Intro & HTN Part 1 Flashcards
what part of the bp represents the “stretch” and “Relax?”
Systolic BP = stretch
Diastolic BP = relax
Measures the force of blood against the arterial walls
Hypertension
when can you diagnose a pt with HTN?
average of 2+ accurate, seated BP readings during 2+ outpatient visits
Only exception → hypertensive emergency
what is a normal bp - ACC/AHA
<120 AND <80
what is an elevated bp - ACC/AHA
120-129 AND <80
what is considered HTN in terms of ACC/AHA
Stage 1 - 130-139 OR 80-89
Stage 2 - ≥140 OR ≥90
difference between primary vs secondary HTN
- primary - no single, reversible cause identified, from complex interactions between multiple factors
- Accounts for 95% of cases - Secondary → definable cause, makes up other 5%
common causes of secondary HTN (9)
- CKD
- Pheochromocytoma
- Renal Artery Stenosis
- Hyperaldosteronism
- Cushing Disease
- OSA
- Coarctation of the Aorta
- Thyroid Dysfunction
- Drug-Induced HTN
difference in BP between younger vs older pts
- Young Patients (<50)
- Systolic and diastolic BP rise
- Predominantly caused by hormonal activation
- Associated with OSA
- Tx initiated when BP >140/90 (JNC) - Older Patients (>60)
- Systolic BP rises, without rise in diastolic pressure
- Predominantly caused by arterial stiffness
- Not associated with OSA
- Tx initiated when SBP >150 (JNC)
Occurs when systolic BP is >140, but diastolic is <90
what type of HTN
isolated systolic
isolated systolic HTN MC happens in who? how?
- older pts
- Results from arterial stiffness and atherosclerosis - Can occur in younger
- MC in athletic males
- Likely due to high stroke volume
what is the best risk predictor of long-term HTN complications? (SBP or DBP)
- DBP - for patients <45 y/o
- SBP - for patients >60 y/o
Persistently elevated BP > 140/90 in the office, but a lower value outside of the clinic
what type of HTN
White Coat
white coat HTN is MC seen in who?
older
is tx needed for white coat HTN?
as long as numbers are within range at home, tx is not necessary
Long-term monitoring required!
Cuff comparison key!
Normal BP in the office, but elevated values at home
Results in same complications as essential HTN
Often a result of lifestyle → alcohol use, tobacco use, caffeine consumption, etc.
what type of HTN
masked
Phenomenon that can occur in elderly patients that results from calcification of peripheral vessels
Results in falsely elevated BP, resulting in symptomatic overtreatment
what type of HTN
pseudoHTN
s/s of pt with pseudohypertension
hypotensive symptoms with elevated office readings
One of the most common chronic conditions in the US
HTN
Average SBP in ___(men/women) is > than in ___(men/women) in early adulthood
men > women
Age-related rise in BP higher in women
DBP increases with ___, then decreases
Results in wider pulse pressure after age 60
when does it stablize?
age
until about 55 y/o
HTN is a major risk factor for ___ and ___, which are the 1st and 5th leading causes of death in the US
heart disease
stroke
prevalence of HTN
- ~119 million adults had HTN
- 57.8% non-Hispanic blacks
— HTN manifests earlier, is more severe, higher rates of morbidity and mortality d/t stroke, LVH, CHF, ESRD than white Americans
- 48.9% in non-Hispanic whites
- 45.2% in non-Hispanic Asians
- 38.6% in Hispanic Americans - Prevalence is increased in older adults
- 77.1% in adults ≥65 y/o
pathogenesis of HTN
BP = CO * systemic vascular resistance
- Maintenance of arterial BP is necessary for organ perfusion
- BP must react to environmental changes to maintain this perfusion over a wide variety of conditions
what factors can cause primary HTN (5)
- Sympathetic nervous system hyperactivity
- RAAS
- Defect in natriuresis
- Abnormal CV or kidney development
- Elevated intracellular Ca and Na
how does Sympathetic Nervous System Hyperactivity cause primary HTN? MC in who?
- “Fight or Flight”
- Acetylcholine and norepinephrine release
— Autonomic neurons that secrete acetylcholine are cholinergic
— Autonomic neurons that secrete norepinephrine are adrenergic - Younger pts
- presents with tachycardia and elevated CO
how does the RAAS system cause primary HTN?
sodium retention + water retention = BP rises
Renin = AT = AT I = AT II = vasoconstriction = BP rises
how does Natriuresis Defect cause HTN
- ↑ salt intake triggers ↑ BP = ↑ natriuresis to bring BP values back into normal range
- Defects in this process result in HTN
how does CV or Renal Defect cause HTN
- elasticity of arteries matches 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 Calcium & Sodium ↑ cause HTN
- Intracellular sodium is elevated in primary HTN
- This can lead to increase intracellular calcium as well
- Theoretically leads to increased vascular smooth muscle tone that is seen in HTN
risk factors of HTN (7)
- OSA
- Excessive Alcohol Use
- Cigarette Smoking
- NSAID use
- Obesity
- Low potassium or high sodium intake
- Metabolic syndrome
Goals of HTN Evaluation (3)
- Assess presence of target-organ damage related to HTN
- Determine the presence of other CV risk factors and disease
- Evaluate for possible underlying secondary causes of HTN
how to measure BP
- Can be taken at home, in clinic, at a pharmacy, or by ambulatory monitoring
- Should be taken in both arms, two times, spaced 1-2 minutes apart at first office visit
- If value varies between extremities, use higher value obtained
automated devices may be inaccurate d/t beat-to-beat variability from this condition
a-fib
home BP monitoring vs ambulatory BP monitoring
- home
- 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 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 to ask HTN pt when obtaining hx
- Assess duration, age of onset, previous levels of high BP
- Previous antihypertensive therapy and its effect on BP
- sx and possible secondary causes of HTN
- Med hx
- Contraceptives, NSAIDs, amphetamines, licorice - Social history
- Alcohol/tobacco use, activity level, diet - Presence of other CV risk factors
- sx that suggest target-organ damage
Neuro dysfunction, HF, CAD, PAD
labs for HTN pts
- UA (protein)
- BMP
- EKG
- fasting-lipid panel
- TSH
- other tests for secondary causes
complications of untreated HTN (4)
- structural and functional changes in the heart and vasculature
- LVH, increased atrial size, CHF, atherosclerosis, microvascular disease, and cardiac arrhythmias - Increased risk of thrombosis
- Increase in morbidity and mortality related to HTN doubles for each 6 mmHg increase in DBP
- Target-organ damage my vary between individuals, even if their BP readings are similar
LVH can lead to what 3 conditions that can lead to death
- diastolic HF = systolic HF
- MI
- ventricular arrhythmias
s/s of HTN CV disease
- Dyspnea, edema
- Palpitations, chest pain
- LV heave or S4 gallop
- LVH criteria on EKG
what disease is a major predisposing factor for both ischemic and hemorrhagic stroke
also increases risk for dementia
more related to SBP
Hypertensive Cerebrovascular Disease
what can actually make sx worse for dementia pts with HTN?
once microvascular disease is noted, lowering BP can actually make symptoms worse
Chronic untreated HTN results in nephrosclerosis
MC in black pts
what is this disease
HTN renal disease
difficult to reverse damage that has already occurred
Narrowing of the retinal arteries
what is this condition
hypertensive retinopathy
hypertensive retinopathy can develop what in the eyes
exudates, cotton-wool spots, and retinal hemorrhages
The degree and duration of HTN are primary determinants of retinopathy
Worse when combined with DM
vascular complications with HTN
- Atherosclerosis
- Condition that causes narrowing and/or hardening of arteries
- Cause by and contributes to increased BP - Aortic Aneurysm / Dissection
- HTN is a major contributing factor for development of aneurysm and/or aortic dissection
non-pharm tx for HTN
- Weight reduction (best)
- Adopt DASH eating plan
- Dietary sodium reduction
- Physical activity
- Moderation of alcohol consumption
ACC/AHA 2017 Management Guidelines for HTN
- normal - promote healthy lifestyle
- elevated - Initiate non-pharmacologic therapy and reassess BP in 3-6 months
- stage 1 - Assess 10 year ASCVD Risk
- If ≥ 10% or clinical ASCVD begin pharm and non-pharm treatment
- If not, begin non-pharm treatment only - stage 2 - Begin pharm and non-pharm treatment
ACC/AHA Antihypertensive medication recommendations
- Goal BP for ALL patients with HTN is <130/80
- Non-African American patients:
- Thiazide, ACEI/ARB, or CCB - African American patients:
- Thiazide or CCB
pt with HF can take what meds?
- diuretic
- BB
- ACEi
- ARB
- aldosterone antagonist
pt with post-MI can take what meds?
- BB
- ACEi
- aldosterone antagonist
pt with risk coronary disease risk could take what meds
- diuretic
- BB
- ACEi
- CCB
pt with DM could take what meds
- Diuretic
- BB
- ACE Inhibitors
- ARB
- CCB
CKD could take what meds for HTN
- ACEi
- ARB
pt with recurrent stroke prevention could take what meds
- diuretic
- ACEi
f/u and monitoring for HTN pts
- Once BP is well controlled and meds proven safe / tolerated, f/up can be as infrequent as every 6 to 12 months
- Lab monitoring is NOT needed if BP is controlled, unless other disease processes are present
- EKG could be obtained every 2-4 years depending on baseline EKG and any symptoms that present
