Hypertension lecture Flashcards
what is defined as HTN?
equal or above 140/90
What percentage of HTN is secondary? (i.e. because of renal, endocrine, congenital etiologies)
5%
____% of cases of HTN are etiology unknown
95%
- Environmental factors
- Sympathetic hyperactivity
- RAA axis
can all lead to…
Hypertension
Obesity Excess Na intake Cigarette smoking NSAIDs Excess alcohol
Exacerbating factors of HTN
Estrogen use Renal dz Renal vascular HTN Endocrine disorders Coarctation of aorta (congenital) HTN in pregnancy
All secondary causes of HTN
Hypertension accelerates progression of..
Renal insufficiency
Any form of chronic renal parenchymal disease can result in..
Hypertension
Marked increase of renin
2 forms:
Fibromuscular hyperplasia
Atherosclerosis
Renal artery stenosis
Fibomuscular hyperplasia (FMH) usually presents in who?
BP markedly elevated; renal function preserved; arteriography diagnostic; angioplasty/stent beneficial in treatment.
Young adults
Athersclerosis renal artery stenosis presents in..
(BP elevated and unresponsive to meds; renal function often impaired; intervention may or may not help; long term med Rx necessary.)
Older adults
Heart’s response to pressure overload
Hypertrophy
Powerful predictor of prognosis, morbidity, mortality, and cardiac events once present.
LVH and hypertension
HTN is major predisposing cause of stroke. What part of BP is most closely correlated with stroke?
Systolic is correlated more with strokes
Retinal changes: Narrowing of arterioles (A/V over .50) A-V nicking- (arteriosclerosis) Silver or copper wired appearance Hemorrhages or exudates Papilledema
signs of HTN
Creatinine
BUN
Potassium levels
MUST CHECK IN HTN PATIENTS! (among other things)
Why must you check potassium levels in HTN?
Bc will most likely put the pt on a diuretic, which can cause HYPOKALEMIA!*
if LVH seen on EKG, what next tests can you run?
Cardiac/echo doppler
DOC for diabetics with HTN
ACE inhibitor (or ARB) along with thiazide or CCB
Focus primarily on ______ as this is the most important target for reducing morbidity and mortality.
Systolic BP
Initial therapy for most HTN patients…
Thiazide diuretics
cost effective, lower systolic BP
Diuretics are most potent in…
Blacks, elderly and obese
more effective in smokers
is Chlorthalidone more or less potent than HCTZ?
MORE!
Avoid diuretics with…
Hypokalemia
Gout
Beta blockers are less effective in…
Black populations
Elderly
New (2008) selective β-blocker with vasodilating properties.
Nitric oxide mediated vasodilation
Loses selectivity in high doses
Nebivolol
What drug class is preferred for blacks and elderly?
calcium channel blockers
Progressive renal insufficiency; more common in black populations, especially in the presence of DM.
Nephrosclerosis
Usually asymptomatic. A.M. headaches may occur.
Late findings include:
-Symptoms related to LVH: Diastolic dysfunction (SOB, DOE).
-Symptoms related to cerebral involvement- *TIA, stroke, hemorrhage.
-Symptoms related to cardiac involvement- MI, angina, HF.
Nephrosclerosis
DOC for HTN and angina?
beta blocker or CCB
DOC for HTN and HF?
ACE inhibitor
DOC for HTN and diabetes? or for HTN and renal dz?
ACE inhibitor/ARB
Goals of treating HTN?
decrease endpoints!
endopoints= MI, Stroke, LVH, PAD, all cause/cardiac mortality, HF and renal failure
MI, Stroke, LVH, PAD, all cause/cardiac mortality, HF and renal failure.
Endpoints (what you are trying to avoid when treating HTN)
Focus primarily on _____ BP as this is the most important target for reducing morbidity and mortality.
systolic
1 DOC for HTN
Thiazide diuretics
- Initial effects via decreased plasma volume
- chronic effects via decreased SVR.
Diuretics
Avoid in patients with hyponatremia and gout
Diuretics
More potent in blacks, elderly and obese. More effective in smokers.
Diuretics
Decrease BP by decreasing CO (-inotropic effect and ↓HR). SVR increases, renin levels decrease.
Less effective in black populations and in elderly.
Beta blockers
Very useful in patients with HTN and other co-morbid conditions: angina pectoris, post MI→↓mortality, HF→↓mortality, essential tremor, migraine headaches, arrhythmias/sudden death (class II anti-arrhythmic)
Beta blockers
selective β-blocker with vasodilating properties.
Nitric oxide mediated vasodilation
Loses selectivity in high doses
Nebivolol (Bystolic)
Mortality and other “end-point” benefits (post MI, HF) applicable primarily to….
lipid soluble beta blockers
Are beta blockers as successful in LVH regression compared to other treatments?
NO
May worsen acute HF; but clearly beneficial for patients with chronic compensated & stable HF and low ejection fraction- ↓mortality.
May worsen advanced PAD and rest pain.
Mask signs of hypoglycemia in Type I diabetics.
CNS: Fatigue, nightmares, depression, sexual dysfunction-
Beta blockers
Inhibit renin-angiotensin-aldosterone system and:
Inhibit Bradykinin degradation
Stimulate vasodilating prostaglandin synthesis.
Useful as initial Rx or when added to other drugs for HTN.
ACE inhibitors
ACE inhibitors Anti-hypertensive efficacy significantly improved when combined with…
diuretic
synergistic effects
May be useful for heart failure in patients who cannot take ACEI; do not inhibit bradykinin breakdown.
Renoprotective in diabetics.
Few side effects, and no cough.
ARBs
Act by peripheral vasodilation
Effective in all demographic groups, and are preferable in blacks and the elderly.
Additional protection against stroke
Ca channel blockers
In addition to vasodilation these drugs have negative inotropic, chronotropic and dromotropic (slow A-V conduction) effects.
Can exacerbate heart failure and cause SA and AV nodal dysfunction.
Also used as anti-anginals and in Rx of arrhythmias.
Nondihydro CCBs
Significant vasodilation, reduction in SVR.
Fluid retention and reflex tachycardia occur (role of ß-blockers and diuretics).
Unlikely to cause heart failure and conduction problems (in vivo).
Must use long acting preparations.
2nd or 3rd line agents in diabetics.
Dihydro CCBs
SE= headaches, periph edema
CCBs
