Hypertension

Question 1

essential (primary) vs secondary HTN

Answer 1

Essential: we don’t know what causes it. Secondary: known cause

Question 2

Prevalence of essential hypertension in US

Answer 2

50-60 million people

Question 3

Lifetime risk of developing hypertension

Answer 3

90% lifetime risk for person who is 55yrs and normotensive

Question 4

Is systolic or diastolic BP more important as CVD risk factor?

Answer 4

For people over 50 yrs, systolic is more important

Question 5

Guyton hypothesis of essential hypertension

Answer 5

Primary defect in renal sodium excretion > increased plasma volume > increased cardiac output > autoregulatory increase in systemic vascular resistance > increase in BP (and afterload mediated normalization of CO)

Question 6

Cellular hypothesis of essential hypertension

Answer 6

in vascular smooth muscle cell, inhibition of Na/K pump leads to elevated cell Na levels and decreased Na/Ca exchange (which normally pumps Na in and Ca out), so cell Ca levels increase. This increases systemic vascular resistance and thus increases BP

Question 7

Percent reduction in stroke, MI and heart failure with lowering BP

Answer 7

stroke: 35-40%. MI: 20-25%. Heart failure : 50%

Question 8

BP goal in patients with diabetes or chronic kidney disease

Answer 8

<130/80

Question 9

Describe how the following lifestyle modifications affect systolic BP: weight reduction, DASH eating plan, dietary sodium reduction, physical activity, moderation of alcohol

Answer 9

weight reduction: 1-20mmHg/ 10Kg weight loss. DASH eating plan: 8-14mmHg. dietary sodium reduction: 2-8mmHg. physical activity: 4-9mmHg. moderation of alcohol: 2-4mmHg

Question 10

algorithm for treatment of hypertension

Answer 10

lifestyle modification first. 1) Without compelling indications: a. stage 1 hypertension- thiazides, consider ACEI, ARB, BB, CCB or combo. B. stage 2 hypertension- 2 drug combo of thiazide, ACEI, ARB, BB or CCB. 2) Wit compelling indications- drugs for compelling indications

Question 11

classification of HTN from JNC-7

Answer 11

normal: 120/80. Pre-HTN: 120-139/80-89. stage 1 HTN: 140-159/90-99. Stage 2 HTN: >160/>100

Question 12

When is ambulatory monitoring of BP used?

Answer 12

when office and self measurement don’t match up

Question 13

causes of secondary hypertension

Answer 13

Chronic kidney disease, drugs, primary hypoaldosteronism

Question 14

19yr old with 180/120 BP, loud abdominal bruit,

Answer 14

renal artery stenosis -fibromuscular hyperplasia in one of the renal arteries

Question 15

symptoms of fibromuscular hyperplasia causing renal artery stenosis

Answer 15

rapid onset HTN

Question 16

how to test for unilateral renal artery stenosis

Answer 16

ultrasound to look for blood flow (doppler), renal angiogram, MRI, CT with contrast, measure renin in right vs left renal vein (the elevated renin will be present in the blocked kidney b/c the kidney makes renin in response to decreased GFR)

Question 17

Treatment for renal artery stenosis

Answer 17

HTN meds in the short run (ie. ACEI, ARBS), fix artery with stent or bypass the artery with another artery (best)

Question 18

16 yr old w/ BP 140/92 (was normal 4 weeks ago), Na is 145, K is 2.5, bicarb 30,

Answer 18

metabolic alkalosis- primary aldosteronism

Question 19

First test for hypokalemia

Answer 19

urine K- if low it is extrarenal, if high it is renal

Question 20

causes of elevated aldosterone levels

Answer 20

secondary aldosteronism (high renin causes high aldosterone), or primary aldosteronism (not driven by something else)

Question 21

types of primary aldosteronism

Answer 21

Aldosterone producing adenoma, idiopathic adrenal hyperplasia (bilateral)

Question 22

Test to determine whether primary aldosteronism is unilateral or bilateral

Answer 22

Measure adrenal veins for aldosterone- the adrenal vein with elevated aldosterone is the side that is affected.

Question 23

Treatment for aldosterone producing adenoma

Answer 23

Remove adrenal gland

Question 24

treatment for idipathic adrenal hyperplasia

Answer 24

Cant remove both adrenals- treat with spironolactone for life