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01 Family Medicine > Hypertension > Flashcards

Hypertension Flashcards

AAFP Board Review lecture: Hypertension

1
Q

How does HTN affect cardiovascular risk?

A

Independent risk factor for ischemic cardiac events

Starting at 115/75 risk of vascular death increases in a log linear fashion

Every 20 inc in SBP or 10 inc in DBP doubles the risk of major CV events and stroke

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2
Q

How does treatment of HTN affect CV risk?

A

Treatment reduces all cause mortality

LVH regresses with treatment

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3
Q

Per JNC 8 Guidelines,

What is the treatment threshold and BP goal for people 18-60 years old with or without CKD/diabetes?

A

Treatment Threshold: BP greater than or equal to 140/90

BP goal: Less than 140/90

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4
Q

Per JNC 8 Guidelines:

What is the treatment threshold and BP goal for people 60 years and older?

A

Treatment threshold: greater or equal to 150/90

BP goal: Less than 150/90

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5
Q

ACC/AHA HTN Guidelines

*AAFP follows JNC

A
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6
Q

What is White coat hypertension?

A

HTN in the clinic but not at “home”

minimal/slightly increased CVD risk

35% prevalence

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7
Q

How do you confirm diagnosis of HTN?

A

Ambulatory BP monitoring or home monitoring

*Stronger association with CV outcomes then BP measured in a clinical setting

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8
Q

What is masked HTN?

A

Normal BP in clinic, HTN at “home”

CVD risk is simialr to essential HTN

Prevalence unknown

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9
Q

How do you define hypertension in children?

A

Greater than the 95th %tile BP for age, gender, height

*Reference the AAP tables

Measure BP starting at age 3

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10
Q

In children what is the most common cause of HTN?

A

Obesity

*No need for secondary work up if obese, family hx, no signs of other causes

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11
Q

What are some clinical signs that suggest secondary causes of HTN in children?

A

Renal vascular or parenchymal disease

Endocrine or rheumatologic disorders

Coarctation of aorta

Drugs

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12
Q

What are the top 2 causes of secondary HTN?

A

Sleep apnea

Primary Hyperaldosteronism

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13
Q

How to diagnose hyperaldosteronism?

A

aldosterone: renin ratio

*Clinical clues reistant HTN, hypokalemia

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14
Q

What are the 2 most common causes of renal artery stenosis?

A

Age less than 30: fibromuscular disease

Age greater than 30: atherosclerotic disease

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15
Q

Presentation of renal artery stenosis?

A

Accelerated or resistant HTN

Flash pulmonary edema

ACEi may cause renal insufficiency or hyperkalemia

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16
Q

How to diagnose renal artery stenosis?

A

MRA of renal arteries

CTA

Duplex US

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17
Q

How to treat renal artery stenosis?

A

Medication, monitor renal function

*stenting does not improve outcomes

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18
Q

Name some other causes of secondary hypertension

A

Pheochromocytoma

Hypercortisolism

Hyperthyroidism

CKD

Alcohol

NSAIDs

Medication side effects (SSRIs, etc.)

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19
Q

JNC 8 HTN Initial Treatment:

Non-black

+/- diabetes

A

Thiazide

CCB

ACEi/ARB

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20
Q

JNC 8 HTN Initial Treatment:

Black population

+/- diabetes

A

Thiazide

CCB

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21
Q

What do thiazide diuretics increase the excretion of? What do they decrease excretion of?

A

Increased excretion: Sodium, Potassium, Magnesium

Decreased excretion: Calcium, Uric acid, Lithium

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22
Q

At what GFR are thiazide diuretics considered ineffective?

A

GFR <30-40

*except metolazone as adjunct therapy

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23
Q

Name 3 thiazide diuretics and their dosing

A

Chlorthalidone 12.5 mg, 25 mg, 50 mg

HCTZ 12.5 mg, 25 mg

Indapamide 1.25 mg, 2.5 mg, 5 mg

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24
Q

Per the JNC 8 guidelines when should and ACEi/ARB be used as the inital treatment?

A

18 years or older with CKD

Improves kidney outcomes

Slows microalbuminuria

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25
Q

SIde effects of ACEi?

A

10-20% with cough (bradykinin accumulation)

Increases lithium levels

Reduced BP response in black population

2-4x higher risk of angioedema in black population

26
Q

Name some ACEi and their doses

A
27
Q

Name some ARBs and their doses

A
28
Q

What is the different between dihydropyridines and nondihydropyridines calcium channel blockers?

A

dihydropyridines: vasodilators, minimal effect on cardiac contractility or AV node

Nondihydropyridines: Slow AV node, negative ionotropic effect, minimal vasodilator effect

29
Q

Name some dihydropyridine calcium channel blockers

A

Amlodipine

Nifedipine

Felodipine

Nicardipine

30
Q

Name 2 Nondihydropyridine calcium channel blockers

A

Verapamil

Diltiazem

31
Q

Define resistant HTN

A

Persistent HTN despite 3 or more medications

32
Q

What are the most common causes of resistant HTN?

A

Poor medication compliance

Caffeine, alcohol, nicotine, cocaine, NSAIDs, OCPs, steroids, EPO, herbs

Secondary HTN causes

33
Q

How to manage resistant HTN?

A

Assess compliance

Consider:

long acting diuretic (chlorthalidone)

Spironolactone

Vasodilating beta blocker (carvedilol, labetalol, nebivolol)

Clonidine, hydralazine, alpha blocker

*Switch from ACEi to ARB not effective

34
Q

Contraindications to starting Aldosterone antagonists

A

Cr less than 2.5 males or less than 2 in females

GFR >30

K less than 5, no hx of severe hyperkalemia

35
Q

Name 2 aldosterone antagonist and their doses

A

Spironolactone 12.5, 25, or 50 daily

Eplerenone 25 or 50 daily

36
Q

Why might an aldosterone antagonist benefit a patient with OSA?

A

Resistant HTN -> higher levels of aldosterone -> secondary pharyngeal edema -> increasing airway obstruction

*an aldosterone antagonist would prevent this cycle

37
Q

If a patient’s creatinine bumps by 20-30% after starting HTN treatment, how should you change the treatment dosing?

A

No change

A 20-30% Cr increase that stabalizes represents a hemodynamic change

Indicates intraglomerular pressure has been reduced, this is further exaggerated by ACEi/ARBs due to dilation of efferent arteriole

38
Q

If a patient’s creatinine bumps by 30% or more after starting HTN treatment, how should you change the treatment dosing?

A

Consider other causes

Change class of medications

39
Q

Per the AHA, what is the first line treatment for HTN in patients with stable ischemic heart disease?

A

Beta blocker

*then ACEi/ARB

40
Q

What role do long acting nitrates play in HTN management?

A

Effective for angina but not HTN

41
Q

Name 3 beta blockers used for HTN in patients with CAD and their doses

A
42
Q

Indications for individual HTN medications:

Patients with heart failure

A

Diuretic

Beta blocker

ACEi/ARB

Aldosterone antagonist

43
Q

Indications for individual HTN medications

Post MI patients

A

Beta blocker

ACEi/ARB

Aldosterone antagonist

44
Q

Indications for individual HTN medications

Patients with CAD

A

Diuretic

Beta blocker

ACEi/ARB

CCB

45
Q

Indications for individual HTN medications

Patients with Afib

A

beta blocker

CCB

46
Q

Indications for individual HTN medications

Patients with diabetes

A

Diuretic

Beta blocker

ACEi/ARB

CCB

47
Q

Indications for individual HTN medications

Patients with CKD

A

ACEi/ARB

48
Q

Indications for individual HTN medications

for recurrent stroke prevention

A

Diuretic

ACEi/ARB

49
Q

Indications for individual HTN medications

Patients with BPH

A

alpha blocker

50
Q

How to manage HTN in older adults? Tx and goal

A

Weight loss, reduce salt intake

Thiazides, CCBs prefered

JNC 8 SBP target <150 (60+ years)

*If DBP drops below 65 before SBP goal is reached, abandon SBP goal

51
Q

Define uncontrolled HTN, Hypertensive emergency and severe asymptomatic HTN

A

Uncontrolled: greater than 180/110

Hypertensive Emergency: with end organ damage

Severe Asymptomatic HTN: without end organ damage

52
Q

In Hypertensive emergency what are some signs of end organ damage?

A

Dissecting aortic aneurysm

Acute pulmonary edema

ACS

Renal injury

Encephalopathy

Stroke

Eclampsia

53
Q

How to treat severe asymptomatic hypertension?

A

Lower slowly

Can be managed outpatient

*usually a chronic problem (not a sudden increase in BP)

54
Q

Side effects of lower BP too quickly in Hypertensive Emergency?

A

End organ ischemia, infarction due to:

peripheral vasodilation -> “steal syndrome”

Reflex tachycardia, increase catecholamine release

55
Q

When should BP be quickly lowered in Hypertensive Emergency?

A

If the patient has aortic dissection

goal SBP less than 110

56
Q

When should BP not be lowered in Hypertensive Emergency?

A

In patients presenting with stroke

57
Q

How should Hypertensive Emergency be managed in patients with subarachnoid or intracerebral hemorrhage?

A

If DBP >130 very slow reduction may be beneficial

58
Q

What type of medication should be used to treat Hypertensive Emergency?

A

Antihypertensives with rapid onset and short duration for careful titration

(Ex: Labetalol)

59
Q

Non pharmacologic treatments for HTN

A

>150 mins of aerobic exercise per week

No more than 2 alcholic drinks per day for men (1 for women)

Na restriction <2400 mg/day (<1500 is better)

DASH diet

Weight loss

60
Q

Non pharmacologic agents for HTN with no evidence of lowering BP

A

Calcium, magnesium

Fish oil, Coenzyme Q

Reduction in caffeine intake

Yoga, acupuncture, relaxation therapy

01 Family Medicine (16 decks)

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