Hypertension Flashcards
What are the four major target organs damaged by hypertension?
Brain - stroke, TIA, dementia
Heart - CHF
Kidneys - chronic kidney disease
Blood vessels - aortic aneurysm, CAD, MI, peripheral vascular disease
What is the definition of hypertension?
Systolic pressure at least 140 OR diastolic pressure at least 90
At what blood pressure does the risk for heart disease and stroke begin to increase with increasing levels?
115/75
What are the JNC stages of blood pressure?
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
What is the difference between hypertensive emergency and hypertensive urgency?
Both have acute severe elevations in BP
Emergency has evidence of target organ damage, urgency does not
What is the correct method for taking BP?
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
What are common sources of error in measuring BP?
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
What is ambulatory monitoring and what are its BP recommendations?
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
What are the findings in white coat hypertension?
Normal 24 hr ambulatory measurements and no evidence of target organ damage but consistently elevated office readings
What is white coat aggravation?
White coat reaction superimposed on persistent ambulatory or nocturnal hypertension that needs treatment
What is masked hypertension?
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
What kind of BP is the stronger predictor of cardiac outcomes?
Nocturnal BP
Persistent nocturnal hypertension could indicate renal disease
What are the changes in BP related to aging?
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
What is the relationship between systolic, diastolic BP and age?
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
What are the three general procedures and three general goals of assessing BP on a patients office visit?
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
What are secondary causes of hypertension and which are the seven most common?
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
What are the clinical features and testing for chronic kidney disease?
Elevated creatinine or abnormal urinalysis
24 hr urine creatinine and protein, renal ultrasound
What are the clinical findings and testing for renovascular disease (renal artery stenosis, fibromuscular dysplasia)?
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
What are the clinical features and testing for aortic coarctation?
Arm pulses stronger than leg pulses, arm BP greater than leg BP, chest bruits, rib notching on chest x ray
MRI, aortogram
What are the clinical features and testing for primary aldosteronism?
Hypokalemia, refractory hypertension
Plasma renin and aldosterone, 24 hr urine potassium, 24 hr urine aldosterone and potassium after salt loading, adrenal CT scan
What are the clinical features and testing for Cushing’s syndrome?
Truncal obesity, purple striae, muscle weakness
Plasma cortisol, urine cortisol after dexamethasone, adrenal ct scan
What are the clinical findings and tests for pheochromocytoma?
Spells of tach, headache, diaphoresis, pallor and anxiety
Plasma metanephrine and normetanephrine, 24 hr urine catechols, adrenal ct scan
What are the clinical findings and tests for obstructive sleep apnea?
Loud snoring, daytime somnolence, obesity
Sleep study
What can cause something that looks like mineralocorticoid excess?
Excessive ingestion of licorice
Has something that inhibits 11-bHSD that normally converts cortisol to cortisone
