Prevelance Of Hypertension Flashcards
How much of a blood pressure increase is needed to double your risk of heart attack/stroke?
20 systolic and 10 diastolic
How does renal artery stenosis cause hypertension?
High renin levels
How does pheochromocytoma cause hypertension?
Large amount of Catecholamines presence caused by increased norepinephrine release from the tumor
How does End stage renal disease (ESRD) cause hypertension?
Fluid overload causes increased volume levels.
Factors that increase blood pressure
Cardiac output: directly proportional
Blood volume: directly proportional
Flexibility of arteries: directly proportional
Blood viscosity: directly proportional
Diameter of arteries: inversely proportional
Primary vs secondary
Primary
- mass majority of cases
- caused idiopathically By age, genetics, alcohol consumption obesity
Secondary
- minorities of cases
- caused usually by an indirect issue such as drugs/medication, kidney disease, apnea, endocrine issues, etc.
What are common etiologies of 2nd HTN in people between 0-18 yrs?
Renal parenchyma disease
Aortic coarctation
Improper Medications
What are common etiologies of 2nd HTN in people between 19-39 yrs?
Thyroid dysfunction
Fibromuscular dysplasia
Renal parenchymal disease
Endogenous Cushing syndrome
- too much cortisol in blood caused by genetic and body abnormalities
What are common etiologies of 2nd HTN in people between 40-64 yrs?
Hyperaldosteronism
Thyroid dysfunction
Exogenous Cushing syndrome
- too much cortisol in the body caused by taking too much of a cortisol-like drug dose
Pheochromocytoma
What are common etiologies of 2nd HTN in people between greater than or equal to 65 yrs?
Renal artery stenosis
Hypothyroid
Chronic kidney disease
What is the most common cause of resistant hypertension?
Obstructive Sleep apnea
Aldosteronism
“Cons syndrome”
Resistant HTN due to adrenal tumors or bilateral adrenal hyperplasia
Causes hypocalemia in some of cases
Most commonly occurs in patients on 3+ medications with blood pressure that wont come down
What are the two most common causes of renal bruits?
Fibromuscualr dysplasia (more common in younger females) - arteries look like “string of pearls “ and narrows the renal arteries due to muscular disorders
Renal artery stenosis (more common in elderly patients)
- atherosclerosis from plaque build up involving renal arteries
- will always show an increase in roughly 30% of serum Cr/K+ when starting ACEI/ARB
How to measure a renal artery bruit
Usually in the upper right or left quadrant in the abdominal wall.
Will sound like a “whoosh”
Examples of bad kidney diseases that often affect HTN
Recurrent UTIs
Kidney stones
Chronic HTN for other reasons
Glomerulonephritis
Polycystic kidney disease
- all alter the renin-angiotensin system, inhibt nitric oxide production (vasodilator) and increase endothelium production*
- all lead to HTN and vasoconstriction
Murmurs in the Aortic region can signify what?
Aortic stenosis
Flow mummers
Aortic valve sclerosis
Murmurs heard in the pulmonic area are indicative of what?
Pulmonic stenosis
Flow murmurs
What is the most common dietary issues for 2nd HTN?
Increased alcohol consumption and high sodium intake
What is alcohols affect on HTN?
Immediately after consumption causes vasodilation (1-2 hrs) and then vasoconstriction.
(biphasic effects)
Can cause HTN when sleeping
How to get an accurate measurement of BP
Make sure resting for 5 minutes and no caffeine/ tobacco/exercise 30 min prior
Arm and back are supported with feet on ground
Never measure BP over clothing
Arm is at heart level
No talking
Which measurement (DBP or SBP) is most determinetal for heart disease?
Both are, so MAP is more important
MAP = SBP + 2(DBP)/3
Nocturnal Dip
Normal drop in blood pressure of 10-20% when sleeping
- if this doesn’t happen (i.e sleep apnea/being black) there is a higher risk of CV events.
White coat HTN
BP naturally goes up when people know they are being monitored in the office
Because of this, 24-hr monitoring is the best source for determine BP
Masked HTN
Usually young males who have normal BP when in the office but outside of the office they have high BP during daily activities
First choices for Tx of HTN
ACE/ARBs/CCB/ diuretics
Most effective diuretic is chlorthalidone*
- hydrochlorothiazide is more commonly used since cheaper, but is less effective*
- try to keep to QD dosing (once a day) or less*
Lifestyle treatments
Diet low in sodium and high in potassium (DASH)
Recommend aerobic exercise 3-5x wk
Limit ETOH and stress
Get 8 hrs of sleep
Tx for HTN in African American populations
Usually start w/ diuretics and CCBs
Don’t respond well to ACE inhibitors and ARBs
Tx for HTN in patients with migraine
Beta Blockers and CCBs are first line
Tx for HTN in patients with Gout
DONT use diuretics since it increases Uric acid levels
Anything else is okay
Tx for HTN in diabetic populations
W/ nephropathy = ACE and ARBs
Without nephropathy = ACE ARB and CCBs
- dont use diuretics much since they raise glucose levels*
Measurements for chronic mild/moderate and severe HTN in pregnancy
Chronic = known history or HTN for the 1st 20 weeks of gestation
Mild/ moderate = 140-159/90-109
Severe = >160/>110
- most agencies (especially ACOG) suggest to not treat/ discontinue current HTN drugs unless severe HTN is present (160/110) or greater*
- this is because these limit blood supply to the placenta and therefore the child
ACOGs definition of Pre-eclampsia
Severe HTN (>160/>110) w/ any of the following 1) platelet leaves <100K
2) liver enzymes 2x normal level
3) serum creatine levels are double normal level
4) Serve RUQ pain
5) Pulmonary edema
6) Visual dysfunctions starting along side pregnancy
Lifestyle Tx for HTN in pregnancy
DASH diet and cutting off tobaccos/alcohol w/ mild exercise
DONT use low salt or weight loss recommendations
This is used in mild-severe HTN, but meds are only used in Severe HTN
HELLP syndrome
Hemolysis
Elevated Liver enzymes
Low Platelets
When these symptoms arise, can be considered a subset of severe pre-eclampsia that can develop eclampsia
30% mortality rate and needs to be treated w/ magnesium sulfate, IV HTN drugs and corticosteroids
Antihypertensives safe for pregnancy
Beta blockers (except for atenolol which causes growth retardation)
Centrally acting agents (a-methyldopa)
CCBs
DONT USE ACEIs/ARBs, NITROPRESSIDE AND SPIRONOLACTONE
Is the majority of pediatrics HTN primary or secondary?
Primary now due to rising obesity and type 2 diabetes
Hypertensive crisis
HTN emergency and urgency
Urgency: Categorized as severe HTN without end organ damage
- SBP > 180 and/or DBP > 110mmHg
- NO acute end organ injury
- more common in men
Emergency: categorized as severe HTN with end organ damage
- can’t envelop malignant HTN (HTN that is widespread and affects at least 3 organs)
Most common systems affected in “end-organ” damage during HTN emergency
Cerebral and cardiac
Includes the one or more of the following:
1) stroke
2) vascular dementia (silent strokes)
3) chronic kidney disease/ ESRD
4) MI
5) LVH
6) CHF
7) Aortic aneurysm
8) retinopathy and retinal artery thrombosis
Treatment of HTN emergency
Follow PEARLS protocol
- lower BP SLOWLY (prevent hypotension and increased baroreflex)
- 3 exceptions to this*
- eclampsia
- ischemic/hemorrhagic stroke
- aortic dissection
Tx for HTN emergency in aortic dissections
Lower HR to under 60 bpm immediately and SBP under 120 within 20 min
- usually IV beta blocker then nitroprusside or Nicardipine
Tx for HTN of hemorrhagic stokes
Aggressively lower SBP to 140-160 within 2 hrs
Spontaneous intracranial hemorrhagic stoke occurs if SBP is 220 mmHg or higher
Broad definition of HTN
> 130 SBP
> 80 DBP
How has the prevelance of HTN changed from 2000-2017?
All areas have gotten worse except for canada
Are there gender disparities for HTN?
Generally no, however men do have slightly higher incidence rates
How has HTN guidelines changed?
Before 2017:
- HTN = > 140/90
- 25-30% of population
After 2017 (NOW)
- HTN = > 130/80
- > 140/90 is now equivalent to Stage 2 HTN
- 46% of population
What three organizations dont adhere to the new 2017 HTN guidelines?
AAFP, ACP and European Union
“A” causes for 2nd HTN
Improper accuracy of measurement
Aldosteronism
Sleep apnea (MOST COMMON)
“B” causes for 2nd HTN
Bruits
Bad kidneys
“C” causes for 2nd HTN
Catecholamines
Coarctation of aorta
Cushing’s syndrome
“D” causes for 2nd HTN
Improper drug use
Diet (increased salt/alcohol consumption, decreases activity levels)
“E” causes for 2nd HTN
Erythropoietin (blood doping)
Endocrine
How do ACE inhibitors and ARBs cause renal function to decline in renal artery stenosis?
Blocks angiotensin 1 -> angiotensin 2 conversion
Prevents glomerulus from maintaining pressure = poor kidney perfusion (poor filtration since the fluid does not stay in the glomerulus long enough)
Cushing syndrome explanation
Excess cortisol production due to tumors on the adrenal gland or pituitary gland (most common).
- pituitary gland tumor: causes overproduction of ACTH
Leads to resistant HTN, obesity, elevated glucose levels, easy bruising and osteoporosis.
- shows really prominent stretch mark lines (striae) in the stomach and breasts.
More common in 20-40 year olds and females vs males.
Cushing disease vs syndrome
Syndrome = Cushing disease caused by a multitude of reasons
- caused by direct overproduction of cortisol due to adrenal gland tumors
- less common
Disease = Cushing disease caused by genetics only.
- is caused by over production of ACTH in the pituitary which leads to overproduction of cortisol is the adrenal glands
- more common
Erythropoietin causes HTN how?
Stimulates over production of erythrocytes in the blood which jacks up blood viscosity.
- illegal blood doping is an example of this.
- even more common in chronic renal failure
testosterone supplementation can also cause the same thing
What are examples of endocrine issues that can cause HTN?
Hyper/hypothyroidism
Hyper-parathyroidism
Acromegaly: growth hormone excess
Cushing’s syndrome
Physcial exam specifics for HTN patients
Question compliance
Confirm readings of HTN (2-3 measurements)
Check optic discs for hypertensive retinopathy
Check for cardiac murmurs or peripheral bruits
Palpate the thyroid (check for tenderness, enlargement and nodules
Check peripheral pulses
Breif neuro exam checking for visual or cognitive changes
Labs to order in evaluating primary HTN
Chem panel (w/ fasting)
CBC
Lipid panel
TSH panel
UA
EKG
Labs to order for suspicion of secondary HTN
BNP and possible echos
Aldosterone/renin ratio (aldosteronism)
Urinary catecholamines
Sleep studies
cortisol panel
MRI angiogram or renal arteries
Tx for HTN in patients with chronic kidney disease
ACE inhibitors and ARBs
- DONT use diuretics
Tx for HTN in patients with coronary artery disease
BBs first line after the MI
ACE/ARBs for stable CAD or only Left ventricular heart failure
- add thiazides diuretics or dihydropyridine if treatment is a failure at first*
4 types of HN in pregnant patients
1) Chronic HTN
- cause with known history of HTN or is present during the 1st 20 weeks of gestation
severe is classified as >160mmHg/ > 110mmHg
2) pre-eclampsia or eclampsia only
- HTN with increased renal/liver enzymes in the blood
* eclampsia is w/ seizures*
3) pre-eclampsia/eclampsia superimposed on chronic HTN
4) gestational HTN
- new HTN developing >20 was
Treatment of HTN in patients with chronic kidney disease
ACEIs and ARBs are 1st line therapy
Treatment of HTN in patients with coronary artery disease
If MI is present: BBs
If stable ACD or LV heart failure: ACEIs and ARBs
can add thiazides if the above uses dont solve the HTN
