Hypertension Flashcards by Alana Meikle

desired BP for someone with no comorbid conditions/DM/CKD

less than 140/90

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what kind of BP cuff should you use in the office

automated office BP measuring electronic device recommended

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after elevated BP found in office, what should you consider

24 hour ambulatory BP monitoring or home BP monitoring to confirm

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what should guide pharmacologic tx of HTN

consider the context of patients overall CV risk and not just treat their BP

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in what patients is lifestyle management recommended for HTN

mild HTN (140-159/90-99), low risk for CV disease and no comorbidities

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define HTN

sBP above 140
or
dBP above 90
or 
both

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how often should you screen for HTN

in patients 45 years and older, BP should be recorded at least once every 5 years –> this should be the average of several measurements

ensure standardized technique–> patient sitting, select arm with higher BP

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what is the algorithm for HTN diagnosis

select which arm to use by measuring BP in both arms with the patient in seated position
measure BP three more times using the arm with the higher reading, then discard the 1st reading and average the latter two
if dBP above 130 or BP above 180/110 with signs and symptoms, then this is severe HTN and should be treated immediately
if BP above 140/90, do investigations and workup to assess for target organ damage and CVD risk assessment (consider 24 hours ambulatory/home BP)
make another followup appt to assess BP again
if normal on next visit, not hypertensive// if above 140/90 then has mild HTN // if above 16/100 then moderate HTN// if above 180/110 then severe HTN and see above

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what are important things to ask about on history for HTN

risk factors (modifiable and non modifiable)

exogenous factors

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what are the modifiable risk factors for HTN

smoking
physical activity
poor diet
body composition 
poor sleep/OSA
psychological factors

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what are the non modifiable risk factors for HTN

age
family history
ethnicity (african, caribbean, south asian origin)

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what are exogenous factors contributing to HTN

white coat HTN–20% of people with high in office readings

prescription drugs (NSAIDS, steroids, OCP, decongestants)

alcohol
stimulants
sodium

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what rx drugs can contribute to HTN

NSADIS
steroids
OCP
decongestants

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what are important things to do on physical exam for HTN

fundoscopy
central and peripheral CV exam
abdominal exam

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what investigations should be done for HTN

UA
urine ACR
potassium
sodium
Cr/eGFR
HbA1c
full lipid profile 
ECG

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what tool can be used for CV risk assessment

framingham score

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how many visits are required to diagnose HTN

two, or one plus home/ambulatory assessment

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what are indications to consult a specialist in the case of HTN

hypertensive emergency
sudden onset in the elderly
abnormal nocturnal differences
signs or symptoms suggestive of secondary causes of HTN
resistant HTN

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define resistant HTN

BP still difficult to control after treating with 3 antihypertensive meds

what is a hypertensive emergency

BP above 130 or BP above 180/110 with signs/symptoms

what is the desirable BP reading in people with DM according to BC guidelines

140/90

this does not align with the canadian hypertension education program recommendation or the canadian diabetes association recommendation of 130/80–> it is mostly consensus based

further trials are needed

why do lifestyle management in the setting of mild HTN

because benefits of pharmacological treatment are not known in this population and may not outweigh potential harms i.e increased risk of falls

recent systematic review showed med tx did not reduce total mortality, total CV events, CAD or stroke in this population

however, benefits of lifestyle management in this group are well documented

what lifestyle interventions have been shown to have an impact on BP

diet and weight control
reduced sodium intake
reduced alcohol intake in heavy drinkers
DASH diet (big drop)
physical activity 
relaxation therapies

when should you consider pharmacological therapy for HTN

if average BP is above 140/90 with target organ damage or CVD risk above 20%

average BP above 140/90 with 1 or more comorbidities

BP above 160/100

desirable BP not reached with lifestyle management

how do you pick which antihypertensive to use

generally they are all equally effective when lowering BP take into account cost of the drug, any side effects, any potential contraindications ``` without specific indications, consider monotherapy with one of the following: thiazide duiretic long acting CCB ACEi (in NON black patients) ARB ``` *alpha blockers are no longer first line

which of the front line antihypertensive are cheapest

thiazide diuretics i.e HCTZ also consider chlorthalidone

are beta blockers first line for HTN

they are not a preferred first line drug but may be used for patients younger than 60 and with specific indications like stable angina

what if BP is not well controlled with monotherapy

add one or more of the first line drugs to the regimen combination of ACEi and ARB is not recommended caution when combining verapamil or diltiazem with a beta blocker

first line antihypertensive for patients with CAD

ACEi or ARB or beta blockers (for patients with stable angina)

first line antihypertensive for patients with recent MI

beta blockers plus ACEi or ARB (ARB if ACEi intolerant) or long acting CCB

first line antihypertensive for patients with LVH

ACEi/ARB or thiazide or long acting CCB do not use direct arterial vasodilators like hydralazine

first line antihypertensive for patients with heart failure

beta blockers plus ACEi/ARB aldosterone antagonist may be added in patients with recent CV hospitalization, acute MI, elevated BNP or NYHA class II-IV symptoms **monitor for hyperkalemia *avoid beta blockers if bradycardic

first line antihypertensive for patients with CVA

ACEi plus thiazide *do not treat HTN during acute stroke unless extreme BP increase

first line antihypertensive for patients with DM with microalbuminuria, CKD, CVD or CVD risk factors

ACEi/ARB *loop diuretics to be considered in HTN patients with CKD with ECF volume overload

first line antihypertensive for patients with diabetes

ACEi or ARB or thiazide

first line antihypertensive for patients with CKD without diabetes

ACEi/ARB -monitor renal function and potassium thiazide for additive therapy loop diuretic if volume overload

first line antihypertensive for patients with renovascular disease

thiazide or ACEi or ARB avoid ACEi/ARB if bilateral artery stenosis or unilateral disease with solitary kidney

how do you follow up HTN

follow up two weeks after starting antihypertensive meds with eGFR then follow up at monthly intervals until BP in desired range for two consecutive visits review every 3-6 months as long as patient remains stable periodically consider reducing doses or discontinuing meds monitor kidney function whenever meds are changed annual measurement of eGFR and urine ACR and examine RFs and evidence of target organ damage

causes of secondary HTN

drug induced--NSAIDS, estrogen renal disease renovascular disease (RAS) primary hyperaldosteronism cushings pheo coarctation of the aorta pregnancy associated HTN hypercalcemia hypo/hyperparathyroidism polycythemia neurological causes of increased ICP--i.e stroke

what questions help ID cushings or primary hyperaldosteronism

``` weight gain easy bruising hirsutism thirst polyuria ``` oligo/amenorrhea impotence weakness backache headache superficial skin infections

symptoms of pheo

``` episodes of anxiety palpitations profuse sweating pallor tremor nausea vomiting angina pulmonary edema ```

target organ damage from HTN

``` MI stroke nephropathy retinopathy cardiomegaly LVH/LV mass/diastolic dysfunction ```

exam for HTN

BP after patient rested for 10 min in warm surroundings --do both arms check for postural drop--present in pheo pulses--excludes coarctation fundoscopy for papilledema heart sounds--S4, systolic ejection click or murmur, heave, displacement of apex beat, signs of CHF abdominal bruits indicating RAS

what is osler's sign

a palpable radial or brachial pulse when BP cuff is inflated greater than the sBP this leads to false elevation of BP in the elderly because of non compressible vessels

physical signs of cushings

``` purple straie hirsutism moon face buffalo hump bruising acne central obesity ```