Monday HTN lecture Flashcards
What are 5 types of HTN?
1) Essential
2) Secondary hypertension
3) Resistant HTN
4) Asymptomatic severe HTN (HTN urgency)
5) HTN emergency (covered in Emergency Medicine)
What are 2 types of hypertensive crisis?
1) Hypertensive urgency
2) Hypertensive emergency
1) What is HTN an independent risk factor for?
2) Risk of vascular death increases from a “normal” blood pressure of < __________ mm Hg
3) What happens for every 20 mm Hg systolic or 10 mm Hg diastolic increase?
1) Ischemic cardiovascular events
2) 120/80
3) Risk of major cardiovascular events & stroke doubles
Treatment of HTN reduces what?
All causes of mortality and results in regression of pathologic cardiac structural changes
What does physiology help you do?
Helps you with identification of secondary causes of HTN and how the interventions work to reduce blood pressure.
Physiology review:
Primary role of sympathetic system is to do what? What is the resting state?
Regulate BP; resting state of moderate vasoconstriction
Physiology review:
How is vascular tone typically regulated?
Sympathetic stimulation = relative vasoconstriction (except?)
Decrease in sympathetic stimulation = relative vasodilation
Physiology review:
What converts angiotensin 1 into angiotensin II?
ACE in lungs + renal endothelium
Physiology review:
What is the effector chemical in the RAAS?
Angiotensin II
Physiology review:
What are the effects of angiotensin II?
1) Increase symp. activity
2) Tubular sodium + Cl reabsorption, K+ excretion, H2O retention
3) Stimulates adrenal cortex to increase aldosterone secretion
4) Arteriolar vasoconstriction (increases BP)
5) Pituitary gland’s posterior lobe to secrete ADH (increasing H2O reabsorption)
Give examples of modifiable and non-modifiable risk factors for HTN
1) Modifiable: Smoking, obesity, high-sodium diet, excessive alcohol consumption, and physical inactivity.
2) Non-modifiable: Family history, age, male sex, and ethnicity
Give an example of a co-morbidity related to secondary HTN
Chronic kidney disease
What are 4 questions you should be able to answer regarding HTN?
1) What is normal blood pressure?
2) Who should be screened for HTN?
3) How is blood pressure measured?
4) What blood pressure threshold is used to diagnose HTN?
True or false: Not all guidelines agree on what normal BP is
True
What are the 2 main BP guidelines?
ACC/AHA 2017
JNC-8 2014
What does the USPSTF say abt screening for HTN in kids?
Not enough evidence to conclude
What does the USPSTF say abt screening asymptomatic pregnant women for HTN?
Recommends screening for hypertensive disorders in pregnant women with BP measurements throughout pregnancy (B)
How is HTN screened and diagnosed?
Office visit BP measurements to screen
Out of office BP measurements to diagnose
Describe the diagnosis of HTN
-Challenging in busy practice
-Accurate diagnosis HTN is important – correct methodology of measuring BP
Describe screening BP in the office
1) Patient: Sitting quietly for 5 minutes, feet and back supported
-Avoid smoking, caffeine, and exercise for 30 minutes prior to measurement
2) Equipment: BP cuff should encircle 80% of arm, arm at heart level
-Manual or automatic
3) Initial visit: Measure in both arms (highest is documented BP)
-3 measurements 1-2 minutes apart, average used to determine BP
1) What is a reasonable alternative to ABPM for HTN Dx?
2) What are better predictors of CV disease than office BP?
1) Home BP monitoring is a reasonable alternative
2) Both ambulatory and home BP monitoring
1) Describe white coat HTN
2) Describe masked HTN
1) HTN in office, no HTN at home. Minimal/ slight increase in CVD risk, up to 35% prevalence
2) No HTN in office, but HTN at home. Similar to sustained HTN regarding CVD risk; limited data on prevalence
What should you do if an office BP suggests elevated BP?
1) Ambulatory BP measurement: GOLD STANDARD; limitations due to insurance coverage
2) Home BP measurement: initial modality to confirm for most patients
3) Out of office confirmation not practical (equipment, insurance, skill, and cost)
-Average of serial office BP measurements spaced over a period of several visits
What are the criteria for a Dx of HTN?
1) Diagnosis of HTN (ICD-10 code I11.9) = serial BP measurements >130/80 mm Hg
ICD-10 code R03.0 = elevated BP w/o dx of HTN
2) At least 2 readings
3) On at least 2 different occasions
4) Out of office confirmation is recommended
-To rule out white coat HTN + capture masked HTN
HTN crisis is quantified as what according to ACC thresholds?
> 180 systolic or 120 diastolic
ACC/AHA guidelines; list them for:
1) Clinical CVD or 10yr ASCVD risk >/=10%, diabetes, HTN, CKD, CHF, CAD, PAD
2) Secondary stroke prevention
1) >/=130/80 threshold for Tx; goal of <130/80
2) >/= 140/90 threshold for Tx; goal of <130/80
ACC/AHA guidelines; list them for:
1) No clinical CVD and 10yr ASCVD risk <10%
2) Older persons (>/=65 years; noninstitutionalized, ambulatory, community-living adults)
1) >/= 140/90 to Tx, goal of <130/80
2) >/= 130/80 to Tx, goal of <130 (SBP)
Diagnostic evaluation of HTN should focus on several major areas, including what? (4 things)
1) Possible secondary HTN
2) S/Sx of coexistent illness
3) HTN mediated organ damage – brain (and retina), heart, PVD, kidneys
-Acute or chronic
4) Assessment of overall cardiovascular risk
Describe primary HTN
Common
Onset is gradual
Usually over 40 y/o
Symptoms remote from onset
+ Family history
Idiopathic
Life long
Describe secondary HTN
(important)
Less common
Onset acute
Younger/elderly onset
Symptomatic at onset
Family Hx +/-
May resolve with treating underlying etiology
List the ACC BP thresholds (4 categories)
1) Normal: <120 and <80
2) Elevated: 120-129 and <80
3) HTN stage 1: 130-130 or 80-89
4) HTN stage 2: >/= 140 or >/= 90
List 2 common causes of secondary HTN not emphasized on the slides (but that he mentioned)
Thyroid issues (esp. hyper), hyperaldosteronism (Addison’s disease)
Secondary HTN causes:
1) How common is OSA?
2) Main Sx?
3) How is it screened for?
4) How is it diagnosed?
5) How is that scored? How is it treated?
1) Very common condition
2) Snoring
3) STOP-BANG
4) Sleep study
5) AHI 5-15 is mild
15 – 30 is moderate
> 30 is severe
-CPAP device
Secondary HTN causes:
1) What is chronic kidney disease?
2) What are 2 types of renovascular disease?
1) Renal parenchymal diseases
2) Atherosclerosis
Fibromuscular dysplasia
Secondary HTN causes:
1) What are 2 types of renal parenchymal disease?
2) What are a couple clues?
3) The first-line imaging test is what?
4) Do you need to refer these pts?
1) Glomerulonephritis and polycystic kidney disease
2) Early-onset and resistant HTN
-Frequent urinary tract infections, hematuria, nocturia, family history of polycystic kidney disease, and/or elevated serum creatinine level
3) Renal ultrasonography, to assess for the presence of underlying disease
4) Referred to a nephrologist for further evaluation, including possible kidney biopsy
1) Renovascular disease has a prevalence of up to _______ of patients with secondary HTN.
2) Who is it suspected in?
3) Renal artery stenosis also should be considered if there is more than a _____% decrease in eGFR after management with an angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB)
1) 1/3
2) Patients with resistant/difficult-to-control HTN
3) 30%
1) What are some clues for renal artery stenosis?
2) What may it present with?
1) Younger than < 30 y/o, most common due to fibromuscular disease
Older than 30 y/o, most common atherosclerotic disease
2) Accelerated or resistant HTN, renal disfunction, flash pulmonary edema
-ACEi/ARBs may worsen renal function and/or hyperkalemia
Clinical findings suggestive of renovascular disease in a hypertensive patient include what 2 things?
1) Bruits (abdominal/renal): systemic effects of atherosclerotic vascular disease
2) Significant increase in serum creatinine after starting Rx for HTN
Renovascular disease in HTN pts:
1) What is the initial diagnostic imaging?
2) What is as effective as renal artery revascularization (angioplasty or stenting) in managing atherosclerotic RAS?
1) Renal magnetic resonance angiography (MRA)
2) Medical therapy
Recommended medical approach to renal artery stenosis includes what? (4 things)
1) Improved glycemic control for patients with diabetes,
2) Rx: initiation of a renin-angiotensin system (RAS) antagonist – e.g., spironolactone
3) Rx: antiplatelet and statin therapy (for atherosclerosis – a systemic process)
4) Lifestyle - smoking cessation
Secondary causes of HTN:
Renovascular disease: Who should you Tx with revascularization?
Patients who do not benefit from medical management and for those with Takayasu arteritis (large vessel arteritis/fibrosis) or fibromuscular dysplasia
Describe primary hyperaldosteronism (incl. who it’s found in, what supports Dx, what is on BMP, etc)
1) Present in 5-10% of HTN patients and 7-20% of those with resistant HTN
2) Unprovoked hypokalemia further supports this diagnosis although is not present on the majority of cases
3) Low K+ noted in BMP
4) Diagnosis is based on aldosterone:renin ratio
What are some other secondary causes of HTN? Incl. in children.
1) Pheochromocytoma
2) Hypercortisolism
3) Hyperthyroidism
4) Excessive alcohol
5) Meds: NSAIDS, corticosteroids, some antidepressants, sympathomimetics
6) In children: coarctation of aorta, renal parenchymal disease
Give the OLDCARTS for HTN
CC: none – found with screening BP or may have CC consistent with end organ damage
Onset, duration, timing – chronic, insidious (may be acute if secondary)
Location: cardiovascular (may be more widespread if secondary)
Character: asymptomatic (may have end organ damage if secondary)
Alleviating: none (treat underlying cause is secondary)
Aggravating: OTC and Rx medications, anxiety, lifestyle
Risk factors:
Modifiable – smoking, obesity, excessive salt intake and alcohol consumption, physical inactivity
Non-modifiable – family history, age, sex, ethnicity
Associated Symptoms: primary HTN – none, secondary HTN varies
When looking for signs of end organ damage on PE:
1) What should you look for regarding general appearance?
2) What abt in VS?
1) Distribution of body fat, skin lesions, muscle strength, alertness/orientation (brain, aldosterone, Cushing’s)
2) BMI, BP both arms (Subclavian Steele syndrome) and one leg (aortic coarctation)
When looking for signs of end organ damage on PE, what may fundoscopy show for hypertensive retinopathy?
-Ischemia causes optic nerve edema, cotton wool spots
-While leakage causes hemorrhage and disc edema
-Elevated retinal artery BP causes A-V nicking, copper wire arterioles
When looking for signs of end organ damage on PE, what should you look for for each of the following?:
1) Neck
2) Lungs
3) Abdomen
4) Extremities
1) Palpation and auscultation of carotids and thyroid gland
2) CTA
3) Renal masses, bruits over abdominal aorta and renal arteries, femoral pulses
4) Peripheral pulses, edema
When looking for signs of end organ damage on PE, what should you look for for each of the following?:
1) Skin
2) Neurologic
1) Stigmata of Cushing’s
2) MS changes (confusion), visual disturbance, focal weakness
When looking for signs of end organ damage on PE, what should you look for on a cardiovascular exam?
1) Cardiac PMI displacement (enlarged LV), S4 gallop (stiff LV)
2) Palpate peripheral pulses and listen for bruits; especially renal
Subclavian Steel Syndrome:
1) What is it?
2) What does it cause?
1) Right subclavian stenosis
2) Blood flows from left vertebral artery to basilar to right subclavian artery to right arm resulting in potential posterior CNS ischemia
Coarctation of the aorta:
1) What is it?
2) What does it result in?
1) Stenosis of the aortic arch
2) Blockage of blood flow to the descending aorta and distribution
-Overload and elevated BP of head and UE
Hard exudates, inflamed macula, flame hemorrhage, and cotton wool spots may indicate what?
HTN damage
What lab testing should you do for HTN?
1) CBC (CKD with microcytic anemia)
2) Renal panel – electrolytes (K+) and serum creatinine to calculate eGFR (CKD)
-look for hyperaldosteronism
3) Urinalysis – proteinuria + …. Prompt urinary albumin to creatinine ratio
4) Fasting glucose or A1C
5) TSH
6) Lipid profile (additional) CV risk
1) Why should you do an ECG for HTN?
2) What should you calculate if appropriate?
1) ECG for LVH, LAE
Echo if LVH seen on ECG
2) 10-year ASCVD risk
What additional testing should be done & for who with HTN?
1) Urinary microalbumin to creatinine ratio in all patients with CKD or DM
2) Microalbumin : creatinine ratio is recommended annually in all DM
Describe Targeted approach of evaluation for secondary HTN in patients with unusual presentation
1) New onset in young or old age
2) Presentation with severe HTN
3) Abrupt onset in previous normotensive patient
4) Significant recent elevation in BP in a patient with previously well controlled HTN (compliant patient)
1) What is drug resistant HTN a sign of?
2) Give examples of clinical clues for a specific cause of HTN
1) Drug resistant HTN (3 or more drugs and still not well controlled BP) concerning for secondary HTN
2) Abdominal bruit (RAS), low serum K+ (primary aldosteronism)
