The Washington Manual

Question 1

What’s the definition of hypertension?

Answer 1

The presence of blood pressure elevation to a level that places patients at an increased risk for end organ damage in several vascular beds including the retina, kidneys, brain, heart, and large conduit arteries

Question 2

What is the definition of hypertensive crisis?

Answer 2

Hypertensive urgencies and emergencies

Question 3

What is the definition of hypertensive urgency?

Answer 3

• Substantial increase in BP, usually with diastolic >120
• Features:
  
  • optic disk edema
  • progressive end-organ complications rather than damage
  • severe perioperative HTN

Question 4

What is the definition of hypertensive emergency?

Answer 4

• systolic BP >210, diastolic >130
• Presenting with:
  
  • HA
  • blurred vision
  • focal neurologic sx and malignant HTN

Question 5

What is malignant hypertension?

Answer 5

Elevated BP with papilledema

Question 6

Having HTN increases risk for CVA by how much?

Answer 6

4x per the Framingham study

Question 7

Having HTN increases your risk for CHF by how much?

Answer 7

6x per the Framingham study

Question 8

What is the breakdown between primary and secondary hypertension?

Answer 8

90% vs 10%

Question 9

What are causes of secondary HTN?

Answer 9

TRACKPADS

• Thyroid dx (hyper)
• Renovascular dx (renal artery stenosis)
• Aorta, coarction of
• Cushing syndrome
• Kidney disease, chronic
• Pheochromocytoma
• Aldosteronism (hyper)
• Drugs (OCPs, decongestants, NSAIDs, appetite suppressants, cyclosporins, exogenous thyroid hormone, recent alcohol consumption, caffeine, anabolic steroids, ma haung, illegal stimulants)
• Sleep apnea

Question 10

How do you take an accurate BP?

Answer 10

Use correct size BP cuff (inflatable bladder encircles at least 80% of arm)

Take 2 readings, 2 mins apart, in each arm

Question 11

What are indications to do a workup for secondary hypertension?

Answer 11

• Age at onset: younger than 30 or older than 60
• HTN thats difficult to control after therapy intiated
• Stable HTN that has become difficult to control
• Clinical occurence of HTN crisis
• Presence or s/sx of 2ndary cause such as hypokalemia or metabolic alkalosis not explained by diuretic therapy

Question 12

What are your target areas in a PE of a hypertensive patient?

Answer 12

• Investigate for end organ damage or 2ndary cause of HTN by noting the presence of:
  
  • Carotid bruits
  • S3 or S4
  • Cardiac murmurs
  • neuro defects
  • elevated JVP
  • rales
  • retinopathy
  • unequal pulses
  • enlarged/small kidneys
  • cushingoid features
  • abdominal bruits

Question 13

Name two medications that can cause rebound HTN

Answer 13

Beta blockers

Alpha agonists

Question 14

What is the workup for a patient with possible target organ damage?

Answer 14

• UA
• HCT
• plasma glucose
• BMP
• CBC
• Calcium
• Uric acid
• FLP
• EKG
• CXR
• Check (LVH)

Question 15

What is the MOA of thiazide diuretics?

Answer 15

Blocks sodium reabsorption predominately in the distal convoluted tubule by inhibition of the thiazide-sensitive Na/Cl cotransporter

Question 16

What is the mechanism of action of a loop diuretic?

Answer 16

Blocks sodium reabsorption in the thick ascending loop of Henle through inhibition of the Na/K/2Cl cotransporter

Question 17

What are the most effective hypertensive agents in patients with renal insufficiency?

Answer 17

Loop diuretics with GFR <35

Question 18

How do potassium sparing diuretics work?

Answer 18

• Competitively inhibiting the actions of aldosterone on the kidney (spironolactone and eplenerone)
• Inhibiting the epithelial Na+ channel in the distal nephron to inhibt the reabsorption of sodium and the secretion of potassium ions

Question 19

Potassium sparing diuretics are often combined with what other agent, and why?

Answer 19

Thiazide diuretics because they are a weak diuretic on their own

Question 20

What are side effects of thiazide diuretics?

Answer 20

• Weakness, muscle cramps, impotence
• Hypokalemia, hypomagnesemia, HL (increases LDL and TGs), hypercalcemia, hypergylcemia, hyponatremia, and rarely azotemia
• possible pancreatitis
• Limited when used in small doses (12.5-25mg)

Question 21

What are side effects of loop diuretics?

Answer 21

• Hypomagnesemia, hypocalcemia, hypokalemia
• Irreversible ototoxicity

Question 22

What are side effects of spironolactone and eplenerone?

Question 23

What are side effects of triamterene?

Answer 23

Renal tubular damage and renal calculi

Question 24

What is the MOA of beta blockers?

Answer 24

• Competitive inhibition of the effects of catecholemines at beta-adrenergic receptors, which decreases HR and CO
• Decreases plasma renin and cause a resetting of baroreceptors to accept lower level of BP
• Cause release of vasodilatory prostaglandins, decrease plasma volume, and may have CNS mediated anti-HTN effect

Question 25

What are the two classes of beta blockers?

Answer 25

Cardioselective with beta-1 blocking effects

Non-cardioselective with beta-1 and beta-2 blocking effects

Question 26

Which of the two classes can be given to pts with COPD, DM, or peripheral disease?

Answer 26

At low doses, the cardioselective agents

At higer doses, the medication loses its beta-1 selectivity and may cause unwanted effects in these patients

Question 27

Which are the beta adrenergic antagotnists with ISA? What is their special feature?

Answer 27

• They cause less bradycardia
• Some beta blockers (eg oxprenolol, pindolol, penbutolol, and acebutolol) exhibit intrinsic sumpathomimetic activity (ISA)
  
  • Agents are capable of exerting low-level agonist activity at the B-adenergenic receptor while simulatenously acting as a receptor site antagonist
  • therefore, may be useful in individuals exhibiting excessive bradycardia with sustained beta blocker therapy

Question 28

What are side effects of beta blockers?

Answer 28

• High degree AV block, HF, Raynauds phenomenon, impotence
• Lipophilic BB (propranolol) have higher incidence of CNS side effects including insomnia and depression
  
  • Propranolol can also cause congestion

Question 29

How can beta blockers affect an FLP?

Answer 29

Increased TGs and decreased HDL with non-selective BB

Question 30

What are side effects of labetalol?

Answer 30

Hepatocellular damage

Postural HTN

Positive ANA

Lupus like syndrome

Tremors

Potential HoTN in setting of halothane anesthesia

Question 31

Which beta blockers are more likely to cause reflex tachycardia?

Answer 31

Carvedilol and lebatalol due to initial vasodilatory effect

Question 32

What can happen with abrupt withdrawal of a chronic beta blocker and why?

Answer 32

Chronic antagonism increases receptor density, so it can precipitate angina pectoris

Question 33

What were the findings of the ALLHAT trial?

Answer 33

• Decreased cardiovascular and cerebrovascular morbidity and mortality with the use of thiazide diuretics thus this class of drug is favored as first line therapy unless there is a contradiction to their use or the characteristics of a patient’s profile (concomitant disease, age, race) mandate the institution of a different agent
• Calcium channel antagonists and ACE inhibitors have a low-side effect profile and have been shown to decrease BP to degrees similar to those observed with diuretics and B-adrenergic antagonists, resulting in reductions in morbidity and mortality similar to diuretics, making them reasonable initial agents