Hypertension Flashcards
Primary HTN aka: _________________
No specific cause can be identified
These are the ________ of HTN cases
essential HTN
majority
Secondary HTN involves a ___________ cause identified
specific
For JNC 8
Patients > age 60 start treatment at ____________ and treat to under those thresholds.
Patients <60 start treatment at ____________ and treat to under those thresholds.
Treat patients with kidney disease or diabetes to less than __________
150/90
140/90
140/90
The ACC/AHA high BP guidelines
Normal: less than _____________
Elevated: Systolic _________ and diastolic less than ________
Stage 1: Systolic _________ or diastolic between ___________
Stage 2: Systolic at least __________ or diastolic at least____________
120/80
S-120-129, D- less than 80
S-130-139, D- 80-89
S- 140, D- 90
Environmental/Lifestyle factors that can impact blood pressure:
1.
2.
3
4.
5.
- obesity
- sodium intake
- alcohol
- cigarettes
- exercise
What can cause elevation of blood pressure?
1.
2.
3.
4.
vasoconstriction
increased vascular tone
increased HR
increased intravascular volume
How is the renin-angiotensin system involved in hypertension?
- renin + angiotensin = angiotensin I
(renin is secreted by juxtaglomerular cells in response to various stimuli) - angiotensin I + Ace = angiotensin II
- Angiotensin II(increased aldosterone) = vasoconstriction
What are the cardiovascular complications for hypertension?
1.
2.
3.
4.
left ventricular hypertrophy
congestive heart failure
atherosclerosis
aortic dissection
What are the cerebrovascular complications of hypertension?
1.
2.
3.
stroke
dementia
encephalopathy
-severe HTN
-impaired consciousness
-retinopathy with papilledema
-seizures
What is the renal complication for hypertension?
hypertensive nephropathy
What is the ophthalmologic complication for hypertension?
hypertensive retinopathy
Who is annual screening for essential hypertension recommended for?
1.
2.
Screening must be done properly by office blood pressure and if its elevated, confirming the diagnosis with_________________.
Adults 40 yrs+
Those who are at increased risk for high BP
-high-normal bp 130-139/85-89
-overweight/obese and AA
ambulatory blood pressure monitoring (ABPM)
The USPSTF recommends that adults aged _______ to _______ years with normal BP who do not have other risk factors should be rescreened every _______ to ________ years.
18, 39
3, 5
To assess for essential hypertension, the BP needs to be ______________ taken in both arms, at least ________ separate visits at least ___________ weeks apart. The pulse is _________ or ___________
> 140-150/90
2
1-2
normal, tachy
What is the lab work up for essential HTN?
1.
2.
3.
4.
5.
Additional workup
1.
CBC
UA
CMP
TSH
Lipid pannel
additional: EKG
What are the causes of secondary hypertension?
1.
2.
3.
4.
5
6
7
8
9.
renal parenchymal disease
renal vascular hypertension
(-renal vascular stenosis)
primary hyperaldosteronism
sleep apnea
cushings syndrome
pheochromocytoma
coarctation of the aorta
pregnancy
medication induced
____________________ is the most common cause of secondary hypertension. It includes several diseases such as ____________, ______________, ______________ and ________________. This disease causes increased _________________ volume and increased activity of the ________________
renal parenchymal disease
glomerular, tubular, polycystic kidneys, diabetic nephropathy
intravascular, RAA system
__________ is likely the cause of HTN in diabetic patients.
renal parenchymal disease
How is secondary hypertension diagnosed?
UA, renal function tests, FBS, renal u/s
Renal vascular hypertension is usually due to____________________. Mechanism is excessive renin release due to _____________________
renal artery stenosis.
decreased renal blood flow.
Renal vascular hypertension is HTN onset before the age of _________. It involves
1.
2.
3.
20
fibromuscular hyperplasia
epigastric/renal bruitis
atherosclerosis of aorta or peripheral arteries
What is the definitive diagnostic test for renal vascular hypertension?
renal arteriography
The treatment of renal vascular hypertension for young or low risk patient is _____________________. For an older patient with diffuse atherosclerosis its _____________________.
- stenosis correction via percutaneous stent placement in the renal artery
- manage medically and closely follow BP and kidney function
______________ is the most common potentially curable cause of HTN. It is excessive unregulated secretion of aldosterone from the adrenal cortex. You want to suspect this when hypertension is associated with _________________.
You want to get the following labs:
1.
2.
3.
You want to get the following imaging:
1.
2.
The treatment is ___________________
primary hyperaldosteronism
hypokalemia
Labs:
1. plasma aldosterone
2. plasma renin activity
3. plasma aldosterone/renin ratio
Imaging:
1. MRI
2. CT
removal of the adenoma
What are the clinical signs of someone with sleep apnea?
1.
2.
3.
4.
5.
6.
It is diagnosed with a _____________. The treatment is ________________.
large neck
crowded oropharynx
snoring
observed apneic episodes
daytime fatigue
poor concentration
sleep study, continuous positive airway pressure (cpap)
Cushings disease/syndrome is an excess in __________________. There is _____________ and _____________ retention and increased __________________. Suspect an excess of glucocorticoids if these symptoms are present:
1.
2.
3.
4.
5.
6.
glucocorticoid.
salt and water
angiotensin secretion
1. central obesity
2. muscle wasting
3. thin skin
4. easy bruising
5. psychological changes
6. hirstuism
_______________ is a tumor in the adrenal gland producing excess norepinephrine and epinephrine. Labile HTN due to changes in ________________ and _____________. Suspect this in the presence of
1.
2.
3.
4.
associated HTN
pheochromocytoma
cardiac output, vascular changes
1. HA
2. sweating
3. anxiety
4. CP
Hypertension in pregnancy is a common cause of maternal and fetal morbidity and mortality. The pathogenesis is increased _______________.
estrogen
5% of women of estrogen containing oral contraceptive pills exhibit consistent BP elevations over _________________. This is more common in women over ________, those taking OCP for more than ___________ and _____________.
140/90.
35
5 yrs
obese
What are some non pharmocological treatments for managing essential hypertension?
1.
2.
3.
4.
5.
Dash diet (rich in fruits, veggies, low fat dairy)
Decrease sodium (eat less than 2.4g)
Regular aerobic excercise (min 30 min)
Decrease alcohol consumption (M 2 drinks, W 1)
STOP SMOKING
For essential HTN, In the general population, pharmacologic treatment should be initiated when blood pressure is _______________ or higher in adults 60 years or older or ________________________ or higher in adults younger than 60.
150/90
140/90
What should an initial antihypertensive treatment include? If the target BP is not reached within _____________ month after initiating therapy, the dosage of the initial med should be increased, or a second med should be added.
thiazide diuretic, CCB, ACE inhibitor
Black population: ARB or a thiazide diuretic or a CCB
one month
In essential hypertension, the drug therapy goals is to decrease blood pressure. You want to avoid complications such as
1.
2.
3.
4.
5.
Which drug is appropriate based on the risk of DM and HF?
stroke
MI
CHF
Kidney failure
dementia
ACE/ARB
What are the big 5 drug options for essential hypertension?
- diuretics
- ACEIs(angiotensin converting enzyme inhibitors)
- ARBs (angiotensin II receptor blockers)
- BB
- CCB
How do diuretics decrease BP?
With long term therapy, diuretics also decrease ________________. There are three groups, what are they?
increasing fluid excretion by kidneys > decreases intravascular volume.
peripheral vascular resistance.
thiazide, loop, K+ sparring
Adverse effects of diuretics
1.
2.
3.
Thiazide meds:
1.
2.
Loop meds:
1.
K+ sparring meds
1.
decrease K+
Insulin resistance
elevated LDL cholesterol and triglycerides
Thazide: HCTZ, chlorthalidone
loop: furosemide
K+ sparring: spirinolactone
Angiotensin converting enzyme inhibitors (ACEI) end in ______________. They are _________ protective and their side affects are ______________ and ______________.
pril.
renal
cough
angioedema
Angiotensin II receptor blockers (ARBs) end in ____________. They have fewer side effects than ____________. They have similar _____________ properties
sartan. ace
renal protective
Beta blockers decreases ____________and ________________. These are the drugs that end in ____________. This is NOT usually first line HTN treatment. These drugs are cardioprotective meaning that they have affects agsinst
1.
2.
3.
4.
These have good crossver benefit for _____________ or ___________ patient. Use caution with ___________ or _____________ patients.
HR, cardiac output
olol
1. angina
2. MI
3. Stable CHF
4. A fib
migraine, anxiety
COPD, asthma
The primary mechanism of CCBs is _________________.
There are 2 subclasses of essential HTN
1.
2.
This class of drugs are beneficial in _____________ and _____________ patients and less benefit fot patients with ____________ than ACE inhibitors
What are the side effects?
1
2
3
4
5_________ with non dihydropidines
vasodilation
non dihydropidine- verapamil, diltiazem
dihydropidine- “dipidine” agents e.g amlodpipine
CAD, CVA
DM
- hypotension
- HA
- flushing
- peripheral edema
- constipation
Direct renin inhibitors block ___________ which stops the conversion of _____________ to ______________.
renin, angiotensin, angiotensin II
Alpha blockers relax ___________ and _________________. HTN + BPH.
smooth muscle, lower peripheral vascular resistance
Central sympatholytics decrease ___________ outflow > __________ and decrease HR.
_____________ for pregnancy; _____________ patch
efferent peripheral sympathetic > vasodilation.
methyldopa; clonidine
Vasodilators work on _____________ vasodilation. It works well on ________________ patients.
peripheral, African American
What would an anti HTN regimen be for an uncomplicated patient?
Higher level HTN is ___ / ______ or more than _______/_______ mmHg above goal. Likely will not reach goal with one agent. It is appropriate to use combination therapy as first line.
start with a diuretic, ACE, ARB OR CCB in nonblack population.
CCB or diuretic in black population
> 160/ >100
20/10
Diuretic=
HF
ACE inhibitors=
DM, post-MI, chronic kidney disease
ARB=
DM, chronic kidney disease (ACE intolerant pt)
BB=
post MI, afib, heart failure
CCB=
high risk CAD, african american
Diabetic patients are more at risk for CV events, kidney disease and stroke. The goal BP is ___________ regardless of age. The tx should always include__________or _________due to beneficial effects in diabetic nephropathy. These patients will most likely require more than one medication such as _________ and _________. You want to avoid __________ in patients with DM because it masks hypoglycemia.
<140/90
ACE inhibitor
ARB
Diuretics, CCB
BB
In the african american population you want to start with _____________ and or _____________. Poor response to _____________ when used alone BUT use ____________ in combination with ______________/_________ for pt with DM2 or CKD(for renal protection). This population responds well to _____________ (bidil-combination vasodilator)
diuretics
CCB
ACE inhibitors
ACE
diuretic/CCB
vasodilators
The elderly population is more at an increased risk for
1.
2.
3.
4. You want to avoid ______________
stroke risk
fall risk
less affect with ACE inhibitors
BB
Follow up for treated hypertension requires a
1. Recheck in ______________ weeks after initiation of therapy
2. Monitor appropriate lab testing: electrolytes __________ weeks after diuretic initiation then yearly. Kidney function in patients on ACE or ARBS at __________ weeks then yearly.
3. BP checks in office every _________ once goal is reached.
4. Yearly ___________levels
5. _________ every other year
2-3
3-4
6-12
6 months
cholesterol
ECG
Resistant HTN is failure to reach BP control in adherent patients on full doses of _____ drug regimen. You want to rule out secondary reasons why the pt isnt at goal
3
Hypertensive urgencies:
1. Significantly elevated BP with the RISK of ___________.
The BP needs to be reduced within a few hours. Asymptomatic severe HTN is_____________ persisting after period of observation. Optic disc edema. Treatment goal is BP reduction over _______________using anti-hypertensive agents such as
1.
2.
3.
end organ damage
>220/125
24-48 hours
labetolol
captopril
clonidine
Hypertensive emergencies:
Elevated BP associated WITH ________________ requiring BP reduction within ____________ hour.
This includes
1.
2.
3.
The treatment for this is to _____________ medication chosen based on organ system involved.
target organ damage
1
1. hypertensive encephalopathy(HA, irritability, confusion, ALS)
2. hypertensive nephropathy (hematuria, proteinuria, renal dysfunction)
3. intracranial hemorrhage, aortic dissection, eclampsia, pulmonary edema, unstable angina, MI
decrease BP
Patients under 60 BP goal
<140/90
Patients over 60 BP goal
<150/90
- are first line for treating HTN in uncomplicated pts
diuretics, ACE inhibitors, or CCBs
