Lecture 3 - Hypertension & Dyslipidemia Guidelines Flashcards
Cardiovascular Mortality Risk Doubles with each ______ increase in BP
20/10 mm Hg
Hypertension can be diagnosed using one of the
following three acceptable measurement strategies:
- Ambulatory blood pressure monitoring (ABPM)
- Home blood pressure monitoring (HBPM)
- Office-based blood pressure measurements
Diagnosis of Hypertension: Home Measurement
Why do we like it?
What are some drawbacks?
Why do we like it? • Available • Inexpensive • No white coat syndrome • Can improve BP control and compliance
What are some drawbacks?
• Training/BP technique
• Access to appropriate/accurate device
Diagnosis of Hypertension: ABPM
Why do we like it?
What are some drawbacks?
Why do we like it?
• Detects morning bp surge • Quick results
• Dippers v. non-dippers
• If treatment is working at the best time
What are some drawbacks? • Availability
• Expense
Dippers v. non-dippers
Dipper blood pressure dips at night where as non-dippers
Non-dippers are more at risk as BP should dip when you sleep…natural surges in the am
Non-dippers or dippers need ambulatory BP monitoring
Non-dippers
The proper measurement of office-based BP requires attention to all of
the following:
(6)
- Time of measurement
- Type of measurement
- Cuff placement
- Patient condition
- Technique of measurement
- Number of measurment
Oscillometric method
Analyzes pulse waves collected
from the cuff during constricted
blood flow
(Automated one at most doctors offices)
Auscultatory method
Listening to the internal sounds of the body, usually using a stethoscope
(Most efficient way uses ear)
Correct Office Based Measurement:
Cuff Placement
• Bladder midline over brachial artery • Two finger lengths above “elbow bend”
Correct Office Based Measurement:
Type of Measurement Device
Oscillometric method
Auscultatory method
Correct Office Based Measurement:
Patient Condition
- Patient position (sitting, feet on floor etc)
* Extraneous variables (caffeine, smoking etc)
Correct Office Based Measurement:
Technique of Measurement
Depends on skill of operator
Correct Office Based Measurement:
Alternative Sites for Measurement
Radial artery Brachial artery Dorsalis pedis artery Popliteal artery Posterior tibial artery
Postural Hypotension
AKA?
What is it?
Add what to diet?
- Aka orthostatic hypotension
- Low BP when you stand up from sitting/laying down
- Add sea salt to diet to increase BP
Pathophysiology of Postural Hypotension
Normal
- Stand up
- Gravity moves blood to legs
- ** Baroreceptors in neck and heart arteries sence low BP
- Send signals to brain
- ** Signals heart to breat faster and vessels to constrict to increase BP
**_____ in neck and heart arteries sense low BP
Signals heart to beat ____ & vessels to ____
Baroreceptor
faster & constrict
**Pathophysiology of Postural Hypotension
Abnormal
- Stand up
- Gravity moves blood to legs
- **Interruption of natural process
- Less blood circulating to heart
- Decreased BP
Risk Factors for Postural Hypotension
Risk Factors for Postural Hypotension
- Age
- Postprandial hypotension
- Dehydration
- Medications
- Pregnancy
- Certain disease
- Bed rest
- Alcohol
Postprandial hypotension
A condition in which a person’s blood pressure drops after they eat
Classification of Hypertension
Sys/Dia
- Normal
- Stage 1
- Stage 2
- Normal = 120/80
- Stage 1 = >130-139 / 90
- Stage 2 = >140/90
Non-Pharmacologic Treatment for hypertension
6
- Weight reduction
- Adopt DASH eating plan
- Dietary sodium reduction
- Physical activity
- Moderation of aalcohol consumption
- Stop smoking
Recommended sodium intake
less than 1500 mg/day
Hypertension BP goals for general population with no diabetes or CKD:
- Older than 60
- Younger than 60
<150/90
<140/90
Hypertension BP goals for population with diabetes or CKD:
- All Ages Diabetes present and no CKD
- All Ages and races with CKD present with or without diabetes
140/90
Treatment for nonblack
- Thiazide
- ACEI
- ARB
- CCB
(alone or in combo)
Treatment for black
- Thiazide
- CCB
Blood pressure reduction is less with ______ or _____ compared with other drug classes in African Americans
What’s the exception
ACE inhibitors or ARBs
Exception: If they have chronic kidney disease (start on ACE and ARB)
If ACEI, ARB, CCB and Thiazide are not working what is the next step?
- Reinforce lifestyle and adherence
- Add medication class (beta-blocker, aldosterone antagonist)
What are the four
main classes of drugs that are recommended for use as initial monotherapy:
- ACE Inhibitor (ACEI)
- Angiotensin receptor blocker (ARB)
- Thiazide diuretic
- Calcium channel blocker (CCB)
ACE Inhibitors work to prevent ________ being converted to __________
Angiotensin I to Angiotensin II
This prevents the retention of fluid + vasoconstriction that would raise the BP
Volume Regulating Hormones drugs
ARBs = targets vasoconstriction
Aldosterone antagonist = aldosterone
Thiazide diuretic = targets Na+ and water retention
ARBs
Vasoconstriction
HTN Drug Classes:
-pril
ACE Inhibitor
HTN Drug Classes:
-pine
CCBs
HTN Drug Classes:
sartans
ARBs
HTN Drug Classes:
ACE Inhibitors
Inhibits ACE, preventing conversion of ang I to ang II (see RAAS pathway)
HTN Drug Classes:
ARBs
Blocks ang II from binding to receptor on vascular smooth muscle
HTN Drug Classes:
Inhibits Ca movement through Ca channels –> vasodilation and decreased BP
How do you calculate estimated VLDL?
TG/5
What cholesterols are measurable?
- T-C (total cholesterol)
- HDL (HDL cholesterol)
- LDL (LDL cholesterol)
How do you calculate estimated LDL?
LDL = TC - HDL - VLDL
Not to be used when TG > 400mg/dl
LDL Cholesterol desirable range
< 100
HDL Cholesterol desirable range
< 40 males
< 50 women
Non-HDL Cholesterol (TC-HDL) desirable range
< 130
Four Major Statin Benefit Groups
- Individuals with clinical ASCVD (Atherosclerotic vascular disease)
- Primary elevation of LDL > 190mg/dL
- Diabetes & 40-75 years of age with LDL between 70-189mg/dl
- Patient 40-75 with LDL between 70-189 with estimated 10 years ASCVD risk of 7.5
We want 10 year ASCVD rate to be ______
> 7.5%
less
10 year ASCV Risk Calculator
Provides an estimate of an individual’s risk of having a cardiovascular event during the next 10 yrs
What is the BMI range one should aim for?
18.5 - 24.9 kg/m2
Saturated fats
• Molecules
“saturated” with hydrogen molecules
• Typically solids
at room temperature
(High LDL..example coconut oil)
Trans fat
• Industrial process that adds hydrogen to liquid vegetable oils to make them more solid
• **AKA: ____ partially hydrogenated oils
Unsaturated fats
- Monounsaturated
- Polyunsaturated
- Usually liquid at room temp
(Healthy body can’t make these)
Cholesterol
- Waxy substance
* Most of what we require is produced by our bodies
____________ aka “statins”
are the primary pharmacologic agent used
HMG- CoA Reductase Inhibitors
Statins
Inhibit the enzyme HMG-CoA reductase, which prevents the conversion of HMG-CoA to mevalonate..the rate limiting step in cholesterol synthesis
(decrease LDL + TG; increase HDL)
Bile Acid Sequestrants/Bile Acid Binding Resins
Binds bile acids in intestine forming a complex that is excreted in the feces
↓LDL
↑HDL
No change or ↑TG
Fibrates
↓LDL, but can ↑LDL if TG are high
↓ TG
↑HDL
Fish oils
↓TGs
↑HDL, can ↑LDL
Statins target what?
Inhibit HMG- CoA reductase which limits cholesterol
Pharmacologic agents used to
decrease TG include:
(4)
- Fibric Acids
- Fish Oils
- Nicotinic acid
- Statins
Only add a pharmacologic agent to treat TG once LDL goal is reached and if TG remain ______-
≥ 200mg/dL
Epidemiologic data suggest that ___% to ___% of the population believed to have hypertension may have lower blood pressure outside of the office setting
15% to 30%
The average nocturnal blood pressure is approximately ___% lower than daytime values in both normotensive and hypertensive patients
15%
Adverse fish oil effect
Increase LDL
Adverse bile acid effect
No change in TG
Adverse Fibrate effect
Increase LDL (if TG is high)
