Hypertension

Question 1

In what race is HTN most prevalent?

Answer 1

Black

Question 2

What is normal blood pressure?

Answer 2

Systolic <120 and diastolic <80

Question 3

What is pre-hypertension?

Answer 3

Systolic 120-139 or diastolic 80-89

Question 4

What are the stages of hypertension?

Answer 4

Stage 1: systolic 140-159 or diastolic 90-99

Stage 2: systolic >160 or diastolic >100

Question 5

What is blood pressure calculated as?

Answer 5

Cardiac output x systemic vascular resistance

Question 6

What are the major factors of systemic vascular resistance?

Answer 6

SNS, RAA system and plasma volume

Question 7

Risk factors of primary HTN

Answer 7

Age, race, family hx, smoking, high sodium diet, excess alcohol intake, obesity/weight gain, physical inactivity, dyslipidemia, vitamin D deficiency

Question 8

What is secondary hypertension?

Answer 8

High BP from an identifiable medication or medical condition

This MUST be addressed first to achieve adequate BP control

Question 9

What are some etiologies of secondary HTN?

Answer 9

Renal disease, renovascular disease, meds (estrogen, NSAIDs, steroids), thyroid/parathyroid disease, CoA, primary hyperaldosteronism, Cushing’s syndrome, pheochromocytoma, obstructive sleep apnea

Question 10

What are the characteristics of primary hyperaldosteronism?

Answer 10

Hypokalemia, metabolic alkalosis

Question 11

What are the characteristics of Cushing’s syndrome?

Answer 11

Skin atrophy, striate, proximal muscle weakness, uneven body fat distribution

Question 12

What is the triad of pheochromocytoma?

Answer 12

H/A, sweating, tachycardia due to an inconsistent BP

Question 13

What is the gold standard for diagnosing HTN?

Answer 13

Ambulatory BP monitoring (confirms HTN out of office when BP elevated at screening)

Question 14

What is white coat HTN?

Answer 14

Erroneously high BP in clinic due to anxiety

Question 15

What is masked HTN?

Answer 15

Erroneously low BP in clinic (idiopathic)

Question 16

When is nocturnal monitoring useful?

Answer 16

For predicting cardiovascular events

Question 17

General principles for taking BP

Answer 17

Serial measurements required
Do both arms
Comfortable, quiet setting
Avoid eating, exercise, smoking and caffeine right before

Question 18

Why must you evaluate for signs of end organ damage?

Answer 18

In case they also have heart failure, renal failure, stroke/CVA, dementia, aortic dissection, retinopathy (accelerated/malignant HTN)

Question 19

What do you see on the retina that is the difference between moderate (accelerated) and severe (malignant) HTN?

Answer 19

Both have exudates, cotton wool spots, AV nicking but severe has edema of the optic disk

Question 20

What diagnostic studies should be ordered for primary HTN?

Answer 20

Lipid profile, urinalysis, creatinine, blood glucose, electrolytes, EKG
LUBE

Question 21

How should you approach the management of HTN?

Answer 21

Does initiating tx at specific BP thresholds improve health outcomes?
Does tx to a specific BP goal improve health outcomes?
Are there differences in benefits/harm between antihypertensive drugs or drug classes on specific health outcomes?

Question 22

What is the first line management for all patients with essential HTN?

Answer 22

Lifestyle modifications

Question 23

What are the big 4 HTN meds?

Answer 23

Diuretics, ACE-1, ARB and CCBs (others are beta blockers, alpha blocker, central alpha agonists and direct renin inhibitors)

Question 24

What are the recommendations for HTN medications?

Answer 24

1. Everybody’s goal is 140/90 (only exception if people over 60 who don’t have kidney disease or diabetes and then it is 150/90)
2. If you have CKD, start with an ACE or ARB. If you’re black, start with a thiazide or CCB. If you’re neither, you start with any of 4.
3. If 1 doesnt work, add one from a different class and then a different class if needed. DONT use an ACE or ARB together. If on 3/4 and not better, consider other classes or refer

Question 25

What is resistant HTN?

Answer 25

BP that is not controlled despite adherence to an appropriate 3 drug regiment or requires at least 4 meds to achieve control

Question 26

What is the MOA of all diuretics?

Answer 26

Decrease body’s sodium stores by inhibiting sodium reabsorption in the nephron and because water will follow, it reduces plasma volume and PVR

Question 27

Types of diuretics?

Answer 27

Thiazide types (used most), loop, potassium sparing, aldosterone antagonists

Question 28

What is the difference in the classes of calcium channel blockers?

Answer 28

Non-dihydropyridine has more of a cardiac depressant effect

Dihydropyridine are more selective as vasodilators with less cardiac depression (ipines)

Question 29

What are the types of beta blockers?

Answer 29

Cardioselective (B1 receptors) and noncardioselective (B1 and B2 receptors)

Question 30

What is hypertensive urgency?

Answer 30

Asymptomatic severe HTN (diastolic <120) and no evidence of end organ damage (usually nonadherence to med or diet)

Question 31

What is a hypertensive emergency?

Answer 31

Severe HTN (diastolic >120) and evidence of acute end organ damage

Question 32

Some causes of a hypertensive crisis

Answer 32

Abrupt change in meds, high salt load, neurological/cardiac/vascular emergency, pregnancy, sympathetic overactivity, renal emergency

Question 33

What is the goal of tx for hypertensive urgency?

Answer 33

Reduce BP to <160/120 by resting in quiet, increasing dose of meds, adding new one, restricting sodium

Question 34

Tx for hypertensive emergency

Answer 34

Hospitalized in ICU and address underlying cause

Question 35

How do you reduce the BP in a hypertensive emergency?

Answer 35

No more than 25% within minutes to 1 hr because ischemia to brain occurs if too fast
If stable then get to normal BP in 24-48 hrs
No sublingual nefidipine