Hypertension Flashcards by Priya Yenebere

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What are the BP cutoffs for the different categories? Normal, elevated BP, Stage 1, Stage 2?

Normal: SBP < 120 mm Hg and DBP < 80 mm Hg
Elevated BP: SBP < 130 mm Hg and DBP < 80 mm Hg (Pre-HTN category is no longer used.)
Stage 1: < 140mm Hg or DBP < 90 mm Hg
Stage 2: SBP ≥ 140 mm Hg or DBP ≥ 90 mm Hg

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What are the HTN cutoffs based on ambulatory BP monitoring?

24-hour average > 130/80 mm Hg
Daytime (awake) average > 135/85 mm Hg
Nighttime (asleep) average > 120/70 mm Hg

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What is the goal BP for everyone? Give some exceptions to this cutoff.

< 130/80

Older adults ≥65 years old with HTN and a high burden of comorbidity and limited life expectancy, clinical judgment, patient preference, and a team-based approach to assess risk/benefit are reasonable for decisions regarding intensity of BP-lowering and choice of antihypertensive drugs.

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At what BP cutoffs should your start pharmacological therapy? (after the lifestyle modifications)

HTN stage 2 (average SBP ≥ 140 mm Hg or DBP ≥ 90 mm Hg)

HTN stage 1 (average SBP 130 to 139 mm Hg or DBP 80 to 89 mm Hg) if:
Known atherosclerotic cardiovascular disease (ASCVD) or 10-year risk ≥10%
Diabetes mellitus (DM) type 2, or
CKD

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In what clinical scenarios do you start BP meds for BP > 130/80?

HTN stage 1 (average SBP 130 to 139 mm Hg or DBP 80 to 89 mm Hg) if:
Known atherosclerotic cardiovascular disease (ASCVD) or 10-year risk ≥10%
Diabetes mellitus (DM) type 2, or
CKD

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Asymptomatic mild/moderated aortic stenosis with normal EF - what is the BP goal?

130-139/70-89

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DPB cutoff for patients > 65yo?

Do not lower DBP <65 (associated with increased risk of stroke)

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Definition for drug-resistant HTN

Not at goal while on 3 BP meds (one is a diuretic)

At goal, but on 4 meds (one is a diuretic)

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Acute hypertensive nephropathy associated with hypertensive emergencies

What do you see on histopathology?

Fibrinoid necrosis of small arterioles (pink, amorphous fibrinoid materials within vessel wall due to necrosis) and “onion skinning” of small renal arteries

“Onion skinning” is used to describe hyperplastic arteriosclerosis with thickened concentric smooth muscle cell layer with thickened, duplicated basement membrane and narrowed lumen

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Chronic hypertensive nephropathy

What do you see on histopathology?

Slowly progressive thickening and sclerosis of renal resistance vessels with relative sparing of glomerular capillaries

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Name some meds that can cause secondary HTN (pretty much skip to the back and look at the list)

Nonsteroidal anti-inflammatory drugs (NSAIDs), COX-2 inhibitors
Oral contraceptives
Adrenal steroids
Glucocorticoids
Cyclosporine (CSA) and tacrolimus
Antidepressants (monoamine oxidase [MAO] inhibitors)
Erythropoiesis-stimulating agents (reduced nitric oxide [NO] synthesis, increased entholin-1)
Vascular endothelial growth factor (VEGF) inhibitors, such as sunitinib (downregulate NO expression)
Sympathomimetics (decongestants, anorectics)
Ephedra, ma huang, bitter orange
Licorice (including some chewing tobacco)

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Best proven nonpharmacologic interventions for prevention and treatment of HTN:

Weight reduction
DASH diet
Sodium restriction
Increased K intake
Physical activity
Moderation of EtOH consumption
Stop smoking (for overall CV risk)

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Initial drug selection dependent on underlying condition:
- systolic HF, post-MI
- benign prostate hypertrophy
- essential tremors, hyperthyroidism, migraine, atrial fibrillation/flutter with rapid ventricular rates, angina
- hyperaldosteronism
- Gordon syndrome or osteoporosis
- Liddle syndrome

ACEI/ARB for systolic HF, post-MI
α-blockers for benign prostate hypertrophy
BBs for essential tremors, hyperthyroidism, migraine, atrial fibrillation/flutter with rapid ventricular rates, angina
mineralocorticoid receptor antagonist for hyperaldosteronism
thiazide diuretics for Gordon syndrome or osteoporosis
amiloride for Liddle syndrome

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If there is no compelling indication, which meds are first-line therapy?
ALLHAT trial

Thiazides, CCBs, ACE/ARB

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Mainstay anti-HTN drug combo to start?
When do you add loops?
When do you add MRAs?

“AB + CD”
ACE/ARB + BBl and/or CCB + diuretic (thiazide)

Loops reserved for severe HF or severe CKD

MRAs considered in ischemic HF or resistant HTN

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When should you initiate 2-drug therapy in drug naïve patients?

When BP > 20/10 above goal

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White coat HTN definition

SBP <130/80 outside. >130/80 in office after 3 mo of lifestyle/diet

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How does thiazides (or thiazide-like) diuretics affect bone health?

Thiazides (and thiazide-like) offer long-term protection against fractures when compared to other anti-HTN meds

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What electrolyte abnormality is common with thiazides and what anti-HTN med can you offer concurrently to help offset this?

Thiazides give you hypokalemia; add an MRA to help this

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Specific contraindications:
Angioedema
Bronchospasm
Depression
Liver disease
Pregnancy or planning
2nd or 3rd degree heart block

Angioedema - avoid ACEi (also sometimes seen in ARB)
Bronchospasm - avoid BBl
Depression - avoid reserpine
Liver disease - avoid methyldopa
Pregnancy or planning - avoid ACE/ARB/renin inhibitors
2nd or 3rd degree heart block: BBls and nondihydropyridine CCBs

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Special considerations

When should you use ACEI/ARB?

1) Non-DM patients with HTN and albuminuria >= 30

2) Patients with CKD and HTN

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Special considerations

When should you use a direct renin inhibitor with an ACE/ARB?

Not a lot of positive data for this. High rates of hyperkalemia as well as one study mentioning increased stroke rate

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Special considerations

Hypertension and weight?

ACCOMPLISH trial: addition of CCB over a diuretic to an ACEi in patients with NORMAL weight (better CV outcomes)

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Special considerations

Renin > 0.65mg/ml/h?
Renin < 0.65?
Common demographics for each?

PRA > 0.65 (younger caucasians): HTN associated to vasoconstriction; responds well to ACE/ARB or BBl

PRA < 0.65 (Blacks, older caucasians): volume related HTN; responds well to diuretics and CCB

Special considerations BP management in AA? How many meds? With or without HF or CKD? #htn #brb

2 drug combo works best With HF or CKD: RAS inhibition should be prescribed Without HF or CKD (and don't meet a 2 drug criteria): initiate with thiazide or CCB

Special consideration HTN and elderly: what's a good BP goal? #htn #brb

Increased mortality for BP < 130/80

In what part of the nephron is the SGLT2 expressed? #htn #brb

Expressed in the S1 and S2 segments of the proximal tubule

Do SGLT2 inhibitors affect BP? #htn #brb

Mild BP reduction (likely due to osmotic/diuretic effect

What are the BP goals in the setting of acute ischemic strokes receiving thrombolytic therapy? Before thrombolytics? After thrombolytics? #htn #brb

Before thrombolytics: <185/110 After thrombolytics: < 180/105 in the first 24 hours

What are the BP goals in the setting of acute ischemic strokes NOT receiving thrombolytic therapy? #htn #brb

BP goal < 220/120

What is the BP goal in acute intracranial hemorrhage? With increased ICP? Without increased ICP? #htn #brb

If SBP >180 mm Hg or MAP > 130 mm Hg plus evidence/suspicion for elevated ICP, consider monitoring ICP and reducing BP to keep cerebral perfusion pressure at 61 to 80 mm Hg. If SBP >180 mm Hg or MAP > 130 mm Hg plus evidence of or suspicion for elevated ICP, consider monitoring ICP and reducing BP to keep cerebral perfusion pressure at 61 to 80 mm Hg. Use labetalol and nicardipine

What is carotid hyperperfusion syndrome following a CEA? How does it present? How do you manage it? What meds to use? What meds to avoid? (Lots of info - just look at the answer) #htn #brb

- Occurs during first week after surgery - A postop increase in cerebral blood flow after reperfusion - Ipsilateral: pulsatile headaches, seizures, intracranial hemorrhage, cerebral edema - Contralateral: neurologic symptoms Management: - Continuous intraop and postop BP monitoring - Strict BP <120 - Preferred agents: IV labetalol or clonidine - Avoid vasodilators, such as nitroglycerin, sodium nitroprusside

At what number and size parameters can simple cysts be associated with HTN? #htn #brb

# of cysts >= 2 and increased size of > 1.4-2cm Cyst decompression may help (anecdotes) RAS blockers may be beneficial

How does proteinuria increase risk of HTN? What meds can you use because of this? (Lots of info - just skip to answer side) #htn #brb

- Proteinuria with loss of plasminogen in urine leads to the formation of plasmin by tubular urokinase-like plasminogen activator. Plasmin directly stimulates the distal tubular sodium epithelial channel (ENaC) The activated ENaC enhances sodium reabsorption. - Based on the above, amiloride and triamterene may be considered in the management of edema and salt sensitivity in patients with proteinuria and HTN

What kind of imaging studies do you need for renal artery stenosis? GFR cutoffs? #htn #brb

Normal kidney function - CTA (depicts renal branch arteries better) or MRA (both are better at finding proximal than distal lesions) GFR < 30 - US duplex (or maybe non-con MRA)

Advantages of a captopril renal scan? Disadvantages? #htn #brb

Advantages: -High negative predictive value: a negative test essentially rules out clinically significant RAS. -Provides relative function of each kidney prior to invasive intervention Disadvantages: Sensitivity and specificity of captopril renal scintigraphy are reduced in patients with bilateral renal artery stenosis (RAS), impaired kidney function, and urinary obstruction.

Renal arterial doppler is most effective for detecting [proximal/distal] lesions #htn #brb

Proximal lesion (fibromuscular dysplasia is more distal lesions)

What is BL renal artery stenosis at risk for? What other lab findings are they are risk for? #htn #brb

May easily develop flash pulmonary edema Because they are inhibited by volume expansion, they develop hyperkalemia and MetAc (not hypoK and MetAlk)

Fibromuscular dysplasia - what part of the vessels does it affect? #htn #brb

Arteriopathy that affects large and medium sized arteries Usually distal to the first 2cm of the aorta (image: RAS, FMD, PAN)

When do you surgical revascularize fibromuscular dysplasia rather than angioplasty? #htn #brb

For dilations > 1.5cm

When should do invasive therapy for renal artery stenosis? #htn #brb

In young, low comorbidity patients with: - rapidly progressive disease (AKI with RAAS inhibition) - failure to achieve BP even on appropriate meds - Unexplained "flash pulmonary edema"