Module 2.1 - Hypertensive Vascular Disease Flashcards
What is the normal range for blood pressure and what is the treatment/follow-up for this blood pressure range?
- Normal Range = <120/<80
- If normal, evaluate yearly & encourage healthy lifestyle changes
What is the blood pressure range for prehypertension and what is the treatment/follow-up for this blood pressure range?
- Prehypertension range = 120-129/<80
- If BP is in this range recommend healthy lifestyle changes & reassess in 3-6 months
What is the blood pressure range for Stage I hypertension and what is the treatment/follow-up for this blood pressure range?
- Stage I Hypertension BP = 130-139/80-89
Treatment/Follow-up:
- For pts in this BP range assess 10-yr atherosclerotic cardiovascular disease risk (ASCVD)
- Refer to ASCVD risk calculator at
http: //www.cvriskcalculator.com/
- Refer to ASCVD risk calculator at
- If risk <10% start with healthy lifestyle changes and reassess 3-6 months
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If risk is > 10% with hx of CVD, DM, or CKD recommend healthy lifestyle changes and begin BP lowering medication
- Reassess 1 month
- If goal not met within 1 month, consider different medication or titration
- Continue monthly f/u until goal is reached (Goal is < 130/80)
What is the blood pressure range for Stage II hypertension and what is the treatment/follow-up for this blood pressure range?
- Stage II HTN BP = _>_140/ _>_90
Treatment/Follow-up:
- Recommend healthy lifestyle changes and BP lowering medication (2 different meds of different classes)
- Reassess in 1 month
- If goal is met, reassess 3-6 months
- If goal not met, consider different medication or titration.
- Continue monthly f/u until the goal is achieved.
What is the blood pressure range for a hypertensive urgency and what is the treatment/follow-up for this blood pressure range?
- Hypertensive Urgency BP = >180/>120
- Many of these patients are noncompliant with antihypertensive therapy; reinstitute or intensify antihypertensive drug therapy
What are the goals of treatment for African Americans with HTN?
- Recommendations include using 2 or more antihypertensive medications to achieve a target of less than 130/80 mm Hg in this group
- Thiazide-type diuretics and/or calcium channel blockers are more effective in lowering BP alone or in multidrug regimens
- Morbidity and mortality related to hypertension are more common in African Americans and Hispanic adults compared with white adults.
What are the goals of treatment for older adults with HTN?
- Treatment of HTN with a SBP treatment goal of < 130/80 is recommended for non-institutionalized ambulatory community dwelling adults (Age < 65) with an average SBP 120mmHg or higher.
- For older adults > 65 with HTN and a high burden of co-morbidities and limited life expectancy, clinical judgment, patient preference and a team-based approach to assess risk/benefit is reasonable for decisions regarding intensity of BP lowering and choice of anti-hypertensive medications
What 3 steps should be taken to manage a patient with high blood pressure?
- Analyze baseline studies
- Use nonpharmacologic strategies
- Use pharmacologic measures
What are some nonpharmacologic strategies to manage high blood pressure?
- Restriction of dietary sodium to no more than 1500mg/day (optimal goal)
- Weight loss, if overweight
- Adopt a DASH (Dietary Approaches to Stop Hypertension) diet (rich in fruits, vegetables and low fat dairy products, with reduced saturated and total fat)
- Exercise 90-150 minutes/week aerobic exercise
- Stress management planning
- Reduction or elimination of alcohol consumption (fewer than 2 drinks per day for men and one drink daily for women or lighter weight persons)
- Smoking cessation
- Maintenance of adequate potassium, calcium and magnesium intake.
What is the goal of pharmacologic therapy with BP medications?
The goal is to prescribe the least number of medications possible at the lowest dosage to attain acceptable blood pressure; thereby, decreasing cardiovascular and renal morbidity and mortality (target end organ damage).
What are the first line antihypertensive medications?
- Thiazide diuretics (preferred of the preferred)
- CCBs
- ACE-Inhibitors
- ARBs.
What brand and dosage of thiazide diuretics is usually prescribed?
- Chlorthalidone - 12.5mg or 50mg tabs x1 daily
- Hydrochlorothiazide - 25mg or 50mg tabs x1 Daily
What are things to monitor for with Thiazide diuretics (ex: hydrochlorothiazide)?
- Monitor for hyponatremia and hypokalemia, uric acid and calcium levels
- Use with caution in hx of acute gout
- Screen for sulfa allergy prior to use
How do ACE inhibitors work?
Causes vasodilation and block sodium and water retention
What brand and dosage of ACE inhibitors is usually prescribed?
- Captopril - 12.5mg-150mg tabs x2-3 Daily
- Lisinopril - 10mg-40mg tabs x1 Daily
What are things to monitor for with ACE Inhibitors (ex: Lisinopril)?
- DO NOT use in combination with ARBs or direct renin inhibitor.
- Increased risk of hyperkalemia, especially in patients with CKD or in those on K+ supplements or K-sparing medications
- Do not initiate if K+ is greater than 5.5 mEq/L
- Do not use if history of angioedema with ACE inhibitors
- Avoid in pregnancy
- May cause cough, rash, taste disturbances
What brand and dosage of Angiotensin Receptor Blockers is usually prescribed?
- Losartan - 50mg-100mg tabs x1-2 Daily
What are things to monitor for with ARBs (ex: Losartan)?
- DO NOT use in combination with ACE/direct renin inhibitor
- Increased risk of hyperkalemia in CKD or in those on K+ sparing drugs
- Do not initiate if potassium is greater than 5.5 mEq/L
- May cause acute renal failure in patients with severe bilateral renal artery stenosis.
- DO NOT use if hx of angioedema with ARB; patients with history of angioedema with an ACE inhibitor can receive an ARB 6 weeks after ACE-I discontinued
- Avoid in pregnancy
What brand and dosage of Calcium Channel Blockers is usually prescribed?
- Amlodipine - 2.5mg-10mg x1 Daily
- Nicardipine - 5mg-20mg x1 Daily
- Nifedipine - 60mg-120mg x1 Daily
What are things to monitor for with CCBs (ex: Amlodipine)?
- Avoid use in patients with heart failure with reduced ejection fraction; amlodipine or felodipine may be used if required
- Monitor heart rate, especially when administering verapamil and diltiazem
- May be used for angina, arrhythmias and migraines
- May cause headache, flushing, bradycardia.
- Associated with dose-related pedal edema, which is more common in women than men
What brand and dosage of Loop Diuretics are usually prescribed?
- Bumetanide - 0.5mg-4mg x2 daily
- Furosemide (Lasix) - 20mg-80mg x2 daily
In what situations are loop diuretics used to control blood pressure?
- 2nd line agents for blood pressure control
- Preferred diuretics in patients with symptomatic heart failure
- Preferred over thiazides in patients with moderate-to severe CKD (GFR < 30mL/min)
What is the usual dose of metoprolol given and when is this drug used to control BP?
- Metoprolol succinate - 50mg-200mg x1 Daily
- Beta Blockers are not recommended as 1st line agents unless the pt has ischemic heart disease or heart failure with reduced EF
- Metoprolol is preferred in patients with bronchospastic airway disease because it will not induce coughing
What is the usual dose of clonidine prescribed and when is it used to control HTN?
- Clonidine PO - 0.1mg-0.8mg x2 daily
- Generally reserved as last line due to significant central nervous system adverse effects, especially in older adults
- May cause dry mouth, sedation, depression, headache, bradycardia
What is the usual dose of hydralazine prescribed and what is its MOA?
- Hydralazine - 50mg-200mg PO x2-3 daily
- MOA: Directly relaxes the vascular smooth muscle resulting in arterial vasodilation
What are the 8 systemic complications of chronic/untreated hypertension?
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Aneurysms
- Caused by increased cerebral artery pressures weakening and damaging the artery wall causing aneurysms to form and potentially rupturing.
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Chronic Kidney Disease
- Secondary to renovascular disease causing chronic ischemia and atrophy of the renal tubules
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Cognitive Changes
- Long-standing HTN is a major risk factor for vascular cognitive impairment and a potential risk factor for Alzheimer’s disease
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Hypertensive Retinopathy
- Damages blood vessels in the retina resulting in dim vision, headaches, visual disturbances and loss of vision
- HTN increases the risk of a number of ocular diseases, including diabetic retinopathy
- The two most common causes of vision loss, age-related macular degeneration and glaucoma, may be increased by the presence of systemic HTN.
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Cardiovascular Disease
- Narrowing of coronary arteries
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Heart Failure
- Secondary to left ventricular hypertrophy
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Peripheral Artery Disease
- Narrowing of peripheral arteries resulting in limb ischemia, neuropathy
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Intracerebral Hemorrhage
- Accounts for 8-13% of all strokes and is more likely to result in death or major disability than ischemic stroke or subarachnoid hemorrhage.
What are the 3 classifications of retinal microvascular changes due to HTN?
- Mild: retinal arteriolar narrowing r/t vasospasm, arteriolar wall thickening or opacification and arteriovenous nicking
- Moderate: hemorrhages, either flame or dot-shaped, cotton wool spots, hard exudates and microaneurysms
- Severe: some or all of the above, plus optic disc edema; the presence of papilledema mandates rapid lowering of the blood pressure.
