Hypertension Flashcards
History in confirmed hypertension
- Duration and Previous treatment
- Past/current symptoms
IHD
Heart failure
Cerebrovascular disease
Peripheral arterial disease - Symptoms of CKD
Oliguria
Nocturia
Hematuria - Suggestions of secondary cause
Cushings: weight, mood, acne, myopathy, menstrual
Conns: fatigue, headA, parasthesia
Phaeochromocytoma: sweating, headA, tachyC
Sleep apnea: daytime sleep, snoring, obesity
Nephrogenic: PCKD, RAS, GN
HyperPTH: stones, bone, groans, psychic moans - Other chronic conditions influencing management/+CV risk
Asthma, COPD
Diabetes
Lipids
DM
CKD
Alcoholism
Heart failure - Lifestyle
Smoking
Alcohol
Diet
Physical activity
Weight - Medication, FHx, occupation etc
Physical examination
- Vitals
- Evidence of underlying cause
Endocrine
Focal neurological - Complications
CVS: ++pulse, CCF, bruits, PVD, aneurysms
Palpable kidneys, bruits
Optic fundi: nipping, hemorrhage, exudates, cotton wool, papilloedema
Goals of HTN evaluation
- Identify all risk factors
- Detect end organ damage
- Identify secondary causes
Overview of management
1. Lifestyle Weight reduction Diet Limit alcohol Physical activity Smoking cessation 2. Pharmacotherapy 3. Manage comorbidities Low dose aspirin Lipid management Diabetes management
Principles of drug treatment
- Start with lowest does
- If not tolerated->change
- If not managed 6 weeks->add second drug
- Still not, tolerated->+dose of one type
- Can add third drug
- Consider other reasons for non-responding
When is pharmacotherapy intervention required immediately
When >180/110, >160/15% CVD risk
ATSI w/ hypertension
Associated conditions
PVD \+Cholesterol >7.5 CKD Diabetes Aortic FHx of premature CVD Cerebrovascular CAD
Evidence of end organ
- CKD: proteinuria:creatinin >30mg/mmol, >300mg protein, eGFR a:cr >2 M, >2.5 F
- LVH on ECG
- Vascular disease->bruits, HTN retinopathy
Options for pharmacotherapy
- ACEi
- ARB
- B blocker
- CCB
- Diuretics
Defining
High normal 130-139/85-89
Mild 140-159/90-99
Moderate 160-179/100-109
Severe >180/110
Grading HTN retinopathy
- Tortuous silver/copper wiring
- AV nipping
- Flame hemorrhages and cotton wool spots
- Papilloedema
Define malignant hypertension
Systolic >200/130 + bilateral retinal hemorrhages and exudates +papilloedema (may or may not)
Management of malignant and why
Renal failure, cardiac failure, encephalopathy
Fibriniod necrosis
Investigations in HTN
1. Quantify risk Glucose Cholesterol 2. End organ damage ECG Urinalysis UEC FBC and Hct 3. Exclude secondary UEC (low K in conns), +Ca in hyperPTH Consider other secondary tests TSH
Treatment resistance
- Volume overload->CKD
- White coat
- Medications that +BP
- Secondary causes
- Non-adherence
- Undisclosed alcohol/drug use
- Sleep apnea
- High salt
Treatment with comorbidities: angina, AF, Asthma/COPD, bradyC, Depression, HF, diabetes w/ albumin, post stroke, pregnancy, CKD
1. Angina->ACEi, BB, CCB Atenolol/metoprolol Peridopril Amlodipine 2. Asthma/COPD->Cardioselective CCB Verapamil Diltiazem XBB 3. AF->BB, ACEi, cardio CCB 4. BradyC/heart block Verapamil Diltiazem XBB 5. Depression Avoid BB, clonidine, methyldopa
Treatment with HF, diabetes w/ albumin, post stroke, pregnancy, CKD
1. HF ACEi, ARB Thiazide BB->bisoprolol, carvedilol Spirinolactone 2. Diabetes ACEi, ARB Avoid BB, thiazide diuretics 3. Post-stroke ACEi, ARB, low dose thiazide (hydrochlorthiazide) 4. Pregnancy Methyldopa Nifedipine 5 CKD ACEi ARB->candesartan
Combinations of anti-hypertensives to avoid
ACEi +ARB
ACEi+K sparing
Verapamil + beta blocker
Good combination anti-HTN
ACE- + CCB or thiazide
Side effects of thiazide diuretics
Low potassium, low sodium, postural hypotension, impotence
Not in gout!
Side effects of CCB
Flushes
Fatigue
Gum hyperplasia
Ankle edema
Side effects of ARB
Urticaria
Vertigo
Pruritus
Side effects of beta blocker
Bronchospasm Heart failure, block Cold peripheries Lethargy Impotence
Caution in asthma, heart failure, heart block
Features of hypertensive emergency
BP >210/130 Neurological, cardiovascular Oliguria, polyuria Abnormal fundoscopic examination Abnormal neurological examination
Investigations in HTN emergency
ECG FBC w/ smear UEC Urinalysis MCS CXR CT without contrast MRI Spot urine or plasma metanephrine
Management of HTN emergency
- Labetolol
- If LVF-> GTN + frusemise
- Aortic dissection->Labetolol or esmolol
- ARF->fenoldopam
- Hyperandrogenic->Benzodiazepines
- Eclampsia->Hydralazine, labetolol or nicardipine
Contraindications to diuretic
Hypokalemia Hyponatremia Hyperuricemia Hyperlipidemia (thiazide) Gout (Loop)
Side effects of clonidine
Postural hypoT
Dry mouth
Rebound HTN with abrupt withdrawal
Side effects of ACEi
Leukopenia Pancytopenia Hypotension Cough Angioedema Urticarial rash Hyperkalemia Acute renal failure (if RAS)
Secondary causes
- Renal
PCKD
RAS
GN - Endocrinology
Cushings: weight, mood, acne, myopathy, menstrual
Conns: fatigue, headA, parasthesia
Phaeochromocytoma: sweating, tachyC. headA, palpitations
HyperPTH: stones, bone, groans, psychic moans
Hyperthyroidism - Drugs: caffiene cocaine, sympathomimetic,TCA
- Sleep apnea: daytime sleep, snoring, obesity
- Coarctation of the aorta
- Carcinoid
Hypertensive encephalopathy
Severely elevated BP
Confusion
+ICP
+/- seizures
DIfferentiate HTN urgency vs emergency
Emergency is associated with end organ damage
Normal range of cerebral autoregulation
MAP of 60-120 mm
Goal reduction in hypertensice emergency in chronic HTN
Reduction in MAP no more than 25% or to diastole 100-110
Why is labetolol good in HTN emergency
Combined alpha and beta->lowers resistance and prevents reflex tachC
Should people with HTN crises and stroke have immediate lowering of BP and why
No, may worsen ischemia
