Hypertension and dyslipidemia therapeutics tutorial Flashcards
Beta-blockers are first-choice in the management of hypertension. T/F
False
- -Beta-blockers are no longer first choice medication for hypertension
- -Starting a smoking patient with wheeze on a beta-blocker (albeit a beta 1 selective agent) is questionable and should have prompted revaluation when symptoms occurred.
what is the isolated systolic hypertension?
A form of hypertension that is characterized by elevated systolic BP and normal diastolic BP (and widened pulse pressure). It most commonly occurs in the elderly population because of a decrease in arterial compliance. It may also occur due to an increase in cardiac output (e.g., anemia, hyperthyroidism, aortic insufficiency, AV fistula). It is associated with an increased risk of cardiovascular events (MI, stroke, renal dysfunction).
what is the white coat hypertension?
- -Definition: arterial hypertension detected only in clinical settings or during blood pressure measurement at a physician’s practice
- -Etiology: anxiety experienced by the patient
- -Clinical features: consistently normal blood pressure measurements and normalization of elevated blood pressure outside of a clinical setting
- -Diagnostics: 24-hour blood pressure monitoring
what is the primary (essential) hypertension?
- -No specific cause; multifactorial etiology including epigenetic/genetic and environmental factors
- -Accounts for 85–95% of cases of hypertension in adults
- -Accounts for 15–20% of cases of hypertension in children < 12 years of age
- -Age at onset: 25–55 years (prevalence is increasing in adolescents)
what is secondary hypertension?
- -Caused by an identifiable underlying condition
- -Accounts for 5–15% of cases of hypertension in adults
- -Accounts for 70–85% of cases of hypertension in children < 12 years of age
- -Age at onset < 25 years or > 55 years
- -RECENT can help you remember the causes of secondary hypertension: R = Renal (e.g., renal artery stenosis, glomerulonephritis), E = Endocrine (e.g., Cushing syndrome, hyperthyroidism, Conn syndrome), C = Coarctation of aorta, E = Estrogen (oral contraceptives), N = Neurologic (raised intracranial pressure, psychostimulants use), T = Treatment (e.g., glucocorticoids, NSAIDs).
what are the endocrine causes of secondary hypertension?
- -Primary hyperaldosteronism (Conn syndrome): most common cause of secondary hypertension in adults
- -Hypercortisolism (Cushing syndrome)
- -Hyperthyroidism
- -Pheochromocytoma
- -Primary hyperparathyroidism
- -Acromegaly
- -Congenital adrenal hyperplasia
what are the renal causes of secondary hypertension?
- -Renovascular hypertension (e.g., due to renal artery stenosis)
- -Polycystic kidney disease (ADPKD)
- -Renal failure (renal parenchymal hypertension)
- -Glomerulonephritis
- -Systemic lupus erythematosus
- -Renal tumors
other causes of secondary hypertension except renal and endocrine??
- -Coarctation of the aorta
- -Obstructive sleep apnea
- -Medication: sympathomimetic drugs, corticosteroids, –NSAIDs, oral contraceptives
- -Recreational drug use: amphetamines, cocaine, phencyclidine
- -Isolated systolic hypertension:
what is the coarctation of the aorta?
A congenital heart defect that involves the narrowing of the aorta at the aortic isthmus. Frequently associated with other congenital heart defects (e.g., bicuspid aortic valve, VSD and/or PDA) and Turner syndrome.
what is the pathophysiology of aortic coarctation?
1) Genetic defects and/or intrauterine ischemia → medial thickening and intimal hyperplasia form a ridge encircling the aortic lumen → narrowing of the aorta → ↑ flow proximal and ↓ flow distal to the narrowing
2) Compensatory mechanisms
- -Myocardial hypertrophy and collateral blood flow (e.g., intercostal vessels , scapular vessels) develop in cases of discrete stenosis to compensate for the left ventricular outflow tract obstruction (common) → onset of symptoms usually later in childhood
- -In long segment stenosis, there is no time for development of compensatory mechanisms → closure of PDA after birth → left ventricular pressure and volume overload → hypoperfusion of organs and extremities distal to the stenosis, heart failure, cardiogenic shock
what are the clinical features of aortic coarctation in adults?
- -Hypertension
- -Variability in blood pressure in the upper and lower extremities
- -Headache, epistaxis, tinnitus (Caused by brachiocephalic hypertension)
- -Claudication of the lower extremities with exertion
how aortic coarctation is diagnosed?
1) Best initial test: upper and lower extremity blood pressure measurement and search for brachial-femoral delay
2) Pulse oximetry: ↓ SpO2
3) Echocardiography with doppler (confirmatory test): location and extent of stenosis; concurrent anomalies
4) X-ray
- -Cardiomegaly and ↑ pulmonary vascular markings
- -“Figure of 3” sign (Also referred to as hourglass-like narrowing of the aorta; caused by pre- and postdilatation of the aorta with an indentation at the site of coarctation.)
- -Rib notching (on inferior border of the ribs)
5) Genetic testing for Turner syndrome
what is the reason of rib notching in aortic coarctation?
Internal thoracic and intercostal arteries dilate and form collaterals in cases of aortic narrowing. The increased perfusion leads to pressure atrophy and resorption of the neighboring ribs, which may be visible in chest x-rays as inferior rib notching. This is a finding of chronic disease, commonly observed in children aged > 5 years.
what are the lifestyle factors that increase BP?
- -Salt –Salt added at table and in the cooking. Much processed foods eaten.
- -Calories–Excess calories and BMI 29 kg/m2
- -Alcohol intake
- -lack of exercise
what are the signs of end-organ damage in hypertension?
1) cardiac
- -Congestive heart failure, dilated cardiomyopathy, hypertrophic cardiomyopathy
- -Coronary artery disease and myocardial infarction
- -Atrial fibrillation
- -Aortic aneurysm
- -Aortic dissection
- -Carotid artery stenosis
- -Peripheral artery disease
- -Atherosclerosis
2) Brain
- -Stroke , TIA
- -Cognitive changes such as memory loss
3) Hypertensive nephrosclerosis
- -Pathophysiology: chronic hypertension → narrowing of afferent arterioles and efferent arterioles → reduction of glomerular blood flow → glomerular and tubular ischemia → arteriolonephrosclerosis and fibrosis (focal segmental glomerulosclerosis) → end-stage renal disease
- -Typical findings
- -Initially microalbuminuria and microhematuria
- -With disease progression, nephrosclerosis with macroalbuminuria (usually < 1 g/day) and progressive renal failure occur.
4) Eyes
- -Hypertensive retinopathy
- -Fundoscopic examination:
- -Cotton-wool spots
- -Retinal hemorrhages (i.e., flame-shaped hemorrhages)
- -Microaneurysms
- -Arteriovenous nicking
The lifestyle measures that are widely recognized to lower BP and cholesterol and/or cardiovascular risk are:
1) Smoking cessation (reduces CV risk)
2) Diet
- -Weight reduction through decreased calorie intake
- -Reduction of salt intake
- -Increase in fruit & vegetable intake,
- -Decrease in saturated & total fat intake
3) Reduction of excessive alcohol intake
4) Greater physical exercise
