Step Up - Ambulatory Medicine Flashcards
Pathophysiology of the effects of HTN on the heart:
A. Incr. systemic vascular resistance (afterload) –> concentric LVH –> Decr. LV function. As a result, the chamber dilates –> Symptoms and signs of HF.
B. HTN accelerates atherosclerosis, leading to higher incidence of CAD (as well as peripheral vascular disease and stroke).
HTN - Target organ damage:
Heart --> LVH, MI, CHF. Brain --> Stroke, TIA. Chronic kidney disease. Peripheral vascular disease. Retinopathy.
Most deaths due to HTN are ultimately due to:
MI or CHF.
Goals in evaluating a patient with HTN:
- Look for 2o causes - may be treatable.
- Assess damage to target organs (heart, kidneys, eyes, CNS).
- Assess overall cardiovascular risk.
- Make therapeutic decisions based on the above.
HTN diagnosis - Important to keep in mind:
Unless the patient has severe HTN or evidence of end-organ damage, never diagnose HTN on the basis of one BP reading.
–> Establish the diagnosis on the basis of at least 2 readings over a span of 4 or more weeks.
Observe the following to obtain an accurate BP reading:
- The arm should be at heart level, and the patient should be seated comfortably.
- Have the patient sit quietly for at least 5min before measuring the BP.
- Make sure the patient has not ingested caffeine or smoked cigarettes in the past 30mins (both elevate BP temporarily).
- Use cuff of adequate size - a small cuff can falsely elevate BP readings). The bladder within the cuff should encircle at least 80% of the arm.
Order the following lab tests to evaluate target organ damage and assess overall cardiovascular risk:
- Urinalysis.
- Chemistry panel: K, BUN, Cr.
- Fasting glucose - If diabetic, check microalbuminuria.
- Lipid panel.
- ECG.
Always obtain a … in reproductive age women before starting an antihypertensive medication.
Pregnancy test.
Which antihypertensives are toxic to pregnant women?
- Thiazides.
- ACEIs.
- CCBs.
- ARBs.
Which antihypertensives are safe in pregnancy?
Beta-blockers and hydralazine.
If a patient presents with moderate-to-severe HTN, consider:
Initiating THERAPY right away instead of waiting 1-2 months to confirm diagnosis and start treatment.
HTN - Pharmacologic Treatment - 7 Classes of drugs:
- Thiazides.
- Beta-blockers.
- ACEIs.
- ARBs.
- CCBs.
- Alpha-blockers.
- Vasodilators (hydralazine, minoxidil).
Unless there is a compelling indication to use a specific HTN drug class, it makes…:
Little difference whether the initial drug is a β-blocker, ACEI, ARB, CCB, diuretic.
Thiazide diuretics are the best initial choice for:
African-Americans, because “salt-sensitive” HTN is more common in them.
–> HOWEVER, if an African-American patient has diabetes, an ACEI is still the INITIAL agent of choice.
ACEIs are preferred in ALL diabetic patients because of:
their protective effects on kidneys.
ABRs in HTN treatment:
Recent studies suggest that ARBs have the same beneficial effects on the kidney in diabetic patients as ACEIs.
CCBs in HTN treatment:
Cause arteriolar vasodilation.
3 classes of HTN drugs that are used for initial monotherapy are:
- Thiazides.
- Long-acting CCBs (most often a dihydropyridine).
- ACEIs/ARBs.
HTN Treatment - ACCOMPLISH trail:
Showed that treatment with antihypertensive combination therapy - Benazepril + Amlodipine - was more effective than treatment with the ACEI + diuretic.
–> DESPITE these findings, thiazides remain a common initial drug choice.
HTN treatment - When to start treatment:
- Based on the patients total cardiovascular risk, not just elevation in BP.
- For any level of BP elevation, the presence of cardiovascular risk factors and/or comorbid conditions dramatically accelerates the risk from HTN, and therefore modifies the treatment plan.
- -> Estimation of overall risk depends on cardiovascular risk factors and clinical risk factors.
HTN treatment - Cardiovascular risk factors:
- Smoking.
- Diabetes.
- Hypercholesterolemia.
- > 60.
- Family history.
- Male sex (higher than for female only until menopause).
HTN treatment - Clinical risk factors:
- Presence of CAD.
- PVD.
- Prior MI.
- Any manifestation of target organ disease.
- LVH.
- Retinopathy.
- Nephropathy.
- Stroke or TIA.
All people should be screened with fasting lipid profile every … starting at … .
5yrs. age 20.
Risk factors for coronary artery disease (CAD) in evaluation of patients with hyperlipidemia:
- Current cigarette smoking (dose-dependent risk).
- HTN.
- DM.
- Low HDL (60mg/dL) is a negative risk factor (substract 1 from total).
- Age:
- -> Male: >45.
- -> Female: >55. - Male gender - if you count as a risk factor, do not count age.
- Family history of premature CAD.
Threshold levels for hyperlipidemia - Total cholesterol:
Ideal –> 200-240.
High –> >240.