Hypertension 101

Question 1

What are the BP goals for diabetics for JNC7 and for ADA?

Answer 1

JNC7 <130/80 ADA < 140/80 unless you can achieve < 130/80 without undue burden

Question 2

What is definition of Stage 1 and Stage 2 HTN?

Answer 2

Stage 1 HTN >140/90
Stage 2 HTN >160/100, if either diastolic or systolic is in range you get the diagnosis. For example, 150/110 is stage 2 HTN

Question 3

Name 3 prescription medication classes that are secondary causes of HTN.

Answer 3

oral contraceptives - progesterone is the bad player for HTN
NSAIDs
Prednisone
Effexor at 150mg or greater
Amphetamines

Question 4

Name two OTC medications that can cause HTN.

Answer 4

Decongestants (psuedoephedrine)

Afrin nasal spray

Question 5

Name three herbals known to cause HTN.

Answer 5

Ma Huang, bitter orange, ephedra, also licorice

Question 6

Name 6 diseases that are causes for secondary HTN.

Answer 6

sleep apnea, renal disease, primary aldosteronism, pheochromocytoma, Cushing’s disease, thyroid disease, hyperparathyroidism

Question 7

What are the five lifestyle modifications for treatment of HTN in order of effectiveness?

Answer 7

Weight reduction
DASH diet
exercise
sodium restriction 
moderating alcohol consumption (no more than 1 drink/ day for women no more than 2 drinks per day for men)

Question 8

What is the first line treatment for stage 1 HTN without compelling indications?

Answer 8

Thiazides are first line. Chlorthalidone is stronger than HCTZ and all initial studies showing benefits of thiazides done with chlorthalidone, but has higher rate of electrolyte disturbance.

Question 9

What should be your strategy for treatment of Stage 2 HTN?

Answer 9

Start two medications one of them being a thiazide

Question 10

What are the diseases with compelling indications and their associated medications?

Answer 10

Diabetes - ACE/ARB, thiazides
Heart Failure - BB, ACE/ARB, AA 
MI - BB, ACE/ARB AA
CKD - ACE/ARB
CVA - ACE, thiazides

Question 11

Other than HTN what are the diseases that are favorably effected by the following medication classes: beta blockers, calcium channel blocker, thiazides and alpha blockers?

Answer 11

BB - tremor hyper thyroidism and migraine prophylaxis
CCB - Raynaud’s and migraine
thiazides - osteoporosis
alpha blockers - BPH

Question 12

What 5 situations should you avoid ACE/ARB?

Answer 12

pregnancy
woman of reproductive age unless also diabetic
angioedema
hyperkalemia, 
ACUTE renal failure

Question 13

In what 4 situations should you avoid Beta blockers?

Answer 13

bronchospastic disease
depression
diabetes especially with hypoglycemia unawareness
greater than first degree heart block

Question 14

In what 4 situations should you avoid thiazides?

Answer 14

gout
lithium use
sulfa allergy
hyponatremia

Question 15

In what 2 situations should you avoid CCB?

Answer 15

CHF

fluid overload

Question 16

In what situations should you avoid aldosterone antagonist?

Answer 16

Hyperkalemia, specifically K > 5

SCr >2.5

Question 17

What are best agents for isolated systolic HTN

Answer 17

CCB and thiazides

Question 18

What are the two best first choices in African Americans for HTN?

Answer 18

thiazides and CCB

ACE/ARB do not work as well in AA

Question 19

In the absence of compelling indications what are your first three classes of medications and the strategy to use them?

Answer 19

Thiazides, ACE/ARB and CCB
thiazide first line, maximize one agent before adding another. Maximum dose for thiazides is 25 mg. Drug therapy is additive. start two medications for stage two. In presence of compelling indications you would maximize those medications first.

Question 20

What two lab changes can occur with initiation of ACE/ARB and what should you do about them?

Answer 20

serum creatinine can rise up to 30% this is short lived and should normalize in 2 weeks. If creatinine rises above 30% or does not normalize should consider stopping ACE/ARB and working up for renal artery stenosis
patient’s can develop hyperkalemia which is an indication for discontinuing ACE/ARB

Question 21

When should you consider referral to renal for HTN?

Answer 21

All patients with CKD

Maximum doses of 4 antihypertensives without good control.

Question 22

How do you make the diagnosis of HTN?

Answer 22

BP > 140/90 on two occasions 24 hours apart using good technique

Question 23

What is the initial work-up for HTN and why do you do each test?

Answer 23

EKG - looking for LV hypertrophy
UA looking for proteinuria as an indication for possible renal disease
CBC - ruling out polycythemia vera
metabolic panel - looking at renal function and electrolytes, electrolyte abnormalities may be indication of Cushing’s or primary aldosteronism