Hypertension Flashcards
Most common cause of secondary hypertension
Renal/renovascular disease (renal artery stenosis)
Essential Hypertension
No identifiable cause
>95% of cases
Most common secondary cause of htn in young women
birth control pills
Major complications of HTN
cardiac: coronary artery disease, CHF with left ventricular hypertrophy, stroke, renal failure
- -> account for majority of deaths related to untreated HTN
End organ damage of HTN
heart, eyes, CNS, kidneys
Aortic dissection
htn associated with increased risk
Goals in evaluating patient with htn
look for secondary causes
assess damage to target organs
assess overall cardiovascular risk
Retinal changes
- AV nicking: discontinuity in retinal vein secondary to thickened arterial walls)
- 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
Nephrosclerosis
arteriosclerosis of afferent + efferent arterioles and glomerulus
Definition of htn
blood pressure of:
>140/90 in general population
>130/80 in diabetics and renal disease
Other kidney manifestations
decreased gfr
dysfunction of tubules
–> eventual renal failure
Diagnosing hypertension-what not to do
Never based on one bp reading (unless severe htn or evidence of end organ damage)
Diagnosing htn-what to do!
establish diagnosis based on at least 2 readings over a span of 4 weeks
Accurate bp reading
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)
Lab tests to evaluate target organ damage in htn
- urinalysis
- chemistry panel: serum K, BUN, Cr
- fasting glucose (if pt is diabetic check for microalbuminemia)
- lipid panel
- EKG
- -> if h&p or lab tests suggest 2ndary cause of htn order appropriate tests
Management of normal bp
no treatment
120/80
Management of prehypertension
lifestyle modification
120-139/80-89
Management of Stage I htn
lifestyle modification, drug therapy
140-159/90-99
Management of Stage II HTN
lifestyle modification and drug therapy (2 drug combo for most)
>=160/>=100
Antihypertensive therapy in pregnant women
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
Alcohol and bp
alcohol has pressor action; excessive use can increase bp
Therapy in pt with moderate to severe htn
consider initiating therapy immediately instead of waiting 1-2 months to confirm diagnosis
Best initial pharmacotherapy in African-Americans
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
Side effects of thiazide diuretics
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
Beta blockers (effects + side effects)
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)
ACE inhibitors (effects + side effects)
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
HTN treatment and diabetes prevention
treatment with ACE inhibitors and ARBs associated with decreased risk of new-onset diabetes in patients with HTN
Angiotensin Receptor Blockers (ARB) effects + side effects
inhibit RAAS
have same beneficial effects on kidney in diabetic patients as ACE inhibitors
Calcium channel blockers
vasodilation of arteriolar vasculature
HTN in patient with Benign prostatic hyperplasia
alpha blockers!
decrease arteriolar resistance
not 1st line for htn otherwise
Vasodilators (hydralazine and minoxidil)
typically given in combination with beta blockers and diuretics in patients with refractory htn
BP goals in pts with HTN
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)
Three classes of drugs used for initial monotherapy
- thiazide diuretics
- long-acting calcium channel blockers (most often dihydropyridine)
- 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
Cardiovascular risk factors for HTN
smoking, diabetes, hypercholesterolemia, age over 60, family hx, male sex (higher than females only until menopause)
Clinical risk factors for HTN
presence of coronary artery disease, peripheral vascular disease, prior MI; any manifestations of target organ disease (LVH, retinopathy, nephropathy, stroke or TIA)
HTN screening
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
Causes of secondary HTN
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
