Hypertension I Flashcards
What does blood pressure measure?
The force of blood against the arterial walls
Why is the definition of hypertension important clinically?
It refers to value where medical therapy reduces morbidity and mortality related to BP
How many BP readings do you need to qualify as having hypertension?
2+ accurate, seated BP readings during 2 or more outpatient visits
Exception: hypertensive emergency
What classifies as elevated blood pressure according to the ACC/AHA?
120-129 AND <80
What classifies as stage 1 hypertension according to the ACC/AHA? Stage 2?
130-139 OR 80-89
140+ OR 90+
What is the difference between primary and secondary hypertension?
We do not know the cause of primary hypertension and secondary has a definable cause
What are examples of causes of secondary hypertension (9)?
CKD
Renal artery stenosis
Cushing Disease
Coarctation of the Aorta
Drug-induced HTN
Pheochromocytoma
Hyperaldosteronism
OSA
Thyroid dysfunction
When young patient have hypertension, how does it present differently?
Both systolic and diastolic BP usually rise
Predominantly due to hormonal activation
Associated with OSA
Tx initiated when BP >140/90 (JNC)
When older patients have hypertension, how do they present differently?
Systolic BP rises without rise in diastolic
Predominantly due to arterial stiffness
Not associated with OSA
Tx initiated when SBP according to JNC
A patient presents with systolic BP >140, but diastolic <90. What is this called?
Isolated systolic hypertension
What patient population is more likely to have isolated systolic hypertension and why?
Older patients; arterial stiffness and atherosclerosis
Why would a younger patient have isolated systolic hypertension?
MC in athletic males, most likely due to high stroke volume
Is systolic or diastolic BP a better predictor of risk?
SBP is better predictor of risk in elderly (>60)
DBP is better predictor of risk for patients <45
A patient consistently has elevated BP >140/90 in the office, but a lower value outside of the clinic. What condition do they have?
White Coat Hypertension
Which patient population is more likely to have white coat hypertension?
Older patients
How is white coat hypertension treated?
Treatment not necessary as long as within range at home
A patient has a normal BP in the office, but elevated values at home. What condition do they have?
Masked Hypertension
What causes masked hypertension? How should these patients be treated?
Lifestyle: alcohol, tobacco, caffeine use
Same as normal hypertension if work-up doesn’t show outside cause
An elderly patient has elevated BP but feels hypotensive. What condition should you be aware of? How would you verify this?
Pseudohypertension, invasive intra-aortic reading
What is the cause and complication of pseudohypertension?
Calcification of peripheral vessels results in falsely elevated BP
Leads to symptomatic over treatment
Which epidemiological factors predispose a patient to BP?
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
As we age, what happens to diastolic BP?
Increases until about 55 y/o, then decreases causing wider pulse pressure after age 60
HTN is a major risk factor for ______
Heart disease and stroke
Blood pressure = ____ x _____
Cardiac output x systemic vascular resistance
Primary HTN results from complex interactions between multiple _____, _____, and ______ factors
Genetic, endogenous, environmental
What pathophysiological components may be related to pathogenesis of HTN?
Sympathetic nervous system hyperactivity
Renin-angiotensin system activity
Defect in natriuresis
Abnormal cardiovascular or kidney development
Elevated intracellular calcium and sodium levels
What is the name of the neurons that secrete acetylcholine? Norepinephrine?
Cholinergic, adrenergic
Which population is more likely to have sympathetic nervous system hyperactivity leading to HTN? How does it present?
Younger patients, tachycardia and elevated cardiac output
How is natriuresis related to BP in a normal patient? What happens in a patient with HTN?
Increased salt intake —> increase in BP —> increase in natriuresis —> BP normalizes
Defective natriuresis
How is CV or renal defect related to HTN?
Aortic elasticity or microvasculature abnormalities increase risk of HTN
How is calcium and sodium related to the pathogenesis of HTN?
Intracellular sodium is elevated in primary HTN —> increase in intracellular calcium —> increased vascular smooth muscle tone
What are risk factors for HTN?
Obstructive sleep apnea
Excessive alcohol use
Cigarette smoking
NSAID use
Obesity
Low potassium or high sodium intake
Metabolic syndrome
What are the goals of evaluation for HTN?
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
How should blood pressure be obtained at the first office visit
Both arms, two times, spaced 1-2 minutes apart
If value varies between extremities, use higher value obtained
In patients with A. Fib, ______ may be inaccurate
Automated devices
What should you keep in mind with home BP monitoring?
Allows for continued monitoring
Helps diagnose white coat HTN
Patient must be educated on device use
Ensure home device is accurate
What is ambulatory BP monitoring?
BP machine automatically obtains multiple readings over an extended period of time
What are the benefits of ambulatory BP monitoring?
Able to assess masked HTN and medication efficacy
Assessment of nighttime risk of elevated BP or non-dipping BP
What are important historical questions to ask about HTN?
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
What medications are important to ask about for HTN?
Contraceptives, NSAIDs, amphetamines, licorice
What social history is important to ask about for HTN?
Alcohol/tobacco use, activity level, diet
The PE for HTN should be directed at assessing for signs of _____ or ____
Target-organ damage, secondary causes of HTN
The physical exam for HTN typically requires a _____ on initial assessment, then can focus on _____ at follow up visits
Head-to-toe exam, target-organs
What does a pulse pressure of >60 mmHg suggest on HTN assessment?
increased CVD risk
What does tachycardia with HTN suggest on physical exam?
Hyperthyroid, pheochromocytoma, HF
What does cushingoid body habitus suggest?
Cushing syndrome
What do oral-facial tumors suggest during a HTN physical exam?q
MEN-2A/2B (pheochromocytoma)
What do neurofibromas, cafe-au-lait spots on HTN physical exam suggest?
Pheochromocytoma
What do hemorrhages, exudates, or Papilledema suggest on HTN physical exam?
Hypertensive retinopathy/accelerated hypertension
What do bruits suggest on HTN physical exam?
Carotid disease
What finding would suggest coarctation of aorta on HTN physical exam?
Rib bruits
What finding would suggest renal artery stenosis on HTN physical exam?
Post flank bruits
What findings would suggest heart failure on physical exam?
Tachycardia, crackles, wheezes
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?
Poly cystic kidneys, renal artery stenosis
If you feel diminished pulses, radial-femoral pulse delay in a patient with HTN, what condition should you be thinking of?
Coarctation of the aorta
If you hear bruits on physical exam of a patient with HTN, what condition should you suspect?
Vascular damage
What lab tests should be ordered to work up a hypertensive patient?
UA, BMP, EKG, fasting lipid profile, TSH, other tests directed at secondary causes
What are complications of untreated HTN?
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
What structural and functional changes in the heart and vasculature can occur due to hypertension?
LVH, increased atrial size, CHF, atherosclerosis, microvascular disease, and cardiac arrhythmias
How is left ventricle hypertrophy related to mortality?
Can cause diastolic heart failure leading to systolic heart failure —> death
or cause myocardial ischemia or ventricular arrhythmias leading to death
What are signs and symptoms of hypertensive cardiovascular disease?
dyspnea, edema
Palpitation, chest pain
LV heave or S4 gallop
LVH criteria on EKG
A patient was recently diagnosed with hypertensive cardiovascular disease and wants to know what this means long term. What can you tell them
LVH can improve with proper BP management
How can hypertension impact the brain?
Predisposing factor for ischemic and hemorrhagic stroke
Increases risk for dementia
What impact can lowering a patients blood pressure after they have vascular and Alzheimer type dementia have?
Make symptoms worse once microvascular disease noted
Chronic untreated HTN results in ______. Which population is it more common in?
Nephrosclerosis, black patients
How can hypertensive renal disease be prevented?
Appropriate BP management
(But difficult to reverse damage that has already occurred
What does hypertensive retinopathy cause?
Narrowing of retinal arteries
Development of exudates, cotton-wool spots, and retinal hemorrhages
What are major determinants of retinopathy?
Degree and duration of HTN
Condition that causes narrowing and/or hardening of arteries that is caused by and contributes to increased BP
Atherosclerosis
What are vascular complications of hypertension?
Atherosclerosis, aortic aneurysm
What are lifestyle modifications for management of HTN?
Weight reduction (maintain normal body weight)
Adopt DASH eating plan
Dietary sodium restriction
Physical activity
Moderation of alcohol consumption
What are lifestyle modifications for management of HTN?
Weight reduction
DASH eating plan
Dietary sodium reduction
Physical activity
Moderation of alcohol consumption
You recommend a DASH eating plan for a patient with hypertension. What recommendations will that include?
Diet rich in fruits, vegetables, and low-fat dairy products with a reduced content of saturated fat and total fat
How much should a patient with HTN reduce dietary sodium?
To no more than 100 mEq/day
How much physical activity should a patient with HTN engage in?
Aerobic physical activity such as brisk walking at least 30 minutes per day, most days of the week
How much alcohol consumption is recommended for a patient with HTN?
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
What is management of patient with elevated BP according to ACC/AHA guidelines?
Non-pharmacological therapy and reassess BP in 3-6 months
What is management of stage 1 hypertension?
Assess 10 year ASCVD risk and begin pharm and non-pharm treatment if >10%
If not, non-pharm only
What is management of stage 2 hypertension according to ACC/AHA guidelines?
Begin pharm and non-pharm treatment
What is the goal BP for all patients with HTN?
130/80
What medications are first line for non-African American patients?
Thiazide, ACEI/ARB, or CCB
What medications are first line for HTN in African American patients?
Thiazide or CCB
Which HTN medications would you not use with heart failure?
CCB
Which HTN medications would you use for post-myocardial infarction?
Beta-blockers, ACE inhibitors, or aldosterone antagonist
Which HTN medications would you use for high coronary disease risk?
Diuretic, beta-blocker, ACE inhibitor, CCB
Which HTN medications would you not use for diabetes mellitus?
Aldosterone antagonist
Which HTN medications would you use for chronic kidney disease?
ACE/ARB
Which HTN medications would you use for recurrent stroke prevention?
Diuretic or ACE inhibitor
How often should you follow up/get labs for hypertensive patients?
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
How often should you follow up/get labs for hypertensive patients?
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
