Hypertension

Question 1

What is the definition of HTN in adults according to JNC 8 guidelines?

Answer 1

> 140/90

if > 60 yo then > 150/90

Question 2

At what age do you begin screening for HTN in peds?

Answer 2

3 years old

Question 3

How do you define HTN in the pediatric population?

Answer 3

> 95th percentile BP for age, gender, and height

Question 4

A patient has HTN and hypokalemia. What is the test you should order to eval possible causes of secondary hypertension?

Answer 4

Aldosterone: renin ratio

Question 5

What is the leading cause of secondary HTN

Answer 5

sleep apnea

Question 6

What are some clinical clues that renal artery stenosis might be the cause of secondary hypertension

Answer 6

• ACE inhibitor leads to bump in creatinine and hyperkalemia
• accelerated or resistant HTN
• flash pulmonary edema

Question 7

According to the JNC 8, what is initial treatment in non-black population, including those with diabetes?

Answer 7

Thiazide or CCB, or ACE/ARB

Question 8

According to the JNC 8, what is initial treatment in black population, including those with diabetes?

Answer 8

Thiazide or CCB

• thiazide more effective than ACE for improving HF in AA
• CCB more effective than ACEI for reducing stroke in AA

ACE/ARB still recommended in CKD and HF

Question 9

At which GFR is a thiazide diuretic no longer considered effective?

Answer 9

• When GFR < 30-40 since not delivering enough fluid to distal convoluted tubule
• exception is metolazone which helps with diuresis when given before a loop

Question 10

Which diuretics are effective in CKD stage IV-V and which are not?

Answer 10

Thiazides are no longer effective -> distal convoluted tubule
Loop diuretics are still effective -> loop on henle

Question 11

Explain why spironolactone can be a helpful therapy in resistant hypertension and OSA?

Answer 11

Resistant HTN - HTN despite 3 or more drugs. Associated with increased levels of aldosterone –> secondary pharyngeal edema and increased upper airway obstruction.

Great choice for pts with OSA

Question 12

What is the limit of creatinine change that is acceptable after starting ACE/ARB

Answer 12

• Increase in Cr of 20-30% is normal and represents hemodynamic change
• increase > 30%, consider structural issue

Question 13

After MI, which medication is more important? Beta blocker or ACEI?

Answer 13

The beta blocker is more important, per AHA guideliens. ACEI/ARB recommended in pts already on beta blocker

Question 14

Which beta blockers are used in ischemic heart disease?

Answer 14

• metoprolol succinate
• carvedilol
• bisoprolol

Question 15

What are the preferred anti-HTN meds in the elderly?

Answer 15

Thiazide diuretics and CCB

Question 16

In the elderly population, when should you cease targeting an elevated SBP?

Answer 16

When DBP is reduced to > 65 mmHG, stop targeting a high SBP

Question 17

Systolic Murmur heard at right second intercostal space

Answer 17

Aortic stenosis or bicuspid aortic valve (screen 1st degree relatives)

Question 18

Systolic Murmur heard at left second intercostal space

Answer 18

Pulmonary stenosis - crescendo decrescendo

Question 19

Systolic Murmur heard at left lower sternal border

Answer 19

Tricuspid regurgitation

Question 20

Systolic Murmur heard at the apex

Answer 20

mitral regurgitation

Question 21

How do you monitor a patient with aortic stenosis?

Answer 21

Echo every 3-5 years in asymptomatic patients with mild aortic stenosis

Question 22

Diastolic Murmur heard at left second intercostal space

Answer 22

Aortic regurgitation - increased when pt leans forward, holds breath after expiration
Pulmonary regurgitation - increases with inspiration

Question 23

Diastolic Murmur heard at apex

Answer 23

Mitral stenosis - in Left lateral decubitus

Question 24

Diastolic Murmur heard at left lower sternal border

Answer 24

Tricuspid stenosis