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Primary Care > Hypertension > Flashcards

Hypertension Flashcards

1
Q

Definition of hypertension

A

Systolic over 140 OR diastolic over 90

Need to get two elevated measurements, one in each arm, on 2 or more visits

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2
Q

When should screening be done for hypertension?

A

Start in healthy individuals at age 18 and older

Screen every 2 yrs for person with bp less than 120/80

Yearly if p is between 120-139 or diastolic 80-90

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3
Q

Proper blood pressure measurements techniques

A

Patient seated quietly for 5 min in a chair

Width of cuff should be at least 40% arm circumference

Length of bladder shoudl wrap around 80% of arm circumference

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4
Q

Proper initial history for pt with new essential htn

A

A) Does patient already have hypertension and if so for what duration?
B) Does the patient have congestive heart failure symptoms?
C) Does the patient have peripheral vascular disease?
E) Does the patient have diabetes?
F) Does the patient have a history or symptoms of cardiovascular disease?
G) Does the patient have renal disease?
H) Does the patient have cholesterol issues?
I) Does the patient have retinopathy?
J) Does the patient have a family history of premature heart attack or stroke death(s)?
K) Does the patient have a family history of diabetes?
L) Does the patient have a family history of hypercholesterolemia?
N) Review all medications including over the counter and complementary medications?
O) Review any weight change issues?
P) Review smoking history?
Q) Review alcohol and drug history?
R) Review diet history?
S) Review psychosocial stressors?

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5
Q

Physical exam for pt with essential htn

A

A) Two blood pressure measurements 2 minutes apart on each arm
B) Calculate the BMI (body mass index)
C) Fundiscopic exam
E) Examine the thyroid
F) Check for neck bruits
G) Ausculate the heart for rate and murmurs
H) Check the PMI (point of maximal impact)
I) Check for abdominal bruits
L) Assess peripheral veins
M) Evaluate for lower extremity edema
N) Neurological evaluation

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6
Q

Classification of bp for adults >18 years old

A

Normal: <120/80

Prehtn: 120-139 or 80-89

Stage 1 htn: 140-159 or 90-99

Stage 2 htn: >160 or >100

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7
Q

Hypertension in patient with renal disease or diabetes?

A

140/90

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8
Q

Initial labs in hypertensive pt?

A

A) Electrocardiogram
C) Urinalysis
E) Blood glucose
F) Blood hematocrit or serum hemoglobin
H) Serum potassium (K)
I) Serum creatinine (or the corresponding estimated GFR)
J) Serum calcium (Ca)
N) Fasting serum cholesterol panel (total cholesterol, LDL, HDL, triglyceride)
P) Measurement of urinary albumin excretion or albumin/creatinine ratio

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9
Q

CVD risk factors

A

• Hypertension*
• Cigarette smoking
• Obesity* (BMI >30 kg/m2)
• Physical inactivity
• Dyslipidemia*
• Diabetes mellitus*
• Microalbuminuria or estimated GFR <60 ml/min
• Age (older than 55 for men, 65 for women)
• Family history of premature CVD
(men under age 55 or women under age 65)
*components of metabolic syndrome

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10
Q

Target organ damage in htn

A

• Heart
o Left ventricular hypertrophy
o Angina or prior myocardial infarction
o Prior coronary revascularization
o Heart failure
• Brain
o Stroke or transient ischemic attack
• Chronic kidney disease
• Peripheral arterial disease
• Retinopathy

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11
Q

Identifiable causes of secondary htn

A
  • Sleep apnea
  • Drug-induced or related causes
  • Chronic kidney disease
  • Primary aldosteronism: hypokalemia, dx with plasma aldo while pt is on antihypertensive drugs (except spironolactone) –> calculate plasma aldo conc/plasma renin activity; follow with aldo suppression testing
  • Renovascular disease: i.e. renal artery stenosis - upregulates the renin/angiotensin system
  • Chronic steroid therapy and Cushing’s syndrome
  • Pheochromocytoma: tumors of chromaffin cels of adrenal medulla; 24h catecholamine/metanephrine urine excretion
  • Coarctation of the aorta
  • Thyroid or parathyroid disease
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12
Q

When do you worry about secondary htn?

A

When bp fails to be controlled by optimal medical management and based on your clinical assessment of the patient

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13
Q

Metabolic syndrome

A

Risk factors that raise risk for heart disease and other health problems like diabetes and stroke

3/5 of these: abdominal obesity, high triglyceride level, low HDL level, high blood pressure, high fasting blood sugar

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14
Q

Hypertensive emergency

A

Marked hypertension with evidence of end orgn damage that requires immediate bp control

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15
Q

Malignant htn

A

Marked hypertension with papilledema (optic disc swelling), retinal hemorrhages, or exudates and is considered a subset of hypertensive emergency

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16
Q

Hypertensive urgency

A

Marked htn that requires bp control within hours but without evidence of end organ damage

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17
Q

Targets for tx of essential htn for adults

A

<150/90
Grade A recommendation: Age >/= 60

DBP <90:
Grade A recommendation: Age 35-59
Grade E recommendation: Age 18-29

SBP <140
Grade E: Age <60,

<140/90
Grade E recommendation- for chronic kidney disease or diabetes, >18 years old

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18
Q

Classification of evidence behind JNC 8 guidelines

A

High quality: studies that are well designed

Moderate: studies that are okay

Low: studies that have many limitations

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19
Q

Classification of strength of recommendation A–> N

A

A: strong

B: moderate

C: weak

D: recommendation against

E: expert opinion- there is insufficient evidence or evidence is unclear or conflicting, but this is what the committee recommends

N: no recommendation for or against - insufficient evidence

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20
Q

Goal of lifestyle modifications and htn?

A

Reduce bp

Enhance anti-hypertensive drug efficacy

Decrease CV risks

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21
Q

What is the bp reduction associated with- weight reduction? Dash eating plan? dietary sodium reduction? physical activity? moderation of alcohol consumption?

A

Wt reduction: 5-20 mmHg/10 kg weight loss

DASH eating plan: 8-14 mmHg

Dietary sodium reduction: 2-8 mmHg

Physical Activity: 4-9 mmHg

Moderation of alcohol consumption 2-4 mmHg

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22
Q

Evidence based recommendations about lifestyle modifications: BMI, diet, sodium, physical activity, alcohol

A

BMI 18.5-24.9

DASH, USDA food pattern, or AHA eating plan (strong recommendation)

Lower sodium intake (strong); reduce sodium intake to 2.4 g (moderate)

Combine DASH and lower sodium (strong)

Engage in moderate to vigorous aerobic physical activity 3-4x/week, 40 min/session (moderate)

Limit alcohol to no more than 2 drinks (men) or 1 drink (women)

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23
Q

First line agent for most patients

A

Thiazide type diuretics: reduce morbidity and mortality; known benefits/SE profiles, inexpensive

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24
Q
A
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25
Q

What if the first line agent doesn’t optimize the bp?

A

Add another - ACEI, ARB, beta blocker, or calcium channel blocker

ACEI/ARB: best if CKD

CCB: best in black population

beta blockers are not recommended for initial drug therapy but can be used as add on thearpy

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26
Q

How do you treat stage 2 htn?

A

Most will require 2 drug combination

Usually thiazide + ACEI/ARB/BB/CCB

You can use a combo pill/start two at once:

  • hyzaar: hydrochlorothiazide and losartan
  • lisinopril-hydrochlorothiazide
27
Q

Initial dose and target dose of lisinopril

A

10 mg, 40 mg, 1/day

28
Q

losartan: starting dose, target dose, doses/day

A

50, 100, 1-2x/day

29
Q

metoprolol: starting dose, target dose, doses/day

A

50, 100-200, 1-2

30
Q

amlodipine: starting dose, target dose, doses/day

A

2.5, 10, 1x/d

31
Q

diltiazem: starting dose, target dose, doses/day

A

120-180, 360, 1

32
Q

chlorthalidone: starting dose, target dose, doses/day

A

12.5, 12.5-25, 1x/d

33
Q

hydrochlorothiazide: starting dose, target dose, doses/day

A

12.5-25, 25-100, 1-2x/day

Recommended dose is 25 mg to balance safety and efficacy

34
Q

3 goals of htn therapy

A
  • Reduction of cardiovascular and renal morbidity and mortality.
  • Treat to BP <140/90 mmHg in patients younger than 60 years, or patients wtih diabetes or chronic kidney disease.
  • Achieve a SBP goal <150/90 in persons >60 years of age.
35
Q

What are the drug treatment titration strategies? 3 total

A
  1. maximize first med before adding a second one
  2. add second med before reaching maximum dose of first med
  3. start wtih 2 med classes separately or as fixed dose combination
36
Q

Strategies to Combine and Titrate Antihypertensive Drugs (Thiazide, CCB, ACEI, ARB) to Achieve Goal Blood Pressure

A

A Start one drug, titrate to maximum, and then add a second drug
After adding the second drug, titrate up to the maximum recommended dose. Add a third drug if necessary (but do not use ACE and ARB together) and titrate up to the maximum recommended dose.

B Start one drug and then add a second drug before achieving maximum dose of the initial one
After reaching maximum dose of both drugs, add third drug if necessary (but do not use ACE and ARB together) and titrate up to the maximum recommended dose.

C Begin with 2 drugs at the same time, as 2 separate pills, or as a single pill combination
Some JNC 8 committee members recommend starting with 2 drugs when SBP is >160 mm Hg and/or DBP is >100 mm Hg, or SBP is >20 mm Hg above goal and/or DBP is >10 mm Hg above goal. After reaching maximum dose of both drugs, add third drug if necessary (but do not use ACE and ARB together) and titrate up to the maximum recommended dose.

37
Q
A
38
Q

When should you add another drug?

A

If goal BP is not reached within a month of treatment, increase the dose of the initial drug or add a second drug from any one of the classes in the recommended list

Add and titrate a third drug if necessary

If on 3 meds its not under control, refer to specialist

39
Q

What dictates max dose in a patient?

A
  • This may be the maximum allowed dose of a drug as set by a pharmaceutical manufacturer or federal drug enforcement agency. An example is metoprolol whose initial starting dose is 25 – 50mg/day and the maximum allowed dose is 400mg/day.
  • The maximum dose may be determined by the drug’s side effect profile. Metoprolol may have a maximum allowed dose of 400mg/day, however if the patient’s pulse is 58 at a metoprolol dose of 50 mg/day – then that is the maximum dose for the patient due to bradycardia.
  • The maximum dose may also be determined by patient preference. A patient may refuse to take sustained release nifedipine at 90 mg/day because the 90mg pills are too large. They may agree to take the smaller 60mg pill.
  • It is important to cite in your clinical notes why a patient has achieved a maximum dose of an anti-hypertensive drug.
40
Q

Tobacco and htn

A
  • Nicotine increases blood pressure and reduces the efficacy of blood pressure medications
  • Hypertensive patients should be vigorously encouraged towards smoking reduction and cessation at every visit by their physicians.
41
Q

When should patients with htn be monitored/come for follow up?

A
  • Patients should return for monthly follow up and adjustment of medications until the BP goal is reached.
  • More frequent visits for stage 2 hypertension or with complicating co-morbid conditions.
  • Serum potassium and creatinine should be monitored 1–2 times per year.
  • After blood pressure is at goal and stable, follow up visits at 3- to 6-month intervals.
  • Although not mentioned in JNC 7 or JNC 8, consideration should be given to periodic rechecking fasting cholesterol panels and glucose, and possibly urine microalbumin if initial surveillance was negative.
42
Q

Good drugs for heart failure

A

Thiazides, BB, ACEI, ARB, aldosterone antagonists

Diuretics reduce HF

Beta blockers reduce cardiac work demand

ACEI/ARB reduce afterload

Low dose aldosterone antagonists reduce morbidity and mortality in CHF but these agents should not be titrated to higher levels (neg outcomes)

43
Q

htn med for post-MI

A

BB, ACEI, aldo antagonists

44
Q

HIgh CAD risk

A

thiazide, ACE, CCB

45
Q

Diabetes

A

ACEI, ARB (initial)

thiazide, BB, CCB as addon

ACE inhibitors and ARBs are renal protective in addition to lowering blood pressure which makes these agents ideal first line choices for diabetes and renal disease.

Beta blockers in diabetics, contrary to common teachings, do not mask hypoglycemia and are actually excellent reducers of morbidity and mortality

46
Q

Chronic kidney disease

A

ACEI, ARB

47
Q

Recurrent stroke prevention

A

Thiazide, ACEI

48
Q
A
49
Q

Thiazide diuretics: what to look out for

A
  • May be a problem in urine incontinent patients or in elderly who become urine incontinent
  • Studies have shown that doses above 25mg a day of HCTZ (hydrochlorothiazide) does not decrease BP or morbidity and mortality
  • watch chemistry levels (hyponatremia or hypokalemia)
  • avoid in gout patients
  • start at lower doses in elderly who may be very sensitive
  • may slow demineralization in osteoporosis
  • may be associated with erectile dysfunction
50
Q

Loop diuretics

A
  • monitor electrolytes and creatinine
  • start at lower doses in the elderly
  • not included in JNC 8 treatment algorithm

Furosemide (lasix), bumetanide (bumex), torsemide, ethacrynic acid

51
Q

Beta bockers

A
  • check initial EKG and pulse
  • you don’t have to avoid in diabetic patients
  • excellent for use in tachyarrhythmias / fibrillation, migraines, essential tremor, and perioperative hypertension
  • usually avoided in patients with asthma and 3rd degree heart block
52
Q

ACEI

A
  • watch potassium (hyperkalemia), sodium (hyponatremia), and elevated creatinine levels
  • great for renal protection
  • reduces microalbuminuria
  • first line in renal disease
  • shown to have direct heart remodeling effects
  • a rise of up to 35% above baseline in creatinine is acceptable
  • ACE inhibitor cough is common in 15 – 20% of patients due to bradykinin production
  • Angioedema is a serious side effect to monitor in patients
  • avoid in pregnant women as they are Category C drugs
53
Q

ARB

A
  • reduces microalbuminuria and macroalbuminuria
  • shown to have heart remodeling effects
  • avoid in pregnant patients as they are Category C drugs
  • less bradykinin production
54
Q

Ca+ channel blockers

A
  • may be useful in Raynaud’s Syndrome
  • may be useful in certain arrhythmias
  • often causes leg edema (15-30% depending on different studies)
  • short acting calcium channel blockers are contraindicated for use in essential hypertension and hypertensive urgencies or emergencies
55
Q

Aldosterone Antagonists and Potassium Sparing Diuretics

A
  • may cause hyperkalemia
  • avoid in patients with K ≥ 5 prior to starting meds
  • low dose aldosterone antagonists reduce morbidity and mortality in congestive heart failure patients but increase sudden death at higher doses
56
Q

Alpha blockers

A
  • no proven decrease in morbidity and mortality demonstrated in research studies
  • not mentioned in JNC 7 or JNC 8 algorithms for treatment of essential hypertension
  • only useful as adjunct in hard to control blood pressure
  • may be useful in prostatism but should not be used as a first line anti-hypertensive in patients with BPH
57
Q

What is the definition of resistant hypertension as per JNC 7?

A

The failure to reach goal blood pressure in patients who are adhering to full doses of an approximate three drug regimen that includes a diuretic.

58
Q

Causes of resistant htn?

A

• Improper BP measurement
• Excess sodium intake
• Inadequate diuretic therapy
• Medication
o Inadequate doses
o Drug actions and interactions (e.g., nonsteroidal anti-inflammatory drugs (NSAIDs), illicit drugs, sympathomimetics, oral contraceptives)
o Over-the-counter (OTC) drugs and herbal supplements
• Excess alcohol intake
• Underlying identifiable causes of hypertension (secondary hypertension)

59
Q

Htn in women

A

Women are more likely than men to be aware that they have hypertension, to have medical treatment, and to actually have their blood pressure under control

D/C OCPs: can cause elevated bp in women

ACE inhibitors and ARBs may not be a good choice in women of reproductive age and / or may be trying to get pregnant

60
Q

Htn in minority patients:

A

BP control rates are lowest in Mexican Americans and Native Americans.

Prevalence, severity, and impact of hypertension is increased in African Americans.

African Americans demonstrate somewhat reduced BP responses to monotherapy with BBs, ACE inhibitors, or ARBs compared to diuretics or CCBs. But these differences are eliminated by adding adequate doses of a diuretic

61
Q

Htn in the elderly: special considration

A

An elderly person starts at lower doses but ends up on as much blood pressure medication as a younger person to control their hypertension

62
Q

What is the most common primary dx in america?

A

primary htn

63
Q
A

Primary Care (5 decks)

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