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Resistant HTN Flashcards

1
Q

What is resistant HTN?

A

When you have tried 3 different BP meds at max dose and are still hypertensive

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2
Q

Normal BP?

A

Under 120/80

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3
Q

Pre-HTN?

A

120-139 OR 80-89

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4
Q

Stage 1 HTN?

A

140-159 OR 90-99

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5
Q

Stage 2 HTN?

A

Over 160 OR over 100

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6
Q

What is the BP goal in average population?

A

140/90

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7
Q

What conditions turn the goal BP into 130/80?

A

Kidney disease, heart disease, or diabetes

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8
Q

What is the most common form of HTN?

A

Essential HTN

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9
Q

If your patient doesn’t have essential HTN, what’s the next most likely cause?

A

Renal HTN

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10
Q

If your patient has HTN, what do you do first?

A

Lifestyle modifications

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11
Q

Is weight reduction good for lowering BP?

A

Not so much…although it’s good for overall health, weight reduction doesn’t have a direct effect on lowering BP

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12
Q

How does exercise help lower BP?

A

It reduces vascular tone

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13
Q

If life style modifications didn’t work and your patient has Stage 1 HTN, what is the 1st drug you should give?

A

Either a diuretic (thiazide-type) or beta blocker

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14
Q

If your patient has chronic kidney disease (stage 3 or lower) or diabetes, what should your first-line drug be for Stage 1 HTN?

A

ACEi or ARB

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15
Q

If your patient presents with Stage 2 HTN, what will you do?

A

Give 2 drugs…thiazide diuretic and and another drug (usually beta-blocker)

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16
Q

Which drug class shows decreased mortality in patients with CHF or CAD?

A

Beta blockers

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17
Q

So if your patient has CHF and CAD and is HTN, what do you give them?

A

Probably go with a diuretic and beta blocker, if they have CHF too, possibly consider ACEi as well

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18
Q

If the first drug you prescribed was a beta blocker for your HTN patient, and they still aren’t at their goal, what should be the 2nd drug you add?

A

DIURETIC

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19
Q

Why is it so important to have diuretics on board to treat HTN?

A

Because a diuretic will decrease Na/Volume which will activate the RAA system, which then will let your ACEi/ARB come in and work more effectively to squash it
-Basically, diuretics make the other BP meds more effective

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20
Q

When would you prescribe a CCB for HTN and why?

A

In situations where the patient is allergic to other drugs…CCV don’t have a benefit in mortality and are really only to be used as supplements once the other drugs have been tried

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21
Q

What stages of kidney disease can ACEi and ARB be used in?

A

Anything stage 3 or lower

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22
Q

Why can’t ACEi or ARB be used in Stage 4 or Stage 5 kidney disease?

A

Because they block RAA and can block perfusion to the kidney resulting in a decrease in GFR in a kidney that already has a low GFR leading to acute kidney failure

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23
Q

What condition do you not give ACEi or ARB to a patient due to the risk of triggering acute kidney failure?

A

Bilateral renal artery stenosis

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24
Q

GFR in Stage 3 kidney disease?

A

Under 60

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25
GFR in Stage 4 kidney disease?
Under 30
26
GFR in Stage 5 kidney disease?
Under 15 --> They need dialysis
27
What drug class is given more often to patients with HTN and Type I diabetes?
ACEi
28
What drug class if given more often to patients with HTN and Type II diabetes?
ARB
29
If your patient is taking an ACEi and gets a nasty cough, what do you do?
Switch them to an ARB
30
What are 2 AE of BB that you should address/keep an eye out for in your patients (especially because these might make them not take their meds)
1. Erectile dysfunction | 2. Depression
31
What is a big cause of resistant HTN?
Lack of patient compliance
32
If you use a regular cuff on an obese arm, will you get an accurate BP reading?
NOPE, it's gonna be false high
33
What can cause pseudoHTN in older patients?
Hard arteries.... they don't compress well and can give false high readings
34
What were the 2 drugs he focused on that can cause HTN?
1. Birth control | 2. NSAIDS
35
How do birth control and NSAIDS act to cause HTN?
They increase salt and water retention, leading to an elevation in BP
36
If you think your patient has HTN due to a renal problem, what do you check?
Creatinine
37
What type of HTN does hypothyroidism cause?
Diastolic HTN
38
What type of HTN does hyperthyroidism cause?
Systolic HTN
39
If your patient has hypokalemia that responds to K, you thinking it might be secondary HTN?
NOPE... probably the effect of a diuretic
40
Do you have to have hypokalemia to have secondary HTN?
NOPE
41
If your patient has elevated aldosterone and decreased renin, what are you thinking?
Primary aldosteronism
42
If your patient has increased renin levels and normal or slightly elevated aldosterone levels, what are you thinking?
Renal artery stenosis
43
If your patient has primary aldosteronism and has a mass on 1 adrenal gland, what do you do?
REMOVE IT
44
If your patient has bilateral masses causing primary aldosteronism, how do you treat it?
Suppress the aldosterone production with spironolactone
45
If you suspect your patient has renal artery stenosis, what screening test can you start with?
Catopril
46
How does the catopril test work?
You compare blood flow to the 2 kidneys, one will show poor flow. You then administer catopril which will block RAA. If the kidney with poor flow is just small catopril will have no effect on its flow. If the kidney with poor flow is due to renal artery stenosis, it's flow and perfusion will be further blocked by the administration of catopril
47
What is the gold standard in diagnosis for renal artery stenosis?
Renal artery angiogram
48
Name 4 causes of secondary HTN
1. Renal artery stenosis 2. Primary hyperaldosteronism 3. Kidney disease/failure 4. Pheochromocytoma
49
If your patient has some HTN going on associated with high levels of renin (perhaps renal artery stenosis), what drugs are gonna be your go-to?
1. ACEi 2. Beta-blocker - Both of these will block renin secretion
50
Can you give an ACEi to someone with bilateral renal artery stenosis?
NO DUMMY, you'll send then into renal failure
51
What drugs are poor choices to give for someone with HTN from increased renin levels (renal artery stenosis)?
1. Alpha-blocker 2. Diuretics 3. CA- Antagonists - These drugs all cause decreased volume or vasodilation, all of which can cause an increase in renin secretion...however, once using and ACEi and BB, these can be added in some cases
52
If your patient has HTN, and you find kidney disease, do you still need to investigate what's causing the HTN?
NOPE... kidney damage is associated with HTN
53
10 Clinical clues for renal artery stenosis?
1. Age of onset of HTN (under 30 or over 55) 2. Abrupt onset of HTN 3. Acceleration of previously well-controlled HTN 4. HTN refractory to an appropriate 3-drug regimen 5. Accelerated retinopathy 6. Malignant HTN 7. Systolic-diastolic abdominal buit (patient has to be really thin to hear this) 8. Flash pulmonary edema (afterload goes up so fast, the LV fails) 9. Evidence of generalized atherosclerosis obliterans--> VASCULOPATH 10. Acute renal failure with ACEi
54
What is the number 1 cause of renal artery stenosis in older patients?
Atherosclerotic renal artery disease
55
What is the number 1 cause of renal artery stenosis in younger patients?
Fibromuscular dysplasia--> Medial hyperplasia
56
What are the 3 requirements for salvaging a kidney with renal artery stenosis via angioplasty and stenting?
1. SIZE (height over 9cm) 2. VIABLE (evidence of function in involved kidney) 3. PERFUSION (angiographic filling of the distal renal arterial tree by collateral circulation
57
What is the % required for insurance to pay for a stent in renal artery stenosis?
70% (if under this... use drugs)
58
What are the 5 features of presentation with primary aldosteronism?
1. Mild to severe HTN 2. Hypokalemia and metabolic alkalosis 3. Carbohydrate (glucose) intolerance due to intracellular K 4. Hypomagnesemia and hypocalcemia 5. Cardiac arrest (b/c electrolytes are all out of whack)
59
Does primary aldosteronism or renal artery stenosis present with more severe hypokalemia?
Primary aldosteronism
60
What are some pertinant negatives seen in primary aldosteronsim that we might just see in renal artery stenosis?
1. Malignant HTN 2. Retinopathy 3. Pulmonary edema
61
3 ways to diagnose primary aldosteronism?
1. Low serum renin 2. High serum aldosterone 3. CT of abdomen
62
If your patient has a unilateral mass causing primary aldosteronism, how you do treat it?
Surgery to remove the adrenal gland
63
If your patient has bilateral masses causing primary aldosteronism, how you do you treat it?
Spironolactone or tiamterene (block aldosterone)
64
What is pheochromocytoma?
It is a disease of the neuron system resulting in increased Epi and NEpi secretion due to hyperplasia of chromaffin cells/neurons
65
What is the presentation of a patient with pheochromocytoma?
1. Catecholamines 2. HTN 3. Tachycardia, HA, diaphoresis, pallor, CP, nausea, weakness 4. Hyperglycemia, lipid abnormality
66
Are the symptoms associated with pheochromocytoma constant or episodic?
EPISODIC
67
Are plasma catecholoamine levels helpful in diagnosing pheochromocytoma?
No, because they can fluctuate
68
What is done to test for pheochromocytoma?
1. Urine collection during sleep...NEpi levels by radioenzymatic techniques 2. 24hr urine looking for direct metabolites of NEpi and Epi (NEpi, metanephrine, normetanephrine, VMA) --> This method is old 3. CT of abdomen (chest to belly) 4. Nuclear scan- Meta idobenzylguanidine
69
In the 24 hour urine check for metabolites of NEpi and Epi testing for pheochromocytoma, what must the levels be for a diagnosis?
They must be 2x normal because these can slightly elevated due to stress
70
What are you looking for on the CT scan testing for pheochromocytoma?
Look at the adrenal glands and sympathetic chains for hyperplastic chromaffin cells
71
How does the nuclear scan testing for pheochromocytoma work?
Meta idobenzylguanidine tags chromaffin cells making them light up and giving you a 100% diagnosis
72
How do you treat pheochromocytoma?
1. Surgical removal 2. 7-10 days of alpha blocker 3. Volume expansion
73
Can you give clonidine to patient with pheochromocytoma?
NEVERRRRR... it's a central acting NEpi and Epi inhibitor... if you block this, you can cause collapse/shock right away in these patients
74
Why do we give an alpha blocker to patients with pheochromocytoma?
It causes vasodilation against the NEpi/Epi affect
75
Do we give a beta blocker to patients with pheochromocytoma before or after the alpha-blocker?
AFTER
76
Why do we give a beta-blocker to pheochromocytoma patients and why after the alpha blocker?
BB will help against Epi affect on the heart, but it can cause peripheral constriction on top of what the Epi/NEpi is doing, so we need to make sure the alpha-blocker is given before this
77
Why is it so important to hydrate pheochromocytoma patients after surgery?
Without the constant Epi/NEpi, these patients will vasodilate and be really dehydrated
78
How does Cushings syndrome present?
Endogenous corticosteroid production leading to salt and water retention causing secondary HTN
79
What are 2/3 of the causes of Cushing syndrome from?
Pituitary ACTH production due to microadenoma
80
What are 2 other causes of Cushing Syndrome?
Ectopic production of ACTH cacrinoma or part of MEA syndrome
81
7 Things you can do to diagnose Cushing Syndrome?
1. Morning and evening cortisol level 2. 24 hour urine for 17 hydroxy corticosteroid 3. 17 ketosteroid 4. ACTH level 5. Dexamethasone suppression test 6. CT scan- Head and Shoulder 7. Iodocholesterol isotopic
82
How do you treat Cushing Syndrome?
Surgery
83
What are some lifestyle modifications to lower BP?
Exercise, stop excessive drinking of liquids, decrease salt intake, and diet
84
What basic blood tests can help distinguish some different causes of HTN?
1. Glucose- Diabetes 2. Cholesterol- Hyperlipidemia (most common cause of essential HTN) 3. Creatinine- Renal failure 4. Potassium- Renal artery stenosis or primary aldosteronism

Renal 2 (10 decks)

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