Hypertension Special Populations

Question 1

As age increases,

Answer 1

SBP goes up and DBP goes down

Question 2

Trends in the elderly:

Answer 2

Arterial stiffness increases
Sodium sensitivity increases
White coat effect increases

Question 3

ESH/ESC 2013 Guidelines for Elderly

Answer 3

 In persons 160 mmHg, recommend reducing SBP to between 140-150 mmHg
 In “fit elderly persons” 80 years of age and with initial SBP >160 mmHg, recommend reducing SBP to between 140-150 mmHg

Question 4

ACCF/AHA 2011 Guidelines

Answer 4

 For 65-79 years old
• Goal of less than 140/90 mmHg
• Thiazide diuretic can be first line agents
 For >80 years old
• Goal of SBP 140-145 mmHg
• SBP less than 130 and DBP less than 65 should be avoided
• Obtain standing BPs to assess for orthostatic hypotension
 For >80 years old + Comorbid disease
• Elderly + Diabetes: less than 130/80

Question 5

ASH/ISH Guidelines for Elderly

Answer 5

 80+ years of age: less than 150/90
• less than 140/90 if DM or CKD
 CCB or thiazide then ACEi/ARB
• Even if they have a compelling indication

Question 6

JNC8 Guidelines

Answer 6

 >60 years old: less than 150/90

• less than 140/90 if DM or CKD

Question 7

SHEP (systolic hypertension in elderly program) target BP and outcomes

Answer 7

T: 20 mmHg reduction or less than 160
O: Beneficial to reduce BP

Question 8

Syst-Eur (systolic hypertension in Europe) target BP and outcomes

Answer 8

• Target SBP: less than150 mmHg

* Outcome: Decreased total rate of stroke by 42%

Question 9

HYVET (hypertension in the very elderly trial) target BP and outcomes

Answer 9

• 80+ years old
• Target: less than 150/80 mmHg
• Outcome: decreased all mortality, stroke death, HF, any CV event but NOT stroke risk

Question 10

Sprint RCT target BP and outcomes

Answer 10

• SBP: less than 120 (intensive) vs less than 140 (standard)
• Outcome: intensive group- decreased rates of fatal and nonfatal major CV events and death BUT higher rate of adverse events (so we don’t do intensive)

Question 11

***Risk of BP Medications in the Elderly

Answer 11

Prone to ADRs
Lots of comorbidities and CI to look out for
Cognitive impairment
Number of medications
Orthostatic hypotension

Question 12

Define Orthostatic Hypotension

Answer 12

Drop in SBP >20 mmHg or DBP >10 mmHg

Increased risk for falls

Question 13

Strategies for HTN medications in Elderly

Answer 13

 Start low and go slow: (½ full start dose)

 Once daily regimens

Question 14

Too low levels in Elderly

Answer 14

SBP less than 110 or DBP less than 70

Question 15

Define Hypertension Pregnancy Disorder

Answer 15

Two BP measurements of greater than or equal to 140/90 mmHg measured greater than or equal to 6 hours apart

Question 16

Define Chronic HTN

Answer 16

HTN present before pregnancy
OR is diagnosed before the 20th week of gestation
OR if HTN persists for greater than 3 months post partum

Question 17

Define Gestational HTN

Answer 17

Elevated BP during pregnancy after 20 weeks without other signs and symptoms of pre-eclampsia or chronic HTN
BP return to normal with 3 months after delivery
- SBP greater than or equal to 140 or DBP greater than or equal to 90 on 2 separate occasions at least 6 hours apart

Question 18

Likelihood of Gestational HTN leading to pre-eclampsia?

Answer 18

Increased if onset is before 35 weeks gestation

Question 19

Define Pre-eclampsia

Answer 19

BP greater than 140/90 on 2 occasions
OR BP greater than 160/110 in association + proteinuria (300 mg/24 hr) OR at least 1 severe feature (thrombocytopenia- platelets 1.1 or 2x baseline, pulmonary edema)

Question 20

Signs and symptoms of pre-eclampsia

Answer 20

Headache
Visual Changes
Ab pain
N/V

Question 21

Onset of pre-eclampsia

Answer 21

3rd trimester

Question 22

Impact on MOTHER of chronic HTN

Answer 22

• Preterm delivery
• More C sections
• Placental abruption
• Preeclampsia → eclampsia

Question 23

Impact on CHILD of chronic HTN

Answer 23

• Growth retardation
• Perinatal death
• NICU admissions

Question 24

Why wouldn’t you treat HTN in pregnancy?

Answer 24

• 4-5 months of mild HTN does not contribute to long-term maternal CVD risk
• Reduced maternal BP would compromise fetal circulation
• Increased risk for fetal adverse effects from exposure to medications in utero

Question 25

What are your treatment options for HTN in pregnancy?

Answer 25

• Methyldopa (Drowsiness, dry mouth)

* Labetalol (Alpha and beta blocker activity)

Question 26

What should you avoid treating with in pregnancy?

Answer 26

ACEi/ARB

Question 27

BP Goal for Pregnancy Treatment?

Answer 27

 Start treatment when SBP >150 or DBP >100

 OR start treatment when SBP >140 or DBP >90 if high risk patient

Question 28

Symptoms of Hypertensive Urgency

Answer 28

Headache
Anxiety
SOB
Visual disturbances
Confusion
Nosebleeds
ASYMPTOMATIC

Question 29

Hypertensive Urgency Examination

Answer 29

Look for target organ damage
Medication history
Comorbid conditions (prior renal and CV disease)

Question 30

Define Hypertensive Urgency

Answer 30

BP greater than 180/120 mmHg without progressive target organ dysfunction

Question 31

Treatment Goals

Answer 31

Reduce BP in hours to days

Aim for stage 1 HTN and then go to normal BP goal

Question 32

Treatment Plan

Answer 32

Give one-time dose, in clinic of oral antihypertensive then adjust existing HTN regimen or add new medications

Question 33

Medication options for Hypertensive Urgency

Answer 33

Clonidine (hypotension, drowsiness, dry mouth)
Captopril (may repeat in 1 hour; hypotension, renal failure)
Labetalol (may repeat in 2-3 hours; bronchoconstriction heart block, orthostatic hypotension

Question 34

Symptoms of Target Organ Damage

Answer 34

Blurry vision
Headache
Chest pain
Confusion
SOB
Back pain
Numbness/weakness
Visual changes
Difficulty speaking
ANY SYMPTOMS = EMERGENCY