Hypertension

Question 1

What is the definition of hypertension?

Pre-hypertension?

Answer 1

Hypertension is systolic >140 and/or diastolic >90mmHg.
Prehypertension is defined as systolic btw 120-139 and diastolic btw 80-89. Because BP increases with age, prehypertensive individuals are twice as likely to get hypertension than those with lower values.

Question 2

When a person’s systolic and diastolic BP fall in different categories, which do you go with for determining blood pressure stage?

Answer 2

the higher number regardless of if its systolic or diastolic

Question 3

What are the four main “target organs” damaged by hypertension?

Answer 3

1. Brain- strokes
2. Heart- CHF
3. Kidneys- chronic kidney disease/renal failure
4. blood vessels- aortic dissection, MI

Question 4

What are the 4 blood pressure stages and what are the systolic and diastolic ranges for each?

Answer 4

1. normal 160 and >100

Question 5

Calculation of seated blood pressure is based on the ____________ on ____________.
(basically, how do you determine if someone is hypertensive?)

Answer 5

mean of 2 or more reading on 2 or more separate office visits.

Question 6

When someone presents in the ED or office with severe hypertension, what is targeted to determine whether or not the elevated BP is causing rapidly progressive target organ dysfunction?

Answer 6

History and physical

Question 7

What is a hypertensive emergency?
How does it differ from hypertensive urgency?

What medication is given for each?

Answer 7

Acute, severe elevation in BP that is complicated by evidence of target organ dysfunction like:
1. coronary ischemia
2. disordered cerebral function (blurry vision, dizzy)
3. stroke
4 .renal failure
5. pulmonary edema (CHF)
What characterizes emergency is the clinical state of the patient (symptoms of organ failure)
Immediate ICU for hemodynamic monitoring and IV therapy (nitroprusside)

Hypertensive urgency is severe elevation in BP but without evidence of progressive target organ dysfunction (oral medication in ER and 24 hour follow-up)

Question 8

What are the most common hypertensive emergencies?

Answer 8

1. acute aortic dissection
2. post-coronary artery bypass graft hypertension
3. acute MI
4. unstable angina
5. eclampsia in pregnancy
6. head trauma

Question 9

Describe the Korotkoff ausculatory method for taking BP.

Answer 9

Arm cuff is inflated to occlude arm circulation.

The cuff pressure is released slowly until the cuff pressure equals the heist intra-arterial pressure (first Korotkoff sound- systolic).
The sounds are heard with each heart beat until the cuff pressure is below diastolic pressure. When you stop hearing sounds is diastolic #.

Question 10

What are some “good techniques” for making sure you get an accurate blood pressure?

(patient position, things they should avoid, where should the stethoscope be? how many readings should be done, etc)

Answer 10

1. patient should be seated x 5min
2. back should be supported
3. arm should be bare and at heart level
4. make sure the cuff size is appropriate
5. no tobacco or caffeine 30 min before
6. 2 readings in both arms, seated and standing
7. patients cant look at you (white coat hypertension)
8. stethoscope should be AT the cuff not under

Question 11

Why do you need to measure BP seated and standing, especially in older people, diabetics and those with Parkinson’s?

Answer 11

To make sure there is not a postural fall in BP due to autonomic insufficiency

Question 12

What are common pitfalls that may give a falsely elevated BP reading?

Answer 12

1. scale not at eye level
2. scale not calibrated
3. white coat
4. stethoscope under cuff
5. back unsupported
6. patient not relaxed
7. isometric contractions (increase PVR, BP)

Question 13

What is white coat hypertension?
What fraction of patients have this?
What gives a better estimate of the patients usual BP?

Answer 13

Some patients get anxiety going to the doctors office and their blood pressure is higher at the office then when measured at home .
1/3 of patients with elevated office pressure have normal home or ambulatory monitoring.

The patients can get a better estimate by self-monitoring of BP outside of the office (but their monitor needs to be checked for appropriate cuff size and accuracy)

Question 14

How can patient’s who are self-monitoring reduce reporting bias?

Answer 14

1. record pressures at fixed intervals
2. keep all readings if possible
3. get a device with a printer

Question 15

What is ambulatory monitor?
What are appropriate BP values when using this?
What is the only Medicare-approved indication for performing ambulatory monitoring?

Answer 15

BP is taken over a 24 hour period while the patient is in their usual activities and at sleep. This technique is superior to office readings at predicting fatal and non-fatal MI and stroke.

Daytime: 135/85

nighttime: 120/70
mean: 130/80

Medicare approves it if the patient has consistent high BP in the doctors office with repeated normal home readings in the absence of target organ damage.

Question 16

What is white coat aggravation?

Answer 16

a white coat hypertension reaction superimposed on persistent ambulatory or nocturnal hypertension that needs treatment.

Question 17

What is masked hypertension?

Answer 17

When BP is underestimated at the doctors.
This patient has higher ambulatory BP due to sympathetic overactivity due to tobacco, caffeine, stress, etc that dissipates when they come to the office.
10% of patients have this and can be undertreated, increasing their cardiovascular risk.

Question 18

What is nocturnal hypertension?
What is the only way to measure it?
Patients with what ailment commonly have nocturnal hypertension?

Answer 18

It is when the person has hypertension when they sleep (BP normally dips in sleep).
It is recorded by ambulatory monitoring and is a stronger predictor of cardio outcomes than office or daytime self-monitoring.

Patients with chronic kidney disease are at increased risk due to sympathetic overactivity and expanded volume.

Question 19

What is the residual risk of developing hypertension in a women who is normotensive at 65?

Answer 19

90%- pretty much everyone is going to get hypertension

Question 20

How do systolic and diastolic BP change with age?

Answer 20

Systolic BP progressively rises with age. If ppl live long enough 90% will get hypertension.
Diastolic pressure rises until age 50 and then decreases.
Patients older than 50 will have a wider pulse pressure.

Question 21

What type of hypertension do people have before age 50?
What is the main hemodynamic fault?

What type of hypertension do people have after 50? What is the main hemodynamic fault?

Which of these forms of hypertension is at a higher risk for a fatal heart attack?

Answer 21

Under 50:
Combined systolic and diastolic hypertension due to vasoconstriction at the level of resistant arterioles.

Over 50:
Isolated systolic hypertension with systolic >140 but diastolic less than 90. This is due to decreased distensibility of large conduit arteries (collagen replaces elastin)

Isolated systolic is at a higher risk because of the wider pulse pressure.

Question 22

Who is considered a “high-risk” patient for cardiovascular events?

How is “overall risk” assessed?

Answer 22

1. very high BP
2. additional cardio factors (diabetes, renal failure)
3. preexisting complications from hypertension (stroke or heart attack)

Overall risk = high BP+ other risk factors + target organ damage

Question 23

What are the 5 medical and 4 behavioral “major” risk factors for cardiovascular disease?

Answer 23

Medical
1. DM
2. chronic kidney disease
3. dyslipidemia
4. Age
5. family history of premature CVD 
Behavioral 
1. smoking
2. obesity (BMI over 30)
3. physical inactivity
4. alcohol intake/dietary intake (especially Na)

Question 24

What are the major complications of undiagnosed, untreated, or under treated hypertension?
What organs are involved and how does it present?

Answer 24

Brain: stroke, TIA, dementia
Eyes: Retinopathy
Heart: CHF, A fib
Kidney: chronic kidney disease
Vasculature: aortic aneurysm, dissecting aorta, CAD, peripheral vascular disease, angina

Question 25

What are the 3 things used to assess a patients overall risk for cardiovascular disease?

Answer 25

1. Comprehensive history
2. physical exam
3. Lab tests

Question 26

What 8 things should be assessed on the physical exam to check for organ dysfunction associated with hypertension?

Answer 26

1. neuro exam
2. fundoscopy (look at retina)
3. carotid auscultation, thyroid palpation
4. lungs: rhonchi and rales
5. heart: size, rhythm, sound
6. BP
7. renal mass, bruits over aorta
8. peripheral pulses, edema

Question 27

What are the 3 goals for the initial patient evaluation for someone with hypertension?

Answer 27

1. Stage the BP
2. Assess overall cardiovascular risk
3. seek clues for secondary causes

Question 28

“high risk” hypertensive people have what 6 signs?

Answer 28

1. DM
2. chronic kidney disease
3. est. coronary disease
4. atherosclerosis of other arteries (carotid bruits, abdominal aortic aneurysms, peripheral artery disease)
5. high risk for CAD
6. CHF

Question 29

What is primary hypertension? What are contributing factors?

Answer 29

The disease causing mechanism is uknown but has to do with:

1. genetics- cell mem alteration
2. obesity- insulin
3. endothelial factors- structural changes-renin-ang
4. stress- sympathetic
5. diet/kidney retention -fluid volume

Question 30

When are the 2 situations when secondary causes of hypertension should be sought out?

Answer 30

1. compelling finding on physical exam or labs (hypokalemia suggests aldosteronism)
2. when hypertension is so severe it is refractory to multiple drugs and leads to hospitalization for urgent care

Question 31

What are the 7 most common secondary causes of hypertension?

Answer 31

1. chronic kidney disease
2. renovascular disease (renal artery stenosis, fibromuscular dysplasia)
3. coartaction of the aorta
4. primary aldosteronism
5. cushings syndrome
6. pheochromocytoma
7. obstructive sleep apnea

Question 32

What are the clinical features of chronic kidney disease?

What are the diagnostic tests?

Answer 32

Clinical features:
Elevated serum creatinine, abnormal urinanalysis.

Lab tests:
24 hour creatinine and renal ultrasound

Question 33

What are the 2 types of renovascular diseases?
What are the 5 clinical features of renovascular disease?
What are the lab tests?

Answer 33

1. Renal artery stenosis-due to atherosclerosis
2. fibromuscular dysplasia- 20s females, AD, associated with cerebral aneurysm

The clinical features are:

1. new elevation in creatinine
2. marked elevation in creatinine with ACEI or ARB
3. refractory hypertension
4. flash pulmonary edema
5. abdominal bruit

Lab tests:

1. captopril renogram
2. Doppler sonography
3. MRI or CT angiogram

Question 34

What are the clinical features of coarctation of the aorta?

What are the lab tests?

Answer 34

CF:
1. arm pulse >leg pulse
2. arm BP> leg BP
3. chest bruit
4. rib notching on CXR
Lab Tests:
1. MRI
2. Aortagram

Question 35

What are the clinical features of obstructive sleep apnea?

What are the lab tests?

Answer 35

CF:

1. loud snoring
2. daytime somnolence
3. obesity

Lab tests:
sleep study

Question 36

What are the clinical features of primary aldosteronism?

What are the lab tests?

Answer 36

CF:

1. hypokalemia
2. refractory (unresponsive to drugs) hypertension

Lab tests:

1. plasma renin and aldosterone
2. 24 hour K+ urine
3. adrenal CT

Question 37

What are the clinical features of Cushing’s syndrome? What are the lab tests?

Answer 37

CF:

1. truncal obesity
2. purple striations
3. muscle weakness

Lab tests:

1. plasma cortisol
2. urine cortisol
3. adrenal CT scan

Question 38

What are the clinical features of Pheochromocytoma?

What are the lab tests?

Answer 38

It is a rare catecholamine-producing tumor of the adrenal chromaffin cells.

CF:

1. spells of tachycardia
2. headache
3. diaphoresis
4. pallor
5. anxiety

Lab tests:

1. plasma metanephrine
2. 24 hour urine catechols
3. adrenal CT

Question 39

What are the 2 most common causes of primary aldosteronism?

Why does it cause hypokalemia?

Answer 39

1. unilateral aldosterone-producing adenoma
2. bilateral adrenal hyperplasia

It causes hypokalemia by overstimulating Na/K pump in the distal nephron

Question 40

What is the new recommended BP treatment threshold for most patients?
What about for older patients?
What three principles of the drugs will increase compliance and decrease negative reactions?

Answer 40

130/80. Giving medication below this there isn’t a big reduction in morbidity or mortality. Older patients should be around 150/90.

1. long-acting (24hrs) will increase compliance
2. low dose combinations up to 3 drugs (start one, wait a week, start the next, etc)
3. minimize side effects and cost