HYPERTENSION Flashcards
FIRST-LINE TREATMENT OF HYPERTENSION
1 First-Line for Uncomplicated Hypertension:
* In non-Black patients under 60 years old with no compelling indications (e.g., diabetes, CKD, heart failure). JNC 8, ACC/AHA GUIDELINES
Thiazide diuretics are a preferred first-line choice for hypertension management. Thiazides, especially chlorthalidone, are well-documented to reduce systolic and diastolic blood pressure by promoting sodium and water excretion, leading to decreased plasma volume and peripheral vascular resistance.
Proven Cardiovascular Benefits:
* The ALLHAT trial (Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial) demonstrated that thiazide diuretics (chlorthalidone) were superior to
ACE inhibitors (lisinopril) and calcium channel blockers (amlodipine) in preventing heart failure and stroke in hypertensive patients.Chlorthalidone is preferred over hydrochlorothiazide (HCTZ) due to its longer half-life and greater potency in lowering BP over 24 hours.
Beta-blockers are no longer first-line for primary hypertension unless the patient has a compelling indication such as:
Post-myocardial infarction (MI)
Heart failure with reduced ejection fraction (HFrEF)
Atrial fibrillation
* Beta-blockers like atenolol are less effective in stroke prevention than thiazide diuretics or
ACE inhibitors. Aldosterone Antagonists (Spironolactone)
- Used for Resistant Hypertension
* Spironolactone is not a first-line drug for primary hypertension.
* It is mainly used for resistant hypertension
(BP uncontrolled with 3 or more agents) or in patients with hyperaldosteronism.
ARBs (Losartan) - Alternative, But Not First-Line in This Case
* Losartan (ARB) or ACE inhibitors (e.g., lisinopril) are preferred first-line options in:
Chronic kidney disease (CKD) (to slow nephropathy progression)
Diabetes with albuminuria
Heart failure (to improve cardiac function)
* In this patient without CKD, diabetes, or heart failure, a thiazide diuretic is preferred over ARBs/ACE inhibitors.
Thiazide diuretics, particularly
chlorthalidone, are the preferred first-line treatment for uncomplicated hypertension in a 54-year-old White male with BP >140/90 on multiple readings. They offer effective BP control, cardiovascular protection, and superior outcomes compared to other antihypertensive classes in similar patients.
HYPERTENSION MANAGEMENT DECISION -MAKING FLOWCHART
BP > 140/90 on 3 occasions?
Assess for Compelling indications. If there are no compelling indications, the first choice is a
Thiazide diuretics (Chlorthalidone) preferred.
If there are compelling indications, choose ACEI/ARB for CKD, Diabetes or Heart Failure (preferred in CKD, Diabetes, HF).
Spironolactone (Resistant hypertension only. Here BP is uncontrolled with three medications including a diuretics).
Choose Beta-blocker If patient has CAD, HFrEF, Arryhthmia. See more under AI Prescription Legislation Debate under Chatgpt.
COPD MANAGEMENT
Key Takeaways
* ABCD classification is no longer used (replaced in 2023).
* ICS (inhaled corticosteroids) are only recommended for high eosinophils (≥300) or frequent exacerbations.
* LAMA (e.g., Tiotropium) is now first-line for many patients.
* Triple therapy (LAMA + LABA + ICS) is reserved for severe cases.
* Exacerbation prevention is key (vaccination, smoking cessation, pulmonary rehab).
Current GOLD 2023 Approach
Instead of ABCD, GOLD 2023 focuses on:
- Three treatment groups: Mild (PRN
bronchodilator), Moderate (LABA/LAMA),
Severe (Triple therapy) - Focus on symptom burden (CAT, mMRC) & exacerbation risk
- ICS only for specific cases (eosinophils ≥
300, history of frequent exacerbations)
Updated Treatment Algorithm (2023)
Patient Type. Recommended Treatment
Low symptoms, low risk: SABA or SAMA PRN (Albuterol/ (pratropium)
Persistent symptoms: LAMA or LABA
Frequent exacerbations: LAMA + LABA
Severe exacerbations
or eosinophils ≥ 300: LABA + LAMA + ICS
Persistent symptoms
despite triple therapy: Consider PDE-4
inhibitors, lacrolides,
biologic Jupilumab.
Tezepelumak
PULMONARY EMBOLISM
Pulmonary Embolism (PE) Workup Using Wells Criteria
The Wells Criteria is a clinical prediction tool used to estimate the probability of a Pulmonary Embolism (PE) and guide further testing. The mnemonic “Don’t Die, Tell The Team to Calculate” helps recall key components.
- Components of Wells Criteria for PE
Criteria Points
DVT Signs (leg swelling, pain, tenderness) 3
Diagnosis of PE most likely 3
Tachycardia (>100 bpm) 1.5
Thromboembolism history (prior DVT/PE) 1.5
Immobilization/Surgery in past 4 weeks 1.5
Cancer (active or treated in past 6 months) 1
Hemoptysis (coughing up blood) 1
- Wells Score Interpretation
Total Score Risk Category Recommended Next Steps
≤ 4 points Low Probability (PE Unlikely) Perform D-dimer test
> 4 points High Probability (PE Likely) CT Pulmonary Angiography (CTPA) or V/Q Scan
* D-dimer is highly sensitive but not specific. A negative D-dimer in low-risk patients rules out PE. * CTPA (CT Pulmonary Angiography) is the gold standard for diagnosing PE. * If CTPA is contraindicated (e.g., kidney injury, contrast allergy), a V/Q scan may be used.
- PE Clinical Signs & Symptoms
- Sudden-onset dyspnea (most common)
- Pleuritic chest pain
- Tachycardia
- Tachypnea
- Hypoxia
- Hemoptysis (less common)
- Signs of DVT (unilateral leg swelling, tenderness, redness)
- Next Steps After Diagnosis
- Stable Patients:
- Anticoagulation: DOACs (Apixaban, Rivaroxaban) or LMWH (Enoxaparin) + Warfarin.
- Duration:
- First-time PE, provoked (surgery, immobility, estrogen use) → 3-6 months
- Unprovoked PE → Long-term if recurrent or high-risk
- Unstable Patients (Hypotension, Shock):
- Thrombolysis (Alteplase, tPA)
- Embolectomy in critical cases
- Special Considerations
- Pregnancy: Use LMWH instead of DOACs.
- Cancer-related PE: LMWH is preferred over DOACs.
- Recurrent PE despite anticoagulation: Consider IVC filter.
- Key Takeaways
✅ Wells Score guides workup (D-dimer for low-risk, CTPA for high-risk).
✅ PE is a life-threatening emergency, requiring rapid diagnosis & anticoagulation.
✅ DOACs (Apixaban, Rivaroxaban) are first-line for most patients.
✅ Thrombolysis is reserved for hemodynamically unstable patients.
✅ DVT prophylaxis (early ambulation, LMWH, SCDs) is key in hospitalized patients.
PULMONARY EMBOLISM
Here is a Pulmonary Embolism (PE) Workup Flowchart, outlining the step-by-step approach based on Wells Criteria, D-dimer testing, and CT Pulmonary Angiography (CTPA).
IV. Flashcards for Quick Recall
Flashcard 1: Wells Criteria Scoring
Q: What Wells Score suggests a high probability of PE?
A: >4 points → Order CTPA
Flashcard 2: First-Line Anticoagulation
Q: What is the first-line anticoagulant for stable PE?
A: DOACs (Apixaban, Rivaroxaban)
Flashcard 3: Signs of Unstable PE
Q: What are the signs of a massive (unstable) PE?
A: Hypotension, tachycardia, hypoxia, altered mental status
Flashcard 4: Next Step in High-Risk PE
Q: What is the next step in a high-risk patient (Wells >4)?
A: Skip D-dimer → Order CTPA
PULMONARY EMBOLISM CASE STUDY
HPI: sudden-onset shortness of breath and pleuritic chest pain that started 3 hours ago, reports swelling in her right leg for the past 3 days. She has a history of hypertension, obesity (BMI: 32), and a recent knee replacement surgery 2 weeks ago.
Physical Exam Findings:
* Unilateral right lower leg swelling and tenderness
* Clear lungs bilaterally, but patient reports pain with deep inspiration
Initial Tests Ordered:
1. Wells Score Calculation:
* DVT signs (3 points)
* PE most likely diagnosis (3 points)
* Tachycardia >100 bpm (1.5 points)
* Recent surgery/immobilization (1.5 points)
* Total: 9 points (High risk for PE)
2. D-dimer → Elevated
3. CT Pulmonary Angiography (CTPA) →
Filling defect in the pulmonary artery (confirms PE)
DIAGNOSIS: ACUTE PULMONARY EMBOLISM.
MANAGEMENT:
Stable PE:
* Start anticoagulation:
* First-line: DOAC (Apixaban, Rivaroxaban)
* Alternative: LMWH (Enoxaparin) +
Warfarin
* Duration:
* Provoked PE (e.g., surgery, immobilization) → 3-6 months
* Unprovoked PE → Consider long-term anticoagulation
Unstable PE (Hypotension, Shock):
* Thrombolysis (tPA/Alteplase) or Surgical
Embolectomy
Prevention:
* DVT prophylaxis in hospitalized patients (SCDs, LMWH)
PULMONARY EMBOLISM
Wells Criteria Application
A 67-year-old male with a history of COPD and atrial fibrillation presents to the ER with acute shortness of breath and chest pain that worsens with inspiration. He had a hip replacement 3 weeks ago and reports unilateral left leg swelling. His vitals include BP 130/80 mmHg, HR 102 bpm, RR 26 breaths/ min, Sp02 93% on room air. Based on the Wells Criteria, what is the best next step in management?
A. Perform a D-dimer test
B. Obtain a CT Pulmonary Angiography (CTPA)
C. Start heparin without further testing
D. Order a V/Q scan
Correct Answer: B. Obtain a CT Pulmonary
Angiography (CTPA)
Rationale:
High-risk PE patient (Wells score >4):
* DVT signs (3 points)
* Surgery in last 4 weeks (1.5 points)
* Tachycardia >100 bpm (1.5 points)
* PE most likely diagnosis (3 points)
* Total: 9 points (High probability for PE)
* CTP is the gold standard diagnostic test.
PULMONARY EMBOLISM CASE STUDY
A 45-year-old female with newly diagnosed
PE is hemodynamically stable and has normal renal function. Which of the following is the preferred first-line anticoagulation for outpatient management?
A. Enoxaparin (Lovenox) + Warfarin
B. Apixaban (Eliquis)
C. IV Heparin drip
D. Fondaparinux (Arixtra)
V Correct Answer: B. Apixaban (Eliquis)
Rationale:
* DOACS (Apixaban, Rivaroxaban) are first-line for stable PE
* Warfarin requires bridging with LMWH (e.g., Enoxaparin), making it less convenient
* Heparin is used for unstable PE
* Fondaparinux is an alternative but less commonly used
PULMONARY EMBOLISM
Flashcard 1: Wells Criteria Scoring
Q: What Wells Score suggests a high probability of PE?
A: >4 points → Order CTPA
What is the first-line anticoagulant for stable PE?
A: DOACs (Apixaban, Rivaroxaban)
Signs of Unstable PE
Q: What are the signs of a massive (unstable)
PE?
A: Hypotension, tachycardia, hypoxia, altered mental status
Next Step in High-Risk PE
Q: What is the next step in a high-risk patient (Wells >4)?
A: Skip D-dimer → Order CTPA
