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LMCC Part II > Hypertension > Flashcards

Hypertension Flashcards

1
Q

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

A

less than 140/90

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2
Q

what kind of BP cuff should you use in the office

A

automated office BP measuring electronic device recommended

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3
Q

after elevated BP found in office, what should you consider

A

24 hour ambulatory BP monitoring or home BP monitoring to confirm

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4
Q

what should guide pharmacologic tx of HTN

A

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

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5
Q

in what patients is lifestyle management recommended for HTN

A

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

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6
Q

define HTN

A 
sBP above 140
or
dBP above 90
or 
both
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7
Q

how often should you screen for HTN

A

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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8
Q

what is the algorithm for HTN diagnosis

A
  1. select which arm to use by measuring BP in both arms with the patient in seated position
  2. measure BP three more times using the arm with the higher reading, then discard the 1st reading and average the latter two
  3. if dBP above 130 or BP above 180/110 with signs and symptoms, then this is severe HTN and should be treated immediately
  4. 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)
  5. make another followup appt to assess BP again
  6. 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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9
Q

what are important things to ask about on history for HTN

A

risk factors (modifiable and non modifiable)

exogenous factors

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10
Q

what are the modifiable risk factors for HTN

A 
smoking
physical activity
poor diet
body composition 
poor sleep/OSA
psychological factors
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11
Q

what are the non modifiable risk factors for HTN

A

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

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12
Q

what are exogenous factors contributing to HTN

A

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

prescription drugs (NSAIDS, steroids, OCP, decongestants)

alcohol
stimulants
sodium

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13
Q

what rx drugs can contribute to HTN

A

NSADIS
steroids
OCP
decongestants

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14
Q

what are important things to do on physical exam for HTN

A

fundoscopy
central and peripheral CV exam
abdominal exam

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15
Q

what investigations should be done for HTN

A 
UA
urine ACR
potassium
sodium
Cr/eGFR
HbA1c
full lipid profile 
ECG
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16
Q

what tool can be used for CV risk assessment

A

framingham score

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17
Q

how many visits are required to diagnose HTN

A

two, or one plus home/ambulatory assessment

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18
Q

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

A
  1. hypertensive emergency
  2. sudden onset in the elderly
  3. abnormal nocturnal differences
  4. signs or symptoms suggestive of secondary causes of HTN
  5. resistant HTN
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19
Q

define resistant HTN

A

BP still difficult to control after treating with 3 antihypertensive meds

20
Q

what is a hypertensive emergency

A

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

21
Q

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

A

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

22
Q

why do lifestyle management in the setting of mild HTN

A

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

23
Q

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

A 
diet and weight control
reduced sodium intake
reduced alcohol intake in heavy drinkers
DASH diet (big drop)
physical activity 
relaxation therapies
24
Q

when should you consider pharmacological therapy for HTN

A

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

25
Q

how do you pick which antihypertensive to use

A

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

26
Q

which of the front line antihypertensive are cheapest

A

thiazide diuretics
i.e HCTZ
also consider chlorthalidone

27
Q

are beta blockers first line for HTN

A

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

28
Q

what if BP is not well controlled with monotherapy

A

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

29
Q

first line antihypertensive for patients with CAD

A

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

30
Q

first line antihypertensive for patients with recent MI

A

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

31
Q

first line antihypertensive for patients with LVH

A

ACEi/ARB or thiazide or long acting CCB

do not use direct arterial vasodilators like hydralazine

32
Q

first line antihypertensive for patients with heart failure

A

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

33
Q

first line antihypertensive for patients with CVA

A

ACEi plus thiazide

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

34
Q

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

A

ACEi/ARB

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

35
Q

first line antihypertensive for patients with diabetes

A

ACEi or ARB or thiazide

36
Q

first line antihypertensive for patients with CKD without diabetes

A

ACEi/ARB
-monitor renal function and potassium

thiazide for additive therapy
loop diuretic if volume overload

37
Q

first line antihypertensive for patients with renovascular disease

A

thiazide or ACEi or ARB

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

38
Q

how do you follow up HTN

A

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

39
Q

causes of secondary HTN

A

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

40
Q

what questions help ID cushings or primary hyperaldosteronism

A 
weight gain
easy bruising
hirsutism
thirst
polyuria

oligo/amenorrhea
impotence

weakness
backache
headache
superficial skin infections

41
Q

symptoms of pheo

A 
episodes of anxiety
palpitations
profuse sweating
pallor
tremor
nausea
vomiting
angina 
pulmonary edema
42
Q

target organ damage from HTN

A 
MI
stroke
nephropathy
retinopathy
cardiomegaly
LVH/LV mass/diastolic dysfunction
43
Q

exam for HTN

A

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

44
Q

what is osler’s sign

A

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

45
Q

physical signs of cushings

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

LMCC Part II (52 decks)

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