Hypertension Flashcards
Risk factors for hypertension
age family history tobacco use excessive alcohol use low SES obesity high sodium diet sedentary lifestyle psychosocial stress intrauterine abnormalities
Describe changes in blood pressure that occur with aging
- systolic pressure increases with age
- diastolic increases until age in 50s then decreases
Lifetime risk of hypertension is about __% for adults that are non-hypertensive at age 55 and live to be 80-85 years old
90%
Until age 45, do men or women have higher prevalence of hypertension?
Men
After age 65, to men or women have a higher prevalence of hypertension
Women
Hypertension is defined based on the level of pressure associated with what outcome?
Doubling of long term cardiovascular risk
True or false: pre-hypertension is not associated with increased risk of future cardiovascular disease
False, pre-hypertension is associated with higher CV risk as compared to individuals with normal blood pressure
Also greater risk of chronic kidney disease with even mildly elevated blood pressure
Blood pressure of 145/92 would be categorized as stage ___ hypertension
Stage I
Normal: 160/>100
List secondary causes of hypertension
sleep apnea chronic renal disease primary aldosteronism renovascular disease drug related causes pheochromocytoma coarctation of the aorta thyroid disease parathyroid disease Cushing's syndrome
In which group is hypertension more prevalent: African Americans or non-Hispanic whites?
African Americans
In the US, which ethnic group has lowest rates of controlled hypertension?
Mexican Americans
In the US, which ethnic group has highest age adjusted hypertension related mortality rate?
Puerto Rican Americans
Beginning with a baseline of 115/75, the risk of cardiovascular disease event doubles with each incremental rise of ____ mg systolic and ___ mg diastolic
20 mm Hg systolic/ 10 mm Hg diastolic
What is considered the fundamental defect in primary hypertension?
Control/ regulation of blood pressure (by way of regulation of resistance in blood vessels)
Describe short-term, intermediate, and long-term mechanisms that respond to elevated blood pressure
short-term: cardiovascular reflexes (baroreceptors, chemoreceptors)
intermediate: capillary fluid shifts, vascular compliance, hormones
long-term: kidneys regulate volume
Persistent hypertension develops in response to an increase in __________ or ____________
cardiac output
systemic vascular resistance
Mean arterial pressure is a function of:
- the rate at which the heart pumps blood into large arteries
- the rate at which blood flows out of large arteries into smaller arteries
- arterial wall compliance
MAP=
MAP = DBP + 1/3(SBP – DBP)
SVR=
SVR = (MAP – CVP)/CO
Describe the link between obesity and hypertension
- insulin has direct action on kidney to stimulate sodium retention
- leptin, produced by white adipose, correlates with increased blood pressure
- RAAS is abnormally activated in obesity
Describe the link between dietary sodium intake and hypertension
Promotes: Renal sodium retention Extracellular-fluid volume expansion Vascular smooth-muscle cell contraction Increased systemic vascular resistance
List some populations that are more likely to be sodium sensitive
elderly, Afro-Caribbean race, DM type 2, familial genetic influence, obesity, use of NSAIDs
Describe effects of the SNS that are linked to the development of hypertension
vasoconstriction, tachycardia, renin release, vascular remodeling, and renal sodium retention
SNS activity is increased with age, weight, and ______
Systemic vascular resistance
Younger patients with hypertension tend to have higher circulating levels of __________, augmented SNS activity, and heightened vascular reactivity
catecholamines
What converts circulating angiotensinogen to angiotensin I
Renin
What converts angiotensin I to angiotensin II
ACE
The AT1 receptor is _______ type, and its activation causes:
G protein coupled
causes: vasoconstriction, increased blood pressure, cardiac hypertrophy, smooth muscle proliferation
List some major complications of hypertension
increased afterload–> heart failure, myocardial ischemia and infarction
arterial damage–> atherosclerosis –> aneurysm, stroke, nephrosclerosis/ renal failure, retinopathy
List three conditions that cause production of renin to be activated
- decreased delivery of sodium to macula ensa
- decreased renal perfusion
- renal stimulation by SNS
In addition to converting Ang I to Ang II, ACE also ________________
Degrades bradykinin (causes vasoconstriction, blood pressure elevation)
Angiotensin II stimulates release of ________
aldosterone
List some effects of aldosterone
- increase sodium and water reabsorption
- mediates renal vascular remodeling
- contributes to endothelial dysfunction
- stimulates inflammatory response
The ultimate public health goal of anti-hyeprtensive therapy is to do what?
decrease CV and renal morbidity and mortality
List some key lifestyle modifications and their relative contribution to lowering systolic blood pressure
Weight reduction (5-20mm Hg) DASH diet (8-14 mm Hg) Reduce dietary sodium (2-8 mm Hg) Physical activity (4-9 mm Hg) Moderation of EtOH consumption (2-4 mm Hg) Smoking cessation (3.5 mm Hg)
Describe components of the DASH diet
Low in cholesterol and saturated fat
Emphasis on fruits, vegetables, low fat dairy
Reduce red meat, sugar
Most dietary sodium comes from:
Restaurant and processed foods
Weight loss of as little as ____ lbs reduced blood pressure and prevents hypertension in overweight adults.
10 lbs- CV benefits occur before a patient’s target weight
If there is a difference of >15mm Hg systolic pressure when measuring blood pressure in both arms, follow up should include an evaluation for…
Sublcavian stenosis (lower blood pressure on the affected side)
Normal hemodynamic response when transitioning from supine to standing
- decrease of 5-10 mm Hg systolic pressure
- increase of 5-10 mm Hg diastolic pressure
- increase of 10-20 bpm heart rate
Diagnosis of orthostatic hypotension
- decrease of > 20 mm Hg systolic pressure
- decrease of > 10 mm Hg diastolic pressure
- symptoms of cerebral hypoperfusion
What is the recommended follow up for a patient with normal blood pressure
Recheck in 2 years
What is the recommended follow up for a patient with inital blood pressure suggesting pre-hypertension
Recheck in 1 year
What is the recommended follow up for a patient with inital blood pressure suggesting stage I hypertension
confirm within 2 months
What is the recommended follow up for a patient with inital blood pressure suggesting stage II hypertension
evaluate or refer within 1 month
If >180/110 evaluate and treat within 1 week
24 hour ambulatory blood pressure monitoring is used to rule out
- white coat hypertension
- masked hypertension
- nocturnal hypertension
List some causes of falsely elevated blood pressure readings (pseudohypertension)
cuff too small talking or active listening back unsupported/ feet not on floor/ legs crossed full bladder recent smoking, exercise arm not supported
List three initial objectives for evaluation of a patient newly diagnosed with hypertension
- identify secondary causes of hypertension
- identify other CV risk factors
- assess for target organ damage
List components of the physical exam for evaluation of hypertension
check bp in both arms
check orthostatic blood pressure
CV exam (palpate precordium, auscultate)
vascular exam (pulses, auscultate for bruits)
thyroid exam
abdominal exam for masses, aortic pulsation
lower extremity exam for edema
evaluate optic fundi for vascular changes
What labs should be ordered for evaluation of hypertension
urinalysis blood glucose hematocrit serum potassium serum calcium serum creatinine TSH fasting lipid pannel GFR ECG
What is the treatment goal (blood pressure) for patients with hypertension
140/90
if older than 80 years, goal is 150/90
What is the FDA black box warning for all drugs that inhibit steps in the RAAS system, and why?
- Do not use ACE-inhibitors, angiotensin receptor blockers, or renin inhibitors in pregnant women or women planning on becoming pregnant
- Angiotensin II is necessary for normal fetal kidney development
What is intrinsic sympathomimetic activity, and what drug used to treat hypertension shows sympathomimetic activity?
Pindolol causes weak B adrenergic activation because it is a partial agonist at B receptors, not a pure antagonist. This drug will decrease the resting heart rate and cardiac output less effectively than drugs without ISA but it does prevent the effect of catecholamine stimulation on the heard during exercise and stress
Define resistant hypertension
BP ≥140/90 mmHg while on 3 different BP medication classes (incl. diuretic)
or on 4 antihypertensive drug classes regardless of blood pressure
List criteria for diagnosis of resistant hypertension
Exclude pseudo-resistance
Identify and reverse contributing factors
Discontinue/minimize interfering substances
Screen for secondary causes
What are some factors that affect patient adherence
Misunderstanding of condition or need for treatment
Absence of symptoms
Adverse effects of medications
Cost and simplicity of medication regimen
Cost of follow-up visits
Perceived lack of involvement in care plan
