Hypertension Flashcards
How many Americans are affected by hypertension? How many are adequately controlled?
50 million
25% adequately controlled
Where is there an increased prevalence of HTN?
Elderly
What BP would make you consider a patient to be hypertensive?
140/90 or greater
What are the 4 different types of HTN?
Essential (Primary/idiopathic)
Secondary
Malignant
Hypertensive urgencies and emergencies
95% of all HTN cases, etiology unknown. 2X prevalence in black populations
Essential HTN
5% of HTN cases. Renal, renovascular, endocrine, and congenital etiologies
Secondary HTN
What are the contributing factors to HTN? (7)
- Genetic
- Environmental (diet, smoking, alcohol, weight)
- Sympathetic nervous system hyperactivity
- Renin – Angiotensin – Aldosterone system
- Defect in natriuresis
- Intracellular Na+ and Ca++
- Insulin resistance and metabolic syndrome
What factors exacerbate HTN?
Obesity Excess Na intake Cigarette smoking (norepinephrine) NSAIDS Excess alcohol intake
How does estrogen use cause HTN? What type of HTN is this?
Increases activity of the RAA system which causes volume expansion
2ndry HTN
Renal disease, renal vascular HTN, endocrine HTN, and HTN in pregnancy are all what type of HTN?
2ndry
What type of insufficiency does HTN accelerate?
Renal
How does intrinsic renal disease result in HTN?
Volume expansion and/or increased activity of RAA system
What does renal artery stenosis cause?
Increased renin
What are the two forms of renal artery stenosis?
Fibromuscular hyperplasia (FMH) Atherosclerosis
Presents in young adults - BP markedly elevated; renal function preserved; arteriography diagnostic
FMH
What type of treatment do FMH patients benefit from?
Angioplasty/stent
Older patents - BP elevated and unresponsive to meds; renal function often impaired; intervention may or may not help
Atherosclerosis
What type of treatment helps patients with atherosclerosis decrease their BP?
Long term medication Rx
Decreased LV compliance results in ???
Diastolic dysfunction
What is associated with increased morbidity and mortality in patients with HTN?
LVH
What is the test of choice to diagnose LVH?
Cardiac ultrasound (echocardiography)
What methods can you use to get LVH to regress?
Aggressive treatment
What causes LVH?
It is a compensatory mechanism to LV pressure overload
Why is hypertrophy an issue?
It takes much higher pressure in diastole to relax a ventricle that is hypertropied
What is the major predisposing cause of stroke?
HTN
What causes cerebral infarction in patents with HTN/
Atherosclerosis/small vessel disease
What causes an intracerebral hemorrhage?
Rupture of micro aneurysms from increased BP
Strokes are more closely associated with _____ pressure
Systolic
The average anti-hypertensive medication titrated to the appropriate dose decreases systolic BP by ____mmHg?
10-15
HTN accelerates all other causes of ??
Chronic renal insufficiency
Progressive renal insufficiency; more common in black populations, especially in the presence of DM
Neprhosclerosis
Clinical findings for HTN are usually?
Asymptomatic - maybe some AM headaches
What are some symptoms related to LVH and diastolic dysfunction?
SOB, DOE
What are some symptoms related to cerebral involvement?
TIA, stroke, hemmorhage
What are some symptoms related to cardiac involvement?
MI, angina, HF
What are some abnormals you might find on a cardiac exam of a patient with HTN?
Bruits from atherosclerotic disease
Different upper/lower pulses
Mostly unremarkable
Symptoms of hypertensive retinopathy
A/V narrowing AV nicking Silver/copper wired appearance Hemorrhages or exudates Papilledema
What are some labs you should pay attention to when assessing a patient for HTN?
Creatinine/BUN for renal function
K for electrolytes
According to JNC 8 guidelines, what BP should you Rx with meds in a patient older than 60?
150/90
If you are treating a patient for HTN that is older than 60 yo and their blood pressure is lower than 140/90 on medications, do you need to adjust the medications?
Do not need to adjust meds if BP is well tolerated
According to JNC guidelines, in a patient younger than 60 when should you RX meds? What should the goal of treatment be?
140/90
Goal should be under 140/90
According to JNC guidelines, when should you Rx a patient older than 18 with diabetes or chronic kidney disease? What should the goal be?
140/90
Under 140/90
What should the initial treatment in a nonblack patient with HTN (including patients with diabetes)?
Thiazide-type diuretic
CCB
ACE inhibitor or ARB
What should the initial treatment be in black populations with HTN?
Thiazide-type diuretic or CCB
What should the additional or add-on therapy be in a patient over 18 with chronic kidney disease and HTN?
ACE or ARB to improve kidney outcomes regardless of race or diabetes status
What is no longer indicated as the initial RX for HTN?
Beta blockers
When is it okay to initiate 2 drugs at onset of therapy in a patient with HTN?
BP S greater than 160 or D greater than 100
Diuretics with HTN almost always ??
Requires multiple (average 3) meds
What drugs should be a part of a diuretic regimen for a patient with HTN?
Thiazide diuretic + ACEI (or ARB) + CCB
What is the main goal of therapy with HTN?
Decrease endpoints, not BP alone
Reduce cardiovascular risk for CHD
MI, Stroke, LVH, PAD are all _______
Endpoints
Cause cardiac mortality, HF, and renal failure
What is the most important target for reducing morbidity and mortality?
Systolic BP
What is the equation for calculating BP?
CO X Systemic vascular resistance (SVR)
What is the recommended 1st choice medications for HTN and should be part of any multi-drug combination?
Thiazide diuretics
What are the initial effects of thiazide diuretics? Chronic effects?
Initial: Decreased plasma volume (Decreased preload)
Chronic: Decreased SVR!
Diuretics are more potent in ___ and more effective in ___
Potent: Blacks, elderly, obese
Effective: Smokers
_____ is more potent than HCTZ
Chlorthalidone
Who should you not prescribe a diuretic to?
Patient with hyponatremia or gout
Adverse effects of thiazides
Hypokalemia, Hyperuricemia, Lipid abnormalities
How do beta blockers work to decrease BP?
Decreasing cardiac output by decreasing HR
With beta blockers, ____ increases but ____ levels decrease
SVR increases
Renin levels decrease
Who are beta blockers less effective in?
Black population and elderly
When would a beta blocker be useful?
In a patient with HTN and other co-morbid conditions (Post MI, migraines, arrhythmias, etc.)
The mortality and end point benefits of beta blockers are mostly applicable to what type of beta blocker?
Lipid soluble
Beta blockers are less effective for ____ vs other agents
LVH
In patients with chronic compensated and stable HF with a low ejection fraction, what is clearly beneficial to decrease mortality?
Beta blockers
What are some side effects of beta blockers?
May worsen PAD Masks hypoglycemia Exacerbation of bronchospasm Bradycardia CNS issues - nightmares, fatigue, depression, etc.
Beta blockers should NOT be used as??
1st line mono therapy in patients with HTN
What do ACE inhibitors inhibit?
Renin-angiotensin-aldosterone system
ACE inhibitors inhibit ____ degradation
Bradykinin
ACE inhibitors stimulate
Vasodilating prostaglandin synthesis
What increases the anti-hypertensive efficacy of ACE inhibitors?
Improved when combined with a diuretic
ACEIs are the antihypertensive of choice in ____
Diabetics
What other diseases do ACEIs help with?
HTN, LV dysfunction, HF (when given with loop diuretic)
What do ACEIs help with in patients with LV dysfunction?
Prevents remodeling
When should someone take an ARB? What is the downside?
They are useful for HF patients who can’t take ACEI but don’t inhibit bradykinin breakdown
ARBs are ____ in diabetics
Renoprotective
ARBs do not have the side effect of ____ that ACEIs have
Cough
Act by peripheral vasodilation (after load) and other mechanisms; effective in demographic groups
CCB
What groups are CCBs preferable in?
Blacks and elderly
CCBS provide additional protection against ____
Stroke
Significant vasodilation, reduction in SVR; can cause fluid retention and REFLEX TACHYCARDIA
Dihdyropyridine agents
Vasodilation and negative inotropic, chronotropic, and dromotrophic effects
Non-dihydrophyridine agents
What is the downside to nondihydropyridines?
Exacerbate HF and cause SA and AV nodal dysfunction
Can you use diltiazem with B blockers?
Cautiously, avoid verapamil
Side effects of dihydropyridines
Headaches and peripheral edema
Which CCBs cause bradycardia?
Verapamil and diltiazem
Post-synaptic alpha receptor blockers that relax smooth muscle, decrease SVR
Alpha receptor blockers (terazosin, doxazosin)
When is an alpha receptor blocker useful?
Benign prostatic hyperplasia
Stimulates CNS presynaptic alpha-2 receptors resulting in reduced efferent peripheral sympathetic flow
Central acting agents: Methyldopa, clonidine
Why would someone want to use clonidine?
Compliance benefits - patches are effective for 7 days
What is the initial Rx for treating HTN?
Thiazide diuretics (with some exceptions)
Remember - multiple agents are often needed!
What should you do to a dose of an HTN medication before adding a second agent?
Titrate to moderate/high doses first
Exception = thiazide
What would additional drug therapy include?
Beta blocker
ACEI
CCB
Look at comorbid conditions!!
If initial average BP is greater than 160/90, what should you do when RXing?
Start with dual Rx!
What is the common 3 drug combination that HTN patients are on?
Diuretic, ACEI, and CCB (or beta blocker)
