hypertension Flashcards
hypertension is
elevation of systemic arterial pressure above deemed to carry excessively high risk
what is BP
CO x SVR
- pressure of blood in artery
- specific location in body and time
- function cardiac output and PVR
- influenced by genetic and environmental factors
HTN is a major riskactor for
cardiovascular morbidity and mortality
benefit for lowering BP with antihypertensive treatment
decrease 35-40% stroke
decrease 20-25% MI
decrease 50% CHF
one of the biggest problems for treating HTN
non-compliance
- 40% stay on meds over 10 years
- 40% new patients stop medications
other non compliance issues
expenses
follow up issues
detrimental issues for HTN
obesity sedentary life style salt intake excessive water intake alcohol caffeine
detrimental drugs for HTN
cigarettes NSAIDS recreational drugs decongestants herbal supplements
hormonal regulation of BP
diagram
goals of therapy: isolated HTN, DM, CKD
<150/90
things to look for when someone is being treated
resistant HTN
->140/90 despite 3 drugs
30% need more than 3 drugs anyway
-<30% can get by with 1 drug alone
pathology of systemic HTN
intimal thickening and atherosclerosis
findings on exam
LV enlargement HTN nephrosclerosis intracranial bleeding thromboembolic episodes disease of retina
stages of HTN: normal
<120/80
preHTN
120-139/80-89
stage 1 HTN
140-159/90-99
-treat with diuretics (combo of ACEI, ARB, BB, CCB)
stage 2 HTN
> 160/ or >100
-2 drug combo, diuretics and ACEI, ARB, BB or CCB)
malignant HTN
over 200/130 in presence of retinal abnormalities and often acute vascular damage
risk of complications are
proportional to BP without threshold
how to measure BP to diagnose
3 readings at least 1 week apart
technique
- two readings at least 5 mins apart
- initially take BP in both arms, pick higher value
how is one positioned while having BP taken
- sit quietly for 5 mins
- back supported
- arm supported at heart level
- no caffeine
- quiet, warm setting
first diagnosis of HTN
- not on anti-hypertensives medications
- not acutely ill
- based on average of >2 readings taken at 2 office visits after initial screening visits
- BP should be measured using certified equipment
- proper BP measuring technique should be used
common presentation of HTN patients
often no complaints
- morning headaches (occipital)
- less often change in vision
- palpitations or chest discomfort
- fatigue or shortness of breath with exertion
important past medical history
- prior HTN
- angina
- kidney disease
- diabetes
- drugs
- family history of renal disease of HTN
- alcohol
primary (essential) HTN
no known identifiable etiology
-accounts for 90% of HTN individuals
what to look for in secondary HTN
about 5-10% of patients
- renal parenchymal disease
- renovascular HTN
- coarctation of aorta
- endocrine HTN
- obstructive sleep apnea
- drug induced
secondary HTN
- identifiable etiology
- often cause of resistance HTN
- patients often younger (less than 30) and older (more than 50)
- proscribed treatment options even surgery may be curative
secondary HTN causes
- CKD
- hyperaldosteronism
- renal artery stenosis
- pheochromocytoma
- coarctation of aorta
- hyperthyroidism
- hyperparathyroidism
- cushing’s syndrome
most common cause of secondary HTN
CKD (chronic kidney disease)
- renal parenchymal disease-> CKD, acute, chronic GN orther AKI
- sodium and volume retention
renal causes of secondary HTN
- renal parenchymal disease
- renovascular HTN: atherosclerosis, fibro-muscular dysplasia (women)
- renin production excess
endocrine causes of HTN
hyperaldosteronism, pheochromocytoma, hyper/hypoT, hyperpara, cushing’s, acromegaly, insulin resistance, pregnancy (3rd trimester), oral contraceptives
coractation of aorta
- HTN in children
- exam clues: asymmetric BP, brachial-femoral delay
drug induced HTN
oral conctraceptives NSAIDs some anti-depressants alcohol stimulants decongestants
clues for secondary HTN on physical exam
- prolonges abdominal bruit-> renal artery stenosis
- decreased or diminished femoral pulses-> coarctation
- renal calculi-> hyperparathyroidism
- hypert-> sweating heat intolerance, weight loss, hair loss, tremor
- abdominal striae-> cushings: central obesity, moon faces
- paroxismal H/A, pallor, palpitations-> Pheochromocytoma
treatments of secondary HTN
depends on what it is
pheochromocytoma: surgery
contraceptives: discontinue
primary HTN associating factors
- genetic
- race
- salt sensitivity
- gender (male more likely)
contributing factors for 1 HTN
- salt diet in face of imparied Na excretion
- obesity
- metabolic syndrome
- occupation and stress level
- NSAIDS use
- family size and crowding
- gender
- race
major risk factors for 1 HTN
- obesity
- elevated lipids
- DM
- cigarette
- inactivity
- micro-albuminuria
- age
- family history
kidney role in 1 HTN
most patients with essential HTN do NOT have high renin levels
-renin levels often inappropriately normal (not suppressed)
CO and PVR in primary HTN
- CO: NORMAL in most patients
- PVR is elevated
- plasma renin are normal (inappropriately, should be suppressed)
physical examination of primary HTN
- arterial BP
- target organ disease evaluate
- loud second heart sound (A/P) and S4 gallop
- bruits in carotids, abdomen, thorax
- neurological exam
- coarctation: pressure in legs
- fundascopic exam: look for chronic/acute changes in fundus
- look for evidence for secondary causes
what can be done to check for faulty readings
- measure BP after 5 mins of sitting quietly
- take 3 measurements
- arm supported at heart level
- no smoking within 30 mins of measurement (can raise BP 5-20 mmHg)
lab test for HTN
- U/A
- electrolytes: mainly potassium, calcium
- BUN and creantinine
- FBS
- lipids
- ECG
special tests for HTN
- aldosterone levels
- TSH
- renin
- renal artery dopple/CT, or MRI if suspect renovascular
- dexamethasone suppression test or 24 hr urinary free cortisol measurement
- 240hr catecholamines (VMA, metanephrines) in urine if Pheo suspected
what should be take into consideration with treatment
- benefits, costs, risks
- want to treat disease
- lose weight if obese (can lower systolic BP up to 5-20 for losing 10kg)
how to determine risk
- history (diabetes, family history of cardiovascular disease, smoking, physical activity)
- physical exam
- ECG
- lab tests
direct treatment toward specific risks
weight loss regular physical activity decrease alcohol stop smoking decrease sodium intake increase Ca and K avoid certain drugs (NSAIDs, steroids, stimulants, decongestants, appetite suppressants)
DASH Diet
Dietary Approaches to Stop HTN
- fruits, vegies, low in fats (see 8-14 drop in 8 weeks)
- low sodium
- exercise 30 mins (drops 4-8)
- reduce alcohol (2 for men and 1 for women)
goals
- 140/90, but try to get 130/80 (risk factors DM, carotid disease, AAA, CHF, CR, CAD, PVD)
- systolic <60
when to use drugs
-when lifestyle change not enough
classes of drugs
diuretics CCB ACE-I ARB anti-adrenergics vasodilators
drugs if have CAD and HTN
non-dihydropyridine CCB, ACE-I,
drugs for RF, DM, vascular disease and HTN
ACE-I, ARB
drugs for CHF and HTN
BB, ACE-I, aldosterone
drugs for dementia and HTN
some CCB’s, ACE-I, Altace
drugs for prostatism and HTN
hytrin
ACE-I are preferred
DM, and those with mild to moderate kidney disease (but monitor)
ACE-I and diuretics best for
CHF
avoid B-blockers with
patients with bronchospastic disease and in black and younger people, diabetics on insulin (hypoglycemia)
what do CCB have risk of
short acting CCB increased risk of hypotension and MI
what do african americans do better with
CCB and diuretics
what drug should be used first
- diuretics
- reduction of morbidity from cardiovascular complications
- cheap
- effectiveness
- well-tolerated
if someone isn’t responding to diuretics, why could that be?
have hyperaldosternism
causes of resistance HTN
- improper BP measurement
- excess sodium intake
- inadequate diuretic therapy
- medication
- excessive alcohol intake
drugs for heart failure and HTN
diuretics, BB, ACEI, ARB, aldo ant
drugs for post MI and HTN
BB, ACEI, aldo ant
drugs for high CVD risk and HTN
diuretics, BB, ACEI, CCB
drugs for those with diabetes and HTN
diuretics, BB, ACEI, ARB, CCB
drugs for those with CKD and HTN
ACEI and ARB
drugs for those with recurrent stroke prevention and HTN
diuretics, ACEI
