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Clin Med II > L3: Hypertension > Flashcards

L3: Hypertension Flashcards

1
Q

Hypertension incidence increases with ______.

A

Age

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2
Q

What are the ranges for elevated hypertension (aka pre-hypertension)?

A

SBP: 120-129 mmHg AND DBP: <80 mmHg

Normal: 120/80

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3
Q

What are the ranges for Stage I hypertension?

A

SBP: 130-139 mmHg OR DBP: 80-89 mmHg

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4
Q

What are the ranges for Stage II hypertension?

A

SBP: >/= 140 OR DBP: >/= 90 mmHg

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5
Q

How do you diagnose a patient with SBP and DBP in 2 categories?

A

Dx should be designated to the higher BP category

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6
Q

Name 6 modifiable risk factors for primary HTN.

A
  • Smoking
  • Unhealthy diet
  • Excess alcohol intake
  • Obesity/weight gain
  • Physical inactivity
  • Dyslipidemia
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7
Q

Which race is most likely to develop HTN?

A

African American

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8
Q

Name the 6 non-modifiable risk factors for primary HTN.

A
  • Age (55 years old+)
  • Male gender
  • Family hx
  • Psychosocial stress
  • Obstructive sleep apnea
  • Low socioeconomic/educational status
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9
Q

Secondary HTN is caused by:

A

medications or secondary conditions.

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10
Q

Name the 9 possible etiologies for secondary HTN.

A
  • Renal disease
  • Renovascular disease
  • Obstructive sleep apnea
  • Thyroid/parathyroid disease
  • Coarctation of the aorta
  • Primary hyperaldosteronism (hypokalemia, metabolic alkalosis)
  • Cushing’s syndrome
  • Pheochromocytoma
  • Medication induced
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11
Q

What is the triad for Cushing’s syndrome?

A
  • Skin atrophy
  • Striae
  • Proximal muscle weakness
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12
Q

What is the triad for pheochromocytoma?

A
  • Headache
  • Sweating
  • Tachycardia
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13
Q

When should all individuals start being screened for elevated blood pressure?

A

18 years old or older

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14
Q

How many times a year should adults with normal BP have their blood pressure measured?

A

At least annually (or semi annually for adults whose systolic BP was 120-129)

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15
Q

What is the gold standard for diagnosis of hypertension?

A

If elevated at screening, gold standard is ambulatory blood pressure monitoring (ABPM) to confirm dx

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16
Q

What are the 4 general principles for appropriate measurement of blood pressure?

A
  • Serial measurements required
  • Measure on both arms
  • Comfortable, quiet setting
  • Avoid eating, exercise, smoking, and caffeine
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17
Q

What are the 8 laboratory tests that should be ordered when assessing to see if pt has HTN?

A
  • Fasting blood glucose
  • CBC
  • Lipid profile
  • Serum creatinine with eGFR (kidney function)
  • Serum Na, K, and Ca (electrolytes)
  • Thyroid-stimulating hormone (TSH)
  • Urinalysis (UA)
  • Electrocardiogram
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18
Q

What is another lab test that should be ordered (in addition to the 8 basic HTN labs) for patients with DM or chronic kidney disease?

A

Urinary albumin to creatinine ratio

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19
Q

What is the primary goal of hx taking when assessing for HTN?

A

Questions should be geared toward identifying risk factors and secondary etiologies

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20
Q

What is our primary concern in regards to the physical exam when assessing a patient with HTN?

A

Looking for signs of end-organ damage and secondary etiologies

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21
Q

What is the first-line treatment for pts with essential HTN?

A

Lifestyle changes!

-Diet, exercise, maintaining a healthy weight, smoking cessation

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22
Q

What dietary suggestions can you offer when counseling a pt with HTN?

A
  • Lower sodium intake (less than 1.5 g/day)
  • DASH diet
  • Alcohol reduction (1-2/day men, 1/day women)
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23
Q

What are the “Big 4” classes of medications we use to manage HTN?

A
  1. Diuretics
  2. Angiotensin Converting Enzyme Inhibitors (ACE-I)
  3. Angiotensin Receptor Blockers (ARB)
  4. Calcium Channel Blockers (CCB)
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24
Q

After implementing life style changes, how would you initiate tx (meds) in a pt with Stage I HTN? How would you adjust the dose?

A
  • Single antihypertensive drug (one of the Big 4)

- Titrate up or add a second med as needed to achieve goal BP

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25
Q

After implementing life style changes, how would you initiate tx (meds) in a pt with Stage II HTN?

A

-Start with 2 first-line agents of different classes (separate or fixed dose combo)

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26
Q

Once medication tx has started, how often should patients be following up?

A

Follow ups should occur monthly after starting/changing dose until control is achieve
-Adherence to lifestyle changes and strategies for successful management should also be discussed

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27
Q

If a patient has chronic kidney disease WITH ALBUMINURIA, what should the first medication tx be?

A

ACE inhibitor

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28
Q

What range is classified as albuminuria?

A

> /=300 mg/d or >/= 300 mg/g creatinine

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29
Q

If a patient has DM + ALBUMINURIA, what medications should be considered?

A

ACE or ARB (these 2 medications are kidney protective)

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30
Q

If patient has heart failure with reduced ejection fraction, what medication is NOT recommended?

A

Nondihydropyridine CCBs

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31
Q

If patient has heart failure but preserved ejection fraction, what medications should be considered?

A

ACE, ARB, or beta blocker

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32
Q

What are the other 4 medications (outside of the Big 4) that can be given to treat hypertension?

A
  1. Beta blockers
  2. Alpha blockers
  3. Central alpha agonists
  4. Direct renin inhibitor
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33
Q

What is the definition of resistant HTN?

A

BP that is not controlled despite:
-Adherence to appropriate three-drug regimen
OR
-Requires at least 4 medications to achieve control

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34
Q

What is the MOA for diuretics? What do diuretics accomplish (physiologically speaking)?

A
  • Decreases body’s sodium stores by inhibiting sodium reabsorption in the nephron (H20 follows salt)
  • Reduce plasma volume and peripheral vascular resistance
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35
Q

What is the most preferred diuretic? What type of diuretic is it?

A

Chlorthalidone (thiazide-type diuretics are first line)

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36
Q

What are the common SE of thiazide-type diuretics?

A
  • Electrolyte imbalance (monitor throughout tx)

- Gout

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37
Q

What is a contraindication for thiazide-type diuretics?

A

Sulfonamide sensitivity

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38
Q

What is the preferred tx for a patient with HTN + symptomatic HF?

A

Loop diuretics

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39
Q

What are the precautions and contraindications for loop diuretics?

A

Same as thiazide-type (electrolytes, sulfa allergy)

40
Q

Potassium sparing diuretics are:

A

weak hypertensives (so never used alone)

41
Q

Potassium sparing diuretics should be avoided in patients with:

A

Moderate to severe CKD

42
Q

Potassium sparing diuretics should not be combined with: (drugs)

A
  • ACE-I
  • ARB
  • DRI
  • K supplements
  • To avoid hyperkalemia
43
Q

What is the preferred tx in pts with HTN + primary aldosteronism?

A

Aldosterone antagonists

44
Q

What are the contraindications for aldosterone? antagonists?

A

Renal impairement

45
Q

Briefly describe the renin-angiotensin system (5 steps).

A

Blood pressure falls

  1. Kidneys release renin
  2. Renin turns angiotensin to angiotensin I
  3. Angiotensin converting enzyme (ACE) turns angiotensin I to angiotensin II
  4. Blood pressure rises
  5. Angiotensin II tells adrenal medulla to release aldosterone which results in salt retention (blood pressure rises)
46
Q

What is the suffix for ACE inhibitor drugs?

A

-pril

47
Q

What is the MOA for ACE inhibitors and ARBs?

A

Inhibit RAAS system and stimulate bradykinin (which has vasodilator effect)

48
Q

What are the common SE for ACE inhibitors? (4)

A
  • Hyperkalemia
  • Acute renal failure
  • Angioedema
  • Cough
49
Q

What are the contraindications for ACE-I’s? (3)

A
  • Renal artery stenosis
  • Pregnancy
  • Angioedema
50
Q

What are the compelling indications for ACE-I use?

A
  • DM
  • CKD
  • post-MI
  • heart failure
51
Q

What should an ACE-I never be combined with?

A

ARB

52
Q

What is the suffix for ARB drugs?

A

-sartan

Ex: Losartan

53
Q

What are the compelling indications for ARB use?

A
  • Chronic kidney disease
  • DM
  • Heart failure
54
Q

What are the contraindications for ARB use?

A
  • Pregnancy
  • Renal artery stenosis
  • Angioedema
55
Q

What are the common SE of ARBs?

A
  • Hyperkalemia
  • Acute renal failure
  • Angioedema
56
Q

Which 2 HTN drugs have almost the same exact SE, compelling indications, and contraindications?

A

ACE-Is and ARBs

57
Q

What are the 2 kinds of calcium channel blockers?

A

Nondihydropyridine vs Dihydropyridine

58
Q

Which of the CCB’s has more of a cardiac depressant effect?

A

Nondihydropyridines

59
Q

Which of the CCBs is more selective as vasodilators with less of a cardiac depressant effect?

A

Dihydropyridines

60
Q

What is the suffix for Dihydropyridines?

A

-Pine

“Pines, pines the magical fruit, the more you eat the more you vasodilate”

61
Q

What is the MOA for CCBs?

A

Inhibition of Ca2+ influx into arterial SM cells, which reduces peripheral vascular resistance

62
Q

What are the common SE’s associated with CCBs?

A

Cardio depression, dizziness, headache

63
Q

When should Dihydropyridine CCB use be avoided?

A

In pts with heart failure w/ reduced ejection fraction

64
Q

When should Non-dihydropyridine CCB use be avoided?

A

In pts with heart failure w/ reduced ejection fraction or patients taking beta blockers

65
Q

What is the suffix for beta blockers?

A

-olol

66
Q

What are the common SE associated with beta blockers?

A

Bradycardia

Bronchospasms

67
Q

What are some compelling indications for beta blocker use?

A
  • Post MI
  • Stable HF
  • High CAD risk
  • PREGNANCY
68
Q

When is beta blocker use contraindicated?

A
  • Bronchospastic disease
  • Heart block
  • Acute decompensation of CHF
69
Q

Which 2 HTN drugs should you avoid abrupt cessation?

A

Beta blockers

Central Alpha Agonists

70
Q

What is the suffix for Alpha Blockers?

A

-zosin

71
Q

What are the common SE associated with Alpha Blockers?

A
  • Orthostatic hypotension

- Reflex tachycardia

72
Q

What is a compelling indication for alpha blocker use?

A

Benign Prostate Hyperplasia

73
Q

What are the common SE associated with DRI’s (direct renin inhibitors?)

A
  • Hyperkalemia
  • Renal impairment
  • Hypersensitivity rxns
74
Q

What are the contraindications for DRI use?

A
  • Do not use with an ACE-I or ARB with diabetics

- Pregnancy

75
Q

What are the 2 HTN meds safe to use with pregnancy?

A

Beta blockers

Central alpha agonists (but DOLR)

76
Q

What is the DOLR for HTN?

A

Central Alpha Agonists

77
Q

What is a contraindication for central alpha agonists?

A

Methyldopa (drug) in pts with liver disease

78
Q

What is the definition of hypertensive urgency?

A

ASYMPTOMATIC severe HTN (diastolic > 120 mmHg) and NO evidence of organ damage

79
Q

What is the definition of a hypertensive emergency?

A 
Severe HTN (diastolic > 120 mmHg) and EVIDENCE OF ACUTE END-ORGAN DAMAGE
*rare
80
Q

What is the goal of hypertensive urgency tx?

A

Reduce BP to <160/120 mmHg

81
Q

How is a hypertensive urgency treated?

A

-Goal BP achieved over a period of hours to days (slowly)

Outpatient:

  • Rest in a quiet room
  • Increase dose of current meds
  • Add additional medication (diuretic)
  • Adherence to sodium restriction
  • Follow up to monitor sx of HTN or hypotension
82
Q

What work ups should be ordered in order to address the underlying causes of a hypertensive emergency?

A
  • Neuro exam
  • CXR
  • EKG
  • UA
  • Electrolytes/creatinine
  • CT/MRI
83
Q

How should a hypertensive emergency be treated?

A
  • Pt should be hospitalized in ICU
  • Reduce BP no more than 25% within minutes to 1 hour
  • IV nitrates; CCBs; adrenergic blockers; hydralazine
84
Q

If the patient becomes stable during the tx of a hypertensive emergency, what is the BP goal over 2-6 hours? 24-48 hours?

A

2-6 hours: 160/100-110 mmHg

24-48 hours: Decrease to normal BP

85
Q

What drug is contraindicated with hypertensive emergency tx?

A

Sublingual nifedipine (type of CCB)

86
Q

What are the guidelines for diagnosing orthostatic hypotension?

A

After 5 minutes of lying supine followed by 2-5 minutes of quiet standing, one of the two is present:

  • At least a 20 mmHg fall in systolic pressure
  • At least a 10 mmHg fall in diastolic pressure
87
Q

What are some common etiologies of orthostatic hypotension? (3)

A
  • Autonomic dysfunction (Parkinson’s)
  • Volume depletion (diuretics, hemorrhage, vomiting)
  • Medications (Anti-HTN meds in the elderly)
88
Q

What are the sx of orthostatic hypotension?

A
  • Weakness
  • Dizziness or lightheadedness
  • Visual blurring or darkening of the visual fields
  • Syncope
89
Q

What is the definition of shock (cardiogenic)?

A
  • A state of cellular and tissue hypoxia

- Most commonly occurs when there is circulatory failure manifested as hypotension

90
Q

What are 3 etiologies of cardiogenic shock?

A
  • MI
  • A/V arrhythmias
  • Valve/ventricle septal rupture
91
Q

What are the guidelines for absolute hypotension?

A

SBP < 90

MAP <65

92
Q

What are the guidelines for relative hypotension?

A

Drop in systolic BP >40

93
Q

What are the guidelines for orthostatic hypotension?

A

> 20 fall in SBP or >10 fall in DBP with standing

94
Q

What are the guidelines for profound hypotension?

A

Vasopressor-dependent

95
Q

What is the presentation of cardiogenic shock?

A
  • Hypotension
  • Pulmonary edema (diffuse crackles, JVD)
  • Echocardiography (dilated ventricles, valvular or septal abnormalities)
  • Tachypnea, oliguria, AMS, clammy skin, etc.
96
Q

How do you treat cardiogenic shock?

A
  • ABCs, IV placement, fluids
  • Stabilize patient
  • Determine/treat underlying condition

Clin Med II (9 decks)

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