Hypertension Flashcards
In what race is HTN most prevalent?
Black
What is normal blood pressure?
Systolic <120 and diastolic <80
What is pre-hypertension?
Systolic 120-139 or diastolic 80-89
What are the stages of hypertension?
Stage 1: systolic 140-159 or diastolic 90-99
Stage 2: systolic >160 or diastolic >100
What is blood pressure calculated as?
Cardiac output x systemic vascular resistance
What are the major factors of systemic vascular resistance?
SNS, RAA system and plasma volume
Risk factors of primary HTN
Age, race, family hx, smoking, high sodium diet, excess alcohol intake, obesity/weight gain, physical inactivity, dyslipidemia, vitamin D deficiency
What is secondary hypertension?
High BP from an identifiable medication or medical condition
This MUST be addressed first to achieve adequate BP control
What are some etiologies of secondary HTN?
Renal disease, renovascular disease, meds (estrogen, NSAIDs, steroids), thyroid/parathyroid disease, CoA, primary hyperaldosteronism, Cushing’s syndrome, pheochromocytoma, obstructive sleep apnea
What are the characteristics of primary hyperaldosteronism?
Hypokalemia, metabolic alkalosis
What are the characteristics of Cushing’s syndrome?
Skin atrophy, striate, proximal muscle weakness, uneven body fat distribution
What is the triad of pheochromocytoma?
H/A, sweating, tachycardia due to an inconsistent BP
What is the gold standard for diagnosing HTN?
Ambulatory BP monitoring (confirms HTN out of office when BP elevated at screening)
What is white coat HTN?
Erroneously high BP in clinic due to anxiety
What is masked HTN?
Erroneously low BP in clinic (idiopathic)
When is nocturnal monitoring useful?
For predicting cardiovascular events
General principles for taking BP
Serial measurements required
Do both arms
Comfortable, quiet setting
Avoid eating, exercise, smoking and caffeine right before
Why must you evaluate for signs of end organ damage?
In case they also have heart failure, renal failure, stroke/CVA, dementia, aortic dissection, retinopathy (accelerated/malignant HTN)
What do you see on the retina that is the difference between moderate (accelerated) and severe (malignant) HTN?
Both have exudates, cotton wool spots, AV nicking but severe has edema of the optic disk
What diagnostic studies should be ordered for primary HTN?
Lipid profile, urinalysis, creatinine, blood glucose, electrolytes, EKG
LUBE
How should you approach the management of HTN?
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?
What is the first line management for all patients with essential HTN?
Lifestyle modifications
What are the big 4 HTN meds?
Diuretics, ACE-1, ARB and CCBs (others are beta blockers, alpha blocker, central alpha agonists and direct renin inhibitors)
What are the recommendations for HTN medications?
- 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)
- 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.
- 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
What is resistant HTN?
BP that is not controlled despite adherence to an appropriate 3 drug regiment or requires at least 4 meds to achieve control
What is the MOA of all diuretics?
Decrease body’s sodium stores by inhibiting sodium reabsorption in the nephron and because water will follow, it reduces plasma volume and PVR
Types of diuretics?
Thiazide types (used most), loop, potassium sparing, aldosterone antagonists
What is the difference in the classes of calcium channel blockers?
Non-dihydropyridine has more of a cardiac depressant effect
Dihydropyridine are more selective as vasodilators with less cardiac depression (ipines)
What are the types of beta blockers?
Cardioselective (B1 receptors) and noncardioselective (B1 and B2 receptors)
What is hypertensive urgency?
Asymptomatic severe HTN (diastolic <120) and no evidence of end organ damage (usually nonadherence to med or diet)
What is a hypertensive emergency?
Severe HTN (diastolic >120) and evidence of acute end organ damage
Some causes of a hypertensive crisis
Abrupt change in meds, high salt load, neurological/cardiac/vascular emergency, pregnancy, sympathetic overactivity, renal emergency
What is the goal of tx for hypertensive urgency?
Reduce BP to <160/120 by resting in quiet, increasing dose of meds, adding new one, restricting sodium
Tx for hypertensive emergency
Hospitalized in ICU and address underlying cause
How do you reduce the BP in a hypertensive emergency?
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
