L2 - HTN Flashcards
Describe the correlation in occurence between HTN & Cardiovascular disease:
Continuous & consistent directly proportional relationship that is independent of other risk factors
HTN can lead to what serious medical conditions?
Heart failure (over strained)
HTN –> vessel injury –> atherosclerosis –> MI, Stroke & Kidney Failure
Aneurysm
What is the #1 primary diagnosis in US?
HTN
What % of patients with HTN are unaware they have it?
About 1/3
Correlation of age & HTN risk?
Directly proportional in both sexes
Joint National Commission (JNC) VII guidelines?
Treat until below 140/90
If chronic kidney disease or diabetes, treat until <130/80
How is BP measured for classification purposes?
Average of at least 2 readings per visit at at least 2 visits
HTN stages?
< 120/80 = nl
120/80 < Pre-hypertensive < 140/90
140/90 < Stage 1 HTN < 160/100
Stage 2 HTN >160/110
Urgency/emergency >180/120
For staging or classification purposes, how do you proceed if diastolic & systolic are in different ranges?
Classify based on whichever one is worse
Follow up recommendations based on HTN stages?
nl = recheck in 2 years
Pre-HTN = recheck in 1 year & give info about lifestyle changes
Stage 1 = confirm within 2 months & give info about lifestyle changes
Stage 2 = evaluate or refer within 1 month
>180/110 = treat immediately
American Heart Association (AHA) recommendations?
Treat until below 140/90
If chronic kidney disease, CAD, CAD equivalent (diabetes) or Framingham risk >10% = treat until <130/80
If have heart failure, treat until lower than 120/80
National Kidney Foundation (NKF) guidelines?
If have chronic kidney disease treat until under 130/80
If have proteinuria greater than 1g, treat until <125/75
First thought when see really high BP reading?
Probably was done incorrectly
Common mistakes that can give incorrectly high BP
Not waiting 5 min Cuff too small Checking over clothes or rolling up sleeve Not at level of heart Checking same arm too soon Auscaltory gap Not rechecking
What are the 3 main goals during evaluation of documented HTN?
Find cause
Identify risk factors which may alter treatment or prognosis
Assess for end organ damage & CVD
Meds which can cause HTN?
NSAIDs Oral contraceptives Hormone therapy Steroids Sympathomemetics Ephedra Diet pills Herbal supplements
What food can oddly cause HTN? (Not salt, obesity …)
Licorice
What social habits can cause HTN?
Alcohol Tobacco Stress High salt diet Caffeine Cocaine Methamphedamines
How does caffeine effect BP?
If always have 1-2 cups of coffee, no effect
If suddenly spike in caffeine or take a massive amount can cause HTN
Effect of weight on BP?
Obese people are more likley to have HTN, but just because you are fat doesnt mean you automatically have HTN
More important than absolute weight is change in weight. Sudden increase –> HTN
Poorly controlled chronic HTN can cause what fundoscopic findings?
Permanent Arterial narrowing
AV nicking
Copper Wiring
Silver Wiring
What is AV Nicking?
Abnormal fundoscopic finding in patients with chronic poorly controlled HTN
Represents artery & vein crossing paths –> compression of the vein
What is Copper Wiring?
Chronic HTN –> Arteriosclerosis with moderate vascular changes –> changes light reflex
Diffuse red-brown light reflex
Progresses to silver wiring
What is silver wiring?
Chronic HTN –> Arteriosclerosis with severe vascular changes (vascular wall thickening & hyperplasia) –> changes light reflex
White light reflex
Progressed from copper
Severe acute HTN can cause what fundoscopic finding?
Flame shaped hemorrhage
Ischemia –> white superficial focus = cotton wool spot
Yellow hard exudate
Optic disk edema or papiladema (swelling)
HTN labs?
CMP Lipids Glucose CBC Urinalysis ECG Echocardiogram
- similar to PAD workup
What things in general should make you suspicious that HTN may be SECONDARY to another cause?
< 25 yo Drug resistant (3 drugs at max dose dont work)
HTN with hypokalemia points towards what? Test?
High aldosterone/Conn’s Disease (secondary HTN)
Plasma aldosterone-renin ratio
Intermittent HTN with palpatations, sweating & headaches points towards what? Tests?
Pheochromocytoma (secondary HTN) = adrenal tumor
Serum catecholamines or metanepherines, Ab CT/MRI
HTN with a epigastric bruits points towards what? Test?
Coarctation (secondary HTN). Aorta narrowed –> blood has to pump harder –> entire body effected
Chest Film
HTN with renal artery bruits points towards what? Best test?
Renal artery stenosis (secondary HTN) = renovascular disease
Angiography
Suggested lifestyle changes to lower BP?
Lose weight DASH diet Na reduction Physical Activity Alcohol in moderation
Who generally needs a 2 drug combination for HTN? Which drugs are these usually?
Stage 2 (think 2 for 2)
Diuretic + CCB/BB/ARB/ACEI
Difference between HTN urgency & emergency?
Emergency has some sort of end organ damage
What HTN meds should not be given to pregnant patient?
ACEI
ARB (ang rec block)
If have edema & HTN, what is the best treatment?
Diuretic
If have BPH & HTN, what is the preferred treatment?
Alpha blocker (relax muscle in prostate & bladder)
If you have Raynaud’s & HTN, what is the preferred treatment?
CCB (relax peripheral vessels cuz have less Ca for smooth muscle contraction)
Who should not receive diuretics?
Gout
Hyponatremia
Hypokalemia
Who should not receive beta blockers?
Asthma
Reactive airway disease
2nd or 3rd degree heart block
Who should not receive ACEI?
Patients with history of angioedema
Pregnant patient
Best treatment for HTN patient with diabetes?
ACEI or ARB (both processes that take place in kidney) can have renal protective effects & prevent proteinuria
Same as kidney disease
CVD stands for?
Cardiovascular disease
If have proteinuria greater than 1g, you should treat HTN until BP is <125/75 according to who?
National Kidney Foundation
A patient with prior angioedema should not receive what drug?
ACEI
Somebody with gout should not receive what mediation?
Diuretic
Somebody with hyponatremia should not receive what drug?
Diuretic
Somebody with Asthma or reactive ariway disease should not receive what drug?
Beta blocker
Somebody with gout should not receive what drug?
Diuretic
What is suspected with HTN & high or low TSH?
Hypo or hyper thyroid can be related to HTN (secondary HTN)
What is suspected with HTN & fatigue?
Sleep apnea
Hypothyroidism
Both = secondary HTN
What is suspected with HTN, high Ca & low P? Test?
Hyperparathyroidism (secondary HTN)
Serum PTH
What is suspected with HTN & high aldosterone?
Aldosteronism/Conn’s (secondary HTN) where adrenal tumor causes the release of aldosterone with causes salt & water retention –> more blood volume
What is suspected with HTN & high urinary cortisol? Test?
Cushings (secondary HTN) = pituitary hormone
Dexamethasone suppression test
How are kidney diseases and HTN related?
Limit the kidney ability to excrete fluid –> increased blood volume –> secondary HTN
What is suspected with HTN & adrenomegaly on CT?
Pheocromocytoma
Primary aldosteronism/Conns
Secondary hypertension
Treatment regimen for stage 1 HTN?
Diuretic usually enough on its own
May need additional though
Why is pharm therapy for HTN difficult?
Everyone is different, need to individualize
How to treat HTN emergency?
Oral & IV drugs
If have atrial fibrilization & HTN, best treatment?
beta blocker
If have perioperative HTN, best treatment?
Beta blocker
If have essential tremor & HTN, best treatment?
Beta Blocker
If have migraine & HTN, best treatment?
Beta Blocker
If have thyrotoxicosis & HTN, best treatment?
Beta Blocker
What drugs can cause hyperkalemia & therefore should not be used on a patient with preexisitng hyperkalemia?
ARB & ACEI
How to treat HTN in elderly?
More sensitive (metab slower)
Don’t want BP to drop too much. Start with smaller initial doses
Who probably shouldn’t receive any anti-hypertensive drugs?
Some one with a BP that is already too low
If have HTN + one of the following, beta blocker is the best treatment:
Migraines
Essential Tremor
Perioperative HTN
Atrial Fib
thyrotoxicosis
Which kidney diseases are related to HTN?
Polycystic kidney disease
Renovascular HTN
Glomerular disease (renal parenchymal disease)
Somebody with Conn’sDisease & HTN should not receive what drug?
Diuretic
Best treatment for HTN patient with Kidney Disease?
ACEI or ARB (both processes that take place in kidney) can have renal protective effects & prevent proteinuria
Same for diabetes
What tests for renal parenchymal disease if suspect secondary HTN?
24 hour creatine
GFR
Creatinine
Renal ultrasound (small kidney)
Losing weight will lower your systolic about how many mm Hg?
5-20
DASH diet will lower your systolic about how many mm Hg?
8-14
Lowering Na intake will lower your systolic about how many mm Hg?
2-8
Increasing physical activity will lower your systolic about how many mm Hg?
4-9
Decreasing alcohol intake will lower your systolic about how many mm Hg?
2-4
Main treatment option for somebody with metabolic syndrome & HTN?
Lifestyle changes –> weight loss
