Hypertension Flashcards
Pre eclampsia is
HTN plus proteinuria after 20 weeks
High BP and CLARIFY registry
J shaped relation with CAD but not with stroke
Sulfa based diuretic
HCTZ And Furosemide are Sulfa based
But risk of reaction is low even in sulfa allergic pt
Spironolactone. Triamterene etc doesn’t contain Sulfa
Difference b/w SAM and Pseudo SAM
Pseudo SAM— 1.Seen inIn HTN with LVH
- SAM Peaks between 2/3 rd and End systole while Pseudo SAM at end systole ( i.e. SAM much earlier than maximum movt of Posterior wall while PseudoSAM when postr wall has contracted fully.
- AML returns to initial level prior to opening of MV in SAM while it doesn’t in Pseudo SAM
DBP in elderly should be maintained above
60 mm Hg as per a German presentation
Angiographic appearance inFMD
String of beads
Type of cerebrovascular involvement in FMD
EXTRACRANIAL cerebrovascular i.e. Carotid and Vertebral
In Lower limbs FMD commonly involves which arteries
External iliac arteries
EXTRACRANIAL cerebrovascular involvement occurs in upto—— of FMD patients
2/3rd
Onset of HTN before —–/ in a female u should suspect FMD
35 yrs
Pressure gradient considered significant in Renal FMD
MEAN Pressure drop 10% or more
Role of CTA and Doppler in diagnosing FMD
With experienced operators this is enough in most vascular beds EXCEPT Carotids
Direct Angio is necessary
How FMD Renal angioplasty is different from others
Stenting usually not done. ( Only if there’s dissection)
DOC for HTN in FMD
ACE/ARB
Efferent arteriole means
Post Glomerular arteriole
The rise in Creatinine which is acceptable with ACE/ARB in FMD
Upto 30%
How to check Creatinine after starting ACE /ARB in FMD
After one week
Definition of Resistant HTN
Not controlled with THREE Med which includes a Diuretic
What % of Primary hyperaldosteronism has hypokalemia
Less than 50 %
First test to look for hyperaldosteronism
Plasma aldosterone concentration / Plasma Renin activity
Ratio more than 20 and also PAC should also be elevated
Inappropriate elevation of aldosterone in relation to renin may be seen in …. in addition to hyperaldosteronism
Obesity
Which studies proved Telmisartan and Ramipril are equal
ON TARGET , TRANSCEND
Fractionated catecholamines and metamephrines means
Fractionated catecholamines - Epinephrine, Nor epinephrine and Dopamine
Fractionated metanephrine- means Metanephrine and Normetanephrine
Ie the assay measures all components separately
Common causes of secondary hypertension
Primary Aldosteronism
RAS
Obstructive Sleep Apnea
Renal parenchymal disease
Uncommon-Pheo, Cushing, Hyperparathyroidism, Coarctation , Hypothyroidism
Least specific test for catecholamine metabolites
VMA
Metanephrines- an intermediate metabolite b/w Epinephrine and VMA is now considered as most sensitive and specific test
Atherosclerosis of Renal artery primarily affects adults after
45 yrs
FMD affects females below….and ……part of Renal artery
50 yrs
Distal main Renal A or intrarenal branches
Potential concerns for medical therapy alone for RAS
- Progression of stenosis
- Long term ischemic damage to kidney
- Impaired kidney function with ACE/ARB
Urinary metanephrines includes
Metanephrine, Normetanephrine & 3- ortho methyl dopamine
3OMD is normal in benign pheochromocytoma but Elevated in Malignant Pheo
Hyperaldosteronism initial Evaln after K is
PAC/PRA….Pakkara
How to take morning sample for PAC/PRA
Pt out of bed for at least 2 hours and seated for at least 5-15 mts before sample is drawn
How long should you stop Aldactone before doing PAC/PRA for Hyperaldosteronism
6 weeks
Diuretic also 6 wks- Internet
Other medicines-2 wks- Internet
PAC/PRA results in Primary hyperaldosteronism
Both PAC & PAC/PRA ratio will be high
Ratio of >20 is considered significant & PAC is usually > 15
Effect of beta blockers on PAC/PRA ratio in primary hyperaldosteronism
Reduces PRA and increases ratio but not to significant levels. So continue .
Also PAC Will be less than 15 in Pts without hyperaldosteronism
Safest drugs to take while checking PAC/PRA in primary hyperaldosteronism
Verapamil, Hydralazine, Alpha blockers. -Internet
But uptodate says most Med except Aldosterone inhibitors are ok
Protocol for doing PAC/PRA in Primary hyperaldosteronism
Out of bed at least 2 hours prior
Seated for at least 5-15 mts
Preferably 8 am
According to 2017 update on JNC 7 Guidelines of 2013…
Stage I HTN is
ie 2017 ACC/AHA Guidelines
N.B .- Surpringly not described as update on JNC 8 , 2014 guidelines
130/80 mm Hg
DBP of 80 is Hypertension!!!!
Stage 2 is 140/90
KEY- These are based on ABPM. Office recordings has not changed 😜😜
Stage 1 is same 140/90
Study which supported higher BP targets in elderly and the study which was against it
2008 HYVET- Hypertension in Very Elderly Trial. Target BP was < 150. Age_80 or more
2016 SPRINT produced opposite results
Target BP in SPRINT 2016
120 vs 140 in persons aged more than 50 yrs.
Mean age was 68
Which trial showed Renal denervation is not effective
2014 SYMPLICITY HTN-3 trial
2017 SPYRAL HTN-OFF MEDICINE trial showed that
Renal denervation can reduce BP around 10/5 with modified procedure compared to SYMPLICITY HTN 3
Ideal pulse pressure according to the 2017 CLARIFY registry is
45-65
Rise in serum creatinine of more than ——- with ACE/ARB in CKD should be evaluated for RAS
30%
CKD definition-e GFR <60ml/ 1.72m2/ min with or without proteinuria
ESC 2018 guidelines
Physical activity and BP response- ESC 2018
Acute raise in BP esp SBP
Followed by a short lived decline inBP below baseline
Type of exercise which reduce BP in hypertensives
Aerobic endurance training
ESC 2018
Exercise duration advised for hypertensive Pt ESC2018 guidelines
At least 30mt x 5 days aerobic
Resistance exercise can be done 2-3days/week
Gradually increase aerobics to 300 mts/ week
More the better
Impact of isometric exercise on BP and CV risk
Less well established
ESC 2018
Is RAS a contraindication to ACE/ARB treatment
In BILATERAL RAS its to be avoided
ESC 2018 guidelines
ESC HTN guidelines started from
2003
Then 2007,13, 18
Change in ESC 2018 HTN guidelines regarding treating BP 130-139/85-89
Previous was red. Now yellow
May be considered when CV risk very high DUE to established CVD esp CAD
3to 2b
Difference in guidelines in treating stage 1 HTN between 2013 and 2018 ESC
In low- moderate risk (<5% SCORE) -after a period of LSM start med-class1
Previously it was 2a
Also in >65<80 subset - treatment of grade 1 HTN was 2b before now it is class1
Difference inBP treatment targets between 2013 and 18 guidelines
Before it was just below 140/90.
Now it is for all below 140/90
If tolerated target 130/80 or below in most patients
SBP in <65 , SBP should be
lowered to 120-129 in most
> 65 ::SBP130-139
DBP::<80 for all patients (2a)
Exceptions for SPC (single pill combination)in ESC 2018 HTN subset
- Frail older patients
2. Low risk Gd 1 HTN (((esp if SBP < 150)))
For resistant HTN - after mineralocorticoid antagonist, the drugs mentioned are
Bisoprolol and Doxazosin(alpha blocker)
ESC definition of BP is for people more than
18 years
Guide
HTN grading in ESC 2018 guidelines
ONH- ON Hypertension
O-optimal
N- Normal
H-High Normal
Then Grade 1-3
