Hypertension Flashcards
acceptable increase in creatinine within first 2 months of aceinhibitor therapy
30%
First line therapy: Acei
Htn with hf and systolic dysfunction type 1 dm and proteinuria mi or cad new af left ventricular dysfunction hd
selectively antagonize Ang Ii at the AT1 receptor
ARB
B receptor predominantly in heart adipose and brain tissue
B1
B receptor in lung liver smooth muscle and skeletal muscle
B2
B1 selective
Atenolol, Metoprolol, Bisoprolol, Acebutolol
Nonselective + A blockade or other mechanism
Labetalol Carvedilol Nebivolol
coexisting heart failure and htn
B blocker
inhibit entry of calcium or its mobilization from intracellular stores, lower peripheral resistance
Calcium channel blockers
Most potent vasodilator among ccb
dihydropyridines - amlodipine, nifedipine
augment atrial natriuretic peptide release
ccb
important tx option for renal transplant recipients - reduces initial graft nonfunction by attenuating ischemic and reperfusion injury, preserves long term renal function by protecting against cyclosporine nephrotoxicity
CCBs
cause of edema in dihydropyridines
uncompensated precapillary vasodilation
crosses the blood brain barrier and have a direct agonist effect in a2 adrenergic receptors in the midbrain and brainstem
central adrenergic agonist
most common adverse effect of a agonist
dry mouth
decrease peripheral vascular resistance, act directly on vascular smooth muscle
direct acting vasodilators
direct vasodilator reserved for severe or intractable hypertension
minoxidil
common adverse effect of minoxidil
hypertrichosis
associated with development of sle (direct vasodilator)
hydralazine
derivative of spironolactone that is approx 24x less potent in blocking mr than spironolactone
eplerenone
Bp target < 60
< 140/90
Bp target > 60 yo
< 150/90
Ideal therapy for older patients
vasodilators - ace/arb + hctz, ccb
optimal therapy in pregnant
a-methyldopa, hydralazine or bblocker
angina tx
Bblocker, nitrates, ccb
reduce hr and induce vasodilation
Lvh htn tx
hctz acei ccb arb
avoid vasodilators
reduce sbp
systolic dysfunction htn tx pharma consideration
reduce afterload and preload
acei, arb, hctz, bblocker, aldactone
diastolic dysfunction
improve myocardial compliance
bb, ccb, acei arb
avoid loop diuretics
MI
reduce heart rate, bb, acei
inability to reach desired bp goal despite the use of 3 optimally dosed drugs, one of which is a diuretic or need for four or more medications yo reach desired goal
Resistant htn
most common cause of resistant htn
non adherence
most potent parenteral vasodilator - dilates arteriolar resistance and venous capacitance vessels
sodium nitroprusside
degree of pressure gradient between aorta and poststenotic renal artery before measurable release of renin develops
10-20mmhg
critical lesions require how much of luminal obstruction before hemodynamic effects are detected
70-80%
Effects of angiotensin II
vasoconstriction renal Na retention aldosterone secretion Vascular effects Sns myocardial effects
affects the intima or fibrous layers of the vessel wall, F, smoking, classically away from renal artery, string of bead appearance
fibromuscular disease, medial fibroplasia
most common cause of renovascular disease, at origin of artery
atherosclerosis
appear in the midportion of the vessel, strong predilection for the R renal artery
medial fibroplasia
syndromes associated with renovascular hypertension
- Early or late onset htn
- acceleration of treated essential htn
- Deterioration of renal function in treater essential htn
- Acute renal failure during treatment of hypertension
- Flash pulmonary edema
- Progressive renal failure
- Refractory congestive cardiac failure
lateralizafion is defined as a ratio of more than ___ between the renin activity of the stenotic kidnet and the nonstenotic kidney
1.5
used to monitor after renal revascularizarion to monitor restenosis and target vessel patency
Doppler studies
gold standard for definition of vascular anatomy and stenotic lesions in kidney
Intra arterial angiography
resistive index that reflects intrinsic parenchymao and small vessel disease in the kidney that does not improve after revascularizarion
> 80
Most frequently reported complication after ptra and stenting
Minor - groin hematoma and puncture site trauma
Creatinine and size of kidneys which will unlikely benefit from surgical or endovascilar procedures
Crea > 3 cm, Small kidneys < 8 cm
Indications for revascularizarion
circulatory congestion deteriorating kidney function bilateral high grade ras solitary functioning kidney uncontrolled hypertension
Screening in primary hyperaldosteronism
Plasma aldosterone concentration to renin activity: ARR of 30
False positives Arr
K and Na loading, bb, nsaid, ckd
False negative primary hyperaldosteronism
HypoK, diuretics, acei, arb, ccb
confirmatory tests for Pa
Saline loading
oral Na loading
fludricortisone
Captopril challenge
+ saline loading test
plasma aldosterone > 10 ng/ml (2L in 4h)
+ oral sodium loading test
urinary aldosterone > 12-14 mcg/day (6g/day for 3-5 days)
+ fludrocortisone suppression test after 0.1 mg of fludrocortisone every 6 hrs for 4 days
+ if upright plasma aldo > 6 ng/dL and renin/cortisol low
+ captopril challenge test after 20-25 mg
+ plasma aldosterone elevated and unchanged after 1 amd 2h
initial study in subtype testing of pa
adrenal ct
small hypodense nodule (2 cm in diameter)
Aldosterone producing adenoma
normal adrenals or nodular changes
Idiopathic hyperaldosteronism
> 4 cm, heterogenous, indistinct margins, hemorrhage and necrosis
Aldosterone producing adrenal ca
medical management for GRA
low dose dexa/pred
11B-hydroxysteroid dehydrogenase deficiency
licorice
htn hypoK inappropriate kaliuresis with low aldosterone and renin
liddle syndrome
headache, sweating, hypertension in paroxysms
Pheochromocytoma
tx of pheochromocytoma
alpha blocker - phentolaminr or phenoxybenzamine
screening for acromegaly
Insulin like growth factors
tx for aortic dissection
bblocker plus nitroprusside
120 mmhg in 20 mins
phenomenon where a mild increase in blood pressure results in a concomitant increase in Na excretion
Pressure natriuresis
factor produced by adipocytes found to impair nitric oxide synthesis and enhances endothelin 1 production favoring the devt ko htn in obesity
resistin
when decreased causes insulin resistance, decreased induction of enos, increased sympathetic activity
adiponectin
When increased heightens sns
leptin
causes Na retention causing increased bp
angiotensinogen
isolated office htn, high bp in the office and normal bp in the out of office environment
White coat htn
normal bp in the office, increased outside
masked htn
difficult to control bp with 3 optimally dose drugs one of which is a diuretic, need for 4 or more medications
resistant htn
orthostatic hypotension is defined as a drop of more than how many mmhg in BP after 3 mins of standing
20/10
labile htn and hypotensive symptoms
home bp monitoring
gold standard when patients have home bp values that are borderline
abpm
monitor orthosatic htn
home bp
supine htn and average levels of bp
abpm
autosomal dominant disorder with htn, met alk, low aldo and low renin, increased bp with aldactone intake
hypertension brachydactyly syndrome
hypokalemia, met acid with normal renal fxn, htn
gordon syndrome
hypok, met alk, low plasma aldosterone and renin, enac mutation
liddle syndrome
hypok met alk low plasma and aldosterone, mutation in 11B hydroxysteroid dehydrogenase type 2
Apparent mineralocorticoid excess
Mutation in MR, hypok and met alk, low aldosterone and renin, increased bp due to pregnancy or aldactone intake
Geller syndrome
mutationnof hypertension brachydactily syndrome
phosphodiasterasr E3a
short fingers, stature; brainstem compression from
vascular tortuosity in the posterior fossa
htn brachydactyly syndrome
patients who lack normal BP dip of 20% during sleep
sleep bp that falls by less than 10% compared with awake levels
nondippers
cut off of high renin
6.5 ng/mL/hr
medication of choice high levels of renin
acei, arbs, renin inhibitors, bblockers
Low levels of renin tx of choice
diuretics, aldosterone antagonists, ccbs or a blockers
when to work up for secondary htn
htn younger than 30 with no family hx of htn
> 55 yo with new onset htn, worsening of bp control, recurrent flash pulmo edema, abdominal bruit, inc of more than 30% after raas blocker
treatment of primary hyperaldosteronism
verapamil, hydralazine, peripheral a adrenoreceptor antagonists
cut off size to consider adrenal adenocarcinoma
> 4 cm
diffuse hyperplasia of aldosterone producing cells within adrenal cortex
idiopathic hyperaldosteronism
enlarged limbs of one or both adrenal glands > 10 mm thick
Unilateral adrenal hyperplasia
Management for acute aortic dissection
sbp < 120 within 20 mins
Bblocker and vasodilator
bp target for htn with hemorrhage
10-15% reduction over 1-2 hrs
bp target for major hematuria or kidney injury
0-25% reduction in map over 1-12 h
Bp target for hypertensive enceph
25% over 2-3 h
bp target for acute head injury
0-35% reduction over 2-3h with nitroprusside
