HYPERTENSION Flashcards
what is HTN
elevation of BP in 2 or MORE office visits after an initial screening
- 2 or more readings at each visit
- if disparity between sys and diastolic–> higher value determines the stage
HTN guidelines
- normal, preHTN, stage 1, and stage 2 values
normal: <120 systolic, <80 diastolic
preHTN: 120-129 sys, <80 diastolic
HTN stage 1: 130-139 sys, 80-89 diastolic
HTN stage 2: 140 and > sys, 90 and > diastolic
how are home bp readings done to be as accurate as possible
twice daily (morning and evening) over 3 succcessive days
- get BP after 5 min
- 2 readings separated by 1 min should be averaged
what BP reading for diabetic pts would concern us for testing out of office measurements?
to confirm HTN
AOBP or non > or = 130/80
what bp reading for NON diabetics are we concerned for testing out of office measurements?
to confirm HTN
AOBP > or = 135/85
non-AOBP > or = 140/90
what out of office measurements confirm HTN vs. white coat HTN
ABPM- daytime mean, 24 hr mean
Home BP series
ABPM (continous readings)
- daytime mean >= 135/85
- 24 hr mean>= 130/80
Home BP series
- mean >= 135/85
if readings are BELOW any of these numbers—> white coat HTN
primary HTN- exacerbating factors
alc, tobacco, sedentary lifestyle, NSAIDs, polycythemia vera, african american male, diet, obesity (SALT)
secondary HTN- causes
parenchymal renal ds, renal artery stenosis, coarctation of aorta (constriction aorta causes L & R brachial pressures to be diff), pheochromocytoma, cushings, hypothyroid, hormone use, obstructive sleep apnea (obese)
HTN complications: cardiovasc
CAD, HF, valvular ds, LVH, periph vasc ds, aortic aneurysm/dissection (HTN wears away at endothelial vasc layer=more plaque deposits=weakens wall=secondary blood flow)
HTN complications: nephro
renal sclerosis–> nephrons are NOT favorable under high pressure and calcify more/become sclerotic
HTN complications: neuro
TIA, encephalopathy, aneurysms, dementia, CVA (ischemic and hemorrhagic)
- ischemic: plaque in arteries cause emboli into systemic circ
- hemorrhagic: blood vessel rupture
HTN complications: optic
retinopathy, retinal hemorrhage, blindness
HTN initial testing
- 12 lead EKG (LVH, do echo if seen)
- labs
- lipid profile
labs and reasoning
RULE OUT SECONDARY CAUSES
LABS- cbc, thyroid panel, chemistry, CRP
potassium, blood gluc, creatinine, BUN
pheochromocytoma
- 24 hr urine metanepharine and normetanephrine
thyroid and parathyroid ds
- TSH, T3/T4, serum PTH
primary aldosteronism
- 24 hr urinary aldosterone level/endocrine work up
lipid profile
- atherosclerosis risk
echocardiogram in HTN
- 2d echo
- TEE
what do you VIEW in each, which shows ejection fraction?
2D ECHO (transthoracic)
- view atria, ventricles, valves
- ejection fraction normal 55%, low normal 50-55, low 45 and less
TEE (transesophageal)
- visualize mitral valve and L atrium
- see mitral regurg and L atrial appendage thrombus
HTN Goal BP
DM or CKD: <130/80
All others: <140/90
HTN Tx (non medication)
- lifestyle management: DASH diet ( low salt, saturated fat, inc fruit/veggies)
- aerobic exercise: 30 min or more, 5 day or more
- Wt loss: BMI 18.5-24.9
- smoking cessation (nicotine causes constant endothelial damage)
- limit alc consumption: 2 or less daily for men, 1 or less for women
what lifestyle modification has the BIGGEST effect on reducing HTN?
WEIGHT LOSS (5-20 mmHg)
second: DASH diet (8-14)
cardiovascular risk factors
HTN, cig smoking, obesity, physical inactivity, dyslipidemia, DM, age (>55 m,>65 f), fam Hx
estrogen is cardioprotective for women (onset menopause raises RF age)
best pharmalogic options with certain comorbidities
DM, CKD, CAD, HF
NO comorbid- diuretics (first line)
DM- ACEi or ARB
CKD- ACEi or ARB
CAD (post MI)- BB, ACEi, ARB
HF- BB, ACEi, ARB, or diuretics
HF- make sure pt is on multi drug regimen, puts heart under less strain, trying to get it back to higher EF
step approach to tx HTN (medications)
1: ACE/ARB or CCB or thiazide diuretic
2: ACE/ARB plus CCB or thiazide
3: ACE/ARB plus CCB plus thiazide
4: ACE/ARB plus CCB plus thiazide plus spirinolactone
ACE inhibitors
- suffix
- important notes
- side effects
- pril
- good for HF pts (dec afterload/preload)
- renal protective
- HYPERKALEMIA, throat clearing cough, angioedema, renal impairment
pt should go for BMP 2 weeks after starting
ARBs
- suffix
- important notes
- side effects
-sartan
- vasodilate, dec pre/afterload
- hyperkalemia, cough (less common), angioedema, renal impairment
Beta Blockers
- suffix
- important notes
- side effects
-olol
- can be selective B1 or 2 or non selective
- BRONCHOSPASM, hypotension, fatigue, bradycardia
any inc in dyspnea or bronchospasm, STOP BB or use more selective BB
CCB
- suffix
- important notes
- side effects
-dipine
-verapamil and diltiazem (central acting)
- NEVER PUT HF PATIENTS ON CENTRALLY ACTING CCB (only peripherally acting)
- PERIPHERAL EDEMA, fatigue, hypotension, muscle cramps
central acting are negative inotropic agents that reduce contraction
swelling in lower extremities is common w norvasc
Diuretics (thiazide, loop)
- suffix
- side effects
furosemide and HCTZ
- hypokalemia, hypochloremia, hypotension, pancreatitis, renal failure
Alpha Blockers
- suffix
- important notes
- side effects
- clonidine, terazosin, doxazosin
- vasodilation, dec preload, dec HTN
- add alpha blockers when everything else has been tried
- ORTHOSTATIC HYPOTENSION, dizzy, somnolence, headache
some alpha blockers give prostate issues
avoidance of what medication with this comorbidity?
End stage CKD (stage III, IV)
ACE or ARB
avoidance of what medication with this comorbidity?
hyperkalemia
ACE or ARB, aldosterone antagonists
avoidance of what medication with this comorbidity?
hyponatremia
thiazide diuretics
avoidance of what medication with this comorbidity?
asthma
Beta blockers
avoidance of what medication with this comorbidity?
gout
thiazide and loop diuretics
avoidance of what medication with this comorbidity?
angioedema
ACE
avoidance of what medication with this comorbidity?
2nd/3rd degree heart blocks, bradycardia
BB, non-dihydropyridine CCBs
what is the first line for all patients without comorbidities?
diuretics
hypertensive urgency
- definition
- management
- meds
- goal
BP reading: systolic >180 and/or diastolic >120 WITHOUT evidence of end organ damage
management: gradually reduce mean arterial pressure (no more than 25% over 24-48 hrs)
meds: BB (labetolol), nicardipine (CCB), captopril (ACE)
(A,B,C)
goal: less or equal to 160/100
hypertensive emergency
- definition
- end organ damage ex
BP: systolic >220 or diastolic >120 WITH end organ damage
end organ damage: papilledema, intracranial hemorrhage, encephalopathy, renal failure, unstables angina/MI/CHF/aortic dissection, pulm edema
hypertensive emergency
- causes
noncompliance w meds, renal artery stenosis, hyperaldosteronism, cushings, eclampsia (spilling proteins in pregnancy), vasculitis, polycystic kidney ds, ilicit drug use, alc withdrawal
hypertensive emergency
- goal
- tx
goal: reduce MAP by 25% in 1-2 hrs
- MAP= avg bp during single cardiac cycle
quick reduction of BP can lead to ischemic CVA
IV tx: esmolol, labetolol, hydralazine, nitroglycerin, nitroprusside (RAPID EFFECTS)
white coat HTN
consistenly elevated office bp readings with out of office readings that do NOT meet criteria for HTN
- ambulatory and home blood pressure monitoring
