Hypertension Lecture Flashcards
Case #1 - 65 y/o Female
Brought to the emergency department by her family for INCREASING CONFUSION. The patient also has been complaining of a terrible headache and blurred vision for the last 2 days. She RAN OUT OF HER MEDICATIONS 2 weeks ago and has not filled her prescriptions because her insurance ran out.
PMH: HYPERTENSION and TACHARRHYTHMIA.
MEDS: METOPROLOL, 50 mg twice a day. NKDA
Her temperature is 36.6 C (97.9 F), BLOOD PRESSURE is 200/120 mm Hg, and pulse is 100/min. She has a loud S4.
Lungs: bi‐basilar rales. Electrocardiogram is consistent with LEFT VENTRICULAR HYPERTROPHY.
Case # 1 Which of the following would be the best immediate action? A. Administer lorazepam B. Obtain serum creatinine level C. Observe the patient in a quiet room D. Perform a lumbar puncture E. Administer intravenous NITROPRUSSIDE
ANSWER:
A. Administer lorazepam: would further cloud sensorium, suppress respirations
B. Obtain serum creatinine level: will not protect from target organ damage (& would be included in initial bloodworm)
C. Perform a lumbar puncture: B/P of 200/120 poses great danger, no signs of infection and no h/o falls or “worst headache of (my) life”
D. Observe the patient in a quiet room: High B/P
with symptoms needs acute intervention
E. ADMINISTER INTRAVENOUS NITROPRUSSIDE: QUICK onset, easily titratable to avoid too quickly lowering her B/P, generally well tolerated!!!!!!!!!!!!!!!!!!!****
Hypertensive Urgency vs Emergency
1) URGENCY:
- A SYSTOLIC BP Greater Than 180 or a DIASTOLIC BP Greater Than 130
** NO EVIDENCE of End Organ Damage*
2) EMERGENCY:
- May occur AT ANY BP, but involves DAMAGE to AT LEAST ONE ORGAN SYSTEM!!!!!!!!!!
Signs of Target Organ Involvement
1) CARDIOVASCULAR:
- MI, Angina, Aortic Dissection, Aneurysmal dilation of Large Vessels, LVH
- CHF
2) RENAL:
- Hematuria, Proteinuria, AKI (Previously known as ARF)
3) CNS:
- Cerebral Edema, Altered Mental Status, Bleed, Stroke, or TIA
4) OPHTHALMOLOGIC:
- Rental hemorrhages or Exudates, Papilledema
- A V Nicking!!!!
Case #2 28 y/o Female
She is pregnant in her first trimester & has just been diagnosed with hypertension with no secondary cause established. Her hypertension has not responded to diet, exercise, and stress reduction. As a first line therapy, which of the following would you recommend?
A. Thiazide diuretic
B. Magnesium Sulfate
C. Enalapril
D. Diltiazem
E. Methyldopa (Aldomet)
A.Thiazide diuretic: Decreasing circulating volume is contraindicated in pregnancy d/t decreased perfusion of the placenta and fetus
B.Magnesium Sulfate: No signs of pre-eclampsia
C. Enalapril: Pregnancy category D – ABSOLUTELY CONTRAINDICATED in pregnancy; teratogenic in 1st trimester
D. Diltiazem: Pregnancy category C – Risk to fetus
E: METHYLDOPA (Aldomet) Pregnancy category B, APHA AGONIST **
Case #3 - 19 y/o Female
Otherwise healthy, she comes to clinic for a routine health check. She complains of EPISODIC HEADACHES as well as occasional PALPITATIONS.
A blood-pressure check at that time reveals a pressure of 190/110 mm Hg.
Physical examination reveals an ABDOMINAL BRUIT heard over the UPPER RIGHT and LEFT abdominal quadrants. Because the patient has previously had normal blood pressures as a teenager, and has no family history of hypertension, an extensive search for secondary causes of hypertension is undertaken
Magnetic resonance demonstrates a “STRING OF BEADS” bilaterally.
Which of the following antihypertensives should be used with the utmost vigilance in this patient? A. Amlodipine B. Clonidine C. Hydrochlorothiazide D. Metoprolol E. Fosinopril
Answer:
E: FINSINOPRIL because an ACE Inhibitor can cause more damage to the Kidney when there is Bilateral Renal Artery Stenosis. The Cr will INCR Dramatically
Atherosclerosis vs Fibromuscular Dysplasia
1) ATHEROSCLEROSIS:
Age:
- Greater than 50
Sex:
- MALE
Bilaterally:
- 33%
Progressive:
- +++
Response to ANGIOPLASTY:
- +
Associated Risks: Tobacco, Lipids, Diabetes, Etc…
- +++
2) FIBROMUSCULAR DYSPLASIA
Age:
- Less than 40
Sex:
- FEMALE
Bilaterally:
- 60%
Progressive:
- +
Response to ANGIOPLASTY:
- +++
Associated Risks: Tobacco, Lipids, Diabetes, Etc…
- +
Reno vascular Hypertension associated with Renal Artery Stenosis
1) STENOSIS is a PROGRESSIVE Obstructive Disease
2) STENOSIS RATE of 1.5% per Month
3) If UNTREATED: can lead to TOTAL OCCLUSION
4) Causes of STENOSIS and HYPERTENSION are Atherosclerosis and Fibromuscular Dysplasia
Fibromuscular Dysplasia
1) MEDIAL Fibromuscular Dysplasia:
- MOST COMMON, 85% of all Stenosis, 9/1 Female to Male, Ages 25 - 45, can be seen in Carotids and Iliac Arteries.
- 70% of lesions are BILATERAL
- May appear as Solitary Mid and Distal STENOTIC Lesions or Multiple Constrictions with INTERVENING ANEURYSMAL DILATIONS
2) PERIFIBROMUSCULAR Dysplasia:
- 10 to 25% of Cases
- Usually MID- DISTAL PORTION of RENAL ARTERY
3) INTIMAL FIBROMUSCULAR DYSPLASIA:
- 5%, Males = Females, Infants and Young Adults are MORE FREQUENT
Types of Renal Arterial Stenosis (RAS)
1) ONE STENOSIS: TWO KIDNEYS (UNILATERAL Renal Arterial Stenosis)
- DECR Intravascular VOLUME
- More RENIN mediated (Incr) than the others
- BP usually FALLS with ACE Inhibitors
2) TWO STENOSES: TWO KIDNEYS ( BILATERAL Renal Artery Stenosis)
- INCR Intravascular Volume
- RENIN Mediation is MORE VARIED
- ACE Response UNPREDICTABLE and may WORSEN HYPERTENSION
3) ONE STENOSIS: ONE KIDNEY (UNILATERAL Stenosis in a SOLITARY KIDNEY)
- INCR Intravascular Volume
- RENIN Mediation is MORE VARIED
- ACE response UNPREDICTABLE and May WORSEN HYPERTENSION
Diagnosis of Renovascular Hypertension
1) Renal ULTRASOUND WITH ARTERIAL DOPPLERS****
2) Captopril Test (Reactive RISE in Renin and LARGE FALL in BP After Administration)
3) DSA: Digital Subtraction Angiography
4) MRI: Angiography
5) Arteriography
6) Renal VEIN RENIN Ratio (Ratio of 1.5 or Greater)
Treatment for Renovascular Hypertension
1) AIMED at BP CONTROl and Preservation of renal Function
2) MEDICAL TREATMENT: Antihypertensive Meds
3) UNILATERAL STENOSIS: ACE Inhibitors UNPREDICTABLE, May Worsen
4) BILATERAL STENOSIS or UNILATERAL with 1 Kidney = May see Renal Dysfunction caused by ACE Inhibitors
5) Poor response to 3 or more agents points way to NONPHARMACOLOGIC Interventions (eg Stenting)
6) Surgical Treatment Grafting
Contraindications of ACE Inhibitors
1) BILATERAL Renal Artery STENOSIS
2) UNILATERAL Renal Artery STENOSIS with SOLITARY KIDNEY
3) PREGNANCY!!!!!***
4) Known ANGIONEURMTIC EDEM with Prior ACE administration
5) Relative CONTRAINDICATION: ACE INDUCED COUGH!!!!!
Secondary Hypertension
1) Sleep Apnea
2) Drug Induced Causes
3) Chronic Kidney Disease
4) Primary Aldosteronism
5) Renovascualr Disease
6) Steroid Therapy or Cushing’s Syndrome
7) Pheochromocytoma
8) Coarctation of the Aorta
9) Thyroid Disease
10) Parathyroid Disease
Case #4 - 72 y/o Male
Presents to the emergency department suffering from PALPITATIONS and a HEADACHE. At the time of arrival, he is found to have a BLOOD PRESSURE of 210/120 mm Hg, PROTEINURIA confirmed by dipstick and his funduscopic is on the following slides
PMH: long-standing ESSENTIAL HYPERTENSION
FUNDUSCOPIC EXAM:
- AV (Arteriovenous) NICKING: Long Standing h/o HYPERTENSION!!!!!!
- PAPILLEDEMA: HYPERTENSIVE EMERGENCY!!!!!!!!!!
When told his blood pressure, the patient is SHOCKED. Even prior to diagnosis, he has never had a systolic blood pressure greater than 175 mm Hg. He states that he normally takes a variety of HYPERTENSIVE MEDS, none of which he brought with him, but RAN OUT of “one or two of them” and MISSED LAST NIGHT’S DOSE
Which of the following, if abruptly stopped, is most likely to cause this patient’s symptoms? A. Atenolol B. Clonidine C. Felodipine D. Hydrochlorothiazide E. Lisinopril
Answer:
CLONIDINE: Alpha 2 AGONIST!!!!
Case #5 - 48 y/o Male
Presents to the clinic for a return visit & has a HISTORY OF ADULT ONSET DIABETES. On previous visits, a great deal of time has been spent working with the patient to bring his diabetes and cardiac risk factors under control.
Although his blood glucose levels are better controlled and his lipid levels are near target, his BLOOD PRESSURE REMAINS ELEVATED. The patient has been watching his diet and exercising for the last 6 months, but still has a BLOOD PRESSURE OF 148/92 mm Hg on today’s visit
Which of the following is the most appropriate, first medication to start for this patient’s HTN?
- Acetazolamide
- Clonidine
- Felodipine
- Hydrochlorothiazide
- Lisinopril
- Metoprolol
- Spironolactone
- Terazosin
- Triamterene
- None, continue diet and exercise
Answer:
- ** LISINOPRIL**
- Useful for DM who have Proteinuria and Microalbumineria
- REDUCES Pressure on GLOMERULUS (Less Protein being pushed through)
- Very good at Treating Patients with HYPERTENSION and DIABETES
Primary Causes of Kidney Failure
1) DIABETES (43.8%)
2) High Blood Pressure (26.8%)
Case #6 - 62 y/o Female
Presents to your office to follow up an ELEVATED BLOOD PRESSURE at her annual exam 2 weeks ago. PMH negative, PSH hysterectomy for fibroids. She is on no meds, has no medication allergies, labs have been normal, and her ophthalmology exam was normal 3 weeks ago.
Below which of the following does JNC 8 recommend for management for this patient’s HTN? A. 110/50 B. 120/60 C. 130/70 D. 140/80 E. 150/90
JNC 8:
- The EVIDENCE- BASED GUIDELINE for the MANAGEMENT of HIGH BLOOD PRESSURE in Adults
GRADE A Recommendation for HTN:
- IN the General Population OVER 60 y/o, initiate treatment to ACHIEVE A GOAL OF 150/ 90!!!!!!!
GRADE B Recommendation for HTN:
- In over 18 y/o with CKD, INITIAL or ADD-ON THERAPY should include an ACE INHIBITOR or an ARB!!!!!!!
Systolic Blood Pressure Intervention Trial (SPRINT)
- Published in 2015, recommending MORE INTENSIVE FOALS in OLDER PATIENTS with CARDIOVASCULAR RISKS than JNC 8
- However, DID NOT INCLUDE DIABETES!!!!!!!!!
- So even though study stopped early, due to EARLY EVIDENCE of BENEFIT, many question on its applicability
Case #7 21 y/o Male
Presents to the emergency department complaining of CHEST PAIN AND TIGHTNESS, and SHORTNESS OF BREATH. A friend accompanying him explains that they were at a party when the friend noticed the man was CLUTCHING HIS CHEST. He was also noted to be PALE, DYSPNEIC, and DIAPHORETIC. A medical record obtained from a recent emergency room visit for a broken toe states he has no medical problems, has no allergies, and takes no medications
He is active on the tennis and basketball teams at the YMCA
Father had a MYOCARDIAL INFARCT at age 60, mother takes medication for HYPERLIPIDEMIA, and needs to take antibiotics before dental procedures because of a “problem with a heart valve”
The patient’s BLOOD PRESSURE is 185/105 mm Hg and pulse is 120/min. Oxygen saturation is normal on room air. Physical examination is unremarkable. His temperature is 100F. Electrocardiogram shows ACUTE ST- SEGMENT ELEVATIONS in the anterolateral leads. He is hostile and mumbling incoherently an his eye exam showed BILATERAL PUPILS WITH MINIMAL REACTION TO LIGHT (Very DILATED)
Which of the following is the most likely explanation for these findings? A. Cardiac contusion B. Pheochromocytoma C. Plaque rupture D. Valvular incompetence E. Drug Overdose
Answer:
- DRUG OVERDOSE!!!!!!
Secondary Hypertension
1) Sleep Apnea
2) Drug Induced Causes
3) Chronic Kidney Disease
4) Primary Aldosteronism
5) Renovascular Disease
6) Steroid Therapy or Cushing’s Syndrome
7) Pheochromocytoma
8) Coarctation of the Aorta
9) Thyroid Disease
10) Parathyroid Disease
Cardiovascular Causes
1) MI
2) Acute Left Ventricular Failure
3) Vasculitis
4) Coarctation of the AORTA
5) AORTIC DISSECTION
6) Volume Overload (Including PULMONARY EDEMA)
Coarctation of the AORTA
1) Narrowing of MEDIAL Layer of Aorta
2) COMMONLY AT LIGAMENTUM ARTERIOSUM***
3) Three Different Types:
A) Interrupted
B) Preductal
C) Postductal
Diagnosis of Coarctation
1) Differences in UPPER AND LOWER EXTREMITIES
2) BLOOD PRESSURE:
- SYSTOLIC HYPERTENSION in an INFANT
- 20 mmHG BETWEEN ARMS
3) HEART SOUNDS: If Isolated a SYSTOLIC EJECTION MURMUR in the AORTIC OUTLET and between Scapular
4) RADIOLOGY:
a) Cardiomegaly
b) RIB NOTCHING on PA CHEST
c) “3- Sign” on LATERAL CHEST!!!!!!!!
Case #8 - 56 y/o Male
Presents to the clinic for a return visit. Last 3 visits, his BLOOD PRESSURE has been in the range of 150‐160 SYSTOLIC and 90‐95 DIASTOLIC mmHg.
Despite 3‐6 months of following a healthy diet and exercise program, he has been able to get his blood pressure under control
PMH: neg other than HTN
FH: Brother HTN & died from heart attack in his mid‐60’s
Today his B/P is 162/92!!!!!!!
Which of the following is the most appropriate, COST-EFFECTIVE, first‐line treatment for this patient?
- Acetazolamide
- Clonidine
- Felodipine
- Hydrochlorothiazide
- Lisinopril
- Metoprolol
- Spironolactone
- Terazosin
- Triamterene
- None, continue diet and exercise
Answer:
- CLONIDINE is the MOST COST-EFFECTIVE!!!!!!!!
Case #9 - 52 y/o Female
Well known to you returns for a follow-up visit after being discharged from the hospital. She was seen 3 days ago in follow-up for RECENTLY DIAGNOSED DIABETES MELLITUS TYPE 2 and ESSENTIAL HYPERTENSION.
At her last visit, you switched her from HYDROCHLOROTHIAZIDE to ENALAPRIL.
Approximately 3 days after starting therapy, however, the patient began to DEVELOP FACIAL SWELLING that progressed to STRIDES SHORTNESS OF BREATH.
She was admitted to the hospital for close observation and was told to DISCONTINUE ENALAPRIL. She was advised to discuss which medications to take with her primary care physician. What would you prescribe?
Which of the following is the most appropriate, cost‐effective, first‐line treatment for this patient?
- Acetazolamide
- Clonidine
- Felodipine
- Hydrochlorothiazide
- Lisinopril
- Metoprolol
- Spironolactone
- Terazosin
- Triamterene
- None, continue diet and exercise
Answer:
- HYDROCHLOROTHIAZIDE because this is USED FIRST and it it doesn’t work then use ACE INHIBITOR or ARBs!!!!
Contraindications of ACE Inhibitors
1) BILATERAL RENAL ARTERY STENOSIS
2) UNILATERAL RENAL ARTEYR STENOSIS with SOLITARY KIDNEY!!!!!!
3) PREGNANCY
4) Known ANGRIONEUROTIC EDEMA with PRIOR ACE ADMINISTRATIONS, Needs MEDIC ALERT BRACELET!!!!!!!!!!!!!!!!!**
Case #10 - 55 y/o Male
Presents to the office for an annual visit. He denies any chest pain, palpitations, headache, dyspnea or lightheadedness. He is currently taking insulin for his DIABETES. He has no other medical issues.
He is fairly active and is able to perform all activities of daily living. He has no medical allergies. His BLOOD PRESSURE is 135/85 mm Hg and PULSE is 80/min. His lungs are clear and heart rate is regular. He has no pedal edema. Chemistry panel is unremarkable. An electrocardiogram shows normal sinus rhythm. URIEN STUDIES REVEAL MICROSCOPIC ALBUMIN IN THE URINE
Which of the following is the appropriate management at this time?
A. Encourage lifestyle modification
B. Hydrocholorothiazide 12.5 daily
C. Hydrochlorothiazide 12.5 + metoprolol 25mg bid
D. Lisinopril 10mg daily
E. Metoprolol 25mg bid
Answer:
LISINOPRIL 25 mg DAILY because has DIABETES with ALBUMIN IN URINE
Case #11 - 41 y/o Female
She is referred for evaluation of LONG-STANDING HYPERTENSION. She first was diagnosed 10 years ago on a routine physical examination. At that time, she has a BLOOD PRESSURE of 200/100 mm Hg and her serum POTASSIUM was 2.7 mEq/L, even though she was receiving no medications of any kind. She was started on METOPROLOL and HYDRALAZINE, in addition to POTASSIUM SUPPLEMENTATION
For the ensuing 8 years she remained HYPERTENSIVE and HYPOKALEMIC. Medications were changed 2 years ago, without success. She does not know what medications she is on now, but knows that she is not getting any “WATER PILLS”.
Her BLOOD PRESSURE is 180/100 mm Hg. Current electrolytes show SODIUM 145 mEq/L, POTASSIUM 2.6 mEq/L, and BICARBONATE 38 mEq/L
Which of the following would most likely help diagnose her condition?
- Dexamethasone suppression test
- Renal artery doppler flow
- SpiralCTscanofthechest
- Urinary catecholamines
- Renin and aldosterone levels
EXPLANATION OF ANSWERS
1. Dexamethasone suppression test: clinical presentation DOESNT suggest cortisol excess
- Renal artery doppler flow: NO BRUTIS on exam
- Spiral CT scan of the chest: NO HISTORY to SUGGEST PE (pulm embolus) or pulmonary mass
- Urinary catecholamines: used to test for pheo, NO EPISODIC nature described
- RENIN AND ALDOSTERONE LEVELS – Hyperaldosteronism DROPS POTASSIUM and INCR BLOOD PRESSURE!!!!****
Hyperaldosteronism
PRIMARY:
1) Located IN ADRENAL GLAND WIHTOUT EXOGENOUS STIMULUS
2) ELEVATED ALDOSTERONE and LOW RENIN Levels
3) Types:
A) Aldosterone producing ADENOMA
B) Idiopathic Hyperaldosteronism
C) Bilateral Adrenal HYPERPLASIA
D) Aldosterone Producing Ca++
E) Aldosterone producing RENIN-Responsive ADENOMA
F) ECTOPIC Aldosterone producing Tumor
G) DEXAMATHASONE SUPPRESSIBLE HYERALDOSTERONISM!!!!!!!
SECONDARY:
1) ELEVATED ALDOSTERONE and ELEVATED RENIN LEVELS
2) Causes: A) Diuretics B) CHF C) Cirrhosis D) Ascites E) Nephrosis F) Others
Condition: After MI
Agent:
- Use Beta Blocker, ACE Inhibitor
Caution:
- Direct VASODILATORS (May worsen Coronary Insufficiency)
Condition: CHF
Agent:
- ACE Inhibitor, Diuretics, Beta Blockers (No Pulm Edema)
Caution:
- Beta Blockers, CCB
Condition: Hypertrophic Cardiomyopathy
Agent:
- Beta Blockers, CCB
Caution:
- Diuretics, ACE Inhibitors, Direct Vasodilators
Condition: Bradycardia, Heart Block
Caution:
- Beta Blockers, CCBs
Condition: Tachyarrhythmias
Agent:
- Beta Blockers, Verapamil
Condition: Agina
Agent:
- Beta Blockers
- CCB
- Nitroglycerin
Caution:
- Direct Vasodilators (Decrease Afterload may Decrease Coronary Perfusion)
Condition: COPD/ ROAD
Agent:
- CCB
- Thiazide
- ARB
- ACE?
Caution:
- Betab Blockers
Condition: AORTIC DISECTION
Agent:
- Nitroprusside
- Beta Blockers
Caution:
- Drugs that INCREASE Cardiac Output (Increased Shear Stress)
Condition: Bilateral Renal Artery Stenosis
Caution:
- ACE INHIBITORS
- Angiotensin Blockers
(May Worsen Renal Function)
Condition: Chronic Renal Insufficiency
Agent:
- ACE INHIBITORS (With Serum Creatinine Less than 2.5)
- Lood Diuretics
- CCB
Caution:
- ACE INHIBITORS
- Angiotensin Blockers
(May Worsen Renal Function)
Condition: Renal Transplant
Caution:
- ACE INHIBITORS (May Worsen Renal Function)
Condition: Migraine Headaches
Agent:
- Beta Blockers
- CCB
(May relieve Migraine Symptoms)
Condition: Stroke or TIA
Agent:
- ACE INHIBITORS
(Mya allow reestablishment of CN Autoregulation)
Caution:
- Vasodilators may INCR Intracranial Pressure
Condition: Diabetes
Agent: ACE INHIBITORS
May decrease Renal Failure; DECR Proteinuria
Condition: Pregnancy
Preeclampsia, Eclampsia
Agent:
- Methyldopa
- Hydrazine
- Beta Blockers with Caution
Caution:
- ACE INHIBITORS
- Angiotensin Blockers
- Diuretics
Condition: Gout
Caution:
- Diuretics (Worsen Joint Pain or Precipitate Gout)
Condition: Cocaine Use
Agent:
- Labetalol
- Clonidine
Caution:
- Selective Beta Blockers
(Unopposed Cocaine Induced ALPHA AGONISM)
Condition: GI Bleed
Agent:
- NON SELECTIVE BETA BLOCKER (Lower Portal Blood Pressure)
Caution:
- Beta Blockers
(My mask signs of Acute Bleeding)
Condition: Pheochromocytoma
Agent:
- ALPHA BLOCKER (1st) then BETA BLOCKER (2nd)
Caution:
- SELECTIVE BETA LOCKERS
(Unopposed ALPHA Agonism)
Condition: Benign Prostatic Hypertrophy
Agent:
- ALPHA 1 ANTAGONIST (TERAZOCIN)
Caution:
- SELECTIVE Beta Blockers
(Unopposed Alpha Agonism)
