HTN heather lecture

Question 1

What pathologies is HTN a major contributing factor?

Answer 1

CV disease, stroke, heart failure, renal failure

Question 2

What determines blood pressure?

Answer 2

cardiac output and peripheral vascular resistance

Question 3

What are the two categories of HTN?

Answer 3

Essential (Primary): Chronic elevation in blood pressure without evidence of other disease. Secondary: Elevation in blood pressure results from some other disorder (i.e. kidney disease)

Question 4

How does age effect BP?

Answer 4

Systolic B/P continues a slow rate of increase throughout adult life. Diastolic B/P increases until age 50, then declines from the sixth decade onward.

Question 5

What is isolated systolic HTN?

Answer 5

Elevated systolic pressure when diastolic is normal. most common form of hypertension in people older than age 50. Leads to LVH and left heart failure

Question 6

What are complications of the elevated pulse pressure associated with HTN?

Answer 6

greater stretch of the arteries causes damage to the elastic elements of the vessel. Predisposes to aneurysms and development of intimal damage that leads to atherosclerosis.

Question 7

What are causes of secondary HTN?

Answer 7

Renovascular: Renal artery stenosis and Fibromuscular dysplasia. Adrenal: Hyperaldosteronism and Pheochromocytoma

Question 8

What drugs may interfere with antihypertensive agents or may cause HTN?

Answer 8

oral contraceptives, corticosteroids, NSAIDs, OTC cold remedies w/ephedrine

Question 9

How does stenosis of the renal artery cause HTN?

Answer 9

Decrease in renal blood flow releases renin which increases angiotensin II. Angiotensin II stimulates the release of aldosterone resulting in Na+ and water retention and increased volume.

Question 10

What are the two disease processes that cause renal artery stenosis?

Answer 10

Atherosclerotic renal artery disease: affects the proximal aspect of the renal artery, more common in older men, and bilateral. Fibromuscular dysplasia:
Fibrosis and aneurysm formation in the middle and distal renal arteries. More common in younger women

Question 11

What are the clinical clues to renovascular HTN?

Answer 11

Sudden onset of HTN w/no family history, Drug resistant HTN, Abdominal bruit, Renal insufficiency, Worsening renal function after ACE inhibitor

Question 12

What lab tests should be ordered if you suspect renovascular HTN?

Answer 12

Renal functions, BUN, Creatinine, Plasma renin levels, Angiography is definitive

Question 13

Why is an ACE inhibitor contraindicated in tx of renal artery stenosis?

Answer 13

a kidney that is receiving an inadequate blood supply will activate the RAAS system. Therefore, a single dose of this ACE inhibitor will abruptly reduce renal function in the ischemic kidney

Question 14

What are tx options for renovascular HTN?

Answer 14

balloon angioplasty or stent. may need antihypertensives for life

Question 15

What are the causes of primary hyperaldosteronism?

Answer 15

women: unilateral adrenal adenoma. men: bilateral adrenal hyperplasia

Question 16

How does hyperaldosteronism cause HTN?

Answer 16

Increased aldosterone stimulates excessive renal Na+ retention with resultant volume expansion and hypertension. Increased K+ excretion

Question 17

What tests are ordered if you suspect primary hyperaldosteronism as cause of HTN?

Answer 17

Serum renin level (low), Urine aldosterone levels, Increased serum aldosterone level that does not suppress after saline-induced volume expansion, and CT to differentiate between adrenal adenomas and hyperplasia.

Question 18

What is tx for primary hyperaldosteronism?

Answer 18

resect adrenal tumors. spironolactone (aldosterone antagonist) and additional diuretics for adrenal hyperplasia

Question 19

What is aortic coarctation?

Answer 19

congential narrowing of the aorta (typically just distal to the left subclavian artery). leading to elevated pressures proximal to the coarctation and reduced pressures in trunk

Question 20

What are the adult classifications of hypertensive BP?

Answer 20

Stage 1: systolic 140-159. diastolic 90-99.
Stage 2: systolic > 160. diastolic > 100.
If DBP less than 90 and SBP > 140…. Could be
isolated systolic hypertension

Question 21

What are the adult classifications of normal adult BP and prehypertensive BP?

Answer 21

Normal: systolic <80
Prehypertensive: systolic 120-139 diastolic 80-89

Question 22

Why do baroreceptors not react to elevated proximal pressures associated with aortic coartation?

Answer 22

reflex is blunted due to structural changes in the walls of vessels where the baroreceptors are located. Also become desensitized to chronic elevation in pressure and become “reset” to the higher pressure

Question 23

What might be symptoms of HTN?

Answer 23

Occipital headaches, Blurred vision, Fatigue, Dizziness, Epistaxis, Dyspnea, Chest pain

Question 24

What are symptoms of end organ damage with HTN?

Answer 24

CHF, Cardiovascular disease, Cerebrovascular disease, Uremia, Microalbuminemia, Aortic dissection

Question 25

What are goal blood pressures in different health populations?

Answer 25

Normal: Less than 140/90. Diabetics: Less than 130/80. Renal disease: Less than 125/75

Question 26

What initial lab screenings and diagnostics should be done for HTN?

Answer 26

CMP-assess renal fxn, glucose, electrolytes. Fasting lipids, U/A, CBC, EKG- LVH, prior MI, Echo -evidence of l. ventricular enlargement/failure

Question 27

Describe the risk stratification groups for HTN

Answer 27

Group A: No factors, No target organ disease, CV disease. Group B: At least 1 risk factor or male, not including diabetes. No target organ disease or CV disease. Group C: Target organ disease, clinical CV disease or diabetes w/ or w/o risk factors

Question 28

What lifestyle changes should be made for HTN?

Answer 28

Exercise at least 40 minutes/day. Maintain normal weight. Reduce salt intake. Increase potassium intake. DASH diet. Limit alcohol consumption. Stop smoking. Sleep.

Question 29

When should a patient be diagnosed as hypertensive?

Answer 29

In the absence of end-organ damage, BP is persistently elevated after three to six visits over a several month period.

Question 30

When should antihypertensive therapy be initiated?

Answer 30

if the systolic pressure is persistently > 140 and/or the diastolic pressure is persistently > 90 in the office and at home despite attempted nonpharmacologic therapy

Question 31

How would you treat an urgent hypertensive crisis?

Answer 31

Captopril (Capoten) quick onset (50mg every 1-2hours). Amlodipine also used (2.5-5mg every 2 hours). Clonidine

Question 32

How would you treat a hypertensive emergency?

Answer 32

Admit to hospital. Nitroprusside: minute to minute control with rate of 0.25-8mcg/kg/min. Watch for cyanide toxicity. Nitroglycerin: 5-100mcg/min. Tolerance after 24-48 hours. Labetalol, Hydralazine also IV alternatives.

Question 33

What is a hypertensive crisis?

Answer 33

A sudden increase in blood pressure potentially associated with end organ damage. Urgent: No apparent end organ damage. Emergency: End-organ damage apparent or suspected

Question 34

What are special minority considerations with HTN?

Answer 34

BP control lowest in Hispanic Americans and American Indians. African Americans have increased prevalence of HTN, in part due to resistance to BB, ACEI or ARB when used alone compared to diuretics or CCBs.