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Clin Med Cardio Exam 2 > Hypertension > Flashcards

Hypertension Flashcards

1
Q

How many Americans are affected by hypertension? How many are adequately controlled?

A

50 million

25% adequately controlled

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2
Q

Where is there an increased prevalence of HTN?

A

Elderly

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3
Q

What BP would make you consider a patient to be hypertensive?

A

140/90 or greater

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4
Q

What are the 4 different types of HTN?

A

Essential (Primary/idiopathic)
Secondary
Malignant
Hypertensive urgencies and emergencies

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5
Q

95% of all HTN cases, etiology unknown. 2X prevalence in black populations

A

Essential HTN

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6
Q

5% of HTN cases. Renal, renovascular, endocrine, and congenital etiologies

A

Secondary HTN

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7
Q

What are the contributing factors to HTN? (7)

A
  1. Genetic
  2. Environmental (diet, smoking, alcohol, weight)
  3. Sympathetic nervous system hyperactivity
  4. Renin – Angiotensin – Aldosterone system
  5. Defect in natriuresis
  6. Intracellular Na+ and Ca++
  7. Insulin resistance and metabolic syndrome
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8
Q

What factors exacerbate HTN?

A 
Obesity
Excess Na intake
Cigarette smoking (norepinephrine)
NSAIDS
Excess alcohol intake
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9
Q

How does estrogen use cause HTN? What type of HTN is this?

A

Increases activity of the RAA system which causes volume expansion

2ndry HTN

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10
Q

Renal disease, renal vascular HTN, endocrine HTN, and HTN in pregnancy are all what type of HTN?

A

2ndry

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11
Q

What type of insufficiency does HTN accelerate?

A

Renal

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12
Q

How does intrinsic renal disease result in HTN?

A

Volume expansion and/or increased activity of RAA system

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13
Q

What does renal artery stenosis cause?

A

Increased renin

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14
Q

What are the two forms of renal artery stenosis?

A 
Fibromuscular hyperplasia (FMH)
Atherosclerosis
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15
Q

Presents in young adults - BP markedly elevated; renal function preserved; arteriography diagnostic

A

FMH

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16
Q

What type of treatment do FMH patients benefit from?

A

Angioplasty/stent

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17
Q

Older patents - BP elevated and unresponsive to meds; renal function often impaired; intervention may or may not help

A

Atherosclerosis

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18
Q

What type of treatment helps patients with atherosclerosis decrease their BP?

A

Long term medication Rx

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19
Q

Decreased LV compliance results in ???

A

Diastolic dysfunction

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20
Q

What is associated with increased morbidity and mortality in patients with HTN?

A

LVH

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21
Q

What is the test of choice to diagnose LVH?

A

Cardiac ultrasound (echocardiography)

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22
Q

What methods can you use to get LVH to regress?

A

Aggressive treatment

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23
Q

What causes LVH?

A

It is a compensatory mechanism to LV pressure overload

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24
Q

Why is hypertrophy an issue?

A

It takes much higher pressure in diastole to relax a ventricle that is hypertropied

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25
Q

What is the major predisposing cause of stroke?

A

HTN

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26
Q

What causes cerebral infarction in patents with HTN/

A

Atherosclerosis/small vessel disease

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27
Q

What causes an intracerebral hemorrhage?

A

Rupture of micro aneurysms from increased BP

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28
Q

Strokes are more closely associated with _____ pressure

A

Systolic

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29
Q

The average anti-hypertensive medication titrated to the appropriate dose decreases systolic BP by ____mmHg?

A

10-15

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30
Q

HTN accelerates all other causes of ??

A

Chronic renal insufficiency

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31
Q

Progressive renal insufficiency; more common in black populations, especially in the presence of DM

A

Neprhosclerosis

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32
Q

Clinical findings for HTN are usually?

A

Asymptomatic - maybe some AM headaches

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33
Q

What are some symptoms related to LVH and diastolic dysfunction?

A

SOB, DOE

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34
Q

What are some symptoms related to cerebral involvement?

A

TIA, stroke, hemmorhage

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35
Q

What are some symptoms related to cardiac involvement?

A

MI, angina, HF

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36
Q

What are some abnormals you might find on a cardiac exam of a patient with HTN?

A

Bruits from atherosclerotic disease
Different upper/lower pulses

Mostly unremarkable

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37
Q

Symptoms of hypertensive retinopathy

A 
A/V narrowing
AV nicking
Silver/copper wired appearance
Hemorrhages or exudates
Papilledema
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38
Q

What are some labs you should pay attention to when assessing a patient for HTN?

A

Creatinine/BUN for renal function

K for electrolytes

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39
Q

According to JNC 8 guidelines, what BP should you Rx with meds in a patient older than 60?

A

150/90

40
Q

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?

A

Do not need to adjust meds if BP is well tolerated

41
Q

According to JNC guidelines, in a patient younger than 60 when should you RX meds? What should the goal of treatment be?

A

140/90

Goal should be under 140/90

42
Q

According to JNC guidelines, when should you Rx a patient older than 18 with diabetes or chronic kidney disease? What should the goal be?

A

140/90

Under 140/90

43
Q

What should the initial treatment in a nonblack patient with HTN (including patients with diabetes)?

A

Thiazide-type diuretic
CCB
ACE inhibitor or ARB

44
Q

What should the initial treatment be in black populations with HTN?

A

Thiazide-type diuretic or CCB

45
Q

What should the additional or add-on therapy be in a patient over 18 with chronic kidney disease and HTN?

A

ACE or ARB to improve kidney outcomes regardless of race or diabetes status

46
Q

What is no longer indicated as the initial RX for HTN?

A

Beta blockers

47
Q

When is it okay to initiate 2 drugs at onset of therapy in a patient with HTN?

A

BP S greater than 160 or D greater than 100

48
Q

Diuretics with HTN almost always ??

A

Requires multiple (average 3) meds

49
Q

What drugs should be a part of a diuretic regimen for a patient with HTN?

A

Thiazide diuretic + ACEI (or ARB) + CCB

50
Q

What is the main goal of therapy with HTN?

A

Decrease endpoints, not BP alone

Reduce cardiovascular risk for CHD

51
Q

MI, Stroke, LVH, PAD are all _______

A

Endpoints

Cause cardiac mortality, HF, and renal failure

52
Q

What is the most important target for reducing morbidity and mortality?

A

Systolic BP

53
Q

What is the equation for calculating BP?

A

CO X Systemic vascular resistance (SVR)

54
Q

What is the recommended 1st choice medications for HTN and should be part of any multi-drug combination?

A

Thiazide diuretics

55
Q

What are the initial effects of thiazide diuretics? Chronic effects?

A

Initial: Decreased plasma volume (Decreased preload)

Chronic: Decreased SVR!

56
Q

Diuretics are more potent in ___ and more effective in ___

A

Potent: Blacks, elderly, obese

Effective: Smokers

57
Q

_____ is more potent than HCTZ

A

Chlorthalidone

58
Q

Who should you not prescribe a diuretic to?

A

Patient with hyponatremia or gout

59
Q

Adverse effects of thiazides

A

Hypokalemia, Hyperuricemia, Lipid abnormalities

60
Q

How do beta blockers work to decrease BP?

A

Decreasing cardiac output by decreasing HR

61
Q

With beta blockers, ____ increases but ____ levels decrease

A

SVR increases

Renin levels decrease

62
Q

Who are beta blockers less effective in?

A

Black population and elderly

63
Q

When would a beta blocker be useful?

A

In a patient with HTN and other co-morbid conditions (Post MI, migraines, arrhythmias, etc.)

64
Q

The mortality and end point benefits of beta blockers are mostly applicable to what type of beta blocker?

A

Lipid soluble

65
Q

Beta blockers are less effective for ____ vs other agents

A

LVH

66
Q

In patients with chronic compensated and stable HF with a low ejection fraction, what is clearly beneficial to decrease mortality?

A

Beta blockers

67
Q

What are some side effects of beta blockers?

A 
May worsen PAD
Masks hypoglycemia
Exacerbation of bronchospasm
Bradycardia
CNS issues - nightmares, fatigue, depression, etc.
68
Q

Beta blockers should NOT be used as??

A

1st line mono therapy in patients with HTN

69
Q

What do ACE inhibitors inhibit?

A

Renin-angiotensin-aldosterone system

70
Q

ACE inhibitors inhibit ____ degradation

A

Bradykinin

71
Q

ACE inhibitors stimulate

A

Vasodilating prostaglandin synthesis

72
Q

What increases the anti-hypertensive efficacy of ACE inhibitors?

A

Improved when combined with a diuretic

73
Q

ACEIs are the antihypertensive of choice in ____

A

Diabetics

74
Q

What other diseases do ACEIs help with?

A

HTN, LV dysfunction, HF (when given with loop diuretic)

75
Q

What do ACEIs help with in patients with LV dysfunction?

A

Prevents remodeling

76
Q

When should someone take an ARB? What is the downside?

A

They are useful for HF patients who can’t take ACEI but don’t inhibit bradykinin breakdown

77
Q

ARBs are ____ in diabetics

A

Renoprotective

78
Q

ARBs do not have the side effect of ____ that ACEIs have

A

Cough

79
Q

Act by peripheral vasodilation (after load) and other mechanisms; effective in demographic groups

A

CCB

80
Q

What groups are CCBs preferable in?

A

Blacks and elderly

81
Q

CCBS provide additional protection against ____

A

Stroke

82
Q

Significant vasodilation, reduction in SVR; can cause fluid retention and REFLEX TACHYCARDIA

A

Dihdyropyridine agents

83
Q

Vasodilation and negative inotropic, chronotropic, and dromotrophic effects

A

Non-dihydrophyridine agents

84
Q

What is the downside to nondihydropyridines?

A

Exacerbate HF and cause SA and AV nodal dysfunction

85
Q

Can you use diltiazem with B blockers?

A

Cautiously, avoid verapamil

86
Q

Side effects of dihydropyridines

A

Headaches and peripheral edema

87
Q

Which CCBs cause bradycardia?

A

Verapamil and diltiazem

88
Q

Post-synaptic alpha receptor blockers that relax smooth muscle, decrease SVR

A

Alpha receptor blockers (terazosin, doxazosin)

89
Q

When is an alpha receptor blocker useful?

A

Benign prostatic hyperplasia

90
Q

Stimulates CNS presynaptic alpha-2 receptors resulting in reduced efferent peripheral sympathetic flow

A

Central acting agents: Methyldopa, clonidine

91
Q

Why would someone want to use clonidine?

A

Compliance benefits - patches are effective for 7 days

92
Q

What is the initial Rx for treating HTN?

A

Thiazide diuretics (with some exceptions)

Remember - multiple agents are often needed!

93
Q

What should you do to a dose of an HTN medication before adding a second agent?

A

Titrate to moderate/high doses first

Exception = thiazide

94
Q

What would additional drug therapy include?

A

Beta blocker
ACEI
CCB

Look at comorbid conditions!!

95
Q

If initial average BP is greater than 160/90, what should you do when RXing?

A

Start with dual Rx!

96
Q

What is the common 3 drug combination that HTN patients are on?

A

Diuretic, ACEI, and CCB (or beta blocker)

Clin Med Cardio Exam 2 (6 decks)

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