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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
SIde effects of ACEi?
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
Name some ACEi and their doses
27
Name some ARBs and their doses
28
What is the different between dihydropyridines and nondihydropyridines calcium channel blockers?
dihydropyridines: vasodilators, minimal effect on cardiac contractility or AV node Nondihydropyridines: Slow AV node, negative ionotropic effect, minimal vasodilator effect
29
Name some dihydropyridine calcium channel blockers
Amlodipine Nifedipine Felodipine Nicardipine
30
Name 2 Nondihydropyridine calcium channel blockers
Verapamil Diltiazem
31
Define resistant HTN
Persistent HTN despite 3 or more medications
32
What are the most common causes of resistant HTN?
Poor medication compliance Caffeine, alcohol, nicotine, cocaine, NSAIDs, OCPs, steroids, EPO, herbs Secondary HTN causes
33
How to manage resistant HTN?
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
Contraindications to starting Aldosterone antagonists
Cr less than 2.5 males or less than 2 in females GFR \>30 K less than 5, no hx of severe hyperkalemia
35
Name 2 aldosterone antagonist and their doses
Spironolactone 12.5, 25, or 50 daily Eplerenone 25 or 50 daily
36
Why might an aldosterone antagonist benefit a patient with OSA?
Resistant HTN -\> higher levels of aldosterone -\> secondary pharyngeal edema -\> increasing airway obstruction \*an aldosterone antagonist would prevent this cycle
37
If a patient's creatinine bumps by 20-30% after starting HTN treatment, how should you change the treatment dosing?
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
If a patient's creatinine bumps by 30% or more after starting HTN treatment, how should you change the treatment dosing?
Consider other causes Change class of medications
39
Per the AHA, what is the first line treatment for HTN in patients with stable ischemic heart disease?
Beta blocker \*then ACEi/ARB
40
What role do long acting nitrates play in HTN management?
Effective for angina but not HTN
41
Name 3 beta blockers used for HTN in patients with CAD and their doses
42
Indications for individual HTN medications: Patients with heart failure
Diuretic Beta blocker ACEi/ARB Aldosterone antagonist
43
Indications for individual HTN medications Post MI patients
Beta blocker ACEi/ARB Aldosterone antagonist
44
Indications for individual HTN medications Patients with CAD
Diuretic Beta blocker ACEi/ARB CCB
45
Indications for individual HTN medications Patients with Afib
beta blocker CCB
46
Indications for individual HTN medications Patients with diabetes
Diuretic Beta blocker ACEi/ARB CCB
47
Indications for individual HTN medications Patients with CKD
ACEi/ARB
48
Indications for individual HTN medications for recurrent stroke prevention
Diuretic ACEi/ARB
49
Indications for individual HTN medications Patients with BPH
alpha blocker
50
How to manage HTN in older adults? Tx and goal
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
Define uncontrolled HTN, Hypertensive emergency and severe asymptomatic HTN
Uncontrolled: greater than 180/110 Hypertensive Emergency: with end organ damage Severe Asymptomatic HTN: without end organ damage
52
In Hypertensive emergency what are some signs of end organ damage?
Dissecting aortic aneurysm Acute pulmonary edema ACS Renal injury Encephalopathy Stroke Eclampsia
53
How to treat severe asymptomatic hypertension?
Lower slowly Can be managed outpatient \*usually a chronic problem (not a sudden increase in BP)
54
Side effects of lower BP too quickly in Hypertensive Emergency?
End organ ischemia, infarction due to: peripheral vasodilation -\> "steal syndrome" Reflex tachycardia, increase catecholamine release
55
When should BP be quickly lowered in Hypertensive Emergency?
If the patient has aortic dissection goal SBP less than 110
56
When should BP not be lowered in Hypertensive Emergency?
In patients presenting with stroke
57
How should Hypertensive Emergency be managed in patients with subarachnoid or intracerebral hemorrhage?
If DBP \>130 very slow reduction may be beneficial
58
What type of medication should be used to treat Hypertensive Emergency?
Antihypertensives with rapid onset and short duration for careful titration (Ex: Labetalol)
59
Non pharmacologic treatments for HTN
\>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
Non pharmacologic agents for HTN with no evidence of lowering BP
Calcium, magnesium Fish oil, Coenzyme Q Reduction in caffeine intake Yoga, acupuncture, relaxation therapy

01 Family Medicine (16 decks)

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