Hypertension Flashcards
why dose hypertension seem to be more prevalent in the older categories
females live longer so more of them around
hypertension is a sig risk factor for?
cerebrovascular disease coronary artery disease congestive heart failure renal failure peripheral vascular disease dementia atrial fibrillation erectile dysfunction
what does it mean when a patients home readings correlate with the doctors readings
white coat hypertension not an issue
what is the blood pressure target according to chep
140/90
what is the ultimate goal of therapy
reducecardiovascular and renal morbidity and mortality
what is the difference between the effects of systolic and diastolic levels and morbidity
increasing the diastolic doesnt really change the death rate, increasign systolic see a significant increase in death rate
what is the sprint trial
randomized control trial of intensive vs standard blood pressure control
who was involved in the sprint trial
9361 patients at high risk of CVD
people with DM2 or LVEF <35% were excluded
what were the interventions for sprint trial
intensive <120 vs standard <140 blood pressure control with any antihypertensive for 3.3 years
what were the outcomes of sprint
intensive slightly lowered the risk of CV complications and mortality but
increased the number of serious adverse events and renal failure
what did chep think of sprint
high risk patients should target<120 but caution should be taken in certain high risk groups
drug causes of hypertension
nsaid increase salt and fluid retention so increase CO therefore BP
decongestants
alcohol
estrogen
how long should you allow non drug therapy before considering medications
3-6 months
non drug measures
salt intake - 2000mg dash diet - ruit, veges, low fat dairy, fiber, whole grain, low sat fat and cholesterol exercise 30-60 min 4-7 days bmi of 19-25 moderate alcohol intake reduce caffiene stress management self monitoring BP
salt reduction recommended?
no RCT measuring health outcomes for when salt intake is less than 2.3g
likely to cause harm in both hypertensive andnormotensive people although there is no proof of this either
what was the allhat trial trying to determine
major outcomes in high risk hypertensive patients randomized to ACEi or CCB or diuretic
who was involved in the allhat trial
33357 patients with hypertension and 1 or more other risk factor for CHD events
what was the intervention in the allhat trial
chlorthalidone, lisinopril, or amlodipine for 5 years
what are the results of the allhat trial
all reduced BP the same
no diff between fatal CHD or non fatal MI
no difference in mortality
common side effects of thiazides
increase urination - short lived
muscle cramps
biochemical abnormalities
what are the biochemical abnormalities with thiazides
decreased sodium and potassium
increase uric acid
increased glucose and lipids - dont bother discussing
cautions for thiazides
history of gout
hypokalemia
hyponatremia
side effects of acei
cough
increase serum creatinine and potassium
cautions for aceis
history of bilateral renal artery stenosis
nsaid use becuase they inhibit prostaglandins which cause vasodilation so then there is vasoconstriction in the arteris coming into kidneys so little blood enters the glomerulus meanwhile the acei dilates the efferent and everything goes out with little coming in so no pressure
side effects of beta blockers
cold extremeties fatigue nausea decreased HR decreased exercise toelrance vivid dreams impotence
cautions of beta blockers
asthma
severe reynauds
heart block
over 60 years old
side effects of calcium channel blockers
flushing ankle edema headache (vasodilation in cerebral) increased HR non DHP: decreased HR, heart block, worsened HF, constipation
caution in CCB
history of heart failure
what was the relationship between dose and metabolic effects
increasing the dose leads to progressive hypokalemia and hyperuricemia without further rediction in systemic BP
what is th eBP reduction when using 1/2 of the standard doses
20% reduction
beta blocker reduction of cv events vs placebo
under 60 = better
over 60 = similar
beta blocker reduction of cv events vs other antihtn
under 60 = similar
over 60 = worse, tiny increase in strokes
what population should you use beta blockers in
over 60 yoa
when should beta blockers be used first line for bp reduction
if CHF or angina or as an option for atrial fibrillation
acei
arbs
beta blockers are less effective in which patients
black
compare thiazides acei ccb and beta blockers for cost and convenience
all relatively cheap and most once daily or twice daily dosing
monitoring for acei
cough… should go away in 2-4 weeks
check kidnye function, potassium and sCr levels in a couple of weeks
what should you monitor for thiazides
check sodium and potassium in a couple of weeks
according to chep what is the bp target for patients with diabetes
<130/80
why does usa and europe have target bp of 140/90 for peoplw with diabetes
there are no RCT that have ever shown a bp of 130/80 to reduce complications of DM2
what conclusions did thebmj have about antihypertensive treatment in patients with diabetes
antihypertensive treatment reduces risk of mortality in people with bp over 140. if systolic pressure is less than 140 further treatment is associated with an increased risk of cardiovascular death and no observed benefit
what does chep recommend for people with diabetes and hypertension along with cardiovascular or kidney disease
acei or arb
what does chep recommend recommend for people with diabetes and hypertension wihtout other disorders
acei
arb
dihydropyridine CCB
thiazides
what was the allhat diabetes subgroup study
clinical outsomes in antihypertensive treatment of DM2
13101 patients
compared chlorthalidone, lisinopril, and amlodipine
what was the results of the allhat diabetes subgroup study
no difference in outcomes between all agent
no difference of incidence of ESRD
no diference in coronary heart diseas, stroke, or combined CV disease
what was found in the study of ace inhibitor vs the placebo or other antihtn meds in patients without albuminnuria
acei are the only agents known to reduce incidence of microalbuminuria in diabetes vs placebo
no sig decrease in incidence of doubling of SCr or ESRD
what was the result of acei vs placebo or other antihtn in patients with albuminuria
acei reduce the progression of nephropathy to ESRD
what is the target bp for diabetes
<140/90
what is the effect of combining different medications
doubles th eblood pressure effects but not the side effects
will taking antihtn at night improve outcomes and reduce side effects
maybe but lack of evidence so recommendations are difficult
elderly women are more sensitive to sym inhibition and volume depletion so they will have a higher chance of what
higher chance of orthostatic hypotension
increased morbidity and falls
what might low bp be associated in elderly
dementia
cancer
HF
MI
what is isolated systolic htn
high systolic but low diastolic commin in elderly
what does isolated systolic htn increase in the elderly
increase risk of stroke, MI, renal failure
what was included in the hyvet study
hypertension in the very elderly
n=3845
all over 80 with a systolic BP >160
all had comorbid conditions: CV disease, DM2, smokers
what was the intervention in the hyvet trial
<150/80 target
indapamide and perindopril if needed vs placebo
what was the result of the hyvet study
BP <150/80 decreased CV events 3% over 2 years and 2.2% decrease in mortality
explain the u-curve in the elderly
as BP gets really high and really lo increase the mortality
how low is too low in the elderly
feeling hypotensive
<140/60???
are all diuretics equal?
chlorthalidone found to have a longer duration of action, more potent, better bp reduction
HCTZ less CV event reduction
is hydrochlorothiazide the best diuretic
chlorthalidone or indapamide are equal to and very likely superior HCTZ
what is the treatment of hypertension after a stroke
anthtn therapy should be strongly considered
once patient is stable gradual BP reduction post stroke reduces risk of further strokes
what bp target is recommended post stroke
<140/90
what antihtn should be used posthtn
acei/diuretic combo but actually acheiving target bp may be more important than the agent
is combo of arb and ace recommended in patients with stroke
no
what antihtn do we have that can control bp and rapid heart rate
non DHP
beta blockers
how to treat a hypertensive emergency
quiet room to rest leading to a fall of BP >10-20mmhg
tilt head of the bed 15 degrees up
consider antihtn if above 180/100 for more than 3 hours
