HTN- part II - Exam 1

Question 1

**What are the ACC/AHA guidelines for hypertension?

Answer 1

Question 2

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?

Answer 2

ACE/Arb, CCB, thiazide

black: CCB or thiazide

goal < 130/80

Question 3

If a pt’s BP is NOT well controlled how often should they follow up?

Answer 3

Follow-up visits should be at 4 to 6 week intervals until BP is at goal

Question 4

Rule of thumb – should expect to see a BP reduction of _____ per agent added at _____ dose

Answer 4

10 mmHg

optimum

Question 5

Draw the chart that is for choosing HTN meds based on comorbid conditions

Answer 5

Question 6

What is the highlighted SE of ACEI?

Answer 6

dry cough, angioedema, renal dysfunction

Question 7

What are the highlighted SE of CCB?

Answer 7

HA, palpitations, rebound tachycardia

Question 8

What are the SE of thiazides?

Answer 8

electrolyte abnormalities

Question 9

What is the major side effect for beta blockers?

Answer 9

bradycardia

Question 10

What is the difference between hypertensive urgency and hypertensive emergency?

Answer 10

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

Question 11

What labs would you want to order in an hypertensive urgency?

Answer 11

BMP, UA, EKG and TSH

Question 12

What are 2 important historical questions to ask a pt in hypertensive urgency?

Answer 12

Do they have a history of HTN?

Have you taken your BP meds today?

Question 13

By what percentage and at what rate do you want a pt’s blood pressure to decrease in an hypertensive urgency?

Answer 13

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

Question 14

**How do you calculate MAP?

Answer 14

MAP = DBP + ⅓ (SBP - DBP)

Question 15

What agents if available in office do you want to give to a pt in hypertensive urgency?

Answer 15

Clonidine (Catapres)
Captopril (Capoten)
Metoprolol Tartrate (Lopressor)
Hydralazine

Question 16

Of the medications that can be given for an hypertensive urgency, which one acts on the central sympathetic system? What is the common SE?

Answer 16

clonidine

sedation, so is also given to children to help them sleep

Question 17

Of the medications that can be given for an hypertensive urgency, which medication is a vasodilator? What are the SE?

Answer 17

hydralazine

tachycardia, HA, GI upset

Question 18

Of the medications that can be given for an hypertensive urgency, which one’s response is unpredictable and is NOT first line?

Answer 18

Nifedipine

Question 19

What is considered a hypertensive emergency? Is hospital admission required?

Answer 19

Severe HTN usually greater than 180/120 WITH s/s of end-organ damage

YES!!

Question 20

What are some s/s of end organ damage?

Answer 20

Obvious focal or global neurologic deficit
Abnormal retinal examination
Absent pulses
Asymmetric blood pressure readings
Severe chest pain or back pain
Frank pulmonary edema

Question 21

What are some diagnostic imaging and labs you would want to order in hypertensive emergency?

Answer 21

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

Question 22

What is an acute aortic dissection?

Answer 22

when the walls of the vessels start to separate

Question 23

By how much and what end goal should you ideally want your pt’s BP to be at the end of a hypertensive emergency?

Answer 23

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

Question 24

What form of medication do you want to use in a hypertensive emergency?

Answer 24

parenteral therapy!! IV

Question 25

Ischemic CVA (blocked blood vessel in the brain), what is the goal?

Answer 25

10-15% reduction within first 24 hours

Meds only used if SBP 180-200mmHg

Question 26

Hemorrhagic CVA, what is the goal?

Answer 26

target SBP is <140 mmHg in first 6 hours

Question 27

aortic dissection, what is the goal?

Answer 27

goal SBP <120 mmHg within 20 mins

Question 28

MI, what is the goal?

Answer 28

will need anticoagulation and oxygen; typically use NTG for BP reduction and possible addition of BB but no set goal

Question 29

What are the 5 drug classes of choice during an hypertensive emergency? Which ones are the top 2?

Answer 29

Beta blockers**
Calcium channel blockers **
ACE inhibitors
Direct vasodilators
Nitrates

Question 30

What are the top 8 med options commonly used in hypertensive emergencies?

Answer 30

Nicardipine
Clevidipine
Labetalol
Esmolol
Fenoldopam
Enalaprilat
Furosemide
Nitroglycerin

Nitroprusside: no longer first line due to risk of cyanide toxicity

Question 31

When would you want to avoid CCB in an hypertensive emergency setting?

Answer 31

aortic dissection secondary to reflex tachycardia

Question 32

Which hypertensive emergency medication would you want to avoid in pt with a soy or egg allergy?

Answer 32

Clevidipine (Cleviprex)

Question 33

Hypertensive emergency drugs: _____ is used alongside diuretics; may be continued orally.

Answer 33

Enalaprilat (Vasotec)

Question 34

Hypertensive emergency drugs: ______ is used adjunct to vasodilators

Answer 34

Furosemide (Lasix)

Question 35

BP _____ is ABNORMAL and associated with increased risk in perinatal morbidity and mortality

Answer 35

≥ 140/90

Question 36

What is the textbook answer to dx HTN in pregnancy? What is the textbook answer for gestational HTN?

Answer 36

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

Question 37

**Define preeclampsia

Answer 37

Preeclampsia - new onset HTN (BP ≥ 140/90) AND proteinuria (24h urinary protein >300 mg/24h or creatinine ratio ≥0.3) after 20 weeks gestation

Question 38

What is the definition of chronic HTN in pregnancy?

Answer 38

HTN (BP ≥ 140/90) before 20 weeks gestation or longer than 12 weeks postpartum

Question 39

Pregnant pt acute HTN treatment?

Answer 39

IV labetalol, IV hydralazine, oral immediate-release nifedipine

Question 40

Pregnant pt chronic HTN management?

Answer 40

labetalol, ER nifedipine, or methyldopa

Question 41

What is the target BP in pregnancy? **What medications are CI?

Answer 41

Target BP = 130-150/80-100

ACEI/ARBs are CONTRAINDICATED

Question 42

Define resistant HTN?

Answer 42

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

Question 43

What is the next step when working a pt up for resistant HTN?

Answer 43

**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)

Question 44

What are some possible causes of resistant HTN?

Answer 44

improper BP measurement

volume overload, excessive sodium intake, volume retention from kidney disease

obesity

excessive alcohol intake

nonadherence!!

Question 45

What are some medications that can cause resistant HTN?

Answer 45

NSAIDs

illicit drugs

OCP

steroids

EPO

licorice

selected OTC supplements and medicines

Question 46

If a question states “laterally displaced PMI,” what does this indicate?

Answer 46

left ventricle hypertrophy

aka the heart has been working very hard