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Primary Care Exam 2 > Hypertension > Flashcards

Hypertension Flashcards

1
Q

How do you calculate blood pressure?

A

Blood pressure = cardiac output x peripheral resistance

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2
Q

What changes in the blood pressure formula cause hypertension?

A

Hypertension = increased cardiac output and/or increased peripheral resistance

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3
Q

What is the most common conditions seen in primary care?

A

Hypertension

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4
Q

Who do we screen for hypertension?

A

All adults over 18 years old

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5
Q

What are some major complications of uncontrolled hypertension?

A

Myocardial infarction, stroke, renal failure, death

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6
Q

What is another name for primary hypertension?

A

Essential hypertension

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7
Q

What are some risks for hypertension?

A
  • Age
  • Race
  • Obesity
  • Diet: ETOH, sodium
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8
Q

What causes secondary hypertension?

A

Medical problems

A: Apnea, aldosteronism
B: Bruit, bad kidney
C: Catecholamine, coarctation, Cushing
D: Drugs (ETOH)
E: Endocrine disorders
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9
Q

Which puts you at higher risk for a cardiac event: Elevated SBP or DBP?

A

Elevated SBP

  • Isolated elevation of systolic blood pressure (>140 mmHg) is related to significant cardiac risk
  • Widening pulse pressure is a significant risk factor for cardiovascular event, especially in ordered adults
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10
Q

What is the most common form of high blood pressure in older Americans?

A

Isolated systolic hypertension

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11
Q

What is your white coat hypertension?

A
  • “Labile” hypertension
  • BP persistently >120/80 at the providers office, but not on home measurements
  • Systolic BP is especially elevated
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12
Q

Are people with white coat HTN at risk for cardiovascular events?

A

CV risks appear to be less than people with sustained HTN, but white coat HTN may increase risk of stroke and LV remodeling

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13
Q

What are some important instructions for your patient to heed before having their blood pressure checked in the office?

A
  • Relax, sitting in the chair, feet on floor, > 5 min
  • Avoid caffeine, exercise, smoking for at least 30 min
  • Empty bladder
  • No talking
  • No clothes under cuff
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14
Q

What are some proper techniques for getting an accurate blood pressure?

A
  • Support patient’s arm

- Use correct sized cuff

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15
Q

According to the 2017 ACC/AHA guidelines, what is considered NORMAL blood pressure?

A

< 120/80 mmHg

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16
Q

According to the 2017 ACC/AHA guidelines, what is considered ELEVATED blood pressure?

A

120-129/<80 mmHg

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17
Q

According to the 2017 ACC/AHA guidelines, what is considered STAGE 1 HTN?

A

130-139/80-89 mmHg

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18
Q

According to the 2017 ACC/AHA guidelines, what is considered STAGE 2 HTN?

A

> 140/90 mmHg

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19
Q

At what blood pressure do we treat hypertension?

A

> 130/80 (STAGE 1): Assessed 10-year ASCVD risk…

  • <10%, lifestyle changes and reassess in 3-6 months
  • > 10% or CVD, DM, CKD, start BP-lowering medication

> 140/90 (STAGE 2): BP-lowering medications (2)

Lifestyle modifications for >120/80

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20
Q

What are the risk factors that are considered when calculating ASCVD risk?

A
  • Age (40-79)
  • Gender (male)
  • Race (African American)
  • Total cholesterol (high)
  • HDL cholesterol (low)
  • SBP (high)
  • DBP (high)
  • Treated for HTN?
  • DM?
  • Smoker?
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21
Q 
What is the
- BP level
- intervention
- reassessment
for someone with a normal blood pressure?
A

<120/80
Promote optimal lifestyle habits
Reassess in 1 year

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22
Q 
What is the
- BP level
- intervention
- reassessment
for someone with elevated blood pressure?
A

120-129/<80
Nonpharmacological therapy
Reassess in 3-6 months

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23
Q 
What is the
- BP level
- intervention
- reassessment
for someone with STAGE 1 HTN?
A

130-139/80-89
Assess ASCVD risk

If ~NO~ ASCVD or 10yr risk <10%:

  • Nonpharmacological therapy
  • Reassess in 3-6 months

If ~YES~ ASCVD or 10-yr >10%

  • Nonpharmacological therapy & BP lowering medication (1)
  • Reassess in one month
  • If BP goal met, reassess in 3-6 months
  • If BP goal NOT met, assess & optimize adherence to therapy, & consider intensification of therapy
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24
Q 
What is the
- BP level
- intervention
- reassessment
for someone with STAGE 2 HTN?
A

> 140/90

  • Nonpharmacological therapy & BP lowering medications (2!)
  • Reassess in one month
  • If BP goal met, reassess in 3-6 months
  • If BP goal NOT met, assess & optimize adherence to therapy, & consider intensification of therapy
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25
Q

What are some diagnostics we need to consider when assessing someone with hypertension?

A
  • 12 lead ECG
  • BLOOD GLUCOSE (FBG)
  • Fasting cholesterol panel
  • GFR
  • SERUM CALCIUM
  • SERUM POTASSIUM
  • Urinalysis
  • Tsh
  • Cbc
    (Echo, uric acid, urinary albumin to creatinine ratio)
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26
Q

What are some diagnostics we need to consider when assessing for secondary hypertension?

A
  • Sleep study
  • Hormone levels (aldosterone, cortisone)
  • Urine drug screen
  • Renal ultrasound
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27
Q

What are some lifestyle modifications that help reduce blood pressure?

A
  • Exercise
  • DASH diet
  • Salt restriction
  • Weight reduction
  • Reduction in excess alcohol consumption
  • Limiting NSAIDs
  • Stress reduction
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28
Q

What are some of the blood pressure benefits of exercise?

A
  • Aerobic and circuit weight training 3x/wk can reduce BP as much as a BB or CCB
  • Weight reduction
  • CV conditioning
  • Decrease lipids (increase HDL)
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29
Q

Who benefits the most from sodium restriction in terms of blood pressure reduction?

A
  • African Americans

- Elderly

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30
Q

What is the difference between “no added salt” diet and “low salt” diet?

A

“No salt added” = 4g/day

“Low salt” = 2g/day

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31
Q

What lifestyle modification reduces blood pressure the most?

A

DASH diet + sodium reduction

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32
Q

What is the DASH diet?

A

Dietary Approaches to Stop Hypertension
Goals: 2,000 cal/day
Sodium: 2,300mg (standard), 1,500mg (low)

Whole grains (6-8 servings per day)
Vegetables (4-5 servings per day)
Fruits (4-5 servings per day)
Fat-free/low-fat dairy (2-3 servings per day)
Fats/oils (2-3 servings per day)

Nuts/seeds/legumes (4-5 servings per week)
Meat/poultry/fish (<6 servings per week)
Sweets (<5 servings per week)

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33
Q

In the general NON-BLACK population, including those with DM, what are some initial first-line antihypertensive treatments?

A
  • Thiazide-type diuretics
  • Calcium channel blockers (CCBs)
  • Angiotensin-converting enzyme inhibitors (ACEs) or angiotensin receptor blockers (ARBs)
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34
Q

In the general BLACK population, including those with diabetes, what are some initial first-line antihypertensive treatments?

A
  • Thiazide-type diuretic

- Calcium channel blockers (CCBs)

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35
Q

In the population aged 18+ with CKD, what are the initial antihypertensive treatments to improve kidney outcomes?

A
  • ACEs
  • ARBs

This applies for all CKD patients with HTN, regardless of race or diabetes status

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36
Q

What are some secondary antihypertensives?

A
  • Loop diuretics
  • Potassium-sparing diuretics
  • Beta blockers
  • Alpha blockers
  • Alpha/beta blockers
  • Direct-acting vasodilators
  • Centrally acting alpha agonists
37
Q

What are some of the uses/benefits of thiazide-type diuretics?

A
  • First line in many patients, comparable to all other first-line agents
  • Safe and low-cost
  • Commonly used in combination
38
Q

What is the mechanism of action of size thiazide-type diuretics?

A

Enhanced sodium excretion => reduce intravascular volume => reduce peripheral resistance

39
Q

What are some side effects with thiazide-type diuretics?

A
  • Potassium wasting
  • Hyperglycemia / hypercalcemia / hyperuricemia
  • Sexual dysfunction
  • Urinary frequency
  • Transient increase in LDL
40
Q

What are some cautions with thiazide type diuretics?

A
  • Sulfa allergy
  • Gout
  • Monitor hypokalemia, uric acid, calcium
41
Q

Which is more potent: chlorthalidone or hydrochlorothiazide?

A

Chlorthalidone has 2x potency of HCTZ

42
Q

What are some of the uses/benefits of calcium channel blockers (CCBs)?

A
  • African American patients
  • Nondihydropyridines (Verapamil, Diltiazem) used to rate control patients with AFib or for control of angina
  • Preferred over BB for treatment in patients with airway disease
43
Q

What is the mechanism of action of calcium channel blockers (CCBs)?

A

Block entry of calcium in the heart and vascular smooth muscle => reduces smooth muscle contraction => reduce peripheral resistance

44
Q

What are some side effects of calcium channel blockers (CCBs)?

A
  • Edema
  • Reflex tachycardia / bradycardia
  • Headache
  • Constipation
  • Dizziness
45
Q

When should we be cautious with using calcium channel blockers (CCBs)?

A

Not recommended first line after MI

46
Q

Which class of antihypertensive medications may improve GFR in patients with real insufficiency?

A

Calcium channel blockers (CCBs)

47
Q

What class of antihypertensive medications is a good alternative for patients who have DM/CKD and a history of angioedema with ACE/ARB?

A

Calcium channel blockers (CCBs)

48
Q

What are some of the uses/ benefits of angiotensin-converting enzyme inhibitors (ACEs)?

A
  • First line in CKD, DM
  • Specific use after MI, to reduce heart failure and mortality
  • Reverse LVH and remodeling to hypertension (post MI)
  • Low cost
49
Q

What is the mechanism of action of angiotensin-converting enzyme inhibitors (ACEs)?

A
  • Blocks conversion of renin-activating angiotensin I to angiotensin II => reduces vasoconstriction => also reduces aldosterone (influences Na & water reabsorption in kidneys)
  • Inhibits breakdown of bradykinin (vasodilator)
50
Q

What are some side effects of angiotensin-converting enzyme inhibitors (ACEs)?

A
  • Dry cough (benign)
  • Hyperkalemia
  • Elevated creatinine (AKI)
51
Q

When must we be cautious with using angiotensin-converting enzyme inhibitors (ACEs)?

A
  • Angioedema (critical)
  • Must avoid in pregnancy
  • There are different dosage recommendations for ACE use in HTN vs renal protection
  • Do NOT use with ARB
52
Q

What are some of the uses/benefits of angiotensin receptor blockers (ARBs)?

A
  • First line in CKD, DM
  • Specific use after MI, to reduce heart failure and mortality
  • Reverse LVH and remodeling to hypertension (post MI)
  • Low cost
  • Comparable to ACEs in blood pressure control
53
Q

What is the mechanism of action of angiotensin receptor blockers (ARBs)?

A

-Blocks conversion of renin-activating angiotensin I to angiotensin II => reduces vasoconstriction => also reduces aldosterone (influences Na & water reabsorption in kidneys)

No effect on bradykinin (which removes the risk for cough)

54
Q

What are the side effects of in utensil receptor blockers (ARBs)?

A
  • Hyperkalemia
  • Elevated creatinine (AKI)
    No cough!
55
Q

When should we be cautious with angiotensin receptor blocker (ARB) use?

A
  • Angioedema
  • Avoid in pregnancy
  • Do NOT use with ACE
56
Q

What is the initial antihypertensive drug selection for a black patient?

A

CCB or thiazide diuretic

57
Q

What is the initial antihypertensive drug selection for a non-black patient <60yo?

A

ARB or ACE

58
Q

What is the initial antihypertensive drug selection for a non-black patient >60yo?

A

CCB, thiazide diuretic, ARB, ACE

59
Q

What is the initial antihypertensive drug selection for CKD?

A

ARB or ACE

60
Q

What is the initial antihypertensive drug selection for CAD?

A

BB &

ARB or ACE

61
Q

What is the initial antihypertensive drug selection for DM?

A

ARB or ACE

62
Q

What is the initial antihypertensive drug selection for CHF?

A

BB &

ARB or ACE

63
Q

What is the initial antihypertensive drug selection for a patient with a history of CVA?

A

ARB or ACE

64
Q

What are some examples of thiazide-type diuretics?

A
  • Hydrochlorothiazide (HCTZ)

- Chlorthalidone

65
Q

What are some examples of calcium channel blockers (CCBs)?

A

End with -dipine

  • Amlodipine
  • Diltiazem
  • Nifedipine
66
Q

What are some examples of angiotensin-converting enzyme inhibitors (ACEs)?

A

End with -pril

  • Lisinopril
  • Enalapril
67
Q

What are some examples of angiotensin receptor blockers (ARBs)?

A

End with -sartan

  • Losartan
  • Valsartan
68
Q

What are some examples of loop diuretics?

A
  • Furosemide

- Bumetanide

69
Q

What are some examples of potassium-sparing diuretics?

A
  • Spironolactone

- Amiloride

70
Q

What are some examples of beta blockers (BBs)?

A

End with -olol

  • Atenolol
  • Nadolol
  • Metoprolol
71
Q

What are some examples of alpha blockers?

A

End with -azosin

  • Doxazosin
  • Terazosin
72
Q

What are some examples of alpha/beta blockers?

A

End with just -lol

  • Carvedilol
  • Labetalol
73
Q

What are some examples of direct acting vasodilators?

A
  • Hydralazine

- Minoxidil

74
Q

What are some examples of a centrally acting alpha agonists?

A
  • Clonidine

- Methyldopa

75
Q

According to the 2017 ACC/AHA guidelines, how do you titrate medication for Stage I HTN?

A
  • If ASCVD risk is >10% or known clinical CVD, DM, or CKD, start 1 BP lowering medication
  • If goal is met after 1 month, titrate medication, reassess in 3-6 months
  • If goal is NOT met after 1 month, consider different medication or titration
  • Continue monthly follow-up until control is achieved
76
Q

According to the 2017 ACC/AHA guidelines, how do you titrate medication for Stage II HTN?

A
  • Start 2 BP lowering medications of different classes

- Follow titration schedule of Stage I HTN

77
Q

What are some cautions with prescribing antihypertensive medications in older patients aged 65+?

A
  • Start low, go slow
  • Carefully consider diuretics
  • Monitor renal function closely
  • Review risk of postural hypotension
78
Q

What are some general cautions with prescribing antihypertensive medications?

A
  • Do not use ACE and ARB together in the same patient
  • Is the BP goal cannot be reached due to contraindications or the need to use >3 drugs to reach goal BP, antihypertensive drugs from other classes can be used
  • Referral to a specialist may be indicated for patients in whom goal BP cannot be attained
79
Q

What are some steps to work through in patients with resistant hypertension?

A
  • Confirm resistance
  • Exclude environmental factors
  • Screen for secondary causes
  • Maximize pharmacologic therapy
  • Refer to specialist
80
Q

Arrange these medications in order of “most affordable”:

  1. Lisinopril
  2. Amlodipine
  3. Losartan
  4. Hydrochlorothiazide
A
  1. HCTZ ($4)
  2. Lisinopril ($4)
  3. Amlodipine ($40-50)
  4. Losartan ($40-60)
81
Q

Arrange these medications in order of “safest for future mommy”:

  1. Hydrochlorothiazide
  2. Nifedipine
  3. Lisinopril
  4. Labetalol
A
  1. Labetalol
  2. Nifedipine
  3. HCTZ
  4. Lisinopril
82
Q

Which medications should be used/NOT used in women who are pregnant/planning to become pregnant?

A

USE: the ABCs
Alpha agonist (centrally acting): methyldopa
Beta/alpha blocker: labetalol
CCB: nifedipine

DO NOT USE: the ACEs or ARBs

83
Q

Arrange these medications in order of “easiest regimen”:

  1. Chlorthalidone
  2. Metoprolol
  3. Hydralazine
  4. Benazepril hydrochloride
A
  1. Chlorthalidone
  2. Benazepril HCT (combination medication)
  3. Metoprolol
  4. Hydralazine
84
Q

What are some barriers to antihypertensives care/compliance?

A
  • Lack of understanding of disease
  • Lack of access
  • Side effects
  • Cost
  • Lack of appropriate follow-up by provider, including not following up on missed appointments
  • Confusion regarding medication’s language/reading barriers, pharmacy confusion
  • Therapeutic/clinical inertia
85
Q

What should be documented in the HPI for hypertension?

A
  • Diet
  • Exercise
  • Weight loss
  • Medication adherence
  • Home blood pressure measurements
86
Q

What should be included in the ROS for hypertension?

A
  • HEENT: vision changes
  • Pulm: SOB, cough, orthopnea
  • CV: Chest pain, palpitations
  • Abd: abdominal pain
  • Neuro: dizziness, lightheadedness, weakness
  • Peripheral resistance: edema, leg pain
87
Q

What should be included in the physical exam for hypertension?

A
  • HEENT: fundoscopic exam, thyroid, carotids
  • Lungs
  • CV: Rate, rhythm, murmurs
  • ABD: HSM, aorta
  • Neuro: cranial nerves, strength
  • PV: pulses, edema
88
Q

What is the ultimate goal of into hypertensive therapy?

A

Reduce cardiovascular morbidity and mortality

89
Q

What is the cornerstone of successful/sustained hypertension management?

A

Lifestyle changes

Primary Care Exam 2 (2 decks)

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