Hypertension CIS Flashcards
Case of silent killer. 41 y/o male complaining of headaches.
VS: BMI 34, T 98, BP 145/87 P 75, RR 12
Does this patient have hypertension?
gotta take the measurements twice on two separate days in order to have a diagnosis.
Normal less than 120/80
Prehypertension: 120-139 OR 80-89
Stage 1: 140-159 or 90-99
Stage 2: Systolic ≥160 OR diastolic ≥100*
Calculation of seated blood pressure is based on the mean of two or more readings on two separate office visits.
Contributing risk factors for developing essential HTN?
genetics abdominal obesity salt, alcohol age
HTN leads to increased risk of which conditions?
Stroke, MI renal disease (chronic), ESRD CHF Atrial fibrillation aortic dissection PVD- peripheral vascular disease --> amputations
difference from young people with HTN and old people
young people have more vasospasm (we don’t know why). After 20-30 years, arteriosclerosis fibrosis and thickened walls add to the resistance.
older patients will have age-related changes in the aorta –> isolated systolic hypertension (and high pulse pressure). In younger patients, there is more elasticity of the aorta.
Initial recommended HTN treatment for non-black populations
ACE inhibitors
ARB
CCB
or Thiazide diuretics
if black: CCB or thiazide diuretics.
Case 2: fat, old, weird looking
26 y/o fem 30 lbs eight gain over 2 mos, headaches, thirst,
What is the cause of this patient’s HTN?
what test will confirm it?
Cushing syndrome
dexamethazone suppression test or 24 hour urine cortisol
when to we suspect 2ndary HTN?
evidence of some other disease process that could cause HTN
too young or too old– 30-50 is right age for primary
difficult to treat
HTN that has been controlled for many years suddenly spiking
absence of predisposing factors
89 y/o male w h/o HTN for 40 years usually well controlled on amlodipine, HCTZ
now not controlled anymore
exam: bilateral abdominal bruits
What diagnostic test would you like to order for this patient?
- Captopril test (reactive rise in renin and large fall in BP afer administration)
- DSA - doppler
- MRI- angiography
- Arteriography
- Renal vein renin ratio (ratio off 1.5 or greater)
What are the 2 main causes of renal artery stenosis?
What should we be careful and not prescribe in such patients?
atherosclerosis-mostly unilateral, progressive, associated with risk factors (obesity, etc.)
fibromuscular dysplasia- mostly bilateral, not progressive, responds to angioplasty
Careful about ACE inhibitors and ARBs
54-y/o black male, anxiety, trmors, eight loss, hard time buttoning top button on his shirt. wife says looking wierd
T 100, BP 165/100, pulse 119
what is the cause of his high BP and weird look?
what test should we order?
What should we treat him with?
hypertyroid from Graves disease
TCH and T3/4
Beta blockers
The case of a weakling
55 y/o male no prev history of HTN last check 3 mos ago
presents ER w/ severe muscle weakness w/out focal defficit. No chest pain or SOB. no meds. 210/120, potassium is 1.9- very low. Creatinine normal, urine neg for protein.
Does this patient have a hypertensive emergency? Why or why not?
what is most likely cause of this patient’s HTN?
No. no evidence of end organ damage. There are no numbers for emergency; just the organ damage.
Urgency is systolic over 180 or diastolic over 130.
examples of end organ damage: hematuria, MI, angina, cerebral edema, altered mental status, bleeding from nose, storke, TIA, retinal hemorrhages or exudates, papilledema, A-V nicking
Most likely cause: hyperaldosteronism
Hyperaldosteronism: 2 types
Primary (Conn’s syndrome)- usually adrenal gland adenoma w/out exogenous stimulus. elevated aldosteronen and low renin levels
Secondary Hyperaldosteronism: elevated aldosterone and elevated renin levels from: diuretics, CHF, cirrhosis, ascites, nephrosis, e.g.
What medication will we prescribe for a patient with low potassium?
Spironolactone, because it is an aldosterone antagonist
What adrenal conditions can cause secondary hypertension?
Hyperaldosteronism
Cushing’s
Pheochromocytoma
What is the test for hyperaldosteronism?
aldosterone to renin ratio 20:1 or more
How to rule out pheochromocytoma?
urine catecholamines, VMA vanyllmendelic acids,
Secondary hypertension
sleep apnea drug induced chronic kidney primary aldosteronism renovascular disease steroid therapy or Cushing's pain induced. Pheochromocytoma Coarctation of the aorta Thyroid disease Parathyroid disease
thiazide diuretics
HCTZ and chhlorthalidone
direct vasodilators
hydralazine, minoxidil
