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PNS/Cardiology > Primary and Secondary Hypertension > Flashcards

Primary and Secondary Hypertension Flashcards

1
Q

What is the difference between primary and secondary hypertension?

A

Primary - complex, multifactorial

Secondary - direct treatable cause

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2
Q

What is optimal blood pressure?

A

<80 diastolic

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3
Q

Why does diastolic pressure increase until age 50 and decline after age 50?

A

Vessels become stiffer and lose elasticity and cannot maintain the diastolic pressure

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4
Q

What is the best predictor of mortality due to hypertension?

A

Widened pulse pressure (systolic BP - diastolic BP)

Systolic increases, diastolic increases after age 50 because of stiffer vessels

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5
Q

What should normally happen to BP when asleep?

A

Nocturnal decline of BP (about 10%)

Loss of this decline is predictive of hypertensive events

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6
Q

Why is MAP not an accurate reflection of CV risk?

A

Can have a massive pulse pressure, but still a normal MAP

Hence, pulse pressure should be used instead

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7
Q

What is the definition of isolated systolic hypertension?

A

SBP >140 and DBP <90

Reflects widened pulse pressure due to stiffening of vessels with age

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8
Q

In early hypertensive, does CO or TPR contribute more to the elevated BP?

A

CO (better contraction of heart, less stiff vessels)

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9
Q

In late hypertensives, does CO or TPR contribute more to the elevated BP?

A

TPR (lesser contraction of heart, stiffer vessels)

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10
Q

What are the 3 major systems that regulate blood pressure?

A

Heart
Blood vessels
Kidney

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11
Q

Primary hypertension patients have at least one of 4 mechanisms involved, what are the 4 mechanisms?

A

Inability to handle sodium and water appropriately
Overactivity/overstimulation of sympathetic system
Defect in handling of intracellular calcium in vascular smooth muscle
Defect in RAAS

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12
Q

How does hypertension affect the eyes?

A

Retinal vein and artery thrombosis
AV nicking - enlarged artery crosses vein, indenting it
Copper wiring - can see enlarged artery on end

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13
Q

How does hypertension affect the heart?

A

Coronary artery disease
LV hypertrophy
Arrhythmias
Congestive heart failure

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14
Q

How does hypertension affect the kidney?

A

Renal failure

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15
Q

How does hypertension affect the vasculature?

A

Atherosclerosis

Peripheral vasculature disease

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16
Q

How does hypertension affect the CNS?

A

Strokes (ischemic or hemorrhagic)

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17
Q

What is the definition of malignant hypertension?

A

Severe increase in BP, especially DBP (know that DBP decreases after 50 so would see this in younger age groups)

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18
Q

What are the symptoms of hypertension?

A

NONE! Asymptomatic

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19
Q

What is the target BP in patients under age 60?

A

<140/90

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20
Q

What is the target BP in patients 60 and over?

A

<150/90

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21
Q

What are lifestyle modifications used to treat hypertension?

A

Weight reduction
Dietary sodium restriction
Increased physical activity
Moderation of alcohol/smoking

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22
Q

What categories of drugs are used to treat hypertension?

A

Diuretics
Sympatholytics
Vasodilators
RAS antagonists

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23
Q

How do diuretics help with hypertension?

A

Increased excretion of sodium and water

Decreased CO

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24
Q

How do sympatholytics (alpha and beta blockers) help with hypertension?

A

Prevent vasoconstriction

Decrease HR and sympathetic outflow

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25
Q

How do vasodilators help with hypertension?

A

Calcium channel blockers - prevent vasoconstriction

Direct vasodilators - cause vasodilation

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26
Q

How do RAS antagonists help with hypertension?

A

ACE inhibitor - prevent conversion of AI to AII, prevent vasoconstriction and aldosterone release

ARB - block AII receptor, prevent vasoconstriction and aldosterone release

27
Q

Which drug should you use for first line therapy for uncomplicated hypertension?

A

ABCD - any of these are acceptable first line therapy

ACE inhibitors
ARB
Beta blockers
Calcium channel blockers
Diuretics - most commonly used
28
Q

Which first line therapies do Caucasians normally respond better to?

A

AB

ACE inhibitors
ARB
Beta blockers

29
Q

Which first line therapies do African Americans normally respond better to?

A

CD

Calcium channel blockers
Diuretics

30
Q

If a patient has hypertension in the setting of heart failure, what classes of drugs should be used?

A

Beta blockers
ACE inhibitors
ARB
Mineralocorticoid receptor antagonist

31
Q

If a patient has hypertension in the setting of post-MI, what classes of drugs should be used?

A

Beta blockers
ACE inhibitors
ARB

32
Q

If a patient has hypertension in the setting of high risk-CAD, what classes of drugs should be used?

A 
ACE inhibitor
ARB
Diuretics
Beta blockers
Calcium channel blockers
33
Q

If a patient has hypertension in the setting of proteinuria, what classes of drugs should be used?

A

ACE inhibitor

ARB

34
Q

What is the “Rule of Tens”?

A

For every additional 10 mm Hg reduction in systolic blood pressure that is necessary, 1 additional drug is needed

35
Q

What are reasons for poor BP control during treatment?

A

Dietary indiscretion
Patient discontinues drug
Too few drugs - treatment not aggressive enough

36
Q

What are major causes of secondary hypertension?

A

Chronic kidney disease
Renovascular disease
Adrenal disease
Pheochroocytoma

37
Q

What is the difference between chronic kidney disease and renovascular disease?

A

Chronic kidney disease - disease of parenchyma of kidney, within kidney itself

Renovascular disease - refers to artery leading to the kidney

38
Q

Describe the relationship between chronic kidney disease progression and hypertension

A

As disease progresses, % of patients that develop hypertension increases steadily

39
Q

How does salt retention cause hypertension in chronic kidney disease?

A

Leads to increased blood volume and therefore BP

40
Q

How does kidney injury cause hypertension in chronic kidney disease?

A

Activates RAAS
Activates Sympathetic nervous system
Impaired NO synthesis and endothelium-mediated vasodilation

All of this causes vasoconstriction

41
Q

How does renovascular disease cause hypertension?

A

Constricted renal artery = reduced blood flow to kidney = activation of RAAS

Angiotensin II and aldosterone will cause systemic arteriolar constriction

42
Q

How does the kidney maintain GFR in the setting of renovascular disease?

A

Constricted renal artery –> angiotensin II –> constricts efferent arteriole –> maintains normal GFR

43
Q

Why should patients with renovascular disease never be given an ACE inhibitor or ARB?

A

Will prevent the compensatory constriction of the efferent arteriole, causing GFR to become compromised and leading to ischemia of kidney and damage

44
Q

What are methods for screening for renal artery stenosis?

A

Captopril nuclear scan
Duplex dopplers
Magnetic resonance angiogram
IV arteriography

45
Q

What are the two types of renovascular disease?

A

Atheroma - atherosclerosis in renal artery (most common)

Fibromuscular displasia - increase in medial layer of renal artery

46
Q

Which renovascular disease patients can be cured with renal angioplasty?

A

Patients with fibromuscular dysplasia

47
Q

What are the two adrenal causes of hypertension?

A

Adenoma (tumor)

Hyperplasia (increase in size of adrenal cells)

48
Q

How can you diagnose an adrenal cause of hypertension?

A

Check hormone levels - aldosterone and plasma renin
Hypokalemia

Aldosterone should be increased - adrenal gland is overproducing
Plasma renin should be decreased - suppressed by the high aldo levels
Increased retention of Na+ and water caused by aldosterone will also lead to excretion of K+

49
Q

What drugs can be used to block the effects of aldosterone?

A

Spironolactone

Eplerenone

50
Q

How does apparent mineralocorticoid excess cause hypertension?

A

Excess cortisol outcompetes aldosterone at the mineralocorticoid receptor in the kidneys
Causes excess sodium and water retention and potassium excretion

51
Q

What can cause apparent mineralocorticoid excess?

A

Licorice ingestion (also in chew tobacco)
Cushing’s disease
Congenital adrenal hyperplasia
Liddle’s syndrome

52
Q

What are the different types of congenital adrenal hyperplasia (CAH)?

A

21 hydroxylase deficiency
11 beta hydroxylase deficiency
17 hydroxylase deficiency - also will see sexual side effects

53
Q

What is Liddle’s syndrome?

A

Constitutive activation of sodium channels, results in hypertension and hypokalemia
Aldosterone levels are undetectable

54
Q

What is glucocorticoid remedial hypertension?

A

Autosomal dominant form of low renin hypertension

Hyperaldosteronism
Aldosterone secretion controlled by ACTH instead of Angiotensin II due to abnormal crossover of genes

55
Q

What causes of secondary hypertension are suggested by HIGH ALDO and HIGH RENIN?

A

Renovascular disease
Hypovolemia
LVF

56
Q

What causes of secondary hypertension are suggested by HIGH ALDO and LOW RENIN?

A 
Adrenal causes (adenoma or hyperplasia)
Glucocorticoid remedial hypertension (GRA)
57
Q

What causes of secondary hypertension are suggested by LOW ALDO and LOW RENIN?

A

Apparent mineralocorticoid excess syndrome
Cushing’s disease
Liddle’s syndrome
Congenital adrenal hyperplasia (21, 11, and 17 hydroxylase)

58
Q

What is a pheochromocytoma?

A

Catecholamine secreting tumor of the medulla of the adrenal gland - originating in chromaffin cells

59
Q

What are common signs and symptoms of pheochromocytoma?

A

Hypertension
Headache
Sweating
Palpitations

60
Q

How should pheochormocytoma be managed?

A

ABC’s

Alpha blocker - vasodilate to control blood pressure
Beta blocker - control heart rate
Catecholamine synthesis inhibitor - alpha methyl p-tyrosine

61
Q

How does obstructive sleep apnea cause secondary hypertension?

A

Intermittent asphyxia
Marked BP elevation
Sleep fragmentation

62
Q

What is the treatment for obstructive sleep apnea?

A

Weight reduction

Positive pressure breathing devices

63
Q

What are clues to a patient having fibromuscular dysplasia?

A

Young female, smoker, abdominal bruit

PNS/Cardiology (33 decks)

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