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Primary care of adults 2 > Hypertension (8 questions) > Flashcards

Hypertension (8 questions) Flashcards

1
Q

What percent of patients with diagnosed HTN are controlled?

A

25%

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2
Q

Relationship between age and HTN

A

HTN increases w/age

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3
Q

At what age does pulse pressure change and how

A

PP increases d/t decreased diastolic pressure

after age 50

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4
Q

Hypertension incidence: blacks vs whites

A

more common in blacks

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5
Q

Difference between primary and secondary hypertension

A
  • Primary HTN = “essential HTN”. No identifiable cause. Probably mix of environment & genetic
  • **Secondary HTN: **identifiable cause
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6
Q

Most common cause of HTN before age 50

A

primary HTN

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7
Q

Primary HTN accounts for ___ percent of all HTN

A

95%

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8
Q

Age range for typical onset of primary HTN

A

25-55yo

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9
Q

Some multifactorial causes of HTN: contribution by arterioles

A
  • Constriction of resistance arterioles
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10
Q

Some multifactorial causes of primary HTN: contribution by baroreceptors

A

decreased Baroreceptor sensitivity

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11
Q

Some multifactorial causes of primary HTN: contribution by endothelium

A

Endothelial dysfunction

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12
Q

Some multifactorial causes of HTN: contribution by sympathetic nervous system activity

A

Increased Sympathetic nervous system activity

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13
Q

Some multifactorial causes of primary HTN: contribution by α and β-adrenergic receptors

A

Decreased α and β-adrenergic receptor response

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14
Q

Some multifactorial causes of HTN: contribution by plasma renin

A

Low plasma renin activity

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15
Q

Some multifactorial causes of primary HTN: contribution by insulin system

A

Insulin resistance

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16
Q

Some multifactorial causes of primary HTN: contribution by neurohormonal factors

A

Neurohormonal factors that decrease vascular response (poor dilation)

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17
Q

Causes of secondary HTN

A
  • Medications of drugs
  • Pheochromocytoma (rare)
  • Coarctation of the aorta
  • Primary renal disease
  • Primary aldosteronism
  • Renocvscular disease
  • Cushing’s syndrome
  • Obstructive sleep apnea
  • Increased intracranial pressure
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18
Q

JNC 7: normal BP

A

SBP <120

DBP <80

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19
Q

JNC 7: prehypertension

A

SBP 120-139

DBP 80-89

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20
Q

JNC 7: stage I HTN

A

SBP 140-159

DBP 90-99

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21
Q

JNC 7: Stage 2 HTN

A

SBP: > 160

DBP: > 100

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22
Q

HTN: presentation (initial and late)

A
  • Usually silent
  • Occasionally headache
  • End organ disease symptoms: renal, cardiac, ophthalmologic, cognitive impairment
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23
Q

Goals of JNC7 assessment

A
  • Stage BP: how high is it?
  • Determine CVD risk
  • Determine if secondary HTN is present
  • Determine if any end organ damage is present
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24
Q

Diagnosis of HTN

A
  • Hypertension should never be diagnosed based on only one reading in the office.
    • 2 or more readings, taken at 2 or more visits at least 2 weeks apart. (calculate and average)
  • Measure twice, keep patient sitting and relaxed, use the correct cuff, big arm, big cuff.
  • Inflate cuff 20mm higher than the level that obliterates the radial pulse (esp in older)
  • Both arms, sitting and standing
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25
Q

BP relationship to risk of CVD

A

continuous, consistent, and independent of other risk factors.

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26
Q

How many increments of BP increase to double risk of CVD?

A

Each increment of 20/10 mmHg doubles the risk of CVD across the entire BP range starting from 115/75 mmHg.

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27
Q

Risk factors for CVD

A
  • HTN *
  • Smoking
  • Obesity *: BMI ≥30kg/m2
  • Physical inactivity
  • Dyslipidemia *
  • Diabetes *
  • Age >55 for men or > 65 for women – applies more to white women. Black women develop earlier, 55/45
  • Family history of heart disease— women <65 and men <55
  • Microalbuminuria – indicates renal damage
  • GFR <60ml/min

*components of metabolic syndrome

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28
Q

HTN exam: what should you check?

A
  • Weight gain or loss
  • Retinas: exudate, hemorrhages, papilledema
  • Lung Sounds
  • Heart Sounds
  • Check lower legs/ankles
  • BP & HR :supine-sitting-upright (esp geriatric)
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29
Q

Baseline diagnostic tests for primary causes of HTN

A
  • Comprehensive Metabolic Panel
  • *CBC *
  • Lipids
  • TSH
  • HbA1C
  • UA (Urine MicroAlbumin)
  • EKG
  • Echocardiogram
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30
Q

components of CMP

A
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31
Q

Components of BMP

A
  • BUN: 7 to 20 mg/dL
  • Creatinine: 0.8 to 1.4 mg/dL
  • CO2 (carbon dioxide): 20 to 29 mmol/L
  • Glucose: 64 to 128 mg/dL
  • Serum chloride: 101 to 111 mmol/L
  • Serum potassium: 3.7 to 5.2 mEq/L
  • Serum sodium: 136 to 144 mEq/L
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32
Q

Components of CBC

A

RBC count:

  • Male: 4.7 to 6.1 million cells/mcL
  • Female: 4.2 to 5.4 million cells/mcL

WBC count:

  • 4,500 to 10,000 cells/mcL

Hematocrit:

  • Male: 40.7 to 50.3%
  • Female: 36.1 to 44.3%

Hemoglobin:

  • Male: 13.8 to 17.2 gm/dL
  • Female: 12.1 to 15.1 gm/dL

Red blood cell indices:

  • MCV: 80 to 95 femtoliter
  • MCH: 27 to 31 pg/cell
  • MCHC: 32 to 36 gm/dL
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33
Q

WBC w/differential

A
  • Neutrophils: 40% to 60%
  • Lymphocytes: 20% to 40%
  • Monocytes: 2% to 8%
  • Eosinophils: 1% to 4%
  • Basophils: 0.5% to 1%
  • Band (young neutrophil): 0% to 3%
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34
Q

Diagnostic studies for secondary causes of HTN

A
  • 24hr urine free cortisol and plasma metanephrine levels
  • Renal ultrasound
  • Abdominal imaging: ultrasound, CT Scan, MRI
  • Renal Arteriography
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35
Q

Benefits of lowering BP

A

Average Percent Reduction

Stroke incidence

35–40%

Myocardial infarction

20–25%

Heart failure

50%

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36
Q

What to explain to PT about end organ damage

A
  • Heart: explain to the patient. This is a silent killer
    • Left ventricular hypertrophy
    • Angina or prior myocardial infarction
    • Prior coronary revascularization
    • Heart failure
  • Brain : once again need to partner with the patient
    • Stroke or transient ischemic attack
  • Chronic kidney disease
  • Peripheral arterial disease
  • Retinopathy
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37
Q

JNC 8 target goals for BP

A
  • General population aged ≥ 60 years: 150/90 mmHg (140/90 mmHg for everybody else)
  • Population aged 18 years with DM or CKD: 140/90mmHg
  • Note: Diabetes and renal disease need more aggressive treatment –> 130/80mmHg (JNC 7)
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38
Q

JNC 8: General nonblack population (including those with diabetes), initial antihypertensive treatment

A

a thiazide-type diuretic, CCB, ACEI or ARB.

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39
Q

JNC 8: General black population (including those with diabetes), initial antihypertensive treatment

A

a thiazide-type diuretic or CCB

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40
Q

JNC 8: Population aged18 years with CKD, initial (or add-on) antihypertensive treatment, regardless of race or diabetes status

A

ACEI or ARB

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41
Q

Treatment guidelines for prehypertension:

A

No risk factors or target organ disease–lifestyle changes

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42
Q

Treatment guidelines for stage 1 HTN

A

Lifestyle change but newer approach is aggressive–one drug needed

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43
Q

Tx guidelines stage 2 HTN

A

start with 2 drug therapy

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44
Q

Tx guidelines: diabetes & renal dz

A

need more aggressive treatment–> à 130/80mmHg

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45
Q

Summary of general treatment goals, HTN

A
  • Reduce CVD and renal morbidity and mortality
    • Lower if preserving renal function
  • Lower to slow heart failure progression
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46
Q

Can Hypertension Be Prevented?

A
  • Blood pressure rise is not inevitable with age–prospective follow up study (to DASH?)
  • However, Framingham data suggest that normotensive 55 year olds have a 90% lifetime risk for developing hypertension!
  • Treatment for over one year did not prevent the onset of hypertension only delayed it
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47
Q

Important findings on relationship between diet, weight loss, and BP

A
  • Diet rich in fruits, vegetables, and low-fat dairy foods, with reduced fats lowers BP in a randomized trial (DASH)
  • Population wide–reduce salt in processed food, reduced caloric intake (obesity and sleep apnea directly correlated with HTN)
  • Weight loss (~2.5 kg or 5 lbs) can reduce BP similar to monotherapy
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48
Q

For what populations is low sodium diet especially effective?

A

middle-aged and older individuals, African Americans, and those who already had high BP

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49
Q

Components of DASH diet

A

Nutrient

Amount

Nutrient

Amount

Total Fat

27 % of calorie

Sodium

2,300 mg**

Saturated Fat

6 % of calorie

Potassium

4,700 mg

Protein

18 % of calorie

Calcium

1,250 mg

Carbohydrate

55 % of calorie

Magnesium

500 mg

Cholesterol

150mg

Fiber

30 g

** 1,500mg sodium was a lower goal tested and found to be even better for lowering BP. It was particularly effective for middle-aged and older individuals, African Americans, and those who already had high BP.

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50
Q

Lifestyle Modifications to Manage Hypertension

A
  • Weight reduction
  • Adopt DASH eating plan
  • Dietary sodium reduction
  • Physical activity
  • Moderation of alcohol consumption
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51
Q

HTN mgmt: Weight reduction - recommendation & approximate reduction in SBP

A
  • Maintain normal body weight (body mass index, 18.4-24.9 kg/m2)
  • 5-20 mm Hg; 10-kg weight loss
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52
Q

HTN mgmt: Adopt DASH eating plan - recommendation & approximate reduction in SBP

A
  • Consume diet rich in fruits, vegetables, low-fat dairy products, with reduced content of saturated and total fats
  • 8-14 mm Hg
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53
Q

HTN mgmt: Dietary sodium reduction - recommendation & approximate reduction in SBP

A
  • Reduce dietary sodium intake to no more than 100 mmol/day (2.4 g sodium or 6 g sodium chloride)
  • 2-8 mm Hg
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54
Q

HTN mgmt: Physical activity - recommendation & approximate reduction in SBP

A
  • Engage in regular aerobic physical activity (e.g., brisk walking) at least 30 min/day, most days of the week
  • 4-9 mm Hg
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55
Q

HTN mgmt: Moderation of alcohol consumption- recommendation & approximate reduction in SBP

A
  • Most men: limit consumption to no more than two drinks/day‡ Most women and those who weigh less than normal: no more than one drink/day
  • 2-4 mm Hg
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56
Q

Classes of oral antihypertensive drugs

A
  • Diuretics (Thiazide)
  • ACE inhibitors
  • ARBS
  • Calcium Cannel Blockers (CCBs)
  • Beta Blockers
  • Alpha Blockers
  • Beta Blockers
  • Direct renin inhibitor
  • Sympatholytic Types
  • Diuretics (Loop and K sparing)
  • Central Sympatholytic
  • Direct Vasodilators
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57
Q

If taking a K sparing or ACE/ARB, how often check electrolytes?

58
Q

How long trial lifestyle modifications before moving to pharm therapy?

A

“can try 6mth trial. 1 year is too long/negligent”

59
Q

1st line antihypertensives

A
  • Diuretic (Thiazide): in uncomplicated HTN (JNC)-inexpensive and effective
  • ACEIs
  • ARBs
  • CCBs
60
Q

What if BP goal is not achieved on monotherapy?

A

Combine different 1st line agents

61
Q

White males may do better with ___ as first line

62
Q

Most patients need 2+ antihypertensives. What are recommended combinations?

A
  • ACE WITH DIURETIC
  • ARB WITH DIURETIC
  • BB WITH DIURETIC
  • CCB WITH DIURETIC

Add a second drug from a different class

63
Q

First line pharm for black population

A

thiazide or CCB, but may start w/ACE if diabetic

64
Q

HTN management: BP is 160/100 or greater

A

consider starting with 2 drugs (or combination product)

65
Q

JNC algorithm: first intervention

A

lifestyle modification

66
Q

JNC 7: you’ve tried lifestyle modification. Why would you move to drug therapy?

A

Not at goal BP (

“6 mth trial at most”

67
Q

JNC 7 algorithm: Initial drug choice for stage 1 HTN w/o “compelling indications”

A

thiazide for most

may consider ACEi, ARB, BB, CCB, or combo

68
Q

JNC 7 algorithm: Initial drug choice for stage 2 HTN w/o “compelling indications”

A

2 drug combo for most (usually thiazide type diuretic & ACEi, ARB, BB, or CCB)

69
Q

JNC 7 algorithm: Initial drug choice HTN with “compelling indications”

A

other antihypertensive drugs (diuretics, ACEi, ARB, BB, CCB) - chart w/appropriate meds for each “compelling indication” - e.g., recent MI (BB), Diabetes (ACEi), etc…

70
Q

“Compelling indications”

Angina + HTN, treat with….

A

β-blocker or CCB

71
Q

“Compelling indications”

Atrial tachycardia or A Fib + HTN, treat with….

A

β-blocker, non-DHP CA

72
Q

“Compelling indications”

Essential tremor + HTN , treat with….

A

–β-blocker

73
Q

“Compelling indications”

Heart failure + HTN, treat with….

A

Carvedilol [Coreg]

74
Q

“Compelling indications”

Hyperthyroidism + HTN, treat with….

A

β-blocker

75
Q

“Compelling indications”

Migraine + HTN, treat with….

A

β-blocker, non-DHP CA

76
Q

“Compelling indications”

Osteoporosis + HTN , treat with….

77
Q

“Compelling indications”

Preop Hypertension, treat with…

A

β-blocker

78
Q

“Compelling indications”

BPH + HTN, treat with…

A

α-blocker

79
Q

“Compelling indications”

Raynaud’s Syndrome + HTN, treat with…

80
Q

Bronchospasm, avoid which med(s)?

A

avoid β -Blocker

81
Q

Depression, avoid which med(s)?

A

avoid central α-agonist, reserpine

82
Q

Diabetes and dyslipidemia, avoid which med(s)?

A

avoid High dose diuretics

83
Q

Gout, avoid which med(s)?

A

avoid thiazides

84
Q

Heart bock, CHF: avoid which med(s)?

A

β-blocker, non-DHP CCB

85
Q

Liver Dz, avoid which med(s)?

A

Avoid labetalol, methyldopa

86
Q

PVD, avoid which med(s)?

A

Avoid β-blocker

87
Q

Pregnancy, avoid which med(s)?

A

Avoid ACE I, Angiotensin II blocker

88
Q

Angioedema, avoid which med(s)?

A

avoid ACEi

89
Q

Renal insufficiency, avoid which med(s)?

A

Avoid K+-sparing agents

90
Q

Bilateral renovascular dz, avoid which med(s)?

A

Avoid ACE I, ARB

91
Q

natural products that raise BP

A
  • Blue Cohosh (Caulophyllum thalictroide)
  • Dong quai Ephedra increases BP
  • Licorice (Glycyrrhiza glabra)
  • Yohimbe (Pausinystalia yohimbe)
  • Coltsfoot (Tussilago farfara)
  • Ginseng (Panax ginseng) increases or decreases BP
92
Q

Natural Products that Lower BP

A
  • Coenzyme Q (Ubiquinone) lowers 2-7%
  • Garlic (Allium sativum) may or may not
  • Ginkgo (Ginkgo biloba)
  • Ginseng (Panax ginseng) may lower depending on preparation
  • Hawthorn (Crataegus laevigata)
  • St. John’s Wort (Hypericum perforatum)
  • Black Cohosh (Cimifuga spp.)
  • Omega 3 Fatty Acids
93
Q

Adherence–contributes to lack of control in __ of patients!

94
Q

Tips for managing adherence

A
  • Involve patient in their treatment
  • Maintain contact–email? Telephone?
  • Integrate into routine activities of living
  • Inexpensive and simple pharmacologic choice
  • Combination Products
  • Health literacy (teaching back methods)
  • Establish trusting relationship

ask pharmacist to monitor refills; call and ask; ask at each visit in nonjudgmental way

95
Q

Besides adherence, why might medications fail?

A
  • Smoking
  • Increasing obesity
  • Sleep apnea
  • Insulin resistance/hyperinsulinemia
  • Ethanol excess
  • Anxiety, panic attacks, chronic pain
  • TRUE SECONDARY CAUSE OR RESISTANCE
96
Q

What is true resistance?

A
  • Can’t meet goal with 3 agents including a diuretic
  • At maximal doses
  • Suspect secondary causes
97
Q

What is metabolic syndrome

A
  • 3 of following:
    • Abdominal obesity
    • Glucose intolerance (fasting glucose > 109)
    • High triglycerides
    • Low HDL (

treat each component !

98
Q

Obesity: BMI & waist

A

BMI >30 (waist >39 in. men, >34 in. women)

99
Q

HTN present in ____% of patients with DM

100
Q

Goal BP for diabetic (JNC7, JNC8, ADA 2015)

101
Q

Recommended classes of drug for HTN with DMI and DMII w/renal insufficiency

(and what if they have CHD too?)

A

DMI: ACEi

DMII: ARB

Usually also need loop diuretic and CCB (start after ACEI/ARB), add β-blocker if has CHD

102
Q

Pharm mgmt of HTN in post-MI patients

A
  • Use non-selective beta blocker if at all possible
  • Use ACE I or ARB if LVH or Left Ventricular Dysfunction
  • ASA
  • Lipid lowering agents
103
Q

Mgmt of HTN w/ LVH

A
  • Find LVH on EKG or Echo
  • Salt reduction, weight loss, aggressive BP treatment
  • All classes of antihypertensive cause regression except direct vasodilators
  • Post MI + LVH: Use ACE I or ARB if LVH or Left Ventricular Dysfunction
104
Q

Pharm mgmt: HTN + Congestive Heart Failure

A
  • After MI, ACE I prevents heart failure
  • ACE inhibitors and Beta Blockers–reduce

morbidity and mortality

  • Hydralazine and Isosorbide
  • Symptomatic dysfunction/end stage—ACE I, Beta

blocker, ARB, spironolactone, loop diuretics

  • Only amlodipine or felodipine CA in CHF
105
Q

Treatment of HTN + renal dz

(+ goal BP and what measures of renal dz?)

A

Creatinine > 1.5 (GFR 60), or albuminuria > 300mg

  • Lower BP goal
  • All classes of antihypertensives work
  • ACE/ARB with T1DM/T2DM
  • ACE/ARB with non-diabetic renal disease
106
Q

Treatment: HTN + dyslipidemia

A
  • Lifestyle modifications first
  • Low dose thiazides, no metabolic effects
  • β-blockers reduce HDL but also reduce mortality, MI
  • Alpha-blockers lower cholesterol and increase HDL
107
Q

Treatment of HTN + respiratory dz

A
  • Sleep apnea can reduce HTN control
  • Beta blockers and alpha-beta-blockers can exacerbate asthma
  • ACE I- safe with asthma–if cough, try ARB
  • Avoid sympathomimetic decongestants
  • Cromolyn, atrovent, inhaled steroids OK
108
Q

Treatment of HTN + gout

A
  • Hyperuricemia is common finding– decreased renal blood flow
  • Diuretics can increase uric acid
  • Diuretics rarely cause acute gout
  • If gout, avoid Thiazide
109
Q

Blacks & HTN: global incidence, stroke rate, MI rate, relative ESRD risk

A
  • Highest incidence in the world
  • 80% ­ stroke rate
  • 50% ­ heart attack rate
  • 320% ­ ESRD (end stage renal disease)
110
Q

Blacks & HTN: first line w/ckd & proteinuria

A

ACEI or ARB as initial tx

111
Q

Blacks & HTN: first line w/CKD but no proteinuria:

A

Thiazide diuretics, CCB, ACE or ARB (? as initial tx)

112
Q

Blacks and HTN: response to BBs or ACEi as monotherapy

A

decreased responsiveness

113
Q

Blacks and HTN: relative frequency of angioedema

A

2-4x more frequent

114
Q

Women and HTN: difference in response to Tx

115
Q

Women & HTN: effect of OC on BP

A

increases BP esp w/smoking, age >35

116
Q

Women & HTN: If pt needs OCPs and has HTN?

A

treat the HTN

117
Q

Women & HTN: effect of HRT on BP

A

does not increase BP

118
Q

Women and HTN: considerations in drug selection

A

No ACE inhibitors if child bearing age

119
Q

Pregnancy & HTN: when is HTN considered chronic?

A

present at

120
Q

Pregnancy & HTN: considerations in choosing drug therapy

A
  • Methyldopa [Aldomet] safest choice or vasodilators
  • Beta blockers after 20 weeks- may retard growth if used early in pregnancy
  • Diuretics OK if started before pregnancy
  • ACEIs and ARBs avoided (neonatal renal failure risk)
121
Q

Elderly & HTN: which is better predictor of adverse events, SBP or DBP?

122
Q

New onset HTN in elderly. What two secondary causes of HTN should you consider?

A

Renovascular hypertension and primary aldosteronism more common-especially w/ new onset

123
Q

Elderly & HTN: do salt reduction and weight loss work?

A

yes (TONE trial)

124
Q

Elderly and HTN: considerations in dosing agents

A

Start low (1/2 usual dose) and go slow

Assess for postural hypotension, if present, back off on meds

125
Q

HTN drug of choice in elderly

A

thiazide diuretics

126
Q

HTN and elderly: drug of choice if isolated systolic HTN

A

Thiazide, DHP CCB, ACEI, ARB

127
Q

Elderly & HTN: which meds more likely to cause OH?

A

adrenergic blockers, alpha-blockers, Viagra, diuretics

128
Q

F/U of treated HTN

A
  • Once stabilized limit office visits (3-6 months) and lab work/tests to what is appropriate for the individual patient
  • Consider co-morbid conditions
  • Step-down therapy if achieved favorable lifestyle changes, weight loss, etc…
  • decrease doses or D/C of medications occasionally feasible
129
Q

Important aspects of history in PT w/HTN

130
Q

Important aspects of PE w/HTN

131
Q

BP assessment: caffeine, exercise, smoking

A

avoid at least 30min before BP measurement

132
Q

BP measurement: The inflatable part of the blood pressure cuff should cover about ___% of the circumference of your upper arm.

133
Q

BP measurement: The cuff should cover ___of the distance from your elbow to your shoulder

134
Q

Secondary HTN clues:

Onset: at age 55 yrs

A

fibromuscular dysplasia, athelosclerotic renal artery stenosis, sudden onset– thrombus or cholesterol embolism

135
Q

Secondary HTN clues: Severity

A

Grade II, unresponsive to treatment.

136
Q

Secondary HTN clues:

Episodic, headache and chest pain/palpitation

A

pheochromocytoma, thyroid dysfunction

137
Q

Secondary HTN clues:

Morbid obesity with history of snoring and daytime sleepiness

A

sleep disorders

138
Q

Secondary HTN clues:

Increased creatinine, abnormal urinalysis

A

renovascular and renal parenchymal disease

139
Q

Secondary HTN clues:

Unexplained hypokalemia

A

hyperaldosteronism

140
Q

Secondary HTN clues:

Impaired blood glucose

A

hypercortisolism

141
Q

Secondary HTN clues:

Impaired TFT

A

Hypo-/hyper- thyroidism

142
Q

Give an ACEi or ARB and they get worse, consider…

A

secondary HTN

Primary care of adults 2 (15 decks)

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