Hypertension

Question 0

What are the four major target organs damaged by hypertension?

Answer 0

Brain - stroke, TIA, dementia
Heart - CHF
Kidneys - chronic kidney disease
Blood vessels - aortic aneurysm, CAD, MI, peripheral vascular disease

Question 1

What is the definition of hypertension?

Answer 1

Systolic pressure at least 140 OR diastolic pressure at least 90

Question 2

At what blood pressure does the risk for heart disease and stroke begin to increase with increasing levels?

Answer 2

115/75

Question 3

What are the JNC stages of blood pressure?

Answer 3

Normal: s<80
Pre hypertension: s 120-139, d 80-89
Stage 1 hypertension: s 140-159, d 90-99
Stage 2 hypertension: s at least 160, d at least 100

Question 4

What is the difference between hypertensive emergency and hypertensive urgency?

Answer 4

Both have acute severe elevations in BP

Emergency has evidence of target organ damage, urgency does not

Question 5

What is the correct method for taking BP?

Answer 5

Seated at least 5 minutes
Back supported
Arm at heart level
Correct cuff size
Bare arm
2 reading in both arm seated and standing
Need at least 2 readings on 2 separate occasions to diagnose

Question 6

What are common sources of error in measuring BP?

Answer 6

Scale not at eye level or not calibrated
Stethoscope under cuff or cuff too small
White coat
Patient not relaxed
Back unsupported
Isometric contraction 
Tobacco and caffeine can distort measurement

Question 7

What is ambulatory monitoring and what are its BP recommendations?

Answer 7

Automated monitoring of BP over 24 hr period
Superior to office measurement in predicting fatal and non fatal MI
upper limits of normal are mean daytime of 135/85, mean nighttime 120/70, mean 24 hr period 130/80

Question 8

What are the findings in white coat hypertension?

Answer 8

Normal 24 hr ambulatory measurements and no evidence of target organ damage but consistently elevated office readings

Question 9

What is white coat aggravation?

Answer 9

White coat reaction superimposed on persistent ambulatory or nocturnal hypertension that needs treatment

Question 10

What is masked hypertension?

Answer 10

Office readings underestimate ambulatory BPs due to symp over activity in daily life owing to job or home stress, tobacco abuse, or other adrenergic stimulation that dissipates when coming to the office

Question 11

What kind of BP is the stronger predictor of cardiac outcomes?

Answer 11

Nocturnal BP

Persistent nocturnal hypertension could indicate renal disease

Question 12

What are the changes in BP related to aging?

Answer 12

Systolic pressure rises progressively with age in industrialized societies but not in less industrialized societies
Industrialized - diastolic pressure rises until age 50 and decreases after producing progressive rise in pulse pressure

Question 13

What is the relationship between systolic, diastolic BP and age?

Answer 13

Patients who develop hypertension before age 50 usually have combined systolic and diastolic HT - due to vasoconstriction in resistance arterioles
After age 50 typically have isolated systolic hypertension - due to decreased distensibility of large conduit arteries

Question 14

What are the three general procedures and three general goals of assessing BP on a patients office visit?

Answer 14

History, physical, lab tests
Recognize overt target organ damage (urine analysis and creatinine for renal, EKG)
Identify possible causes
Recognize other common concomitant rim factors

Question 15

What are secondary causes of hypertension and which are the seven most common?

Answer 15

RAAS - *chronic kidney disease, *renovascular, *aortic coarctation, *primary aldosteronism, other mineralocorticoid excess, NSAIDs, *cushings
Symp nervous system - *pheochromocytoma, *obstructive sleep apnea, sympathomimetics, cyclosporine, baroreflex failure, thyroid disease

Question 16

What are the clinical features and testing for chronic kidney disease?

Answer 16

Elevated creatinine or abnormal urinalysis

24 hr urine creatinine and protein, renal ultrasound

Question 17

What are the clinical findings and testing for renovascular disease (renal artery stenosis, fibromuscular dysplasia)?

Answer 17

New elevation in creatinine, or elevation with ACEI or ARB, refractory hypertension, flash pulmonary edema, abdominal bruit
Captopril renogram, duplex Doppler sonography, MR or CT angiogram, invasive angiogram

Question 18

What are the clinical features and testing for aortic coarctation?

Answer 18

Arm pulses stronger than leg pulses, arm BP greater than leg BP, chest bruits, rib notching on chest x ray
MRI, aortogram

Question 19

What are the clinical features and testing for primary aldosteronism?

Answer 19

Hypokalemia, refractory hypertension
Plasma renin and aldosterone, 24 hr urine potassium, 24 hr urine aldosterone and potassium after salt loading, adrenal CT scan

Question 20

What are the clinical features and testing for Cushing’s syndrome?

Answer 20

Truncal obesity, purple striae, muscle weakness

Plasma cortisol, urine cortisol after dexamethasone, adrenal ct scan

Question 21

What are the clinical findings and tests for pheochromocytoma?

Answer 21

Spells of tach, headache, diaphoresis, pallor and anxiety

Plasma metanephrine and normetanephrine, 24 hr urine catechols, adrenal ct scan

Question 22

What are the clinical findings and tests for obstructive sleep apnea?

Answer 22

Loud snoring, daytime somnolence, obesity

Sleep study

Question 23

What can cause something that looks like mineralocorticoid excess?

Answer 23

Excessive ingestion of licorice

Has something that inhibits 11-bHSD that normally converts cortisol to cortisone