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Nephrology > Hypertension > Flashcards

Hypertension Flashcards

1
Q

What is considered Elevated blood pressure, Stage 1 HTN, Stage 2 HTN?

A

Elevate BP= 120-129 and DBP <80

Stage 1= 130-139 Or DBP 80-89

Stage 2= >140 Or DBP >90

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2
Q

What is the formula for pulse pressure and MAP?

A

Pulse Pressure= SBP-DBP

MAP= DBP+ 1/3 PP

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3
Q

Difference between MAsked HTN, White coat HTN, and Sustained HTN

A

Masked HTN: HTN at home but in the clinic; Dx and treated like white coat

White Coat: HTN in clinic but not at home; Dx ABPM; if BP <130/80 lifestyle changes and yearly ABPM; >130/80 lifestyle plus antihypertensive

Sustained HTN: HTN at home and Clinic

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4
Q

How do we diagnose white coat hypertension or masked uncontrolled HTN in patients already on treatment for HTN?

A

If office blood pressure is at goal <130/80 Assess the patient for CVD risk or target organ damage.

If there is CVD risk or end organ damage then screen for masked uncontrolled HTN using Home Blood Pressure Monitor (HBPM) and if HPM is above 130/80 then intensify antihypertensive treatment

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5
Q

When do we screen for white coat HTN in a patient already on medication?

A

If office BP is > 5-10 mmHg above the goal (130/80) while the patient is on >3 medication then screen with HBPM if the HBPM is at goal then Dx white coat HTN and confirm with ABPM; if HBPM is not at goal titrate medications

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6
Q

What are the 2 types of RAS and how are they treated?

A

Atherosclerotic type: Seen in older males start with medical treatment, Antihypertensive medications (including RAAS blockers), Statin, smoking cessation, antiplatelet therapy) if that fails and patient still has refractory HTN or worsening renal function and/or intractable HF; pt need to undergo revasculariazation

Non-Atherosclerotic type: Seen in woman; due to Fibromuscular dysplasia and Takayasu’s. These patients need Revasculariation

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7
Q

What are the management principles of HTN, meaning when should we start treatment and assess patients?

A
  1. BP <120/80 reassess in 1 year
  2. Elevated BP (120-129/<80)= Lifestyle modification and recheck in 3-6 months
  3. Stage 1 HTN (130-139 or DBP 80-89)
    - If pt has had established CVD then start with lifestyle mod and Antihyperten
    - if pt doesn’t have VCD then calculate ASCVD and if >10 or Pt has DM or CKD= start lifestyle+Meds and reassess in 1 month
    - ASCVD<10 or pt doesn’t have DM or CKD start lifestyle changes only and reassess in 3-6 months
  4. Stage 2 HTN (>140, >90)
    - Start treatment within 1 month of Dx with lifestyle meds and 2 HTN meds; reassess in 1 month
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8
Q

Which thiazide diuretic is preffered in HTN?

A

Chlorthalidone is preferred over HCTZ; it is is effective at a lower GFR of 30 while HCTZ is not after a GFR of 50; however, chlorthalidone does cause more HTN.

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9
Q

If ACEI cause angioedema and have to start ARB when should it be started?

A

6 weeks after stoping the ACEI

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10
Q

Patient with HTN and CHF or HTN and GFR<30 should be started on what?

A

Loop Diuretics (BID dosing)

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11
Q

What are the only 2 CCB that can be used in HFrEF?

A

Amlodipine
Felodipine

No other meds: including Procardia, cardene, nimotop)

(Do not use non-dihydropiridine CCB in HFrEF )
Non-dihydro Verapimil and cardizem)

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12
Q

If we start a patient on hydralazine or Minoxidil for HTN what else should they also be on

A

Diuretics and BB because of the reflex tachycardia and fluid retention they cause

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13
Q

What are the first line antihypertensive medications?

A

Thiazide diuretics (Chlorthalidone >HCTZ)
ACEI/ARB
CCB

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14
Q

When do we start 2 first line antihypertensive agents

A

Stage 2 HTN

Or

BP is >20/10 mmHG above the target blood pressure

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15
Q

Post renal transplant patients should be on what antihypertensive if they have HTN?

A

Agent of choice is CCB; ACEI should be used only if pt has other indications such as HF or proteinuria

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16
Q

Post tPA what is the blood pressure goal?

A

<185/105

17
Q

What is the antihypertensive of choice for patient with HTN and Afib.

A

ARB has been shown to decrease recurrence of AF

18
Q

In a pt with HTN and Chronic Aortic Regurgitation which antihypertensive should be avoided?

A

Avoid Beta Blocker to avoid slowing the heart rate

19
Q

What antihypertensive are recommended for pregnant woman

A

Methyldopa
Labetalol
Nifedipine

20
Q

How is resistant HTN defined? And what is the best add on therapy?

A

Patients with uncontrolled HTN or 3 antihypertensive meds from different groups with 1 group being a diuretic or BP is controlled only on 4 meds

The best add on therapy is Spirinolactone

If after that still BP is uncontrolled then consider hydralazine and minoxidil

21
Q

What is the definition for refractory HTN?

A

HTN not controlled on 5 medications

22
Q

What’s is the definition for Hypertensive Urgency vs. Emergency

A

Urgency is SBP >180 or DBP >120) without end organ damage

Emergency presence of end organ damage

They both fall under hypertensive crisis

23
Q

If patient has Hypertensive crisis plus

  1. Aortic dissection
  2. Pre-eclampsia
  3. Pheochromocytoma

What is the blood pressure goal

A

Blood pressure goal for all is to lower BP <140 during the first hour

If pt has Aortic dissection lower it to <120 in 20 minutes (with IV BB)

24
Q

If patient has Hypertensive urgency alone without EOD how should their BP be managed? For example a pt in the ambulatory setting with a BP >190

A

No IV meds needed just restart their home medication and follow up

25
Q

In a patient with hypertensive emergency w/o dissection, or pre-eclampsia, or pheochromocytoma how should they be treated?

A

Reduce the BP by 25% in the first hour

Then to 160/100-110 in the next 2-6 hours

Then normal over 24-48 hours

26
Q

What IV antihypertensive should not be used in patients with severe aortic stenosis

A

IV Nicardipine

27
Q

When should we only use Nitroglycerin in managing hypertensive crisis

A

If there is ACS or acute pulmonary edema. We do not use it in volume depleted patients (dehydrated)

28
Q

IV phentolamine can be used in what scenarios?

A

Pheochromocytoma
MAOI reaction
Cocaine or amphetamine overdose
Clonidine withdrawal

29
Q

Which ACEI is contraindicated in Acute MI

A

Enalaprilat

30
Q

What is the agent of choice for controlling HTN crisis in ACS?

A

Nitroglycerin or Esmolol

31
Q

HTN and Surgery?

A

Perioperatively if BP >160/90 preferred agents are: Clevidipine, Esmolol, Nicardipine, Nitroglycerin

In a patient undergoing surgery delay surgery if SBP >180 or DBP >110

Continue BB if they are already on it

Continue Antihypertensive medical therapy until major surgery

32
Q

HTN and Pregnancy definitions?

A

Chronic HTN= HTN before 20 weeks or pt already on antihypertensive

Gestational HTN:HTN after 20 weeks without proteinuria

Pre-eclampsia:BP >140/>90 4 hours apart in a pt with previous NL BP

-Onset after 20 weeks + Proteinuria (300 mg/24 hours or protein:cr >0.3 or 1+)
If no proteinuria any of these features are considered pre-eclampsia:
PLTL <100,000; Cr >1.1 or doubling from baseline; AST/ALT >2x normal; Pulmonary edema; Neurological or visual symptoms

Severe pre-eclampsia = Any one of the following in pre-eclampsia is considered severe.

  • BP >160/>110 after rapid reconfirmation
  • PLTL <100,000; Cr >1.1 or doubling from baseline; AST/ALT >2x normal; Pulmonary edema; Neurological or visual symptoms; unexplained epigastric or RUQ pain)

Eclampsia= Pre-Eclampsia + Grand Mal Seizure

33
Q

What is the management for prevention of pre-eclampsia?

A

In a patient with h/o early onset pre-eclampsia+ pre-term delivery before 34 weeks or pre-eclampsia in >1 previous pregnancies

Patient should be on daily low dose aspirin 60-80 mg from 12 weeks of gestation

34
Q

When is anti-hypertensive meds warranted in pregnancy?

A
  1. Antihypertensive meds are not recommended for women with:
    - Mild gestational HTN or preeclampsia with BP <160/110
  • Pregnant women with chronic HTN do not need medications if BP is <160/105
  • BP goal for pregnant patients with chronic HTN on treatment is SBP 120-160 DBP 80-105

If they have chronic HTN and EOD then <140/90

35
Q

What medications are used for HTN in pregnancy?

A

First line= Labetalol, Nifedipine, MEthyldopa

Second line=Thiazide diuretics in patients who need diuretics to control their BP (CKD)

For acute lowering in hospitalized patients IV labetalol, IV Hydralzine, oral nifedipine

Nephrology (2 decks)

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