Hypertension part II Flashcards
First-line medications for HTN
ACE
ARBs
CCB
Thiazides
After getting dx with HTN stage 1, what should you do?
Order a lipid panel in order to see if they have an ASCVD > 10% to treat
After 2 readings (for textbook medicine)
How long does it take BP meds to take affect?
4-6 week intervals
Can counsel about at-home cuff (reliable, cross-checked
Want to see if the reading is less than 130/80 to make sure that the treatment is working, and if it is less than 100/60
If a patient has CKD, what should you be mindful of when treating HTN? What do you do for this?
Potassium status
BMP to check kidney function that there is not a jump
Can get renal artery stenosis and order an ultrasound to dx
What patients should specifically be on an ACE or an ARB?
DM
CKD
What meds should you start with for HTN?
Any of them
ACE/ARB should not be taken at the same time though!
CCB
Thiazide
Pick one med, max it out, then pick another, max it out, then pick it out
When do we use BB?
After you max meds out, or if there is a heart issue
Aldosterone antagonist should not be started as well
What should you keep in mind with comorbid treatment and treating HTN?
Could kill two birds with one stone and may be able to treat multiple conditions
After a patient is stable (130/80), how often should you see a patient?
every 6-12 months
How often should you do an EKG for HTN patients?
2-4 years, unless there is additional concerns.
What additional labs can you order for HTN patients?
Lipids
TSH
UA (make sure kidney is ok)
Don’t have to
What are the two different types of hypertensive crises?
Hypertensive urgency
Hypertensive emergency
How is Hypertensive urgency and
Hypertensive emergency treated?
Urgency = outpatient
Emergency = inpatient
What is hypertensive urgency? What is the BP?
Severe HTN w/out ACUTE symptoms
BP > 220/125 mmHg¹
What is the etiology of HTN urgency?
Exacerbation of poorly controlled chronic HTN
What are red flags of a HTN urgency that would merit a referral to inpatient treatment?
HA
No urine
Neurologic issues
What labs should you obtain for HTN urgency?
BMP, UA, and EKG
What is a short-acting HTN treatment that is used for ACUTE treatment only?
Clonidine (very small pill)
Great for fast-acting HTN Urgency
What is the first thing that you should ask a patient in a HTN urgency?
Taken meds? Can call pharmacy to see if they have been picking up meds.
What is the overall goal of HTN urgency treatment?
Reduce BP w/in hours!
Should still start low and go slow
What are the four in-office agents for HTN urgency?
Clonidine
Captopril (ACE-I)
Metoprolol tartrate (short-acting)
Hydralazine (Dosed 3 times a day)
Most (metoprolol)
Common (clonidine)
Cure (captopril)
Hypertension (Hydralazine)
What is a concern of clonodine?
Sedation (clon = clause = santa = sleep)
Worry about driving
What is a concern of captopril?
Excessive hypotension
Worried about
What is a concern of metoprolol tartrate?
bradycardia
Why do you see tachycardia in hydralazine?
Vasodilation, which reduces BP, but requires the heart to pump faster
What is nifedipine and why is it no longer used?
CCB
Response is unpredictable
What differs HTN Emergency from Urgency?
NOT the number, just that there is organ failure
What should you do for HTN Emergency first?
EMS referral with nitroglycerine or clonidine
What PE should you check for HTN emergency?
Head to toe, but need to treat right away
Why do you keep BP elevated for ischemic stroke?
Reducing blood flow can further organ damage
What BP should you do for someone who is actively bleeding?
Lower BP to reduce bleeding
What do you do for the initial evaluation of HTN emergency?
Same as HTN
Why do you do a CXR for HTN emergency?
CXR allows you to check for HF, aortic dissection,
Why do you order a urinary drug screening for HTN emergency?
Cocaine can elevate BP
What labs do you order for HTN emergency?
CBC, CMP, EKG CXR, CT head (w/o 1st), UA, UDS, and so on
Why no contrast for HTN emergency?
Worsens hemmoragic stroke
What type of therapy do you do for a HTN emergency and how quickly do you lower BP and why?
Parenteral therapy should be used
Lower BP by no more than 25% in first 2 hours¹ (not more than this so that you maintain O2 delivery to other tissues)
What is the end BP goal of a HTN emergency?
Then goal BP of 160/100 over next 2-6 hours
What are the specific goals of BP for HTN Emergency for Ischemic CVA, Hemorrhagic CVA, Aortic dissection, and MI?
Ischemic CVA - SBP between 180-200 mmHg with slow reduction
Hemorrhagic CVA - target SBP is <140 mmHg
Aortic Dissection - goal SBP <120 mmHg
MI - will need anticoagulation and oxygen; typically use NTG for BP reduction, but no set goal
What 2 med classes do you use for HTN emergency?
Beta blockers
Calcium channel blockers
What are the 4 preferred HTN emergency meds in order of preference?
Nicardipine (CCB)
Clevidipine (CCB)
Labetalol (BB)
Esmolol (BB)
Fenoldopam (dopamine receptor agonist, rarely used)
If BP is still not managed with the 4 preferred HTN emergency meds, what other meds do you use?
Enalaprilat
Furosemide
Nitroglycerine
Nitroprusside (should not be used!)
What happens to your CO and HR during pregnancy? What is an abnormal BP>
Both increase
CO increases by 40%
HR increases 10 bpm
Abnormal BP is >140/90
How does dx of HTN different in preggos?
Diagnosis requires two elevated readings at least 4 hours apart
What is preeclampsia?
new onset HTN (BP ≥ 140/90) and proteinuria (24h urinary protein >300 mg/24h or creatinine ratio ≥0.3) after 20 weeks gestation
What is the difference between preeclampsia and eclampsia?
eclampsia includes seizures as well as the other characteristics of preeclampsia.
What is gestational HTN?
HTN (BP ≥ 140/90) after 20 weeks gestation w/o pre-existing HTN or proteinuria
What med classes are CI in gestational or chronic HTN in pregnancy?
ACE and ARBs!
What medications do you use for Acute BP treatment?
IV labetalol
IV hydralazine
oral immediate-release nifedipine
What medications do you use for chronic BP treatment?
labetalol
ER nifedipine
methyldopa
What is the target BP for preggos w/ HTN?
Target BP = 130-150/80-100
NOT recommended to reduce BP by more than 25% over 2 hours
Define resistant HTN?
Defined as the failure to reach BP control in patients who are adherent to full doses of an appropriate 3-drug regimen, including a diuretic
MC of resistant HTN?
Noncompliance with meds (because you are maxing out 3 meds)
How do you manage resistant HTN?
Refer to nephro (preferred) or cardio to make adjustments
What can you switch a patient on for resistant HTN?
Consider switching diuretic to aldosterone receptor blocker (spironolactone)
Other than non-compliance, what can cause Resistant HTN?
Improper BP measurements
Volume overload and pseudotolerance
Poor lifestyle
Obesity
Alcohol
Drug-induced
