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Renal 2 > Resistant HTN > Flashcards

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
Q

GFR in Stage 4 kidney disease?

A

Under 30

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26
Q

GFR in Stage 5 kidney disease?

A

Under 15 –> They need dialysis

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27
Q

What drug class is given more often to patients with HTN and Type I diabetes?

A

ACEi

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28
Q

What drug class if given more often to patients with HTN and Type II diabetes?

A

ARB

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29
Q

If your patient is taking an ACEi and gets a nasty cough, what do you do?

A

Switch them to an ARB

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30
Q

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)

A
  1. Erectile dysfunction

2. Depression

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31
Q

What is a big cause of resistant HTN?

A

Lack of patient compliance

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32
Q

If you use a regular cuff on an obese arm, will you get an accurate BP reading?

A

NOPE, it’s gonna be false high

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33
Q

What can cause pseudoHTN in older patients?

A

Hard arteries…. they don’t compress well and can give false high readings

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34
Q

What were the 2 drugs he focused on that can cause HTN?

A
  1. Birth control

2. NSAIDS

35
Q

How do birth control and NSAIDS act to cause HTN?

A

They increase salt and water retention, leading to an elevation in BP

36
Q

If you think your patient has HTN due to a renal problem, what do you check?

A

Creatinine

37
Q

What type of HTN does hypothyroidism cause?

A

Diastolic HTN

38
Q

What type of HTN does hyperthyroidism cause?

A

Systolic HTN

39
Q

If your patient has hypokalemia that responds to K, you thinking it might be secondary HTN?

A

NOPE… probably the effect of a diuretic

40
Q

Do you have to have hypokalemia to have secondary HTN?

A

NOPE

41
Q

If your patient has elevated aldosterone and decreased renin, what are you thinking?

A

Primary aldosteronism

42
Q

If your patient has increased renin levels and normal or slightly elevated aldosterone levels, what are you thinking?

A

Renal artery stenosis

43
Q

If your patient has primary aldosteronism and has a mass on 1 adrenal gland, what do you do?

A

REMOVE IT

44
Q

If your patient has bilateral masses causing primary aldosteronism, how do you treat it?

A

Suppress the aldosterone production with spironolactone

45
Q

If you suspect your patient has renal artery stenosis, what screening test can you start with?

A

Catopril

46
Q

How does the catopril test work?

A

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
Q

What is the gold standard in diagnosis for renal artery stenosis?

A

Renal artery angiogram

48
Q

Name 4 causes of secondary HTN

A
  1. Renal artery stenosis
  2. Primary hyperaldosteronism
  3. Kidney disease/failure
  4. Pheochromocytoma
49
Q

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?

A
  1. ACEi
  2. Beta-blocker
    - Both of these will block renin secretion
50
Q

Can you give an ACEi to someone with bilateral renal artery stenosis?

A

NO DUMMY, you’ll send then into renal failure

51
Q

What drugs are poor choices to give for someone with HTN from increased renin levels (renal artery stenosis)?

A
  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
Q

If your patient has HTN, and you find kidney disease, do you still need to investigate what’s causing the HTN?

A

NOPE… kidney damage is associated with HTN

53
Q

10 Clinical clues for renal artery stenosis?

A
  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
Q

What is the number 1 cause of renal artery stenosis in older patients?

A

Atherosclerotic renal artery disease

55
Q

What is the number 1 cause of renal artery stenosis in younger patients?

A

Fibromuscular dysplasia–> Medial hyperplasia

56
Q

What are the 3 requirements for salvaging a kidney with renal artery stenosis via angioplasty and stenting?

A
  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
Q

What is the % required for insurance to pay for a stent in renal artery stenosis?

A

70% (if under this… use drugs)

58
Q

What are the 5 features of presentation with primary aldosteronism?

A
  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
Q

Does primary aldosteronism or renal artery stenosis present with more severe hypokalemia?

A

Primary aldosteronism

60
Q

What are some pertinant negatives seen in primary aldosteronsim that we might just see in renal artery stenosis?

A
  1. Malignant HTN
  2. Retinopathy
  3. Pulmonary edema
61
Q

3 ways to diagnose primary aldosteronism?

A
  1. Low serum renin
  2. High serum aldosterone
  3. CT of abdomen
62
Q

If your patient has a unilateral mass causing primary aldosteronism, how you do treat it?

A

Surgery to remove the adrenal gland

63
Q

If your patient has bilateral masses causing primary aldosteronism, how you do you treat it?

A

Spironolactone or tiamterene (block aldosterone)

64
Q

What is pheochromocytoma?

A

It is a disease of the neuron system resulting in increased Epi and NEpi secretion due to hyperplasia of chromaffin cells/neurons

65
Q

What is the presentation of a patient with pheochromocytoma?

A
  1. Catecholamines
  2. HTN
  3. Tachycardia, HA, diaphoresis, pallor, CP, nausea, weakness
  4. Hyperglycemia, lipid abnormality
66
Q

Are the symptoms associated with pheochromocytoma constant or episodic?

A

EPISODIC

67
Q

Are plasma catecholoamine levels helpful in diagnosing pheochromocytoma?

A

No, because they can fluctuate

68
Q

What is done to test for pheochromocytoma?

A
  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
Q

In the 24 hour urine check for metabolites of NEpi and Epi testing for pheochromocytoma, what must the levels be for a diagnosis?

A

They must be 2x normal because these can slightly elevated due to stress

70
Q

What are you looking for on the CT scan testing for pheochromocytoma?

A

Look at the adrenal glands and sympathetic chains for hyperplastic chromaffin cells

71
Q

How does the nuclear scan testing for pheochromocytoma work?

A

Meta idobenzylguanidine tags chromaffin cells making them light up and giving you a 100% diagnosis

72
Q

How do you treat pheochromocytoma?

A
  1. Surgical removal
  2. 7-10 days of alpha blocker
  3. Volume expansion
73
Q

Can you give clonidine to patient with pheochromocytoma?

A

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
Q

Why do we give an alpha blocker to patients with pheochromocytoma?

A

It causes vasodilation against the NEpi/Epi affect

75
Q

Do we give a beta blocker to patients with pheochromocytoma before or after the alpha-blocker?

A

AFTER

76
Q

Why do we give a beta-blocker to pheochromocytoma patients and why after the alpha blocker?

A

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
Q

Why is it so important to hydrate pheochromocytoma patients after surgery?

A

Without the constant Epi/NEpi, these patients will vasodilate and be really dehydrated

78
Q

How does Cushings syndrome present?

A

Endogenous corticosteroid production leading to salt and water retention causing secondary HTN

79
Q

What are 2/3 of the causes of Cushing syndrome from?

A

Pituitary ACTH production due to microadenoma

80
Q

What are 2 other causes of Cushing Syndrome?

A

Ectopic production of ACTH cacrinoma or part of MEA syndrome

81
Q

7 Things you can do to diagnose Cushing Syndrome?

A
  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
Q

How do you treat Cushing Syndrome?

A

Surgery

83
Q

What are some lifestyle modifications to lower BP?

A

Exercise, stop excessive drinking of liquids, decrease salt intake, and diet

84
Q

What basic blood tests can help distinguish some different causes of HTN?

A
  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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