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6030 Primary Care Test 2 Complete ☑️ > Module 5 > Flashcards

Module 5 Flashcards

1
Q

HTN

-Stats

A
  1. Leading risk factor for Cardiovascular disease
  2. 30% of Americans, 72 million people
    - Prevalence of >65% in persons older than 60 yrs old
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2
Q

Cardiovascular Disease

-HTN

A
  1. BP level and the risk of CVD events are Continuous, consistent, and INDEPENDENT of other risk factors
  2. The night the BP the greater the risk of MI, HF, CVA, PAD, retinopathy, and kidney dz
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3
Q

Cardiovascular Risk Factors

A
  1. HTN
  2. Smoking
  3. Obesity
  4. Physical inactivity
  5. Dyslipidemia
  6. Diabetes
  7. Poor oral health
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4
Q

HTN

-How to Dx?

A
  1. Dx of HTN is based on average of blood pressure taken on 2 or 3 separate occasions
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5
Q

HTN Screening

-Factors that affect reading?

A

Some factors can transiently elevate BP. These include:

  1. Anxiety, cold, full bladder, recent exercise, Smoking or caffeine w/ 30 minutes of measurement
  2. Meds, oral contraceptives*, appetite suppressants, nicotine
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6
Q

Primary HTN

-Essential HTN

A
  1. Development of HTN w/out a reversible cause

2. Affects approximately 95% of the cases

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7
Q

Primary HTN

-Risk Factors?

A
  1. Age >55 yrs old
  2. Male Gender (ratio closes with age. 55-64 equal; 65-74 women are slightly higher rate)
  3. African American 2:1 to whites (African A usually don’t get treatment until end organ damage)
  4. Obesity
  5. Excessive sodium, low potassium diet, high dietary fat
  6. Physical inactivity
  7. Stress, smoking** and excessive alcohol intake
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8
Q

Primary HTN

-Patho

A
  1. Increase in peripheral arterial resistance resulting from increased cardiac output
  2. BP is a product of cardiac output and Peripheral resistance
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9
Q

Secondary HTN

-What is it?

A
  1. Development of HTN secondary to reversible cause
    Clinical Clues:
    -Presentation is ABRUPT and SEVERE
    -Age <30 yrs and non-obese
    -Negative Family Hx
    -Failure to respond to empirical therapy despite compliance
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10
Q

Secondary HTN

-Causes

A
  1. Renal parenchymal Dz
    - Creatinin level >1.5 mg/dl and GFR less than 50 ml/min
  2. Renal artery stenosis
    - 70-80% blockage in renal artery; renal artery murmur
  3. Primary Hyperaldosteronism
    - Biggest clue is unexplained Hyperkalemia**
  4. Pheochromocytoma (catecholamine-producing tumor of adrenal gland)
    - HTN, headache, excessive sweating, hyper metabolic state, & hyperglycemia
  5. Sleep apnea
  6. Alcoholic
  7. Meds (NSAIDS associated w/ HTN, steroids, tricyclic antidepressants)
  8. Aortic Coarctation
    - HTN in upper extremities; unattainable BP in lower extremities
  9. Cushing’s Syndrome
    - moon face, obesity, striae; urine cortisol needs to be ordered
  10. Thyroid disorder
    - Hypermetabolic state.
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11
Q

Patient Evaluation with HTN

-3 objectives?

A
  1. Assess lifestyle and identify other CVD risk
  2. Reveal identifiable causes of high BP
  3. Assess the presence or absence of target organ damage and CVD
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12
Q

HTN

-Medical Hx of Meds causing HTN

A
  1. Oral Contraceptives
  2. NSAIDS
  3. OTC cold remedies
  4. Anabolic steroids
  5. Licorice in excess
  6. Tricyclic antidepressants
  7. MAOI’s
  8. Diet pills ( 24 hour recall of dietary intake is helpful)
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13
Q

HTN

-ROS

A
  1. Vision change (Last eye exam)
  2. Thyroid problems
  3. SOB or difficulty sleeping at night
  4. Chest pain, edema, pain in legs
  5. Skin changes
  6. Sexual function (Impotence)
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14
Q

HTN

-Possible Differentials (4)

A
  1. White coat syndrome
  2. Isolated systolic HTN
    - SBP of 160 or greater w/ diastolic <90
    - Treat the same as normal HTN
  3. Any one of the secondary causes
  4. Cocaine use
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15
Q

HTN

-Treatment Goal

A
  1. Ultimate public health goal of anti hypertensive therapy is the Reduction of cardiovascular, cerebrovascular, and renal morbidity and mortality! ***
  2. Treating to target systole and diastolic BP that are associated w/ decrease in HTN associated complications
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16
Q

HTN

-Lifestyle Modification

A
  1. Reduction of excess weight (BMI on every patient chart)
  2. Reduce Sodium intake
    - 75% of once daily salt intake comes from processed food!
    - Dash diet helpful as prescriptive pt education
  3. Exercise 3-5x weekly
  4. Less Alcohol
    - Men = 2 drinks daily
    - Women = 1 drink daily
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17
Q

HTN

-Dash Diet

A
  1. Relationship between lower sodium intake and hypertension
  2. BP decreased in response to a universally recommended diet containing:
    - Generous servings of fruits, veggies, and low-fat fairly
    - Reduced sodium, saturated and total fat, and increased potassium
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18
Q

HTN

-BP and Sodium Intake

A
  1. 2300 mg of sodium tolerable upper intake level for general adult population
  2. Excessive sodium linked to high BP.
    - Leading to CVD, stroke and cardiac-related mortality
19
Q

HTN

-Categories JNC8

A
  1. Normal BP
    - 120-129 SBP; and <80 DBP
  2. Pre-Hypertension
    - 130-139 SBP; 80-89 DBP
  3. HTN under 60 yrs old
    - 140/90
  4. HTN over 60
    - 150/90
20
Q

HTN

-Categories 2017 ACC/AHA

A
  1. Elevated BP
    - 120-129 SBP; <80 DBP
  2. Stage 1 HTN
    - 130-139 SBP; 80-89 DBP
  3. Stage 2 HTN
    - 140-159 SBP; 90-99 DBP
21
Q

HTN

-Thresholds for Treatment JNC-8

A
  1. Age 60 or greater
    - Treat starting at >/= 150/90.
    - Treatment goal is <150/<90
  2. Age 59 or less
    - Treat starting at >/= 140/90
    - Same recommendation fo CKD and DM
22
Q

JNC-8 Evidence for Treatment Recommendations

A
  1. Grade A evidence for both general population above and below 60 years old
  2. Goals reduce risk of CVA, HF, and overall mortality/coronary heart disease.
  3. Grade A evidence for ages 30 and up
  4. Grade E “Expert Opinion” in ages 18-29 years old
23
Q

BP Thresholds for Treatment AHA

-Normal BP <120/80

A
  1. Promote optimal lifestyle habits

2. Reassess in 1 year (Class IIa)

24
Q

BP Thresholds for Treatment AHA

-Elevated BP (120-129/ <80)

A
  1. Nonpharmacologic Therapy (class I)

2. Reassess in 3-6 months (Class I)

25
Q

BP Thresholds for Treatment AHA

-Stage 1 HTN (130-139/80-89)

A
  1. Clinical ASCVD or estimated 10y CVD risk factor >/= 10%
  • If YES; Initiate Nonpharmacologic therapy and BP lowering Medication; reassess 1 month
  • If NO; Initiate Nonpharmacologic therapy; reassess in 3-6 months
26
Q

BP Thresholds for Treatment AHA

-Stage 2 HTN (>/= 140/90)

A
  1. Nonpharmacologic therapy
    AND
  2. BP-lowering medication (Class 1)

MAKE SURE BP has been measured and is average of 2-3 readings above 140/90

27
Q

SBP Intervention Trial

-SPRINT

A
  1. Conducted in US and Puerto Rico at 102 clinical sites
  2. One group was treated to a BP of 135-139; second group treated to BP <120
  3. Lower reates of both CV deaths and CV events in group maintained BP at or below 120 SBP
28
Q

Actions to Control CV Risk in Diabetes

-ACCORD TRIAL

A
  1. Multi center RCT, 4733 participants
  2. Primary composite outcome was non-fatal MI, CVA, or death from CV causes.
    - Mean follow-up was 4.7 years
  3. Pt’s with Type 2 diabetes at high risk for CV events:
    - Targeting a SBP of less than 120 compared to less than 140, DID NOT reduce the rate of a composite outcome of fatal and non-fatal major CV events.
29
Q

Evidence for treatment of Diastolic BP

A
  1. Expert Opinion recommendation for goal of <80 DBP
  2. Treatment of <90 DBP is based on RCT beginning in 1960’s
    - Trials have shown improved CV outcomes
30
Q

HTN Treatment

-American Academy of Family Physicians

A
  1. General population, 140/90 is the treatment threshold

- AAFP felt strongly that the JNC8 upheld the scientific rigor that provided strong recommendations to family providers

31
Q

HTN Medications

-4 Types of Meds?

A
  1. Thiazides Diuretics
  2. Calcium Channel Blockers (CCB)
  3. Angiotensin-converting enzyme inhibitor (ACEI)
  4. Angiotensin Receptor Blocker (ARB)
32
Q

HTN Medications

-Thiazides Diuretics

A
  1. Proven to be most effective out of all classes of HTN meds in improving HEART FAILURE outcomes
33
Q

HTN

-Patient Education

A
  1. HTN is a risk factor for CVD and other poor outcomes
  2. Medication: purpose, dose, S/E
  3. Diet: DASH diet; cholesterol
  4. Provide low calorie diet
34
Q

HTN

-When to Refer

A
  1. Pt’s Unresponsive to usual therapy
  2. Suspected secondary HTN
  3. Those w/ signs of renal failure or other target organ damage
35
Q

HTN

-Follow-up and monitoring

A
  1. Once anti-hypertensive drug therapy is initiated
    - Most Pt’s should return Monthly
    - If Pt has comorbidities or severe elevation; see daily, few days, or weekly
  2. Once Pt is at goal, see pt every 3-6 months
36
Q

HTN Special Considerations

-Metabolic Syndrome

A
  1. Abdominal Obesity
    - Waist circum >40 in men >35 in women
  2. Glucose intolerance
    - Fasting glucose >/= to 110mg/dl
  3. BP >/= 130/85
  4. High triglycerides >/= 150mg/dl/ OR Low HDL <40 in men; <50 in females
37
Q

HTN Special Considerations

-Left Ventricular Hypertrophy

A
  1. INDEPENDENT risk factor that increases risk of subsequent CVD
  2. REGRESSION occurs w/ aggressive BP mgmt, including:
    - Weight loss
    - Sodium restriction
    - Treatment w/ previously mentioned drug therapies
38
Q

HTN Special Considerations

-Peripheral vascular disease?

A
  1. Equivalent in risk to ischemic heart disease

2. Treat HTN, manage other risk factors aggressively

39
Q

HTN Special Considerations

-Elderly Population

A
  1. Start low and Go SLOW!!
    - Unsafe drop in BP can cause falls and fractures
  2. HTN occurs in 2/3 of individuals older than 65
40
Q

Postural Hypotention

A
  1. A decrease in standing SBP >10
  2. Associated w/ dizziness or fainting
  3. More frequent with:
    - Older Patients with ISH, Diabetes, Pt’s on Diuretics, Vasodilators, and some psychotropic drugs
41
Q

Hypertensive Crisis

-Definition

A
  1. Defined by SBP >/= to 180 and DBP >/= 120 **

2. Can be a Hypertensive Urgency or Hypertensive Emergency

42
Q

Hypertensive Crisis

-Hypertensive Urgency

A
  1. Most patients with significantly elevated BP have NO acute, end organ damage

NO END ORGAN DAMAGE
-Most Common

Can be managed with:

  • Loop diuretics, beta blockers, ACE inhibitors, calcium antagonists
  • Lower over a 12 to 24 hour period
43
Q

Hypertensive Crisis

-Hypertensive Emergency

A
  1. Significantly elevated BP w/ s/s of acute ongoing target-organ damage
  • Neurologic
  • Cardiac
  • Vascular
  • Renal

Transfer to ER immediately

6030 Primary Care Test 2 Complete ☑️ (8 decks)

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