Hypertension

Question 1

What is the new definition of Stage 1 hypertension?

Answer 1

SBP > 130
or
DBP > 80

On 2+ separate readings of an appropriate sized cup

Question 2

What is the definition of hypertensive crisis?

Answer 2

SBP > 180
or
DBP > 110

Question 3

What is HTN urgency vs HTN emergency?

Answer 3

Urgency -> hypertensive crisis WITHOUT evidence of end-organ damage

Emergency -> malignant HTN WITH evidence of end-organ damage
-> i.e. LV dysfunction, pulmonary edema, stroke / vision changes, renal failure, elevated liver enzymes

Question 4

What type of hypertension is most common in men, especially younger men?

Answer 4

Isolated diastolic hypertension

-> isolated systolic hypertension becomes more common later in life.

Question 5

What is essential hypertension and its cause? Is it more common than the other type?

Answer 5

Essential = primary hypertension, no cause is identifiable
-> 95% of HTN
only 5% of HTN is secondary (identifiable cause)

Question 6

What causes the majority of secondary hypertension?

Answer 6

Intrinsic renal disease

• > i.e. Nephrosis / nephritis
• > Polycystic kidney disease
• > Renal artery stenosis (RAS)
• > Fibromuscular dysplasia

Question 7

Who is most likely to get fibromuscular dysplasia and renal artery stenosis?

Answer 7

Fibromuscular dysplasia -> especially young women, developmental defective in large and medium muscular arteries, especially affecting renal artery

Renal artery stenosis -> especially older men, due to atherosclerosis of renal arteries

Question 8

Give one sleep disorder which can cause hypertension?

Answer 8

Obstructive Sleep Apnea

Question 9

Other than adrenal disorders, give four endocrine disorders or conditions which can cause hypertension?

Answer 9

1. Acromegaly - GH excess
2. Hypothyroidism -> Increases sodium, also increases lipid levels for hardening of arteris
3. Hyperparathyroidism -> increases renin / kidney dysfunction
4. Exogenous hormones -> steroids / oral contraceptives

Question 10

What is one random food associated with HTN?

Answer 10

Licorice

Question 11

What are the adrenal conditions which can cause hypertension?

Answer 11

Cushing syndrome (hyper ACTH, increasing cortisol), primary aldosteronism (increased Na+ uptake), pheochromocytoma

Question 12

What causes of hypertension are associated with decreased distal pulses?

Answer 12

1. Renal artery stenosis -> peripheral vascular disease / atherosclerosis
2. Coarctation of aorta -> decreased lower limb blood flow

Question 13

What would abdominal bruits give you suspicion for?

Answer 13

Renal artery stenosis -> atherosclerosis is causing whooshing of blood flow.

Question 14

What condition in pregnancy is associated with high blood pressure?

Answer 14

Pre-eclampsia

Question 15

What does hypernatremia make you think as the cause of hypertension?

Answer 15

Hypothyroidism -> tends to increase diastolic blood pressure via the RAA axis

Will increase sodium reuptake by kidney all around

Question 16

What test should be ordered for Cushing’s syndrome suspected?

Answer 16

Dexamethasone suppression test

Question 17

For Stage 1 Hypertension, what is the first thing that should be done to manage it?

Answer 17

Lifestyle modification:

1. Weight loss
2. Exercise
3. Tobacco cessation (increases CO and peripheral vascular resistance via catecholamines)
4. Decrease alcohol consumption (2 for men, 1 for women)
5. DASH diet / low sodium diet.

Question 18

Watch the following sketchy videos (2x speed):

Answer 18

1. Loop diuretics
2. Thiazide diuretics
3. ACE inhibitors
4. Alpha-drugs
5. K+-sparing diuretics

Question 19

When are ACE inhibitors contraindicated?

Answer 19

1. C1 esterase inhibitor deficiency
2. Bilateral renal artery stenosis -> angiotensin II is the only thing maintaining GFR by constricting efferent arteriole
3. Pregnancy

Question 20

Why would you use an ARB over an ACE inhibitor?

Answer 20

ARBs do not cause a dry cough

-> note: still contraindicated in bilateral RAS

Question 21

What blood pressure meds are contraindicated in heart failure / should be used cautiously?

Answer 21

Calcium channel blocker -> due to negative inotropic effect

Beta blocker -> use cautiously / ramp up slowly due to negative inotropic effect

Question 22

What are the best blood pressure meds to use post-MI?

Answer 22

Beta blocker + ACE inhibitor

Question 23

What are the best blood pressure meds to use in coronary disease?

Answer 23

Beta blocker + Ace inhibitor, diuretic . CCB also okay

Question 24

What are the bestdrugs to use in diabetes and what should be avoided?

Answer 24

Ace inhibitor / ARB

Avoid: Beta blocker -> harder to tell if hypoglycemic except for sweating

Question 25

Best drugs for chronic kidney disease?

Answer 25

Ace inhibitor / ARB

Question 26

What is the definition of resistant HTN?

Answer 26

Persistently elevated BP despite 3+ medications

Question 27

What are the most common causes of resistant HTN?

Answer 27

Noncompliance or medications at not max dose, use of other drugs which elevate BP, volume overload, or undiagnosed OSA

Question 28

How should you treat resistant HTN?

Answer 28

Maximize dose, add more agents, check for secondary causes (i.e. OSA, or new-onset RAS)

-> experimental obliteration of sympathetic nerve bundle to renal artery (kills B1 stimulation of renin release + drop in renal blood flow due to catecholamines).