L3: Hypertension Flashcards
1
Q
Hypertension incidence increases with ______.
A
Age
2
Q
What are the ranges for elevated hypertension (aka pre-hypertension)?
A
SBP: 120-129 mmHg AND DBP: <80 mmHg
Normal: 120/80
3
Q
What are the ranges for Stage I hypertension?
A
SBP: 130-139 mmHg OR DBP: 80-89 mmHg
4
Q
What are the ranges for Stage II hypertension?
A
SBP: >/= 140 OR DBP: >/= 90 mmHg
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
6
Q
Name 6 modifiable risk factors for primary HTN.
A
- Smoking
- Unhealthy diet
- Excess alcohol intake
- Obesity/weight gain
- Physical inactivity
- Dyslipidemia
7
Q
Which race is most likely to develop HTN?
A
African American
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
9
Q
Secondary HTN is caused by:
A
medications or secondary conditions.
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
11
Q
What is the triad for Cushing’s syndrome?
A
- Skin atrophy
- Striae
- Proximal muscle weakness
12
Q
What is the triad for pheochromocytoma?
A
- Headache
- Sweating
- Tachycardia
13
Q
When should all individuals start being screened for elevated blood pressure?
A
18 years old or older
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)
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
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
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
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
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
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
21
Q
What is the first-line treatment for pts with essential HTN?
A
Lifestyle changes!
-Diet, exercise, maintaining a healthy weight, smoking cessation
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)
23
Q
What are the “Big 4” classes of medications we use to manage HTN?
A
- Diuretics
- Angiotensin Converting Enzyme Inhibitors (ACE-I)
- Angiotensin Receptor Blockers (ARB)
- Calcium Channel Blockers (CCB)
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
25
After implementing life style changes, how would you initiate tx (meds) in a pt with Stage II HTN?
-Start with 2 first-line agents of different classes (separate or fixed dose combo)
26
Once medication tx has started, how often should patients be following up?
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
27
If a patient has chronic kidney disease WITH ALBUMINURIA, what should the first medication tx be?
ACE inhibitor
28
What range is classified as albuminuria?
>/=300 mg/d or >/= 300 mg/g creatinine
29
If a patient has DM + ALBUMINURIA, what medications should be considered?
ACE or ARB (these 2 medications are kidney protective)
30
If patient has heart failure with reduced ejection fraction, what medication is NOT recommended?
Nondihydropyridine CCBs
31
If patient has heart failure but preserved ejection fraction, what medications should be considered?
ACE, ARB, or beta blocker
32
What are the other 4 medications (outside of the Big 4) that can be given to treat hypertension?
1. Beta blockers
2. Alpha blockers
3. Central alpha agonists
4. Direct renin inhibitor
33
What is the definition of resistant HTN?
BP that is not controlled despite:
-Adherence to appropriate three-drug regimen
OR
-Requires at least 4 medications to achieve control
34
What is the MOA for diuretics? What do diuretics accomplish (physiologically speaking)?
- Decreases body's sodium stores by inhibiting sodium reabsorption in the nephron (H20 follows salt)
- Reduce plasma volume and peripheral vascular resistance
35
What is the most preferred diuretic? What type of diuretic is it?
Chlorthalidone (thiazide-type diuretics are first line)
36
What are the common SE of thiazide-type diuretics?
- Electrolyte imbalance (monitor throughout tx)
| - Gout
37
What is a contraindication for thiazide-type diuretics?
Sulfonamide sensitivity
38
What is the preferred tx for a patient with HTN + symptomatic HF?
Loop diuretics
39
What are the precautions and contraindications for loop diuretics?
Same as thiazide-type (electrolytes, sulfa allergy)
40
Potassium sparing diuretics are:
weak hypertensives (so never used alone)
41
Potassium sparing diuretics should be avoided in patients with:
Moderate to severe CKD
42
Potassium sparing diuretics should not be combined with: (drugs)
- ACE-I
- ARB
- DRI
- K supplements
* To avoid hyperkalemia
43
What is the preferred tx in pts with HTN + primary aldosteronism?
Aldosterone antagonists
44
What are the contraindications for aldosterone? antagonists?
Renal impairement
45
Briefly describe the renin-angiotensin system (5 steps).
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
What is the suffix for ACE inhibitor drugs?
-pril
47
What is the MOA for ACE inhibitors and ARBs?
Inhibit RAAS system and stimulate bradykinin (which has vasodilator effect)
48
What are the common SE for ACE inhibitors? (4)
- Hyperkalemia
- Acute renal failure
- Angioedema
- Cough
49
What are the contraindications for ACE-I's? (3)
- Renal artery stenosis
- Pregnancy
- Angioedema
50
What are the compelling indications for ACE-I use?
- DM
- CKD
- post-MI
- heart failure
51
What should an ACE-I never be combined with?
ARB
52
What is the suffix for ARB drugs?
-sartan
| Ex: Losartan
53
What are the compelling indications for ARB use?
- Chronic kidney disease
- DM
- Heart failure
54
What are the contraindications for ARB use?
- Pregnancy
- Renal artery stenosis
- Angioedema
55
What are the common SE of ARBs?
- Hyperkalemia
- Acute renal failure
- Angioedema
56
Which 2 HTN drugs have almost the same exact SE, compelling indications, and contraindications?
ACE-Is and ARBs
57
What are the 2 kinds of calcium channel blockers?
Nondihydropyridine vs Dihydropyridine
58
Which of the CCB's has more of a cardiac depressant effect?
Nondihydropyridines
59
Which of the CCBs is more selective as vasodilators with less of a cardiac depressant effect?
Dihydropyridines
60
What is the suffix for Dihydropyridines?
-Pine
| "Pines, pines the magical fruit, the more you eat the more you vasodilate"
61
What is the MOA for CCBs?
Inhibition of Ca2+ influx into arterial SM cells, which reduces peripheral vascular resistance
62
What are the common SE's associated with CCBs?
Cardio depression, dizziness, headache
63
When should Dihydropyridine CCB use be avoided?
In pts with heart failure w/ reduced ejection fraction
64
When should Non-dihydropyridine CCB use be avoided?
In pts with heart failure w/ reduced ejection fraction or patients taking beta blockers
65
What is the suffix for beta blockers?
-olol
66
What are the common SE associated with beta blockers?
Bradycardia
| Bronchospasms
67
What are some compelling indications for beta blocker use?
- Post MI
- Stable HF
- High CAD risk
- PREGNANCY
68
When is beta blocker use contraindicated?
- Bronchospastic disease
- Heart block
- Acute decompensation of CHF
69
Which 2 HTN drugs should you avoid abrupt cessation?
Beta blockers
| Central Alpha Agonists
70
What is the suffix for Alpha Blockers?
-zosin
71
What are the common SE associated with Alpha Blockers?
- Orthostatic hypotension
| - Reflex tachycardia
72
What is a compelling indication for alpha blocker use?
Benign Prostate Hyperplasia
73
What are the common SE associated with DRI's (direct renin inhibitors?)
- Hyperkalemia
- Renal impairment
- Hypersensitivity rxns
74
What are the contraindications for DRI use?
- Do not use with an ACE-I or ARB with diabetics
| - Pregnancy
75
What are the 2 HTN meds safe to use with pregnancy?
Beta blockers
| Central alpha agonists (but DOLR)
76
What is the DOLR for HTN?
Central Alpha Agonists
77
What is a contraindication for central alpha agonists?
Methyldopa (drug) in pts with liver disease
78
What is the definition of hypertensive urgency?
ASYMPTOMATIC severe HTN (diastolic > 120 mmHg) and NO evidence of organ damage
79
What is the definition of a hypertensive emergency?
```
Severe HTN (diastolic > 120 mmHg) and EVIDENCE OF ACUTE END-ORGAN DAMAGE
*rare
```
80
What is the goal of hypertensive urgency tx?
Reduce BP to <160/120 mmHg
81
How is a hypertensive urgency treated?
-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
What work ups should be ordered in order to address the underlying causes of a hypertensive emergency?
- Neuro exam
- CXR
- EKG
- UA
- Electrolytes/creatinine
- CT/MRI
83
How should a hypertensive emergency be treated?
- Pt should be hospitalized in ICU
- Reduce BP no more than 25% within minutes to 1 hour
- IV nitrates; CCBs; adrenergic blockers; hydralazine
84
If the patient becomes stable during the tx of a hypertensive emergency, what is the BP goal over 2-6 hours? 24-48 hours?
2-6 hours: 160/100-110 mmHg
24-48 hours: Decrease to normal BP
85
What drug is contraindicated with hypertensive emergency tx?
Sublingual nifedipine (type of CCB)
86
What are the guidelines for diagnosing orthostatic hypotension?
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
What are some common etiologies of orthostatic hypotension? (3)
- Autonomic dysfunction (Parkinson's)
- Volume depletion (diuretics, hemorrhage, vomiting)
- Medications (Anti-HTN meds in the elderly)
88
What are the sx of orthostatic hypotension?
- Weakness
- Dizziness or lightheadedness
- Visual blurring or darkening of the visual fields
- Syncope
89
What is the definition of shock (cardiogenic)?
- A state of cellular and tissue hypoxia
| - Most commonly occurs when there is circulatory failure manifested as hypotension
90
What are 3 etiologies of cardiogenic shock?
- MI
- A/V arrhythmias
- Valve/ventricle septal rupture
91
What are the guidelines for absolute hypotension?
SBP < 90
| MAP <65
92
What are the guidelines for relative hypotension?
Drop in systolic BP >40
93
What are the guidelines for orthostatic hypotension?
>20 fall in SBP or >10 fall in DBP with standing
94
What are the guidelines for profound hypotension?
Vasopressor-dependent
95
What is the presentation of cardiogenic shock?
- Hypotension
- Pulmonary edema (diffuse crackles, JVD)
- Echocardiography (dilated ventricles, valvular or septal abnormalities)
- Tachypnea, oliguria, AMS, clammy skin, etc.
96
How do you treat cardiogenic shock?
- ABCs, IV placement, fluids
- Stabilize patient
- Determine/treat underlying condition
