aim for combination pills when able
Which two classes of BP meds should not be combined?
ACE-I and ARBs
What are some possible reasons for poor response to anti-hypertensive therapy?
Inaccurate BP measurement
Suboptimal treatment (dose too low or inappropriate drug combinations)
Poor adherence
Associated conditions: obesity, tobacco, excessive alcohol, OSA, chronic pain, depression
Drug interactions
Volume overload
Secondary hypertension
What are some drug interactions that can cause poor response to HTN therapy?
NSAIDs
Oral contraceptives
Corticosteroids and anabolic steroids
Cocaine, amphetamines
Erythropoietin
Cyclosproine, tacrolimus
Licorice
Oral decongestant (pseudoephedrine)
Monoamine oxidase inhibitors, certain SSRIs
How often should follow-up occur with HTN patients?
Every 1-2 months if uncontrolled
Once 2 consecutive visits are below target, every 3-6 months
