Hypertension Flashcards
Epidemiology of HTN
prevalence increases with age
MC Dx in primary care
More common in black than whites
HTN doubles the risk of what diseases
CV diseases
CHD
CHF
ischemic and hemorrhagic strokes, renal failure and PAD
what happens to systolic BP as we age
it rises
what happens wit SBP of women compared to men
after 60 SBP of women>men
distolic blood pressure increase until when
until age 55 then it decreases
SBP is a better predictor of what
better predictor of morbid events than DBP in older patients per JNC7
why is there such a low rate of control of HTN
poor access to health care and med
lack of adherence w/long term therapy
its a silent disease
major complications of HTN
hypertensive cardiovascular disease
Hypertensive cerebrovascular disease and dementia
kidney disease
atherosclerotic complications
what is the most common cause of death in HTN patients
hypertensive cardiovascular disease.
Major cause of morbidity and mortality in primary HTN
what is the result of Hypertensive cardiovascular disease
LVH-CHF-Ventricular arrhythmias-myocardial ischemia- sudden death
LVH regresses with therapy
complications from hypertensive cerebrovascular disease and dementia
stroke
important risk factor for ischemic stroke
more closely related to systolic vs diastolic
most important risk factor for the development of hemorrhagic stroke
high incidence of vascular and dementia
what is the second most frequent cause of death in the world
stroke
hypertensive kidney disease
the kidney is both a cause and a target of HTN
related to systolic BP
what is the secondary most common etiology of secondary HTN
Primary renal disease
who is HTN kidney disease more common in
blacks than whites
Diastolic BP is a more important cardiovascular RF than elevated SBP in who
younger patients w/o major comorbidities
what is the most important RF for development of hemorrhagic stroke
HTN
HTN is associated with a higher incidence of what 2 diseases
vascular and Alzheimers type dementia
what is a reliable marker of the severe chronic kidney disease
proteinuria
What are complications of Atherosclerotic
blood vessels may be a target organ for atherosclerotic disease secondary to long standing elevated BP
Aortic aneurysms/dissection
What effect does hypertensive therapy have on atherosclerosis
has a lesser impact on this type of complication
how is atherosclerosis controlled
control of multiple risk factors including but not limited to HTN alone
what is the definition of hypertension
a systolic BP of 140mmHg or higher or a diastolic BP of 90mmHg or higher
How is HTN diagnosed
need 2 or more reading on 2 separate occasions over one to several weeks to diagnose HTN
Prehypertension BP is
120-139 or 80-89
Stage 1 HTN is
140-159 or 90-99
Stage 2 HTN is
> 160 or >100
Isolated systolic HTN
> or= 140 and <90
What is essential HTN
makes up 80-95% of patients w/HTN
no single reversible cause, etiology unknown
secondary to multiple genetic and environmental factors
what are the risk factors for HTN
race (more common in blacks) Age (>55 for men, >65 for women) 1st degree relative w/HTN Obesity/Weight gain Diet high sodium/salt Excess ETOH intake Metabolic Syndrome Cigg Smoking Inactivity/sedentary lifestyle Dyslipidemia independent of obesity Polycythermia Vit-D deficiency Low potassium intake
what is metabolic syndrome
central obesity, hyperinsulinemia, insulin resistance, hypertriglyceridemia
what is white coat HTN
20-25% of patients w/stage 1 office HTN have white coat or Isolated office HTN
what are secondary causes of HTN
Primary Renal Disease Drug Induced Renovascular Adrenal Endocrine Disorders Obstructive Sleep Apnea Coarc of the Aorta Pregnancy HTN Genetic Disorders
What is primary renal disease (both acute and chronic)
renal parenchymal disease, (CKD) is the most common cause of secondary HTN
what is the most common cause of Secondary HTN
Chronic Kidney Disease
What drugs cause secondary HTN
Oral contraceptives NSAIDS Antidepressants Decongestants Cocaine Glucocorticosteroids
Arm to leg systolic BP Difference >20mmHg
*Delayed or absent femoral pulses
*Murmur
possible cause
Coarctation of the aorta
*Increase in serum creatinine concentration (≥0.5 to 1mg/dL) after starting ACEI or ARB
*Renal artery bruit
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Renal artery stenosis
What are the 2 types of HTN treatment
Nonpharmacological
Pharmacological
What is the primary goal in HTN treatment
prevent organ damage
What is the secondary goals of HTN treatment
Minimize side effects, minimize patient cost
Increases adherence
Treat comorbid conditions
What are the benefits of treatment
Lowering SBP by 10-12mmHg and DBP by 5-6mmHg confers relative risk reduction of
HTN control is the single most effective intervention for slowing the rate or progression of HTN-related chronic kidney disease
Short term reductions of BP in hypertensive patients over 65 provide greater benefits than that observed in younger patients
What are nonpharmacological lifestyle modifications
Dietary Salt restriction 2.4-6g Weight loss (BMI 18.5-24.9) DASH diet(fruits/Veg, high protein/fiber, low fat dairy, reduced saturated and total fat low red meat) Exercise (30min/day regular) Decrease Alcohol intake <1/day female Vit-D intake Adequate Potassium intake Smoking cessation Limit NSAID Educate patients
What are the pharmacological options?
Diuretics β-Blockers Angiotensin-Concerting Enzyme Inhibitors (ACE-I) Angiotensin II Receptor Blockers (ARB’s) Renin Inhibitors Aldosterone Receptor Antagonists Calcium Channel Blockers (CCB) α-Adrenergic Antagonists Drugs w/ Central Sympatholytic Action Direct Vasodilators
How much do most drugs reduce SBP by
7-13mmHg and DBP by 4-8mmHg
Most patients require combination agents to achieve goal BP
How do Diuretics work
Decrease plasma volume initially, but in long term use they reduce peripheral vascular resistance
What are type of Diuretics
Thiazides
Loop
K+ retaining
What are side effects with Thiazides and Loop and who should you be careful using them with
hypokalemia, insulin resistance, increase cholesterol, increase uric acid
Use w/ caution in diabetics, dyslipidemia, gout, hypokalemia
Who do you use Loop diuretics with
pts w/ reduced GFR and CHF
What are K+ retaining diuretics used for
Weak anti-hypertensives, but may be used in combo w/ a thiazide to protect against hypokalemia
What is 1st line treatment for patients with uncomplicated HTN
Thiazide diuretics
Chlorthalidone is drug of choice
More potent in black and older individuals and obese pts
Beta blockers MOA
Decreases heart rate and cardiac output
What are the side effects of B-blockers
Induce or exacerbate bronchospasm in predisposed patients, bradycardia or AV block, nasal congestion, Raynaud’s phenomenon and CNS symptoms
Abrupt withdrawal can precipitate acute coronary events and severe increases in BP therefore if/when d/c medication, taper slowly
What are beta blockers indicated for?
patients w/ Angina pectoris, post MI, CHF, sinus tachycardia, ventricular tachyarrhythmias
Who do we cautiously use beta blockers with
in patients w/ Type I DM and patients w/ advanced peripheral vascular disease associated w/ rest pain or non-healing ulcers
who are beta blockers contraindicated with?
in asthma, COPD, 2nd or 3rd degree heart block and sick sinus syndrome
how does ACE-Inhib work
Inhibit the renin-angiotensin-aldosterone system
�Effective as monotherapy or in combo w/ diuretics, CCBs and alpha blocking agents
What are the Benefits ACE-I
Side effects
Benefits: Renoprotective
Results in a significant reduction in all cause mortality
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S/E:hyperkalemia, cough, skin rashes, angioedema
Who do ACE-I/Angiotensin II RB work best for
More effective in younger white patients and less effective in blacks and older patients
Who are ACE-I/Angiotensin II RB the drug of choice for?
CHF and Diabetics
they delay the progression of end stage renal disease
Who is ACE-I/Angiotensin II RB contraindicated with
in pregnancy, b/l renal artery stenosis and hyperkalemia
ACE-I others info
Severe hypotension can occur in patients w/ renal artery stenosis (induce acute renal failure that reverses with d/c of ACE-I)
Abrupt increase in creatinine
Angiotensin II receptor blockers MOA
Provide selective blockade of angiotensin receptors
Angiotensin II RB Side effects
hyperkalemia
Do not reduce all cause mortality like ACEI do, but they are renoprotective (delay onset of kidney failure)
Renin inhibitors MOA
Blockade of the renin-angiotensin system
Renin inhibitors info
Aliskiren is the first oral renin inhibitor
As effective as an ACEI or ARB in monotherapy, but not more effective
Not considered a first line agent
Aldosterone Antagonists
Ex. Spironolactone
Effective in resistant HTN and can be used in combination w/ other classes
What other conditions are Aldosterone antagonists indicated for
CHF due to systolic dysfunction and primary aldosteronism
What are the contraindications of Aldosterone antagonists
renal failure and hyperkalemia
what are the side effects of Aldosterone antagonists
Ex. Spironolactone
Effective in resistant HTN and can be used in combination w/ other classes
CCB MOA
Act by causing peripheral vasodilation
What are the 2 types of CCB
Dihydropyridines
Nondihydropyridines
Dihydropyridines
nifedipine
nonDihydropyridines
Verapamil & Diltiazem
Nondihydropyridines should not be combined with
beta blockers because the risk of bradycardia
what are side effects with CCB
H/A, peripheral edema, bradycardia, constipation
CCB indications
Black people respond well to CCB
Nondihydropyridines are also used post
-MI, in supraventricular tachycardias and angina
CCB Caution/contraindications:
Nondihydropyridines: 2nd or 3rd degree heart block
A-adrenergic antagonist MOA
Decrease peripheral vascular resistance
A-adrenergic antagonist indications and benefits
Effective as monotherapy only in men w/ symptomatic BPH (benign prostatic hypertrophy)
Other indications: Pheochromocytoma
Benefits: Increase HDL cholesterol and lower TC
α-Adrenergic Antagonists side effects
Common and include marked hypotension after the 1st dose, post dosing palpitations, HA and nervousness.
Previous and current use can complicate patients undergoing cataract removal resulting in “floppy iris syndrome
Sympatholytic agents MOA
Centrally acting α-2 sympathetic agonists decrease peripheral resistance
Sympatholytic agents
Infrequently used d/t drug intolerance (sedation, fatigue, dry mouth, postural hypotension, erectile dysfunction and drug-drug interactions)
*Methyldopa- used in pregnancy
Direct Vasodilators MOA
Decrease peripheral vascular resistance
Direct vasodilators
Use
Side effect
Not used as monotherapy, but in combo w/ diuretics and B-blockers in resistant pts
What to start initial mono therapy
Used only in the absence of a specific indication and if the BP is <20/10mmHg above goal BP
what are the 3 main classes used to initial mono therapy
Thiazide diuretics
Long lasting CCB
ACE inhibitor or ARB
When to use combo therapy
Used when the BP is more than 20/10mmHg above goal or SBP is >160 and/or DBP is >100
What drugs are used for combo therapy
Typically consists of a Diuretic plus either an ACEI/ARB or CCB
Adding a second drug in combo therapy info
Combo therapy from drugs from different classes has a better BP lowering effect than doubling the dose of a single agent
Higher doses results in increased side effects and it does not mean you will get double the effect
Recommend adding an ACE-I/ARB to a Thiazide or CCB
Resistant HTN deifinition
DBP >90mmHg despite 3 or more anti-hypertensive medications including a diuretic
One or more reasons for resistant HTN
Suboptimal therapy
Volume Overload
Poor compliance w/ medical or dietary therapy
Secondary HTN
Pseudoresistance: Office or “white coat” HTN
Ingestion of substances that can elevate the BP
Associated Conditions: smoking, weight gain, increased ETOH intake, DM, Sleep Apnea, Anxiety, or chronic pain
What to do when following up with a patient with HTN
Reinforce lifestyle modifications at EVERY visit
Reassess risk factors at every visit
Screen for side effects at every visit
Once BP is controlled on a well tolerated regiment
Recommend f/u q6months if at low risk
Recommend f/u q3 months if at high risk
Yearly monitoring of labs (BMP, lipids) if at low risk
Biannual monitoring of labs (BMP, lipids) if at high risk or there are underlying medical conditions
EKG q2 years unless otherwise indicated (risk factors, age or hx of an abnormal EKG)
What is step down therapy
ome pts w/ Stage I HTN are well controlled on a single med or combo
After a period of years w/ a successful lifestyle modification and BP lowering medication, you can consider decreasing the dosage and/or d/c med.
The best way to treat high risk HTN pts
Aggressive Tx early in high risk patients to prevent cardiovascular problems and target organ damage
Consider other medications such as low dose ASA and lipid-lowering agents, etc to treat underlying/co-morbid conditions
�Patient Education is the key to better compliance and BP control!!!
HTN Treatment Goals As per JNC8 guidelines: General population ≥ 60 y: General population <60 y: Population aged ≥18 y with CKD or DM
<140/90
