Hypertension

Question 0

Most common cause of secondary hypertension

Answer 0

Renal/renovascular disease (renal artery stenosis)

Question 1

Essential Hypertension

Answer 1

No identifiable cause

>95% of cases

Question 2

Most common secondary cause of htn in young women

Answer 2

birth control pills

Question 3

Major complications of HTN

Answer 3

cardiac: coronary artery disease, CHF with left ventricular hypertrophy, stroke, renal failure
- -> account for majority of deaths related to untreated HTN

Question 4

End organ damage of HTN

Answer 4

heart, eyes, CNS, kidneys

Question 5

Aortic dissection

Answer 5

htn associated with increased risk

Question 6

Goals in evaluating patient with htn

Answer 6

look for secondary causes
assess damage to target organs
assess overall cardiovascular risk

Question 7

Retinal changes

Answer 7

1. AV nicking: discontinuity in retinal vein secondary to thickened arterial walls)
2. cotton wool spots: infarction of nerve fiber layer in retina
   - -> can cause visual disturbances in scotoma

more serious diseases: hemorrhages and exudates

papilledema: ominous, seen in severely elevated bp

Question 8

Nephrosclerosis

Answer 8

arteriosclerosis of afferent + efferent arterioles and glomerulus

Question 9

Definition of htn

Answer 9

blood pressure of:
>140/90 in general population
>130/80 in diabetics and renal disease

Question 10

Other kidney manifestations

Answer 10

decreased gfr
dysfunction of tubules
–> eventual renal failure

Question 11

Diagnosing hypertension-what not to do

Answer 11

Never based on one bp reading (unless severe htn or evidence of end organ damage)

Question 12

Diagnosing htn-what to do!

Answer 12

establish diagnosis based on at least 2 readings over a span of 4 weeks

Question 13

Accurate bp reading

Answer 13

arm at heart level
pt seated comfortably
pt sit quietly for >= 5 minutes
no caffeine or smoke cigarette in past 30 minutes
adequate cuff size (bladder should encircle 80% of arm)

Question 14

Lab tests to evaluate target organ damage in htn

Answer 14

1. urinalysis
2. chemistry panel: serum K, BUN, Cr
3. fasting glucose (if pt is diabetic check for microalbuminemia)
4. lipid panel
5. EKG
   - -> if h&p or lab tests suggest 2ndary cause of htn order appropriate tests

Question 15

Management of normal bp

Answer 15

no treatment

120/80

Question 16

Management of prehypertension

Answer 16

lifestyle modification

120-139/80-89

Question 17

Management of Stage I htn

Answer 17

lifestyle modification, drug therapy

140-159/90-99

Question 18

Management of Stage II HTN

Answer 18

lifestyle modification and drug therapy (2 drug combo for most)
>=160/>=100

Question 19

Antihypertensive therapy in pregnant women

Answer 19

always obtain pregnancy test in reproductive age women before starting anti htn meds;

• thiazides, ACE inhibitors, calcium channel blockers, and ARBs are contraindicated in pregnancy!*
• Beta blockers and hydralazine are safe in pregnancy

Question 20

Alcohol and bp

Answer 20

alcohol has pressor action; excessive use can increase bp

Question 21

Therapy in pt with moderate to severe htn

Answer 21

consider initiating therapy immediately instead of waiting 1-2 months to confirm diagnosis

Question 22

Best initial pharmacotherapy in African-Americans

Answer 22

thiazide diuretics bc “salt-sensitive” htn is more common in this group

if African American pt has diabetes, ACE inhibitor is still initial agent of choice

Question 23

Side effects of thiazide diuretics

Answer 23

hypokalemia (check serum K regularly); hypokalemia can be exacerbated by high salt intake

other: hyperuricemia, hyperglycemia, elevation of cholesterol and triglyceride levels, metabolic alkalosis, hypomagnesemia

Question 24

Beta blockers (effects + side effects)

Answer 24

decrease HR and cardiac output
decrease renin release

side effects: bradycardia, bronchospasm, sleep disturbances (insomnia), fatigue, may increase triglycerides and decrease HDL, depression, sedation, may mask hypoglycemic symptoms in diabetic patients on insulin (beta1 selective may be preferable)

Question 25

ACE inhibitors (effects + side effects)

Answer 25

inhibit RAAS
inhibit bradykinin degradation
preferred in diabetic patients because of protective effect on kidneys

side effects: acute renal failure, hyperkalemia, dry cough angioedema, skin rash, altered sense of taste, contraindicated in pregnancy

Question 26

HTN treatment and diabetes prevention

Answer 26

treatment with ACE inhibitors and ARBs associated with decreased risk of new-onset diabetes in patients with HTN

Question 27

Angiotensin Receptor Blockers (ARB) effects + side effects

Answer 27

inhibit RAAS

have same beneficial effects on kidney in diabetic patients as ACE inhibitors

Question 28

Calcium channel blockers

Answer 28

vasodilation of arteriolar vasculature

Question 29

HTN in patient with Benign prostatic hyperplasia

Answer 29

alpha blockers!
decrease arteriolar resistance
not 1st line for htn otherwise

Question 30

Vasodilators (hydralazine and minoxidil)

Answer 30

typically given in combination with beta blockers and diuretics in patients with refractory htn

Question 31

BP goals in pts with HTN

Answer 31

lower to <140/90
minimum goal in ppl with diabetes or renal insufficiency = 135/85 (lower than this ideal but often not well tolerated by patient)

Question 32

Three classes of drugs used for initial monotherapy

Answer 32

1. thiazide diuretics
2. long-acting calcium channel blockers (most often dihydropyridine)
3. ACE inhibitors or ARBs

beta blockers not commonly used as initial monotherapy unless specifically indicated bc of adverse effects on cardiovascular outcomes (esp in elderly)

ACCOMPLISH trial showed starting with ACE inhibitor + calcium channel blocker more effective than ACE + diuretic, but despite this thiazide diuretics still often initial drug of choice

Question 33

Cardiovascular risk factors for HTN

Answer 33

smoking, diabetes, hypercholesterolemia, age over 60, family hx, male sex (higher than females only until menopause)

Question 34

Clinical risk factors for HTN

Answer 34

presence of coronary artery disease, peripheral vascular disease, prior MI; any manifestations of target organ disease (LVH, retinopathy, nephropathy, stroke or TIA)

Question 35

HTN screening

Answer 35

all people should be screened with fasting lipid profile every 5 years starting at age 20.

–> earlier and more frequent if strong fam hx and/or obesity

Question 36

Causes of secondary HTN

Answer 36

renal/renovascular disease: renal artery stenosis, chronic renal failure, polycystic kidney disease

endocrine: hyperaldosteronism, thyroid or parathyroid disease, Cushing’s syndrome, pheochromocytoma, hyperthyroidism, acromegaly
medications: oral contraceptives, decongestants, estrogen, appetite suppressants, chronic steroids, tricyclic antidepressants, NSAIDs

coarctation of aorta

cocaine, other stimulants

sleep apnea