HTN- part II - Exam 1 Flashcards
**What are the ACC/AHA guidelines for hypertension?
What is first line HTN meds for non-black pts? What is first line for black pts?
What is the goal BP for pts on HTN meds?
ACE/Arb, CCB, thiazide
black: CCB or thiazide
goal < 130/80
If a pt’s BP is NOT well controlled how often should they follow up?
Follow-up visits should be at 4 to 6 week intervals until BP is at goal
Rule of thumb – should expect to see a BP reduction of _____ per agent added at _____ dose
10 mmHg
optimum
Draw the chart that is for choosing HTN meds based on comorbid conditions
What is the highlighted SE of ACEI?
dry cough, angioedema, renal dysfunction
What are the highlighted SE of CCB?
HA, palpitations, rebound tachycardia
What are the SE of thiazides?
electrolyte abnormalities
What is the major side effect for beta blockers?
bradycardia
What is the difference between hypertensive urgency and hypertensive emergency?
urgency: NO end organ damage BP greater than 180 and/or greater than 110
emergency: s/s of end organ damage. BP greater than 180/120
What labs would you want to order in an hypertensive urgency?
BMP, UA, EKG and TSH
What are 2 important historical questions to ask a pt in hypertensive urgency?
Do they have a history of HTN?
Have you taken your BP meds today?
By what percentage and at what rate do you want a pt’s blood pressure to decrease in an hypertensive urgency?
1: MAP should not be lowered more than 25-30% in the first 2-4 hrs due to risk of sudden hypoperfusion
2: goal: reduce BP within hours with an initial goal of <160/<100
**How do you calculate MAP?
MAP = DBP + ⅓ (SBP - DBP)
What agents if available in office do you want to give to a pt in hypertensive urgency?
Clonidine (Catapres)
Captopril (Capoten)
Metoprolol Tartrate (Lopressor)
Hydralazine
Of the medications that can be given for an hypertensive urgency, which one acts on the central sympathetic system? What is the common SE?
clonidine
sedation, so is also given to children to help them sleep
Of the medications that can be given for an hypertensive urgency, which medication is a vasodilator? What are the SE?
hydralazine
tachycardia, HA, GI upset
Of the medications that can be given for an hypertensive urgency, which one’s response is unpredictable and is NOT first line?
Nifedipine
What is considered a hypertensive emergency? Is hospital admission required?
Severe HTN usually greater than 180/120 WITH s/s of end-organ damage
YES!!
What are some s/s of end organ damage?
Obvious focal or global neurologic deficit
Abnormal retinal examination
Absent pulses
Asymmetric blood pressure readings
Severe chest pain or back pain
Frank pulmonary edema
What are some diagnostic imaging and labs you would want to order in hypertensive emergency?
Blood tests should be selected to screen for thrombotic microangiopathy, AKI, and myocardial damage
Urine is examined for blood and protein, and for screening for substances of abuse (typically cocaine or ecstasy)
Consider CXR/CT to confirm pulmonary edema, myocardial dysfunction, aortic dissection, or acute intracranial bleed, thrombosis, or cerebral microvascular injury depending on presentation
What is an acute aortic dissection?
when the walls of the vessels start to separate
By how much and what end goal should you ideally want your pt’s BP to be at the end of a hypertensive emergency?
Initial goal is to reduce the pressure by no more than 25% (within minutes to 1 or 2 hours) and then toward a level of 160/100 mmHg within 2–6 hours
What form of medication do you want to use in a hypertensive emergency?
parenteral therapy!! IV
Ischemic CVA (blocked blood vessel in the brain), what is the goal?
10-15% reduction within first 24 hours
Meds only used if SBP 180-200mmHg
Hemorrhagic CVA, what is the goal?
target SBP is <140 mmHg in first 6 hours
aortic dissection, what is the goal?
goal SBP <120 mmHg within 20 mins
MI, what is the goal?
will need anticoagulation and oxygen; typically use NTG for BP reduction and possible addition of BB but no set goal
What are the 5 drug classes of choice during an hypertensive emergency? Which ones are the top 2?
Beta blockers**
Calcium channel blockers **
ACE inhibitors
Direct vasodilators
Nitrates
What are the top 8 med options commonly used in hypertensive emergencies?
Nicardipine
Clevidipine
Labetalol
Esmolol
Fenoldopam
Enalaprilat
Furosemide
Nitroglycerin
Nitroprusside: no longer first line due to risk of cyanide toxicity
When would you want to avoid CCB in an hypertensive emergency setting?
aortic dissection secondary to reflex tachycardia
Which hypertensive emergency medication would you want to avoid in pt with a soy or egg allergy?
Clevidipine (Cleviprex)
Hypertensive emergency drugs: _____ is used alongside diuretics; may be continued orally.
Enalaprilat (Vasotec)
Hypertensive emergency drugs: ______ is used adjunct to vasodilators
Furosemide (Lasix)
BP _____ is ABNORMAL and associated with increased risk in perinatal morbidity and mortality
≥ 140/90
What is the textbook answer to dx HTN in pregnancy? What is the textbook answer for gestational HTN?
Diagnosis requires two elevated readings at least 4 hours apart
Gestational - HTN (BP ≥ 140/90) after 20 weeks gestation w/o pre-existing HTN or proteinuria
**Define preeclampsia
Preeclampsia - new onset HTN (BP ≥ 140/90) AND proteinuria (24h urinary protein >300 mg/24h or creatinine ratio ≥0.3) after 20 weeks gestation
What is the definition of chronic HTN in pregnancy?
HTN (BP ≥ 140/90) before 20 weeks gestation or longer than 12 weeks postpartum
Pregnant pt acute HTN treatment?
IV labetalol, IV hydralazine, oral immediate-release nifedipine
Pregnant pt chronic HTN management?
labetalol, ER nifedipine, or methyldopa
What is the target BP in pregnancy? **What medications are CI?
Target BP = 130-150/80-100
ACEI/ARBs are CONTRAINDICATED
Define resistant HTN?
Defined as the failure to reach BP control in patients who are adherent to full doses of an appropriate 3-drug regimen, including a diureti
What is the next step when working a pt up for resistant HTN?
**Rule out secondary causes - Renal ultrasound!
Check for white-coat HTN
Consider switching diuretic to aldosterone receptor blocker (spironolactone)
Refer to a HTN specialist (Nephrology or Cardiology)
What are some possible causes of resistant HTN?
improper BP measurement
volume overload, excessive sodium intake, volume retention from kidney disease
obesity
excessive alcohol intake
nonadherence!!
What are some medications that can cause resistant HTN?
NSAIDs
illicit drugs
OCP
steroids
EPO
licorice
selected OTC supplements and medicines
If a question states “laterally displaced PMI,” what does this indicate?
left ventricle hypertrophy
aka the heart has been working very hard
