Hypertension Flashcards
1
Q
1 killer in us
A
hypertension
2
Q
major determinant in reduction of CV risk
A
BP reduction
3
Q
prevalence htn
A
1 in 3; only 25% controlled
4
Q
most common risk factor for MI stroke
A
htn
5
Q
complications of htn
A
lvh hf stroke ischemic heart disease MI CKD
6
Q
Screening BP
USPSTF
JNC-7
A
USPSTF- annual screening
adults over 40 + high risk (
7
Q
Goals JNC7 vs JNC8 No comorbidities: DM: CHF: Renal insufficiency: RF with proteinuria:
A
no com: 140/90; 80 150/90
CHF: 130/80; ——
Renal insuffiency: 125/75;
8
Q
Optimal Normal Pre-htn Stage I Stage II
A
Optimal: 115/80 Normal: 120/80 Pre HTN: 120-139/80-89 Stage I: 140-159/90-99 Stage II: >160/100
two readings from two separate office visits
9
Q
Definition of BP
A
Cardiac output (volume of blood) X systemic vascular resistance
10
Q
-
-
A
- sympathetic nervous system
- renin-angiotensin-aldosterone system
- plasma volume
11
Q
Sympathetic nervous system "---------" increases \_\_\_\_, \_\_\_\_\_, \_\_\_\_\_ stimulates??? Shunts blood.....
A
fight or flight
increases HR, strength of contraction, rr
stimulates kidney renin release
shunts blood flow to critical organs (cardiac skeletal vasodilation, skin and GI vasoconstriction)
12
Q
Renin-angiotension system why block angiotensin I 1. 2. 3. 4.
A
na/fluid retention
- renin release (kidneys detect decreased bf, renin secreted)
- renin mediated conversion (angiotensinogen to 2)
- angiotensin converting enzyme (ACE) conversion (angio I to ACE to angiotension II; occurs in pulmonary vasculature)
- angiotensin II effects (NA and H20 retention -increased SVR, antagonist to nitric oxide -vasodilator)
13
Q
risk factors for HTN
A
age obesity family history - 2x as common if parent race- AA high NA diet Excessive alcohol DM dyslipidemia
14
Q
Secondary HTN causes
A
OTC meds (OCP, NSAID, TCA, SSRI, glucocorticoids, decongestants, weight loss meds, stimulants) Renal disease Hyperaldosteronism (hypokalemia, met alk) sleep apnea pheochromocytoma cushings thyroid pregnancy coarctation
15
Q
Most common form of hypertension
med choice
A
Isolated systolic hypertension
>140
16
Q
Metabolic syndrome diagnosis
A
3 or more of following: Abdominal obesity >40 men >35 women Glucose intolerance >110 fasting High trig (>150) HTN >130/85 Low HDL
17
Q
S3 s4
A
heart failure HTN
18
Q
aortic insufficiency
A
murmur
19
Q
heaves, lifts, displaced PMI
A
LVH
20
Q
labs
A
Electrolytes Creatinine Fasting glucose Urinalysis Lipid ECG Echo
21
Q
Elderly considerations
A
combo therapy if SBP >160 or DBP >100
pseudohtn from calcified arteries
hypotensive episodes: ambulatory blood pressure monitoring
22
Q
Elderly doc
-
-
A
thiazide diuretic
dehydration
orthostatic hypotension
hypokalemia
23
Q
Diabetes BP
Goals
A
JNC 8
24
Q
First line medication choice diabetes htn
second line
A
ace-i (increase GFR, decreases proteinuria)
OR ARB
then thiazide diuretic
25
AA HTN respond best to
thiazide or CCB above ACEI
increased risk angioedema
26
Ambulatory BP monitoring indications
HTN criteria
Newly dx, white coat htn, drug resistant, symptomatic hypotesion
24 average of 130/80
awake average 135/85
asleep average 120/70
27
When to treat htn
1st-
2nd-
3rd-
1st lifestyle
JNC8 SBP >140 for 150 if >60
DBP >90 despite lifestyle mod
Initiate combo therapy if: Baseline >160/100- beware of orthostatic hypotension
28
Management BP in low risk patient (no CV risk or target organ damage)
Prehtn
Stage 1
Stage 2 or greater
Pre – HTN: 120-139/80-89
Lifestyle Modification
Stage I: 140-159/90-99
Lifestyle Modification
After up to 6-12 months
Thiazide diuretic
Stage II or greater >159/99
Lifestyle Modification
HTN combination therapy
29
```
Management of BP in moderate risk patient
define moderate risk
Prehtn
stage 1
stage 2
```
Smoker, Dyslipidemia, Renal Insuff, >60 years
Male or postmenopausal with + CV FMH
```
Pre–HTN:
120-139/80-89
Lifestyle modification
Stage I:
140-159/90-99
Lifestyle Modification
Thiazide diuretic
Stage II or greater
>159/99
Lifestyle Modification
HTN combination therapy
```
30
```
Management of high risk
define high risk
pre htn
stage 1
stage 2
```
TOD or CV (LVH, Angina or Prior MI, CVA/TIA, Neuropathy, CKD, PVD, Retinopathy)
Pre-HTN or greater
Lifestyle modification
Antihypertensive
Combination therapy if >20/10 over goal
31
Management general guidelines
Titration
Combination therapy if
one step titration- most efficacy
combination if >20/10 mmHg above goal
32
Dx orthostatic hypotension
within 2-5 minutes of standing
20 drop SBP
10 drop DBP
symptoms cerebral hypoperfusion dizziness
33
HTN diet
| Salt intake
No added salt
34
```
DASH diet
whole grains
vegetables
fruits
nuts, seeds, legumes
dairy
fats/oils
```
other: sweets, sodium, red meat, cholesterol
```
whole grains 6-8
vegetables 4-5
fruits 4-5
nuts, seeds, legumes 4-5
2-3 dairy
2-3 fats oils
```
35
Exercise recommendations
150 a week
3x a week at least 30 minutes
4-6 drop SBP
3 drop DBP
36
Weight loss reduction
1 mmhg for every lb
37
Thiazide diuretics
-
-
SE:
mechanism of action:
- hctz - chlorthalidone
Potassium loss occurs only during the first two weeks of therapy
Unless there is an external loss or dosage change
Acts by decreasing blood volume
38
chlorthalidone
benefits
cautions:
Longer half life, Reduced risk of heart failure
Caution hypokalemia, hyponatremia, hyperglycemia, and hyperurecemia
need to cut in half
39
ACE inhibitor
Action:
First line therapy for:
Contraindicated in:
Block conversion from Angiotensin I to angiotensin II
First line therapy:
HF or LV dysfunction (Reverse remodeling)
DM
Proteinuric kidney disease (renal protective)
Absolutely Contraindicated in Pregnancy/Breast feeding
40
AceI adverse effects
-AA more prone to angioedema
Can occur months to years after starting
ACE angioedema not a normal allergic reaction Treatment removal of drug and supportive care (airway management)
-Cough (dry and irritating) - 5 to 20%
More common in women and black patients
stop within 4 days when medication stopped
-Hyperkalemia (5% of patients)
-Renal Insufficiency (Baseline Serum Creatinine
41
ARB
Contraindication
peak effects
proteinuria compared to ace
contraindication: already on ACE, previous angioedema
4-6 weeks
proteinuria control equal to that of ace
42
CCB
drugs
mechanism of action
reynauds??
- Dihydropyridines – Amlodipine (Norvasc)
- Non-Dihydropyridines – Diltiazem, Verapamil
Myocardial (non-dihydropiridine) and vascular smooth muscle relaxation
Favorable in reynauds
43
Amlodipine
Action
SE
```
Peripheral vasculature
Adverse Effects: Peripheral Edema
Women
Doses >5 mg
Adding Ace decreases edema
```
44
Diltiazem, Verapamil (nondihydro)
| Action
Negative inotrope
Peripheral vasculature and cardiac tissue
Slow AV node conduction
45
CCB adverse effects
```
Hypotension
Flushing
Nasal congestion
Tachycardia
Dizziness
Nausea
Nervousness
Bowel Changes
+ PERIPHERAL EDEMA
```
46
Beta blockers
Action: inhibit _____ reduce _______ and ______ and _____ demand
Beta 1
Beta 2
Inhibit effects of circulating catecholamines and reduces myocardial contractility – reduces HR and myocardial O2 demand
```
Block beta adrenergic receptors
Beta 1:
Cardiac Muscle (Contraction)
Allows calcium entry into cells
Inotropic and chronotropic effects
Beta 2:
Smooth muscle
Bronchioles
```
47
Beta blockers general info
Cost
Weaning
Initial therapy??
well tolerated low cost
must wean
Not used for initial therapy unless specific indication: Known CAD, MI, Systolic dysfunction
48
Beta blockers SE
```
SA and AV nodal blockade
Hypotension or Orthostasis
Bradycardia
Bronchospasm(Unlikely to occur in cardioselective)
Major Depression exacerbation
Fatigue
Exercise intolerance
Weight gain
Sexual SE
```
49
Beta blockers med list
Beta 1
Nonselective beta 1 and 2
Alpha 1 Beta 1 Beta 2
Beta 1: atenolol, bisoprolol** most, metoprolol
Nonselective: timolol, nadolol, propanolol
Combined: labetalol, carvedilol (has most BP reduction)
50
Systolic hf med choices
ACE, ARB, BB, Diuretic
51
Post MI med choices
ACEI, ARB, BB
52
Proteinuria CKD med choices
ACE ARB
53
Angina med choices
BB CCB
54
Afib rate control med choices
BB
| (nondihydro) verapamil diltiazem
55
Contraindications
| Angioedema
angio-ace
bronchospasm- BB
pregnancy- ACE ARB
heart block-BB nondihydro (verapamil and diltiazem)
56
Nocturnal BP should be ___% lower than day
Night time dip
15%
if does not dip at least 10% strong predictor of CV outcome compared to daytime
Shift a drug from am to pm
reduce mean BP
