Slide set 6 Flashcards
HTN is
CV syndrome that may change function and structure of the heart and vascular system
Primary HTN is
AKA Essential HTN and has unknown etiology
Secondary HTN is
HTN that has a definable cause and can possibly be cured
Classifications of HTN (5)
Pre-HTN HTN (Stage I and II) HTN Crisis (Urgency/Emergency)
4 elements to HTN
Heart, BVs, Kidneys, and hormones
DX of HTN is based on consistent elevation of
SBP >140 -OR- DBP>90
Resistant HTN is based upon what
Consisttent BP elevation despite Rx adherence with 3 drugs
What contributes to rises in BP
Heart - CO rises sue to SNS BVs - contrict due to SNS, Tone, Ion channels Kidney - Retaining H2O or NA+
What is considered HTN end organ damage
Eyes, Kidneys, Strokes/TIAs, Heart, PAD/PVD
Secondary has the same consequences as primary HTN?
Yes
Factors suggesting secondary HTN (5)
Age of onset (20-50) Severity (Dramatic) Onset nature (usually abrupt)
(MC’s) causing secondary HTN
1.CKD 2.Primary aldosteronism
Screening for 2nd HTN with renovascular DZ - labs
GFR, U/S, Creatinine, UA
Screening for 2nd HTN with Pheochromocytoma - labs
24hr UA Metanephrines/catecholamines
Screening for 2nd HTN with aldosteronism - labs
24H urine aldosterone (>25:1 - serum:ua) Unprovoked hypokalemia May see a U-wave on EKG
Screening for 2nd HTN with Cushings syndrome - labs
Dexamethasone suppression test 24H UA cortisol levels
Screening for 2nd HTN with Sleep Apnea - labs
Sleep study
Screening for 2nd HTN with Coarctation of the aorta - labs
CT angiography (Pulse in UE, delayed LE pulse)
Screening for 2nd HTN with Thyroid - labs
TSH, FT4
Screening for 2nd HTN with Parathyroidism - labs
Serum PTH and calcium
The kidneys are
Selfish, they will kill the body to save themselves
2nd HTN - renal artery stenosis is
Narrowing of one or both renal arteries
What two mechanisms cause renal artery stenosis
Atherosclerosis 2/3 of pts Fibromuscular dysplasia 1/3 of pts
MOA of renal stenosis and HTN
Decreased renal blood flow stimulates RAAS to increase retention,volume,BP
What is an indicator of Bilateral renal artery stenosis
Creatinine rise after admin ACEI
MOA of ACEI
Stops ANG II and bradykinin synthesis
MOA of ARB
Blocks ANG II binding to AT1 receptors
Classic findings of Coarcation of the aorta
Systolic HTN in UE but not in LE CXR has rib notching Reduced femoral pulse
MOA coarctation of the aorta
Impaired blood flow distal to coarctation causes renal perfusion impairment
Pheochromocytoma classic triad
Episodic HA Sweating Tachycardia
Pheochromocytoma is a
Catecholamine secreting tumor found in the adrenal medulla usually
Pheochromocytoma is associated with what mutations
multiple endocrine neoplasia (MEN 2A/2B)
Hyperaldosteronism is
Excessive aldosterone secretion causing increased NA+ retention
What causes increased aldosteronism (3)
Adrenal adenoma (Conn Syndrome)(most pts) Bilateral hyperplasia (Primary) Renin-secreting tumors (Secondary)
Cushing syndrome is
Excess glucocorticoids (Cortisol) that leads to increased blood volume and renin production
Cushings disease refers to
Pituitary adenoma which secretes ACTH in excess
Hyperthyroidism causes HTN by
Excess metabolic activity causes increased cardiac activity (HR) and then (CO)
Hypothyroidism causes HTN by
Volume retention (>DBP usually)
Hyperparathyroidism due to
A parathyroid secreting adenoma secreting excess calcium effecting renal fx and causing HTN
Medications that can cause HTN (6)
Estrogens Corticosteroids EPO
Cocaine/Amphetamines can cause
Acute HTN - HTN crisis or emergency - AMI
BP measuring criteria
2 readings 5m apart with arm at heart level Confirm elevated BP in contralateral arm If BP is high in both arms and pt is <30yo -leg BP If pt is >65, DM, or antiHTN rx check orthostatics
BP documenting criteria
BP, patient position, which arm and cuff size
Ambulatory monitoring indications
White coat HTN & no end organ damage Episodic HTN HOTN symptoms on HTN meds
What association is there between BP, Sleep, CV risk
Absence of 10-20% drop of BP during sleep may indicate CV risk
When to check BP with pts that have NL BP
Every two years
When to check BP with pts that are pre-HTN
Yearly
What dx test can you consider with resist-HTN
CXR, 24H Ambulatory monitor, Echocardiography, microalbuminuria
TXT goals for >60yo - >150/90
Med to reduce BP to <150/90 (if <140 and tolerated - no change to med)
TXT goals for <60yo - >140/90
Med to reduce BP to <140/90
TXT goals for >18yo with CKD or DM - >140/90
Med to reduce BP to <140/90
HTN TXT for nonpharm
Weight loss – decrease in BP 5-20mmHg DASH Diet- decrease in BP 8-14 mmHg Na+ restriction – Decrease in BP 2-8 mmHg Exercise – decrease in BP 4-9 mmHg Mod ETOH Intake – decrease in BP 2-4 mmHg
Can you use ACEI or ARB in pregnancy
NO
What does an ACEI do to K+
Increase K+ (adding loop diuretic helps)
Thiazide lab monitoring
Hypokalemia, hyponatremia
Loop diuretcs lab monitoring
Monitor lytes (k, Mg decrease)
ACEI/ARB lab monitoring
Kidney fx and hyperkalemia
Aldosterone lab monitoring
Hyperkalemia
Thiazides drugs (3)
Chlorthalidone Hydrochlorothiazide Indapamide
TXT of heart failure is based upon if
HF is systolic or diastolic in nature
Pharm TXT of Post MI is
B-BLK or ACEI
Pharm TXT of HTN urgency is
α agonist (Clonidine)
Pharm TXT of BPH is
α antagonist (-zosins)
Pharm TXT of cardiac issues with pregnancy is
- Methyldopa or Labetolol 2. Nifedipine (can be added as 2nd line)
Pharm TXT of CHF is
Combo A/B-BLK (Labetalol or carvedilol)
α agonists (clonidine) SEs (2)
Dry mouth and Rebound HTN
Pharm TXT for pts who fail everything else
Hydralazine and minoxidil
Renin blocker example
Aliskiren
Pts requiring >3 drugs for HTN treatment should be
Referred to HTN specialist Nephrologist Cardiologist Endocrin
What are the two categories of HTN crisis
Urgency or Emergency
HTN crisis refers to
Severely elevated BP
HTN urgency refers to
Severely elevated BP in an asymptomatic pt without end organ damage
Timeline for TXT of HTN urgency is
PO Therapy within hours/days and F/U monitoring
End Organ damage is usually evident when BP is
> 130 DBP
HTN emergency refers to
Severely elevated BP with end organ damage
Timeline for TXT of HTN emergency is
Therapy immediately and ADMIT
HTN crisis etiology
prolonged inadequate control of chronic HTN with a hemodynamic insult
HTN crisis pathophys
Severe elevate BP causes Arteriolar fibrinoid necrosis causing endothelial damage and PLT/Fibrin despostion leading to ischemia
HTN crisis labs
UA, CMP, CBC, CXR, EKG
In HTN crisis if BP is reduced too rapidly what can occur
End-Organ ischemia due to compensatory effects
Goal of TXT in HTN crisis is to reduce MAP by
20-25% and <100 DBP
HTN emergency requires (5)
ICU admit Parenteral Meds Continuous cardiac monitoring Invasive (radial
HTN urgnecy TXT in a pt already on anti-HTN (3)
Increase dose of current med or add another Check adherence Add diuretic and reinforce dietary Na+ restricts
HTN urgency management/pharm
Goal is to reduce BP <160/100 -F/U w/ long acting PO Furosemide PO Clonidine
HTN Emergency management/pharm
Parenteral Labetalol
Labetalol cannot be used in what two cardiac D/Os
Cocaine intoxication and Decomp Systolic HF
HTN Emergency (Aortic dissection) management/pharm
Goal in acute dissection is BP <140/110 Morphine for pain IV labetaolol or Esmolol
HTN Emergency (Pulmonary edema) management/pharm
Goal is by reduction by 20-30%, diuresis IV Nitroglycerin (1st line) IV Nicardipine (favors systolic dysfunction)
HTN Emergency (Cocaine/meth abuse) management/pharm
Initial TXT is benzodiazepine IV Lorazepam IV Diazepam
HTN Emergency (AMI) management/pharm
Goal 20-30% reduction of SBP >160 IV nitroglycerin (1st line) IV or PO Metoprolol
HTN Emergency (Neurologic ER) management/pharm
Get emergency CT scan to determine DX first