Hypertension (8 questions) Flashcards
What percent of patients with diagnosed HTN are controlled?
25%
Relationship between age and HTN
HTN increases w/age
At what age does pulse pressure change and how
PP increases d/t decreased diastolic pressure
after age 50
Hypertension incidence: blacks vs whites
more common in blacks
Difference between primary and secondary hypertension
- Primary HTN = “essential HTN”. No identifiable cause. Probably mix of environment & genetic
- **Secondary HTN: **identifiable cause
Most common cause of HTN before age 50
primary HTN
Primary HTN accounts for ___ percent of all HTN
95%
Age range for typical onset of primary HTN
25-55yo
Some multifactorial causes of HTN: contribution by arterioles
- Constriction of resistance arterioles
Some multifactorial causes of primary HTN: contribution by baroreceptors
decreased Baroreceptor sensitivity
Some multifactorial causes of primary HTN: contribution by endothelium
Endothelial dysfunction
Some multifactorial causes of HTN: contribution by sympathetic nervous system activity
Increased Sympathetic nervous system activity
Some multifactorial causes of primary HTN: contribution by α and β-adrenergic receptors
Decreased α and β-adrenergic receptor response
Some multifactorial causes of HTN: contribution by plasma renin
Low plasma renin activity
Some multifactorial causes of primary HTN: contribution by insulin system
Insulin resistance
Some multifactorial causes of primary HTN: contribution by neurohormonal factors
Neurohormonal factors that decrease vascular response (poor dilation)
Causes of secondary HTN
- 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
JNC 7: normal BP
SBP <120
DBP <80
JNC 7: prehypertension
SBP 120-139
DBP 80-89
JNC 7: stage I HTN
SBP 140-159
DBP 90-99
JNC 7: Stage 2 HTN
SBP: > 160
DBP: > 100
HTN: presentation (initial and late)
- Usually silent
- Occasionally headache
- End organ disease symptoms: renal, cardiac, ophthalmologic, cognitive impairment
Goals of JNC7 assessment
- Stage BP: how high is it?
- Determine CVD risk
- Determine if secondary HTN is present
- Determine if any end organ damage is present
Diagnosis of HTN
- 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
BP relationship to risk of CVD
continuous, consistent, and independent of other risk factors.
How many increments of BP increase to double risk of CVD?
Each increment of 20/10 mmHg doubles the risk of CVD across the entire BP range starting from 115/75 mmHg.
Risk factors for CVD
- 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
HTN exam: what should you check?
- Weight gain or loss
- Retinas: exudate, hemorrhages, papilledema
- Lung Sounds
- Heart Sounds
- Check lower legs/ankles
- BP & HR :supine-sitting-upright (esp geriatric)
Baseline diagnostic tests for primary causes of HTN
- Comprehensive Metabolic Panel
- *CBC *
- Lipids
- TSH
- HbA1C
- UA (Urine MicroAlbumin)
- EKG
- Echocardiogram
components of CMP
- Alkaline phosphatase: 44 to 147 IU/L
- ALT (alanine aminotransferase): 8 to 37 IU/L
- AST (aspartate aminotransferase): 10 to 34 IU/L
- Total bilirubin: 0.2 to 1.9 mg/dL
- BUN (blood urea nitrogen): 7 to 20 mg/dL
- Creatinine: 0.8 to 1.4 mg/dL
- CO2 (carbon dioxide): 20 to 29 mmol/L
- Potassium test: 3.7 to 5.2 mEq/L
- Sodium: 136 to 144 mEq/L
- Calcium: 8.5 to 10.9 mg/dL
- Chloride: 96 - 106 mmol/L
- Glucose test: 70 to 100 mg/dL
- Total protein: 6.3 to 7.9 g/dL
- Albumin: 3.9 to 5.0 g/dL
Components of BMP
- 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
Components of CBC
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
WBC w/differential
- 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%
Diagnostic studies for secondary causes of HTN
- 24hr urine free cortisol and plasma metanephrine levels
- Renal ultrasound
- Abdominal imaging: ultrasound, CT Scan, MRI
- Renal Arteriography
Benefits of lowering BP
Average Percent Reduction
Stroke incidence
35–40%
Myocardial infarction
20–25%
Heart failure
50%
What to explain to PT about end organ damage
- 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
JNC 8 target goals for BP
- 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)
JNC 8: General nonblack population (including those with diabetes), initial antihypertensive treatment
a thiazide-type diuretic, CCB, ACEI or ARB.
JNC 8: General black population (including those with diabetes), initial antihypertensive treatment
a thiazide-type diuretic or CCB
JNC 8: Population aged18 years with CKD, initial (or add-on) antihypertensive treatment, regardless of race or diabetes status
ACEI or ARB
Treatment guidelines for prehypertension:
No risk factors or target organ disease–lifestyle changes
Treatment guidelines for stage 1 HTN
Lifestyle change but newer approach is aggressive–one drug needed
Tx guidelines stage 2 HTN
start with 2 drug therapy
Tx guidelines: diabetes & renal dz
need more aggressive treatment–> à 130/80mmHg
Summary of general treatment goals, HTN
- Reduce CVD and renal morbidity and mortality
- Lower if preserving renal function
- Lower to slow heart failure progression
Can Hypertension Be Prevented?
- 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
Important findings on relationship between diet, weight loss, and BP
- 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
For what populations is low sodium diet especially effective?
middle-aged and older individuals, African Americans, and those who already had high BP
Components of DASH diet
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.
Lifestyle Modifications to Manage Hypertension
- Weight reduction
- Adopt DASH eating plan
- Dietary sodium reduction
- Physical activity
- Moderation of alcohol consumption
HTN mgmt: Weight reduction - recommendation & approximate reduction in SBP
- Maintain normal body weight (body mass index, 18.4-24.9 kg/m2)
- 5-20 mm Hg; 10-kg weight loss
HTN mgmt: Adopt DASH eating plan - recommendation & approximate reduction in SBP
- Consume diet rich in fruits, vegetables, low-fat dairy products, with reduced content of saturated and total fats
- 8-14 mm Hg
HTN mgmt: Dietary sodium reduction - recommendation & approximate reduction in SBP
- Reduce dietary sodium intake to no more than 100 mmol/day (2.4 g sodium or 6 g sodium chloride)
- 2-8 mm Hg
HTN mgmt: Physical activity - recommendation & approximate reduction in SBP
- Engage in regular aerobic physical activity (e.g., brisk walking) at least 30 min/day, most days of the week
- 4-9 mm Hg
HTN mgmt: Moderation of alcohol consumption- recommendation & approximate reduction in SBP
- 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
Classes of oral antihypertensive drugs
- 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