Hypertension Flashcards
classification of normal blood pressure
<120 AND <80
classification of elevated blood pressure
120-129 AND <80
classification of stage 1 hypertension
130-139 or 80-89
classification of stage 2 hypertension
> or equal to 140 or > or equal to 90
risk factors for primary htn
smoking unhealthy diet excess alcohol intake obesity/weight gain physical inactivity dyslipidemia and others
secondary htn etiology
renal disease renovascular disease obstructive sleep apnea coarctation of the aorta primary hyperaldosteronism cushing's syndrome pheochromoctoma medication induced
what is the gold standard for diagnosing elevated blood pressure
ambulatory blood pressure monitoring
what is white coat HTN
erroneously high BP in clinic due to anxiety
what is masked HTN
erroneously low BP in clinic due to being sneaky
what is nocturnal monitoring
useful in predicting cardiovascular events
Basic an optional tests for primary HTN *know well
fasting blood glucose complete blood count lipid profile serum creatine with eGFR serum sodium, potassium, calcium thyroid-stimulating hormone urinalysis electrocardiogram urinary albumnin to creatine ratio in all patients with diabetes or chronic kidney disease
Management of htn first line for ALL patients
dietary modifications: low salt, DASH, EtOH reduction
exercise 3-4 days week
achieve and maintain a healthy weight
smoking cessation
management of htn medications
Diuretics
angiotensin converting enzyme inhibitors ACE-1
angiotensinogen receptor blockers ARB
calcium channel blockers CCB
beta blockers
alpha blockers
central alpha agonists
direct renin inhibitor
what do you use for initiation of antihypertensive drug therapy
first line include thiazide diuretics, CCBs, and ACE inhibitors or ARBs
what do you use for stage 1 initial medication
a single hypertensive drug is reasonable, titrating up or adding a second medication as need to achieve BP goal
what do you use for stae 2 initial medication
starting with 2 first line agents of different classes
how often do you follow up
monthly after starting/change dose of medication until control is achieved
if chronic kidney disease what med should be first
if albuminuria greaterthan or equal to 300 or creatinine then should be an ACE inhibitor
if diabetes mellitus what med first
if albuminurea present ACE or ARB should be considered if not use first line choices
if heart failure what med first
avoid nondihydropyridine CCBs not recommended if ejection fraction is reduced
should receive ACE, ARB, or beta blocker if ejection fraction is preserved
Diuretics MOA
decreases body’s sodium stores by inhibiting sodium reabsorption in the nephron
reduces plasma volume and peripheral vascular resistance
Thiazide-type diuretics preferred what to monitor and contras
Chlorthalidone
monitor for hyponatremia, hypokalemia, uric acid and calcium levels (electrolyte imbalance)
contras: sulfa hypersensitivity
Loop diuretics (secondary agents) diuretics preferred what to monitor and contras
furosemide (lasix)
preffered diuretic in symptomatic HF
monitor for hyponatremia, hypokalemia, and calcium levels
contras: sulfa sensitivity
potassium sparing diuretics diuretics preferred what to monitor and contras
triamterene
weak antihypertensives
Ses: hyperkalemia nephrolithiasis, renal dysfunction
caution combining with ACE-1, ARB, DRI, K supplements
Aldosterone antagonists diuretics preferred what to monitor and contras
spironolactone (aldactone)
preferred agent in primary aldosterone
common add-on in resistant HTN
contra: renal impairment
Ace inhibitors diuretics preferred what to monitor and contras
lisinopril, quinapril, enalapril
inhibit the RAAS system and stimulate bradykinin which has a vasodilator effect
SEs: cough, hyperkalemia, angioedema, dizziness, acute renal failure
Contras: pregnancy, angioedema, renal artery stenosis
cannot combine with ARB
Compelling indications: DM, CKD, post-MI, heart failure
alpha blockers diuretics preferred what to monitor and contras
doxazosin, terazosin, prazosin
MOA: targets a1 receptors on vascular smooth muscle causing peripheral vascular resistance to decrease thus decreasing blood pressure
SEs: orthostatic hypotension and reflex tachycardia dizziness
use mild-moderate HTN and not for monotherapy
compelling indication =BPH
Direct renin inhibitors diuretics preferred what to monitor and contras
aliskiren
MOA: inhibit enzyme activity of renin, reducing the activity of angiotensin I and II and aldosterone
SEs: hyperkalemia, renal impairment, hypersensitivity reactions (anaphylaxis angioedema)
Contras: use with an ACE-I or ARB in diabetics; pregnancy
central alpha agonists diuretics preferred what to monitor and contras
last line
safe for pregnancy
methyldopa is contraindicated in liver failure
avoid abrupt cessation
what is hypersensitive crisis
ASYMPTOMATIC severe HTN (diastolic > 120) and NO evidence of end organ failure
usually nonadherence to chronic antihypertensive meds or low sodium diet
what is hypertensive emergency
severe HTN diastolic > 120 and evidence of acute to end-organ damage
causes of hypertensive crisis
abrupt d/c of BP meds high salt load neurological emergencies (stroke, trauma) cardiac emergencies (HF, MI) vascular emergencies (aortic dissection) pregnancy (pre-eclampsia) sympathetic overactivity (rebound HTN, pheo) renal emergencies
Hypertensive urgency goal and treatment strategy
goal is reduce BP to <160/120 in a few hours to days
treatment:
rest in quiet room
increase dose of current meds
add additional medication (diuretic)
adherence to sodium restriction
follow up to monitor for symptoms of HTN or hypoTN
hypertensive emergency treatment and goal
should be hospitalized to ICU address underlying cause: Neuro exam CXR EKG UA Electrolytes/creatinine CT/MRI
Reduction of BP
no more than 25% within minutes to 1 hour
goal is 160/100-110 over 2-6 hours
if stable, then decrease to normal BP goal over 24-48 hours
IV nitrates; CCBs adrenergic blockers, hydralazine
sublingual nefidipine is contraindicated
how to measure orthostatic hypotension
2-5 min of quiet standing after a five minute period of supine rest:
at least a 20 fall in systolic
at least a 10 fall in diastolic
Etiology of hypotension
autonomic dysfunction
parkinson’s
neuropathies (diabetes)
Volume depletion:
diuretics, hemorrhage, or vomiting
Medication often contribute
anti-HTN meds in the elderly
orthostatic hypotension symptoms and treatment
weakness
dizziness or lightheadedness
visual blurring or darkening of the visual fields
syncope
treat underlying cause but tx is symptomatic
what is cardiogenic shock and how does it commonly occur
a state of cellular and tissue hypoxia
occurs when there is a circulatory failure manifest as hypotension
Etiology of cardiogenic shock
MI
atrial/ventricular arrhythmias
valve/ventricle septal rupture
hypotension range definition etc
absolute SBP <90 MAP <65
relative drop in systolic pressure >40
>20 sys >10 dias
profound (vasopressor-dependent)
presentation of cardiogenic shock
hypotension
pulmonary edema (diffuse crackles, JVD)
Echocardiography (dilated ventricles, valvular or septal abnormalities)
tachypnea, oliguria, AMS, clammy skin, etc
management of cardiogenic shock
ABCs, IV placement, fluids
stabilize pt
determine/treat underlying conditions
