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Clin Med Exam 2 Cardio > Hypertension > Flashcards

Hypertension Flashcards

1
Q

Essential v Secondary hypertension
- whats the difference

A

Essential: primary HTN= no identifiable cause

Secondary: a medical condition known is causing the HTN (ex. cushings, hypothyroid)

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2
Q

Screening for HTN

Defining HTN

A

Defining HTN
- most guidelines see > 140 / > 90 in office to be consistent with HTN dx.
- ACC says > 130 / > 80

readings must be 3 measurements, average last 2, in both arms at initial visit

Screening

  • peds: recommneded age 3 yearly
  • USPSTF: annually 40+ & younger for those at higher risk
  • Q3-5 years is reasonable for those 18-39 with no risk factors

if risk for HTN…. ambulatory monitoring can be done or home BP measurements (help to decrease mortality risk)

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3
Q

History and PE for BP specifics
- body fat distirbution
- skin lesions
- eye conditions

A
  • ask about any elevated BP
  • medications which could influence
  • pregnancy and HTN
  • ASCVD risk conditions
  • look for signs of end organ damage or co-illnesses

Body Fat: apple = higher risk
Skin Lesions: Xanthomas & acanthosis nigricans
Eye: hemorrhages, cotton wool, vascular changes or papilledema
Cardiac: bruits & thyroid & peripheral pulses

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4
Q

Labs for evaulation of HTN

A
  • CBC
  • electrolytes
  • serum creatitine and GFR
  • urinalysis: for protein
  • thyroid
  • ASCVD risk (via lipids and glucose)
  • EKG

higher BP is higher risk for CVD

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5
Q

Management of HTN: what is the first step?

4 parts

A

lifestyle management
1. dietary approach: DASH diet to decrease BP
2. Exercise: aim for 150mins/week moderate or 75mins/week intense
3. limit alcohol: no more thatn 2 a day for men, 1.5 a day for women
4. tobacco cessasion

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6
Q

First Line Pharmacotherapies for HTN
- when do you titrate up? when do you add?

A

want to reduce Systolic by 20 & distolic by 10

First Line Agents
- thiazide dieuretics
- ACE/ARB
- CCB

preferred way: to treat with combo therapy (2 drugs at 1/2 dose) but can titrate

  • if BP 150/90 at start – begin with 2 drugs
  • add drugs at 1 month intervals
  • if at 3 drugs – 1 should be a dieuretic
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7
Q

Thiazide Diuretics
- names
- how they work
- side effects

A

Names: HCTZ, chlorthalidone chlorthalidone more effective

MOA: increase urination & decrease blood volume –> long term decrease in peripheral vascular resistance

Side Effects:
- hypokalemia, hypomagnesmia, hyponatermia, hyperuricemia watch in gout
- erectile dysfunction

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8
Q

ACE inhibitors
- names
- MOA
- Side Effects

A

Names: -pril (lisinopril, ramipril, captopril, enalapril)

MOA: work to block AGII –> therefore blocking RAAS system and decreases reabsorption
monotherapy– not great, combo with CCB or diuretic is most helpful

Side Effects
- dry cough!!!
- angioedema
- monitor renal function

good for black pts, diabeti nephropathy
avoid in bilateral renovascular pts.
avoid in pregnant
do not use with ARB or direct renin

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9
Q

ARBS
- names
- MOA
- Side Effects

A

Names: -sartan (losartan, valsartan)

MOA: block the receptor site for AGII
good for HF pts. and diabetic nephropathy

Side Effects
- angioedema (dont use if they ahd htis wth ACE)
- no cough!!!

never in pregnant or in combo with ACE or direct renin

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10
Q

CCB – dihydropyridines
- names
- MOA
- indications for use
- side effects

A

Names: -pine ( amlodipine, felodipine)

MOA: block calcium influx at endothelium in peripheraly to decrease pressure

indications: good for those with…
angina
elderly
those needing rate control (afib)

Side Effects
- pedal edema

caution in HFrEF pts.

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11
Q

what are secondary therapy for HTN treatment meds?

A
  1. non-thiazide diuretics
    - loops
    - potassium sparing
    - aldosterone antagonists
  2. Beta Blockers
    - cardioselective
    - vasodillitary action
    - combined alpha/beta action
  3. Alpha -1 blockers
  4. centrally acting agents
  5. direct vasodilators
  6. direct renin inhibitors
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12
Q

role of statins in HTN treatment

A
  • in primary prevention of CVD – statin can help those with HTN reduce their risk even furher (even if not high lipids)
  • secondary prevention for those with cholesterol >135, those with CVD or ischemic stokr hx. and HTN
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13
Q

specific therapy for african american pts. with HTN

A
  • younger at age of dx. and difficult to treat
  • use thiazide and CCB
  • ACE/ARB second line (if CKD!!)
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14
Q

women specific treatment for HTN

A
  • NO ACE/ARB or direct renin if pregnant!!!!

pregnant: give methyldopa

  • consider the role of OCPs in HTN
  • more likely to have side effects from CCBs and ACE
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15
Q

Elderly Patients and HTN

SBP goal
treatment considerations

A
  • more likely to have isolated systolic HTN widened pulse pressure

GOAL: SBP of 130 or lower

Treatment considerations
- fall risk
- autonomic responsiveness (slower)
- comorbidities
- limited life
- pt. preferences

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16
Q

HTN tx. for those with Stable Ischemic Heart disease

had an MI or have stable angina

A
  • use goal directed medical therapy for HF pts = beta blockers, ACE/ARB first line

angina: CCB + the BB or ACE/ARB

17
Q

HTN for Heart Failure Pts.

A
  • loops are helpful for those with pulmonary edema
  • HFrEF: avoid non-dyhydropyridines because these slow ventricualr filling and backs up blood
  • HFpreserved EF: chlorthalidone most effective then ACE/ARB or BB
18
Q

HTN meds for Valvular Diseases

aortic stenosis
aortic insuff.
thoracic aneurysum
coartation of aorta

A

AS: use a first line agent

Aortic insufficiency: avoid those which slow HR (BB, CCB)

Thoracic aortic aneurysum: beta blocker preferred to reduce force on the wall

Coartation of aorta: no recommendations

19
Q

Acute ischemic Stroke and HTN meds

secondary stroke prevention

A

start them on anti HTN med after 48 hours

thiazides, ACE/ARB

Secondary Stroke Prevention
- goal BP: < 130/80
- if they never had HTN prior to stroke < 140/90 is ok

20
Q

CKD and HTN meds
goal BP
first line meds

A

goal: < 130/ 80

First Line: ACE!!
- especailly if they have albuminuria, elevated SCr ratio or CKD 3+

ARB is second line

21
Q

DM and HTN

A

goal < 130/ 80

harder to control

all first line treatment is appropriate
- thiazides might increase glucose – watch
- BB may block symptoms of low glucose
- HTN + albumin = ACE

22
Q

Metabolic Syndrome and HTN

A

lifestly modifications!!!!

  • consider teh thizides on inc. glucose
  • BB can affect lipids
23
Q

Asthma and COPD + HTN

A

BB can be not cardioselective – impact and cause worsening of the asthma/COPD

24
Q

white coat HTn v masked HTN

A

White Coat: higher in office
- reading > 135/ 80 in the office
- send home with monitoring

Masked: low in office high at home
- use normal first line meds once discovered

25
Q

what is resistant HTN

A
  • pt. not controlled on 3 meds (1 is diuretic)
  • or pt. on 4 to control
26
Q

what is Secondary HTN

who should we consider this in

A
  • HTn as a result of another medical dx.

consider this in…
- younger than 30 with HTN
- sudden onset of HTN or difficult to control
- end organ damage but HTN not that bad
- sx. of a disease

27
Q

some conditions which can cause secondary HTN

-

A
  • renovascualr disease
  • renal parenchymal disease
  • primary hyperaldosteronsim
  • drug use
  • OSA
28
Q

Renovascualr Disease and HTN

A
  • 1/3 of secondary HTn because of this
  • atherosclerosis of the renal arteries

consider….
- if 30% increase in GFR when started on ACE/ARB
- early onset in women
- difficult and abrupt HTn

Findings
- abdominal bruits

Imaging: MRI with angio (no contrast) to see stenosis preferred

  • CT and US can be done too

**fibromuscalr dysplasis “sting of beads” in arteriers MC in young women

29
Q

Treatment of renovascular disease and HTN

A
  • initiate RAAs blocker like sprinolactone
  • antiplatlet therapy
  • statin
  • control glucose in DM
  • stop smoking
30
Q

Renal Parynchymal Disease and HTN

A

polycystic kidney disease & glomerulonephritis are most common causes

  • First line imaging: renal US

refer to specialist

31
Q

Primary Hyperaldosteronism and HTN

patho
presentations
labs
treat

A
  • abnormal increase in production of aldosterone due to adenoma or hyperplasia of the adrenal glands

Presentation - muscle cramps, famil hx. of HTN, disproportiate end organ damage

Labs: get aldosterone to renin ratio > 20 = dx.
- plasma aldosterone

+ screen: send to endocrinology

Treatment
- unilateral: remove adrenal
- bilateral: MRA (sprinolactone)

32
Q

drugs that can cause secondary HTN

A
  • OCPs
  • ADHA meds
  • TCAs, SSRI, MOAI
  • decongestants
  • NSIADS
  • alcohol
  • caffiene
  • black licorice
  • herbals
33
Q

OSA and HTN

A
  • in 80% of those with resistant HTN
  • do poly som and CPAP
34
Q

Pheochromocytome/paraganglioma & HTn

A
  • released large amounts of SNS leading to sudden HTN
  • orthostatic HTN, hypertensive urgency states
  • confirm with CT or MRI

treat with surgica removal (control BP before surgery)

35
Q

Cushings and HTn

A
  • excessive cortisol triggers HTN
  • typical cushings presentation

Labs
- detamethasone supression test and free cortisol exerction test

treat underlying disease

36
Q

Thyroid Disease and HTN

A

Hypothyroid: increased vascualar resistance
- get TSh and T4 levels & treat with meds

Hyperthyroid: direct adrenergic effects to increase pressure and HR
- TSH and T4 levels
- confrims with US and radioiodine test
- surgial and medical manage

Hyperparathyroidism
- bone pain, kidney stones, abdominal maosn and depression
- get calcium levels
- confrim test with PTH
- surgical removal

37
Q

Coartation of Aorta and HTn

A
  • increased pressure resultsin renal hypoperfusion
  • find low or unidentifiable BP in LE
  • find turners or down syndrome
  • Echo & CXR (rib notching); surgical treatmetn
38
Q

Left Ventricualr Hypertrophy and HTN

A
  • a reuslt of HTN because increase pressure causes increased demand of the heart to pump out blood
  • EKG: tall QRS that touch ; echo most sensitve test
  • ARBS most effective

Clin Med Exam 2 Cardio (9 decks)

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