Hypertension Flashcards
JNC 8
JNC 7 still final word
Definition of hypertension
systolic blood pressure >140
Diastolic blood pressure > 90
diagnosing htn
- at least 2 elevated measurements
- one in each arm
- 2 or more visits
- dx should not be made when pt is acutely ill (ex: pt in pain)
- take measurement in each arm to evaluate whether adult pt actually has “coarctation of the aorta” or another aortic anomaly (where pressure in right arm is high but left arm is low)
screening healthy ppl for high bp
- begin at age 18 and older
- insufficient evidence to recommend an optimal interval for screening adults for htn
- Jnc7: every 2 yrs in ppl w bp < 120/80 and every year if bp 120-139/80-90
Jnc8: no comment on screening for htn
one of most common causes of misdiagnosis or improper mgmt of htn
(+ proper office techniques)
blood pressure measurement errors: made by everyone
proper office techniques:
- pt seated quietly for 5 mins in a chair (not exam table), feet on floor, arm supported at heart level
- auscultory method w properly calibrated and validated instumrent (aneroid device, uses metal spring to measure bp); attached to cuff, accompanied by stethoscope
- use appropriate sized cuff to ensure accuracy: length of bladder should wrap around 80% of arm circumference; width of cuff must be at least 40% of arm circumference
If bp cuff too small or large
if cuff too small: bp reading may be erroneously high
if cuff too large: bp reading may be slightly too low
w increasing prevalence of obesity, many adults no longer fit standard cuffs (may require extra large or thigh cuffs)
Objectives of evaluation of pt w htn
- assess lifestyle and identify other cardiovascular risk factors or concomitant disorders that affects prognosis and guides treatment
- reveal identifiable causes of high blood pressure (secondary htn)
- assess presence or absence of target organ damage and cardiovascular dz
(how? proper h & p)
Elements of proper initial history for pt w new essential htn: what to ask
Proper elements of initial hx of pt w new htn (jnc 7):
- does pt already have htn and if so for what duration?
- -> pts with >10yrs poorly controlled htn may be more likely to have end organ damage - does pt have congestive heart failure symptoms?
- chf considered end organ damage of htn - does pt have peripheral vascular dz?
- pvd conisdered end organ damage of htn - does pt have diabetes?
- pts w diabetes may also have htn as part of metabolic syndrome - does pt have hx or sx of cardiovascular dz?
- cvd is part of end organ damage of htn - does pt have renal dz?
- renal dz is part of end organ damage of htn - does pt have cholesterol issues?
- pts w cholesterol issues may also have htn as part of metabolic syndrome - does pt have fam hx premature heart attack or stroke death (s)?
- pt w fam hx of premature cvd or death (men < 55 yrs or women < 65 yrs) can mean pt has 8x higher risk of cvd or death than rest of pop - does pt have fam hx diabetes?
- fam hx diabetes may mean higher risk of diabetes for pt w htn - does pt have fam hx hypercholesterolemia?
- fam hx high cholesterol may mean higher risk of hyperlipidemia for pt w htn - review all meds including over the counter and complementary meds?
- review of all meds including otc and complementary is cruticial; some common rx meds like birth control pils, amphetamines, thyroid meds, steroids, certain antidepressants may elevate bp
some common otc meds can also elevate bp: pseudoephedrine, appetite suppressants, nsaids
some herbal remedies: ma huang, bitter orange, ginkgo, ginseng, licorice, st. johns wort
- review any weight change issues?
- wt changes esp wt gain are important - review smoking hx
- tobacco smoking elevates bp, contributes to increased morbidity and mortality, interferes w efficacy of bp meds - review alcohol and drug hx
- alcohol and drug hx imp; alcohol intake should be limited to no more than 1oz/30ml ethanol (=2drinks per day in most men) and no more than .5oz/15ml ethanol (one drink) per day in women and lighter weight persons
- cocaine and ketamine use and narcotic withdrawal can elevate bp - review diet hx
- assess diet hx to counsel pt appropriately - review psychosocial stressors
- review psychosocial stressors ; stress directly causes release of angiotensin II and norepinephrine in body (fight or flight) and also makes prioritizing adherence to bp meds hard
Elements of proper initial history for pt w new essential htn: what doesnt need to be asked
- does pt have cancer hx?
- may be part of routine pt hx but doesnt play role in focused hx of pt w htn - does pt have glaucoma dz?
- routine but not focused hx; not directly associated w essential htn; however retinopathy may be considered target end organ damage from htn - does pt have fam hx colon cancer?
- may be routine but doesnt play role in focused hx of pt w htn
Elements of proper initial physical exam for pt w new essential htn: what to do
- 2 bp measurements 2 minutes apart on each arm: look for coarctation of aorta or other anatomical anomalies (cause of secondary htn)
- calculate body mass index: bmi, usually overweight (>25) or obese (>30)
- fundoscopic exam: look for av nicking, papilledema (seen in hypertensive emergencies), cotton wool spots, hemorrhages
- examine thyroid: look for thyromegaly or polyps or other signs of hyperthyroidism (cause of 2ndary htn)
- check for neck bruits: cardiovascular dz
- auscultate heart for rate and murmurs: cardiovascular and valvular dz
- check the point of maximal impulse (PMI): look for signs of hypertrophy or cardiomegaly
- check for abdominal bruits: cardiovascular dz
- assess peripheral veins: cardiovascular or diabetic dz
- evaluate for lower extremity edema: cardiovascular dz
- neurological evaluation: getting good baseline neuro exam is imp even if exam is non focal
Elements of proper initial physical exam for pt w new essential htn: what not to do
- assess tympanic membranes: though its part of general exam, not part of focused physical on pt w htn
- check for hepatosplenomegaly: though part of gen exam, not part of focused PE in pt w htn
- genital exam: not part of focused exam for pt w htn
- general skin exam: not part of focused PE w pt w htn
diagnosing htn in adults >18 yrs: normal
systolic bp <80
diagnosing htn in adults >18 yrs: prehypertension (normal)
systolic bp 120-139
or
diastolic bp 80-89
–> id ppl for whom early intervention by adoption of healthy lifestyles could reduce bp, decrease rate of progression of bp to hypertensive levels with age, or prevent htn entirely
diagnosing htn in adults >18 yrs: stage 1 htn
systolic bp: 140-159
or
diastolic bp: 90-99
diagnosing htn in adults >18 yrs:stage 2 htn
systolic bp: >160
or diastolic bp >100
if systolic and diastolic measurements of bp are in diff htn categories…
classify the pt by the worst of the 2 measurements
Dx of pre htn is confirmed with these values
s bp: 120-139
d bp: 80-89
(average values of 2 or more bp measurements on separate visits)
–> pre htn is not a disease category, so officially these readings are still “normal”
true or false: pts with pre htn are at high risk of progression to htn
true:
- -> pre htn is designation chosen to identify ppl at high risk of developing htn
- -> 50% of prehypertensive patients will eventually develop htn
Are pre hypertensive patients candidates for drug therapy?
It depends.
ppl w prehypertenion are not candidates for drug tehrapy based on their level of bp alone; should be strongly encouraged to practice lifestyle modifications to reduce risk of developing future htn
but if pt w diabetes or renal dz and prehypertension, should be treated (if sp=130 and dp=80)
Initial laboratory testing for htn: what to do in a new dx (stage 1 essential htn, in this example)
- ekg:
- rate and rhythm issues (is pt bradycardic, tachycardic, or have an underlying heart block? are beta blockers or calcium channel blockers contraindicated? is there possibility of undiagnosed hyperthyroidism? are there rhythm disturbances such as atrial fibrillation
- ischemia: does patient have evidence of ischemic disease or previously undiagnosed myocardial infarctions? is there presence of end organ damage?
- hypertrophy: does the pt have ekg signs of cardiac hypertrophy? does pt have left ventricular hypertrophy (LVH)?
* LVH is second best prognosticator of death in all people; reversible w proper attn and medical mgmt; 1st and best prognosticator of death in all ppl is age * - Urinalysis
proteinuria: may be evidence of hypertensive nephropathy (target organ damage)
glucosuria: may be evidence of undiagnosed diabetes or poorly controlled diabetes (co-morbidity and sign of metabolic syndrome) - Blood glucose
- elevated blood glucose: elevated random or fasting blood glucose may be evidence of undiagnosed diabetes or poorly controlled diabetes (comorbidity and sign of metabolic syndrome)
- could possibly affect choice of 1st line agent to be used in managing htn - Blood hematocrit (can also use serum hemoglobin)
- low hematocrit: underlying anemic states in hypertensive pts make the likelihood of major cardiovascular event more likely (strokes, heart attacks)
- if hypertensive pt found to be anemic, underlying cause (ex: colon cancer, uterine fibroids) must be found and addressed + anemia corrected
- anemia may also be product of target organ damage in regards to severe end stage renal disease - Serum potassium
- several blood pressure meds can cause K+ derangements (ACE inhibitors, ARBs, potassium sparing diuretics causing or exacerbating hyperkalemia)
- baseline K level is necessary
- K disturbances can occur in Cushing’s syndrome or primary hyperaldosteronism - Serum Creatinine (or corresponding estimated GFR
- elevated serum creatinine may be indicative of end organ damage (hypertensive nephropathy) from long term uncontrolled htn
- some blood pressure meds also elevate cr (ace inhibitors, arbs, diuretics) - serum calcium (ca)
- 1/3 of patients w hyperparathyroidism and htn can be attributed to renal parenchymal damage due to nephrolithiasis
- increased ca levels can also have direct vasoconstrictive effect
- its unclear why increased serum calcium level in hyperparathyroidism raises bp, while epidemiologic studies suggest that high calcium intake lowers bp
- also not clear why calcium channel blocker agents are effective antihypertensive agents - Fasting serum cholesterol panel (total cholesterol, LDL, HDL, triglyceride)
- lipid profile, after 9-12 hour fast, that includes high density and low density lipoprotein cholesterol, and triglycerides
- hypertenisve pts require entire fasting cholesterol panel to properly assess lipid comorbidities as part of metabolic syndrome and risk of arteriosclerosis
- these pts have fasting lipid panels as surveillance of cholesterol problems, not as general screening tool - measurement of urinary albumin excretion or albumin/creatinine ratio
- measurement of urinary albumin excretion or albumin/creatinine ratio (ACR) considered to be optional except for those w diabetes or kidney dz where annual measurements should be made
- may become a recommended test for all hypertensive patients in future reports bc microalbuminuria does appear to have some prognostic implications
1st and second best prognosticators of death in all ppl
- LVH
2. age (the older you are, the more likely you will die)
Initial laboratory testing for HTN: what not to order in dx of new stage 1 essential htn
- Thyroid function tests
- not generally indicated in initial evaluation of essential htn pts unless you have clinical suspicion of hyperthyroidism or htn control cant be achieved
2 Echocardiogram
- not generally indicated in initial eval of essential htn pts unless have clinical suspicion of CHF, valvular dz, or cardiomyopathy
- Renal artery sonography
- not generally indicated in initial eval of essential htn pts unless have clinical suspicion of renal artery stenosis or htn control cant be achieved - Serum chloride
- not a proper element bc not generally indicated in initial eval of essential htn pts
- there are no derangements of serum chloride due to htn or hypertensive meds
- test may often be bundled w other electrolyte serology thats recommended (K, creatinine, glucose, calcium) - serum cortisol
- not generally indicated in initial eval of essential htn pts unless have some clinical suspicion of cushing’s dz or another metabolic disorder (cause of 2ndary htn) or htn control cant be achieved - random serum total cholesterol
- not cost effective in initial eval of essential htn
- full lipid profile, after 9-12 hr fast, that includes high density and low density lipoprotein cholesterol, and triglycerides is imp and cost effective
- hypertensive pts require entire fasting cholesterol panel to properly assess lipid comorbodities as part of metabolic syndrome and risk of arteriosclerosis
- pts have fasting lipid panels as surveillance of cholesterol problems, and not as general screening tool - MRI of abdomen
- not generally indicated in initial eval of essential htn pts unless have clinical suspicion of aortic aneurysm - complete blood count (CBC)
- although serum hemoglobin recommended in initial eval of essential htn, wbc and platelet counts not generally indicated
- blood hematocrit can also be used - complete liver enzyme panel (LFTs)
- not generally indicated in initial eval of essential htn - chest xray
- not generally indicated in initial eval of essential htn pts unless have clinical suspicion of congestive heart failure or cardiomegaly - serum sodium (Na)
- serum na not generally indicated in initial eval of essential htn pts
- surprising! bc some pts, esp the elderly, have been known to have serum Na derangements from bp meds (ex: hyponatremia fr diuretics and ACE inhibitors)
- this test may often be bundled w other electrolyte serology that is recommended (K, cr, glucose, ca)
Essential htn
95-99% of htn in US
Secondary htn
- far less prominent than essential htn
- should be suspected based on clinical judgment
- when bp fails to be controlled despite optimal medical mgmt
Metabolic syndrome
constellation of dyslipidemia (hypertriglyceridemia and low levels of HDL), elevated bp, impaired glucose tolerance, central obesity
“syndrome x”
will soon overtake cigarette smoking as #1risk factor for heart dz among US
effective interventions: diet, exercise, judicious use of pharmacologic agents to address specific risk factors
wt loss significantly improves all aspects of metabolic syndrome
Identifiable causes of secondary htn
- pheochromocytoma
- primary aldosteronism
- renal artery stenosis
Hypertensive emergency
marked htn w evidence of end organ damage that requires immediate blood pressure control
(wiki: 180/120)
Malignant htn
marked htn w papilledema, retinal hemorrhages or exudates; considered a subset of hypertensive emergency
Hypertensive urgency
- marked htn that requires bp control within hours w out evidence of end organ damage
Age >=60
Initial mgmt of essential htn based on pts characteristics and comorbid indications
goal bp: < 150/90
strength of recommendation: A (strong)
*for pts > 60 years old who are tolerating blood pressure therapy that has resulted in pressure <140/90, it is acceptable to continue that treatment (based on expert treatment)
Age < 60 yrs
Initial mgmt of essential htn based on pts characteristics and comorbid indications
goal bp: diastolic bp < 90
strength of recommendation:
A (strong) for ages 30-59
E (expert opinion) for ages 18-29
Age < 60 years
Initial mgmt of essential htn based on pts characteristics and comorbid indications
systolic bp < 140
strength of recommendation: E (expert opinion)
Chronic kidney disease >= 18 years old
Initial mgmt of essential htn based on pts characteristics and comorbid indications
< 140/90
strength of recommendation: E (expert opinion)
Diabetes age >= 18 yrs old
Initial mgmt of essential htn based on pts characteristics and comorbid indications
goal bp: < 140/90
strength of recommendation (E)
JNC8 recommendations of bp levels that are strong recommendations (level A)
- sbp and dbp target for the elderly
2. dbp target for ages 3-60
high quality
Evidence quality rating
JNC8
well designed, well executed RCTs that adequately represent populations to which results are applied and directly assess effects on health outcomes
well-conducted meta analyses of such studies
highly certain about the estimate of effect; further research is unlikely to change our confidence in estimate of effect
moderate quality
Evidence quality rating
JNC8
RCTs w minor limitations affecting confidence in, or applicability of, the results
- well designed, well executed, non randomized controlled studies and well designed, well executed observational studies
well conducted meta analyses of such studies
- moderately certain about estimate of effect; further research may have an impact on our confidence in estimate of effect and may change the estimate
Low quality
Evidence quality rating
JNC8
RCTs w major limitations
non randomized controlled studies and observational studies w major limitations affecting confidence in, or applicability of, the results
uncontrolled clinical observations w out an appropriate comparison group (eg case series, case reports)
- physiologic studies in humans
- low certainty about estimate of effect; further research likely to have an impact on our confidence in the estimate of effect and is likely to change the estimate
Grade A
Strength of recommendations
strong recommendation
there is high certainty based on evidence that net benefit (benefits minus the risks/harms of the service/intervention) is substantial
Grade B
Strength of recommendations
moderate recommendation
there is moderate certainty based on evidence that net benefit is moderate to substantial
OR
there is high certainty that the net benefit is moderate
