Pharm - HTN Flashcards
The relationship b/w BP and risk of CVD is what?
- continuous
- consistent
- independent of other risk factors
The higher the BP, the greater chance for what? (4)
- MI
- heart failure
- stroke
- kidney dz
List the benefits of lowering blood pressure
- drug therapy substabtially reduces the risks of cardio events and death in pts w/ high BP
- associated w/ reduction in stroke incidence, MI, and heart failure
Identify the methods to determine a patient’s blood pressure most accurately
- pt seated quietly for at least 5 mins in chair (not exam table), w/ feet on floor, arm supported at heart level
- appropriate sized cuff
- 2-3 measurements from at least 2 times during the day should be taken and averaged
- verify on opposite arm
- ambulatory BP monitoring (ABPM)
- check home measurement devices for accuracy
what is ambulatory BP monitoring?
- device that a pt can wear for 24 hrs or more
- provides info about BP during daily activities, exercise and sleep
- correlates better than ofice measurements w/ target organ injury
when is the use of ambulatory BP monitoring warranted?
- white-coat syndrome
- apparent drug resistance (non-adherance usually)
- hypotensive symptoms w/ meds
- episodic hypertension
- autonomic dysfunction
what defines a BP cuff as appropriate size?
-air bladder encircling at least 80% of arm
when is measurement of BP in the standing position indicated?
those at risk for postural hypotension
State the three objectives of patient evaluation
- assess lifestyle and ID other cardio risk factors or concomitant disorders that may affect prognosis or tx
- reveal identifiable causes of high BP
- assess for target organ damage and CVD
What are the major cardiovascular risk factors that are components of the metabolic syndrome? (4)
- HTN
- obesity (BMI > or equal to 30)
- dyslipidemia (elevated LDL or total cholesterol or low HDL)
- DM
What are the identifiable causes of high BP?
- sleep apnea
- drug induced
- chronic kidney dz
- primary aldosteronism
- renovascular dz
- chronic steroid therapy and Cushing’s
- pheochromocytoma
- coarctation of aorta (congenital)
- thyroid/parathyroid dz
List the information to be obtained in the physical examination and assessment of a patient with high blood pressure (9)
- appropriate measure of BP, verifies, and pulse
- optic fundi exam
- calculate BMI
- auscultation for carotid, abdominal and femoral Bruits
- palpation of thryoid
- thorough heart and lung exam
- exam of abdomen for enlarged kidneys, masses, or abnormal aortic pulsation
- palpation of lower extremities for edema and pulse
- neuro assessment
List the routine laboratory tests that should be performed before initiating specific therapy for hypertension (9)
- electrocardiogram
- urinalysis
- blood glucose
- hematocrit
- serum K
- creatinine (or estimated GFR)
- Ca++
- lipid profile
- optional: urinary albumin excretion / albumin/creatinine ratio
why is an electrocardiogram done in lab tests for HTN?
-assess for cardiac dz to establish baseline prior to drug therapy (it may impact rhythm and rate)
why is an urinalysis done in lab tests for HTN?
to assess for secondary causes for high BP
why is a blood glucose done in lab tests for HTN?
to assess for DM or other secondary causes of high BP and to establish a baseline before drug therapy since some meds may affect glycemic control
why is a hematocrit done in lab tests for HTN?
elevations may result in increased BP
why is a serum K done in lab tests for HTN?
- assess for secondary causes such as hyperaldosteronism and Cushing’s
- ACE ARBs and aldosterone antagonists may elevate serum K
- diuretics may lower
why is a creatinine done in lab tests for HTN?
- assess for target organ damage
- establish baseline before drug therapy that may affect renal function
- ACEIs and ARBs may increase serum creatinine
why is a calcium done in lab tests for HTN?
-establish a baseline before drug therapy b/c some meds may alter Ca++ homeostasis
why is a (fasting) lipid profile done in lab tests for HTN?
- assess for cardiovascular risk
- establish baseline
- some meds can negatively impact lipid profile (HCTZ)
What lab test is especially important to run for HTN for pts w/ DM?
- urinary albumin excretion or
- albumin/creatinine ratio
when might additional diagnostic procedures be indicated to identify causes of hypertension
in patients whose:
- age, hx, PE, severity of HTN, or initial labs suggest other causes
- BP responds poorly to drug therapy
- BP begins to increase for uncertain reason after being well controlled
- onset is sudden
screening test for chronic kidney dz
estimated GFR
screening test for coarctation of aorta
- CT angiography
- may see decreased pressure in lower extremities or delayed/absent femoral pulse
screening test for Cushing’s or other glucocorticoid excess states
- hx
- dexamethasone suppression test
- truncal obesity, glucose intolerance, purple striae may suggest Cushings
screening test for drug induced HTN
- hx
- drug screening
screening test for pheochromocytoma
- 24 hr urinary metanephrine and nor-metanephrine
- suspected in pts w/ labile HTN accompanied by HA, palps, pallor, perspiration
screening test for primary aldosteronism and other mineralocorticoid excess states
- 24 hr urinary aldosterone level of specific measurements of other mineralocorticoids
- may see unprovoked hypokalemia
screening test for renovascular HTN
- doppler flow study
- MRA
- may see elevated creatinine or abnormal urinalysis in certain kidney dzs
screening test for sleep apnea
sleep study w/ O2 sat
screening test for thyroid/parathyroid dz
- TSH and serum PTH
- may see hypercalcemia in hyperparathyroidism
ID the circumstances that should raise a clinician’s suspicion for hypertension caused by renal artery stenosis
- onset of HTN before 30 (esp in absence of fam hx)
- significant onset after age 55
- abdominal bruit, especially if diastolic component present
- accelerated HTN
- HTN formerly controlled, now resistant
- recurrent flash pulmonary edema
- renal failure of uncertain etiology (esp in absence of proteinuria or abnormal urine sediment)
- acute renal failure precipitated by therapy w/ ACEI or angiotensin receptor blocker under conditions of occult bilat renal a. stenosis or moderate-sever vol. depletion
