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Cardiovascular > Hypertension I > Flashcards

Hypertension I Flashcards

1
Q

What does blood pressure measure?

A

The force of blood against the arterial walls

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2
Q

Why is the definition of hypertension important clinically?

A

It refers to value where medical therapy reduces morbidity and mortality related to BP

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3
Q

How many BP readings do you need to qualify as having hypertension?

A

2+ accurate, seated BP readings during 2 or more outpatient visits

Exception: hypertensive emergency

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4
Q

What classifies as elevated blood pressure according to the ACC/AHA?

A

120-129 AND <80

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5
Q

What classifies as stage 1 hypertension according to the ACC/AHA? Stage 2?

A

130-139 OR 80-89
140+ OR 90+

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6
Q

What is the difference between primary and secondary hypertension?

A

We do not know the cause of primary hypertension and secondary has a definable cause

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7
Q

What are examples of causes of secondary hypertension (9)?

A

CKD
Renal artery stenosis
Cushing Disease
Coarctation of the Aorta
Drug-induced HTN
Pheochromocytoma
Hyperaldosteronism
OSA
Thyroid dysfunction

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8
Q

When young patient have hypertension, how does it present differently?

A

Both systolic and diastolic BP usually rise
Predominantly due to hormonal activation
Associated with OSA
Tx initiated when BP >140/90 (JNC)

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9
Q

When older patients have hypertension, how do they present differently?

A

Systolic BP rises without rise in diastolic
Predominantly due to arterial stiffness
Not associated with OSA
Tx initiated when SBP according to JNC

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10
Q

A patient presents with systolic BP >140, but diastolic <90. What is this called?

A

Isolated systolic hypertension

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11
Q

What patient population is more likely to have isolated systolic hypertension and why?

A

Older patients; arterial stiffness and atherosclerosis

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12
Q

Why would a younger patient have isolated systolic hypertension?

A

MC in athletic males, most likely due to high stroke volume

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13
Q

Is systolic or diastolic BP a better predictor of risk?

A

SBP is better predictor of risk in elderly (>60)
DBP is better predictor of risk for patients <45

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14
Q

A patient consistently has elevated BP >140/90 in the office, but a lower value outside of the clinic. What condition do they have?

A

White Coat Hypertension

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15
Q

Which patient population is more likely to have white coat hypertension?

A

Older patients

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16
Q

How is white coat hypertension treated?

A

Treatment not necessary as long as within range at home

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17
Q

A patient has a normal BP in the office, but elevated values at home. What condition do they have?

A

Masked Hypertension

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18
Q

What causes masked hypertension? How should these patients be treated?

A

Lifestyle: alcohol, tobacco, caffeine use
Same as normal hypertension if work-up doesn’t show outside cause

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19
Q

An elderly patient has elevated BP but feels hypotensive. What condition should you be aware of? How would you verify this?

A

Pseudohypertension, invasive intra-aortic reading

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20
Q

What is the cause and complication of pseudohypertension?

A

Calcification of peripheral vessels results in falsely elevated BP
Leads to symptomatic over treatment

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21
Q

Which epidemiological factors predispose a patient to BP?

A

Very common and present in nearly all populations!
SBP higher in men in early adulthood
Greater rise in women with aging
Non-Hispanic blacks > non-Hispanic whites > non-Hispanic Asians > Hispanic Americans
High prevalence >65 y/o

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22
Q

As we age, what happens to diastolic BP?

A

Increases until about 55 y/o, then decreases causing wider pulse pressure after age 60

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23
Q

HTN is a major risk factor for ______

A

Heart disease and stroke

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24
Q

Blood pressure = ____ x _____

A

Cardiac output x systemic vascular resistance

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25
Q

Primary HTN results from complex interactions between multiple _____, _____, and ______ factors

A

Genetic, endogenous, environmental

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26
Q

What pathophysiological components may be related to pathogenesis of HTN?

A

Sympathetic nervous system hyperactivity
Renin-angiotensin system activity
Defect in natriuresis
Abnormal cardiovascular or kidney development
Elevated intracellular calcium and sodium levels

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27
Q

What is the name of the neurons that secrete acetylcholine? Norepinephrine?

A

Cholinergic, adrenergic

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28
Q

Which population is more likely to have sympathetic nervous system hyperactivity leading to HTN? How does it present?

A

Younger patients, tachycardia and elevated cardiac output

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29
Q

How is natriuresis related to BP in a normal patient? What happens in a patient with HTN?

A

Increased salt intake —> increase in BP —> increase in natriuresis —> BP normalizes
Defective natriuresis

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30
Q

How is CV or renal defect related to HTN?

A

Aortic elasticity or microvasculature abnormalities increase risk of HTN

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31
Q

How is calcium and sodium related to the pathogenesis of HTN?

A

Intracellular sodium is elevated in primary HTN —> increase in intracellular calcium —> increased vascular smooth muscle tone

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32
Q

What are risk factors for HTN?

A

Obstructive sleep apnea
Excessive alcohol use
Cigarette smoking
NSAID use
Obesity
Low potassium or high sodium intake
Metabolic syndrome

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33
Q

What are the goals of evaluation for HTN?

A

Assess presence of target-organ damage related to HTN
Determine presence of cardiovascular risk factors and disease
Evaluate for possible underlying secondary causes of HTN

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34
Q

How should blood pressure be obtained at the first office visit

A

Both arms, two times, spaced 1-2 minutes apart
If value varies between extremities, use higher value obtained

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35
Q

In patients with A. Fib, ______ may be inaccurate

A

Automated devices

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36
Q

What should you keep in mind with home BP monitoring?

A

Allows for continued monitoring
Helps diagnose white coat HTN
Patient must be educated on device use
Ensure home device is accurate

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37
Q

What is ambulatory BP monitoring?

A

BP machine automatically obtains multiple readings over an extended period of time

38
Q

What are the benefits of ambulatory BP monitoring?

A

Able to assess masked HTN and medication efficacy
Assessment of nighttime risk of elevated BP or non-dipping BP

39
Q

What are important historical questions to ask about HTN?

A

Duration, age of onset, previous HTN
Previous anti hypertensive therapy
Symptoms and possible secondary causes of HTN
Med history
Social history
CV risk factors
Symptoms of target-organ damage

40
Q

What medications are important to ask about for HTN?

A

Contraceptives, NSAIDs, amphetamines, licorice

41
Q

What social history is important to ask about for HTN?

A

Alcohol/tobacco use, activity level, diet

42
Q

The PE for HTN should be directed at assessing for signs of _____ or ____

A

Target-organ damage, secondary causes of HTN

43
Q

The physical exam for HTN typically requires a _____ on initial assessment, then can focus on _____ at follow up visits

A

Head-to-toe exam, target-organs

44
Q

What does a pulse pressure of >60 mmHg suggest on HTN assessment?

A

increased CVD risk

45
Q

What does tachycardia with HTN suggest on physical exam?

A

Hyperthyroid, pheochromocytoma, HF

46
Q

What does cushingoid body habitus suggest?

A

Cushing syndrome

47
Q

What do oral-facial tumors suggest during a HTN physical exam?q

A

MEN-2A/2B (pheochromocytoma)

48
Q

What do neurofibromas, cafe-au-lait spots on HTN physical exam suggest?

A

Pheochromocytoma

49
Q

What do hemorrhages, exudates, or Papilledema suggest on HTN physical exam?

A

Hypertensive retinopathy/accelerated hypertension

50
Q

What do bruits suggest on HTN physical exam?

A

Carotid disease

51
Q

What finding would suggest coarctation of aorta on HTN physical exam?

A

Rib bruits

52
Q

What finding would suggest renal artery stenosis on HTN physical exam?

A

Post flank bruits

53
Q

What findings would suggest heart failure on physical exam?

A

Tachycardia, crackles, wheezes

54
Q

If you feel a palpable kidney, epigastric or post bruits on physical exam of a patient with HTN, what condition should you be thinking of?

A

Poly cystic kidneys, renal artery stenosis

55
Q

If you feel diminished pulses, radial-femoral pulse delay in a patient with HTN, what condition should you be thinking of?

A

Coarctation of the aorta

56
Q

If you hear bruits on physical exam of a patient with HTN, what condition should you suspect?

A

Vascular damage

57
Q

What lab tests should be ordered to work up a hypertensive patient?

A

UA, BMP, EKG, fasting lipid profile, TSH, other tests directed at secondary causes

58
Q

What are complications of untreated HTN?

A

Structural and functional changes in the heart and vasculature
Increased risk of thrombosis
Increase in morbidity and mortality doubles for each 6 mmHg increase in DBP

59
Q

What structural and functional changes in the heart and vasculature can occur due to hypertension?

A

LVH, increased atrial size, CHF, atherosclerosis, microvascular disease, and cardiac arrhythmias

60
Q

How is left ventricle hypertrophy related to mortality?

A

Can cause diastolic heart failure leading to systolic heart failure —> death
or cause myocardial ischemia or ventricular arrhythmias leading to death

61
Q

What are signs and symptoms of hypertensive cardiovascular disease?

A

dyspnea, edema
Palpitation, chest pain
LV heave or S4 gallop
LVH criteria on EKG

62
Q

A patient was recently diagnosed with hypertensive cardiovascular disease and wants to know what this means long term. What can you tell them

A

LVH can improve with proper BP management

63
Q

How can hypertension impact the brain?

A

Predisposing factor for ischemic and hemorrhagic stroke
Increases risk for dementia

64
Q

What impact can lowering a patients blood pressure after they have vascular and Alzheimer type dementia have?

A

Make symptoms worse once microvascular disease noted

65
Q

Chronic untreated HTN results in ______. Which population is it more common in?

A

Nephrosclerosis, black patients

66
Q

How can hypertensive renal disease be prevented?

A

Appropriate BP management

(But difficult to reverse damage that has already occurred

67
Q

What does hypertensive retinopathy cause?

A

Narrowing of retinal arteries
Development of exudates, cotton-wool spots, and retinal hemorrhages

68
Q

What are major determinants of retinopathy?

A

Degree and duration of HTN

69
Q

Condition that causes narrowing and/or hardening of arteries that is caused by and contributes to increased BP

A

Atherosclerosis

70
Q

What are vascular complications of hypertension?

A

Atherosclerosis, aortic aneurysm

71
Q

What are lifestyle modifications for management of HTN?

A

Weight reduction (maintain normal body weight)
Adopt DASH eating plan
Dietary sodium restriction
Physical activity
Moderation of alcohol consumption

72
Q

What are lifestyle modifications for management of HTN?

A

Weight reduction
DASH eating plan
Dietary sodium reduction
Physical activity
Moderation of alcohol consumption

73
Q

You recommend a DASH eating plan for a patient with hypertension. What recommendations will that include?

A

Diet rich in fruits, vegetables, and low-fat dairy products with a reduced content of saturated fat and total fat

74
Q

How much should a patient with HTN reduce dietary sodium?

A

To no more than 100 mEq/day

75
Q

How much physical activity should a patient with HTN engage in?

A

Aerobic physical activity such as brisk walking at least 30 minutes per day, most days of the week

76
Q

How much alcohol consumption is recommended for a patient with HTN?

A

Limit consumption to no more than two drinks per day in men and no more than one drink per day in women and lighter-weight persons

77
Q

What is management of patient with elevated BP according to ACC/AHA guidelines?

A

Non-pharmacological therapy and reassess BP in 3-6 months

78
Q

What is management of stage 1 hypertension?

A

Assess 10 year ASCVD risk and begin pharm and non-pharm treatment if >10%
If not, non-pharm only

79
Q

What is management of stage 2 hypertension according to ACC/AHA guidelines?

A

Begin pharm and non-pharm treatment

80
Q

What is the goal BP for all patients with HTN?

A

130/80

81
Q

What medications are first line for non-African American patients?

A

Thiazide, ACEI/ARB, or CCB

82
Q

What medications are first line for HTN in African American patients?

A

Thiazide or CCB

83
Q

Which HTN medications would you not use with heart failure?

A

CCB

84
Q

Which HTN medications would you use for post-myocardial infarction?

A

Beta-blockers, ACE inhibitors, or aldosterone antagonist

85
Q

Which HTN medications would you use for high coronary disease risk?

A

Diuretic, beta-blocker, ACE inhibitor, CCB

86
Q

Which HTN medications would you not use for diabetes mellitus?

A

Aldosterone antagonist

87
Q

Which HTN medications would you use for chronic kidney disease?

A

ACE/ARB

88
Q

Which HTN medications would you use for recurrent stroke prevention?

A

Diuretic or ACE inhibitor

89
Q

How often should you follow up/get labs for hypertensive patients?

A

Once BP is well controlled and meds proven safe, every 6-12 months
Lab monitoring not needed if BP controlled, except with other diseases
EKG every 2-4 years

90
Q

How often should you follow up/get labs for hypertensive patients?

A

Once BP is well controlled and meds proven safe, every 6-12 months
Lab monitoring not needed if BP controlled, except with other diseases
EKG every 2-4 years

Cardiovascular (17 decks)

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