Hypertension Part 1 Flashcards
What is hypertension? What do you need to diagnose it? What is the exception to this diagnosis?
RECURRENT, not one reading.
It is a quantitative reading that measure the force of blood against arterial walls - must have two or more seated BP readings during outpatient/ in home readings.
Only caveat is a hypertensive emergency.
What patient risks can cause different levels?
Based on mobility/mortality
DM status
What is the systolic vs diastolic BP rubber band analogy?
Systolic (where a rubber band is stretched)
Diastolic (where it is relaxed like letting go of a rubber band)
What is the general difference between primary vs secondary
primary: just HTN
secondary: due to another underlying cause
What are some lifestyle ways to reduce HTN
Exercise
Losing weight
DASH diet (low salt)
Alcohol/caffeine reduction
What are the blood pressure classification for ACC/AHA
Highest number wins (if you have one of the higher numbers, that will dictate the stage of HTN)
Normal <120 AND <80
Elevated 120-129 AND < 80
HTN
Stage 1: 130-139 OR 80-90
Stage 2: 140 or more OR 90 or more
In general, how much does one med reduce BP by?
10 mmHg - which is why you need to be more aggressive with higher stages of HTN
What are some primary HTN? How common is this?
Genetic (multifactorial) no single, reversible cause identified
Accounts for 95% of cases
What are some secondary causes of HTN?
DEFINABLE cause:
1. Meds - birth control, stimulants
2. CKD (should look at BMP or CMP)
3. Renal artery stenosis (does not get enough perfusion, and then it uses the RAAS, jacking up BP)
4. Cushing disease (striae, cushinoid facies)
5. Coarctation of the aorta (because the aorta is occluded)
6. Pheochromocytoma (rare)
7. Hyperaldosteronism
8. Obstructive sleep apnea (d/t not enough oxygen, really important to get undercontrol)
9. Hyper or hypothyroidism (should get a TSH and T4)
How would you approach primary vs secondary?
Changing meds
Lifestyle changes
Manage the blood pressure with meds for both most of the time
How does age affect BP? How is this different for patients <50 vs > 60? Does this change treatment?
Older patients >60
- Vessels do not stretch as they used to
- Lumen narrows because of plaque build-up
Systolic BP rises, without rise in diastolic pressure
Predominantly caused by arterial stiffness
Not associated with OSA
Young patients <50
Systolic and diastolic BP increase
Often associated with OSA
No distinction for treatment, but sometimes older patients get hypotensive, so there are often managed differently
What are some causes of isolated systolic hypertension in older vs younger patients?
systolic BP is >140, but diastolic is <90
Occurs more often in older patients
Results from arterial stiffness and atherosclerosis
Can occur in younger patients
MC in athletic males
Likely due to high stroke volume.
Is systolic or diastolic reading more important for long term outcomes? Why? Is this different for younger patients?
Systolic in older patients - because it shows how hard your heart is working.
Diastolic in a younger patient
Now thought that DBP is a better predictor for patients <45 y/o and SBP is a better predictor for patients >60 y/o
What is white coat hypertension? How do you manage this? Who is it more common in?
Persistently elevated BP > 140/90 in the office, but a lower value outside of the clinic.
Research suggest as long as numbers are within range at home*, treatment is not necessary
Long-term monitoring required!
Cuff comparison key!
MC in older patients
What is Masked hypertension? Should you treat?
Opposite of white coat hypertension. Rare. Normal BP in the office, but elevated values at home.
Often an error in giving the information, usually lifestyle (alcohol use, tobacco use, caffeine consumption, etc.) problem or cuff problem.
What is psedohypertension? What are the s/s of this?
Not getting an accurate reading from the cuff d/t calcification of peripheral vessels.
High blood pressure readings, but inside the blood vessel is low because of how calcified vessels.
High BP but have hypotension s/s
What populations tend to have HTN? Men/women?
- Most populations have HTN
- SBP is higher in men in early adulthood
- Age-related rise in BP higher in women
How does DBP change as we age? What does this result in?
What race has the highest incidence of HTN? How does that change treatment?
Non-hispanic blacks d/t difference in kidneys.
Typically start on calcium channel blockers or thiazides as they are more potent.
What is the equation for BP?
BP = CO x systemic vascular resistance
What are the general pathogensis of primary HTN?
complex interactions between multiple genetic, endogenous, and environmental factors
What are the 5 different specific pathogenesis of primary hypertension?
- Sympathetic nervous system hyperactivity
- Renin-angiotensin system activity
- Defect in natriuresis (sodium excretion)
- Abnormal cardiovascular or kidney development
- Elevated intracellular calcium and sodium levels
What causes Sympathetic Nervous System Hyperactivity leading to HTN? Who is it MC in?
Fight or Flight”
Acetylcholine and norepinephrine release
Most apparent in younger patients
Typically present with tachycardia and elevated cardiac output
How does the renin-angiotensin system lead to HTN? How do we stop this?
Retention of sodium
ACE inhibitors that stop Angiotensin I going to Angiotensin II
How does the Pathogenesis of HTN - Natriuresis Defect
↑ salt intake triggers ↑ in BP which promotes ↑ natriuresis to bring BP values back into normal range
Defects in this process result in HTN
How does pathogenisis of CV or renal defect lead to HTN?
Normally, elasticity of great arteries matches the resistance of peripheral arteries to optimize large vessel pressure waves
Serves to minimize oxygen consumption and maximize coronary flow
If the aortic elasticity or microvasculature is abnormal it increases the risk of HTN later in life
How does increase in calcium and sodium lead to hypertension?
Calcium elevation problems lead to muscle tone issues.
Theoretically leads to increased vascular smooth muscle tone that is seen in HTN
What are the risk factors for HTN
OSA
Excessive Alcohol Use
Cigarette Smoking
NSAID use
Obesity
Low potassium or high sodium intake
Metabolic syndrome
How does NSAIDs lead to HTN?
Compete with the BP medications, leading to worse efficacy of their BP medication
What important to evaluate patients with elevated BP?
Looking for ORGAN DAMAGE
Look at H&P
Evaluate for possible underlying secondary causes of HTN
What is the lab workup for hypertensive patients?
BMP/CMP
Thyroid panel
follow these values over time
How do you get an accurate BP?
Not talking
Legs not crossed
Bare arm
Supported arm
Empty bladder
Support Back
Support feet
How do you get good data. for measuring blood pressure?
After morning meds (to see if the meds work)
At the SAME location
Both arms, two times, with 1-2 minutes apart for first office visit (to allow vessels to relax)
If there are differences in the right and left arm, what should you use?
The HIGHER value
What condition can make BP results not accurate?
A Fib
What are the differences between home BP monitoring and ambulatory BP monitoring?
Home BP Monitoring
Allows for continued monitoring
Helps dx white coat HTN
Patient must be educated on how to use their device
Ensure home device is accurate
Ambulatory BP Monitoring
BP machine automatically obtains multiple readings over an extended period of time (typically 24 hours)
Able to assess masked HTN and medication efficacy
Helps assess nighttime risk of elevated BP or non-dipping BP
What are some historical questions to ask for HTN?
Family history
Social history
Been diagnosed before?
Assess duration, age of onset, previous levels of high BP
Previous antihypertensive therapy and its effect on BP
Symptoms and possible secondary causes of HTN
Symptoms that suggest target-organ damage
Neuro dysfunction, heart failure, CAD, PAD
What med history do you ask for HTN?
Med history
Contraceptives, NSAIDs, amphetamines, licorice
What social history do you ask?
Social history
Alcohol/tobacco use, activity level, diet
Presence of other CV risk factors
What type of PE do you perform for HTN?
Head to toe
What are the tests you order to work up HTN?
- UA (protein)
- BMP
- EKG
- Fasting lipid profile
- TSH
- Other tests based on secondary causes
Why should you treat high blood pressure?
Secondary conditions
#1 cause of death is heart disease
Can lead to structural changes of the heart (thickening of heart muscle, leading to less blood flow)
What are some structural problems d/t high blood pressure?
LVH (d/t heart working to hard), increased atrial size, CHF, atherosclerosis, microvascular disease, and cardiac arrhythmias (conduction changes d/t stretched heart)
What can HTN lead to the blood?
Can lead to thrombosis
How does BP points lead to mortality?
Increase in morbidity and mortality related to HTN doubles for each 6 mmHg increase in DBP
How does left ventricle hypertrophy from HTN lead to sudden death?
LVH leads to:
1. Diastolic heart HF leading to systolic HF leading to sudden death.
2. MI leading to sudden death
3. Ventricular arrhythmias leading to sudden death
What are the s/s of LVH
Dyspnea (SOB)
edema
palpitations
chest pain
LV heave (can see movement of chest d/t heart pumping)
S4 gallop
Can LVH be reversible?
EARLY management can prevent this!!! Through BP management
What are other hypertensive cerebrovascular diseases?
Ischemic stoke
Hemorrhagic stroke (related to SBP, prevented with HTN management)
After a patient has dementia, how does HTN treatment change?
Symptoms can become worse if you lower BP because the brain is already not getting enough O2
How does hypertension lead to renal disease? Who is this more common in?
Chronic untreated HTN results in nephrosclerosis
More common complication in black patients
~25% of patients with ESRD had untreated or poorly treated HTN
Can be prevented with appropriate BP management but difficult to reverse damage that has already occurred
What does hypertension lead to in the eye? What is this worse in?
Narrowing of retinal arteries lead to Development of exudates, cotton-wool spots, and retinal hemorrhages
More problems likely mean longer duration of HTN
Worse when combined with DM
What are the two vascular complications of HTN?
- Atherosclerosis
Condition that causes narrowing and/or hardening of arteries
Cause by and contributes to increased BP - Aortic Aneurysm / Dissection (tears in vessel cause build up of blood in the vessel)
HTN is a major contributing factor for development of aneurysm and/or aortic dissection
What color is artherolsclerosis?
Yellow
What are some lifestyle modifications of HTN
- Weight reduction
- Diet changes (less processed food)
- DASH diet
- Physical activity
- Moderation of alcohol
Losing 10 kg leads to what changes in BP
5-20 mmHg
What do you start a DM patient on?
ACE or ARB
If a patient has stage 1 HTN, what do you do?
130-139 OR 80-89
Assess 10 year ASCVD risk
> 10% begin pharm and non-pharm
<10% non-pharm treatment
bring back early
If a patient has stage 2 HTN, what do you do?
> 140 OR > 90
NEED pharm and non-pharm despite ASCVD risk
What is the goal BP for HTN?
< 130/80
What BP meds do you start with non African American?
Thiazide, ACEI/ARB, or CCB
What are the two non-DHP calcium channel blockers?
Forapimil
What is a DHP calcium channel blocker? What SE does it work on?
Dilates peripheral vasculature, but leads to edema.
How ofter do you follow hypertensive patients after picking a medication and BP is managed?
Follow up every 6-12 months
Lab monitoring only if BP is not controlled
EKG every 2-4 years depending on baseline
