Hypertension Flashcards by Campbell Kennedy

Essential v Secondary hypertension
- whats the difference

Essential: primary HTN= no identifiable cause

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

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Screening for HTN

Defining HTN

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

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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Labs for evaulation of HTN

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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Management of HTN: what is the first step?

4 parts

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

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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Thiazide Diuretics
- names
- how they work
- side effects

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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ACE inhibitors
- names
- MOA
- Side Effects

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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ARBS
- names
- MOA
- Side Effects

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

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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what are secondary therapy for HTN treatment meds?

non-thiazide diuretics
- loops
- potassium sparing
- aldosterone antagonists
Beta Blockers
- cardioselective
- vasodillitary action
- combined alpha/beta action
Alpha -1 blockers
centrally acting agents
direct vasodilators
direct renin inhibitors

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role of statins in HTN treatment

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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specific therapy for african american pts. with HTN

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

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women specific treatment for HTN

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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Elderly Patients and HTN

SBP goal
treatment considerations

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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HTN tx. for those with Stable Ischemic Heart disease

had an MI or have stable angina

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

angina: CCB + the BB or ACE/ARB

HTN for Heart Failure Pts.

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

HTN meds for Valvular Diseases

aortic stenosis
aortic insuff.
thoracic aneurysum
coartation of aorta

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

Acute ischemic Stroke and HTN meds

secondary stroke prevention

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

CKD and HTN meds
goal BP
first line meds

goal: < 130/ 80

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

ARB is second line

DM and HTN

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

Metabolic Syndrome and HTN

lifestly modifications!!!!

consider teh thizides on inc. glucose
BB can affect lipids

Asthma and COPD + HTN

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

white coat HTn v masked HTN

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

what is resistant HTN

- pt. not controlled on 3 meds (1 is diuretic) - or pt. on 4 to control

what is Secondary HTN | who should we consider this in

- 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

some conditions which can cause secondary HTN ## Footnote -

- renovascualr disease - renal parenchymal disease - primary hyperaldosteronsim - drug use - OSA

Renovascualr Disease and HTN

- 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

Treatment of renovascular disease and HTN

- **initiate RAAs blocker** like sprinolactone - antiplatlet therapy - statin - control glucose in DM - stop smoking

Renal Parynchymal Disease and HTN

polycystic kidney disease & glomerulonephritis are most common causes - First line imaging: **renal US** refer to specialist

Primary Hyperaldosteronism and HTN | patho presentations labs treat

- 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)

drugs that can cause secondary HTN

- OCPs - ADHA meds - TCAs, SSRI, MOAI - decongestants - NSIADS - alcohol - caffiene - black licorice - herbals

OSA and HTN

- in 80% of those with resistant HTN - do poly som and CPAP

Pheochromocytome/paraganglioma & HTn

- 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)

Cushings and HTn

- excessive cortisol triggers HTN - typical cushings presentation Labs - detamethasone supression test and free cortisol exerction test treat underlying disease

Thyroid Disease and HTN

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

Coartation of Aorta and HTn

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

Left Ventricualr Hypertrophy and HTN

- 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**