hypertension

Question 1

definition of HTN

Answer 1

equal to or greater than 140/90 mmHg

need at least 3 occasions to diagnose

Question 2

risk factors for HTN

Answer 2

age
smoking
excessive alcohol
excessive Na
physical inactivity
obesity
diabetes
family history
race: more common in blacks (also worse morbidity and mortality associated with HTN)

Question 3

most common cause of hypertension

idiopathic

Answer 3

primary hypertension: essential hypertension

Question 4

causes of secondary hypertension

Answer 4

renal artery stenosis (most common)
chronic kidney disease (CKD) or end stage renal disease (ESRD)
meds: OCPs, NSAIDs, antidepressant, glucocorticoid
illicit drugs: cocaine, amphetamines
adrenal disease: hypercortisolism (Cushing syndrome), hyperaldosteronism (Conn syndrome), pheochromocytoma
hypothyroidism OR hyperthyroidism
↑Ca (smooth muscle contraction, vasoconstriction) due to hyperparathyroidism
coarctation of aorta
obstructive sleep apnea

Question 5

complications of hypertension

Answer 5

left ventricular hypertrophy (form of early end-organ damage due to HTN)
aortic dissection
severe hypertension

Question 6

↑ arterial blood pressure →↑ afterload (back pressure) on left ventricle → work hard to pump against ↑ afterload

Answer 6

left ventricular hypertrophy

Question 7

complications of LVH

Answer 7

↑ myocardial O2 demand (more tissue to oxygenate)
LV becomes stiffer (less compliant)
LV holds less blood during diastole (thickened muscle grows inward into lumen of LV + stiff and can’t relax to fill with blood)
result: left sided heart failure + MI risk

Question 8

heart sound heard with stiffened left ventricle

Answer 8

S4

Question 9

tear in INTIMA (inner layer) of aorta → blood between layers of media → false lumen → blood pumped into 2 lumens

Answer 9

aortic dissection

Question 10

blood vessel layers

Answer 10

intima (inner)
media
adventitia (outer)

Question 11

2 main causes of aortic dissection

Answer 11

HTN (ASCENDING - most common cause)

aortic disease: cystic medial necrosis from Marfan syndrome

Question 12

“tearing” chest pain radiates through to the BACK

may have HIGH bp

Answer 12

aortic dissection

Question 13

WIDENING of mediastinum on CXR (need to follow up with CT with contrast)

Answer 13

aortic dissection

Question 14

type of aortic dissection that involves ASCENDING AORTA or AORTIC ARCH (regardless of how far it travels down)

Answer 14

stanford type A

require SURGERY (life-threatening)

Question 15

type of aortic dissection that is confined to DESCENDING AORTA (distal to L subclavian artery)

Answer 15

stanford type B

require drugs
B = below branches

Question 16

antihypertensive DOC for aortic dissection

Answer 16

B blocker: reduce arterial pressure + reduce slop of rise of blood pressure (due to contracting beat of heart - does the most damage with aortic dissection)

Question 17

definition of HTN urgency

Answer 17

equal to or greater than 180/120 mmHg

WITHOUT end-organ damage (EKG changes, headache, vision, chest pain, renal insufficiency, flash pulm edema)

Question 18

definition of HTN emergency

Answer 18

equal to or greater than 180/120 mmHG

WITH end-organ damage

Question 19

treatment of HTN urgency or emergency

Answer 19

lower bp quickly: short-acting (IV infusion that can be titrated)
IV nitroprusside (cyanide toxicity)
IV labetalol

Question 20

hypertension + high bp in arms, low bp in legs

Answer 20

coarctation of arota

Question 21

hypertension + young individual with acute onset tachycardia

Answer 21

stimulant:
cocaine
amphetamine

Question 22

hypertension + proteinuria

Answer 22

kidney disease

Question 23

hypertension + hypokalemia

Answer 23

hyperaldosteronism

renal artery stenosis: sense low bp →↑ aldosterone →K+ wasting

Question 24

hypertension + hyperkalemia

Answer 24

renal insufficiency

Question 25

hypertension + tachycardia, heat intolerance, diarrhea

Answer 25

hyperthyroidism

Question 26

hypertension + onset between 20-50 yo

Answer 26

essential HTN

Question 27

hypertension + family history of HTN

Answer 27

essential HTN

Question 28

hypertension + paroxysms of increased sympathetic tone: anxiety, palpitations, diaphoresis

Answer 28

pheochromocytoma

Question 29

hypertension + abdominal bruit

Answer 29

renal artery stenosis

Question 30

treatment of hypertension

Answer 30

• diuretics (hydrochlorothiazide)
• ACEi (-pril)
• ARBs (-sartan)
• adrenergic-acting drugs:ß blocker, α blocker
• centrally-acting adrenergic drugs: clonidine, α-methyldopa
• Aliskiren
• vasodilators:dihydropyridine CCB, hydralazine, minoxidil, nitrates

Question 31

save antihypertensive meds for pregnancy

Answer 31

Hypertensive Moms Love Nifedipine
Hydralazine
Methyldopa
Labetalol
Nifedipine (or other dihydropyridine CCBs)

Question 32

antihypertensive that can cause drug-induced lupus

Answer 32

hydralazine

SHIPP: sulfasalazine, hydralazine, isoniazid, procainamide, phenytoin

Question 33

what antihypertensives ↓ preload and/or afterload (can be helpful for CHF or acute MI)

Answer 33

↓afterload: hydralazine (arteries)
↓ preload: nitrates (veins)
both: ACEi/ARB (both cause hyperkalemia and may need to use hydralazine + nitrate instead)

Question 34

antihypertensives proven to improve survival in CHF patients

Answer 34

ACEi
ARBs
Aldosterone antagonists
B blockers: carvedilol, metoprolol, bisoprolol

symptomatic relief: loop diuretic

Question 35

what substances act on smooth muscle myosin light chain kinase

Answer 35

dihydropuridine CCB
epinephrine - B2 R
PGE2
smooth muscle relaxation → vasodilation →↓ bp