Tuesday HTN lecture Flashcards
slide 60-130
When is initial combination therapy recommended?
Stage 2 if you’re 20/10mmHg above goal
When should you ask a pt to RTC after Rx a HTN medication?
4-6 weeks (and perhaps do kidney panel to make sure you’re not causing damage)
What 5 lifestyle changes should you recommend pts do?
1) Smoking cessation
2) Control blood glucose and lipids
3) Diet
4) Physical activity:150 minutes per week moderate to vigorous activity (3-4 session of 30-40 mins/week)
5) Weight loss for BMI > 25%
What diet changes should you recommend pts make?
1) DASH diet
2) NaCl < 2400 mg per day (~ 1 teaspoon), K+ supplementation via diet
3) Avoid excessive ETOH (2 drinks men, 1 drink women)
What lifestyle modifications have no significant evidence?
Calcium or magnesium supplements, relaxation therapy, yoga, or acupuncture
Describe the DASH diet
-A flexible and balanced eating plan that helps create a heart-healthy eating style for life.
-The DASH eating plan requires no special foods and instead provides daily and weekly nutritional goals. This plan recommends:
a) Eating vegetables, fruits, and whole grains
b) Including fat-free or low-fat dairy products, fish, poultry, beans, nuts, and vegetable oils
c) Limiting foods that are high in saturated fat, such as fatty meats, full-fat dairy products, and tropical oils such as coconut, palm kernel, and palm oils
d) Limiting sugar-sweetened beverages and sweets.
In the all-patient populations > 18 y/o with CKD, initial or add-on Rx should include what?
ACEi/ARB to improve renal outcomes
General non-black population, including those with DM, but not CKD: initial treatment should incl. therapy with one of more of what types of drugs?
1) A thiazide type diuretic
2) CCB
3) ACEi or ARB
General black population, including those with DM but not CKD: initial treatment should incl. therapy with one of more of what types of drugs?
1) A thiazide type diuretic
2) CCB
1) Main objective of HTN treatment is to do what?
2) What should you do to meet these goals?
3) What is the goal in most ppl?
1) Obtain and maintain goal BP
2) Add and titrate Rx as necessary to meet these goals
3) < 130/80 mm Hg
ACC/AHA guidelines: Hypertensive patients with an estimated 10-year ASCVD risk less than 10% should try _______ to _______ months of lifestyle modifications before initiation of pharmacotherapy
3 to 6
AHA/ACC guidelines: patients with an initial BP of ___________ mm Hg or higher AND a high cardiovascular risk should be treated initially with lifestyle modifications and pharmacotherapy
130/80
JNC-8 guidelines:
1) General population treatment threshold is _______ mm Hg
2) Elderly patient treatment threshold is ____________mmHg
1) 140/90
2) 150/90
True or false: Any of the following 3 classes of medications may be used in most patients alone or in combination for initial therapy:
1) Thiazide diuretics
2) CCB
3) ACEi or ARB
True
1) What are thiazide diuretics used for?
2) What are 2 main groups of effects?
1) HF and HTN
2) Decreased or increased excretion of substances
What are the 2 things with decreased excretion with thiazide diuretics?
1) Uric acid (Contraindicated in gout)
2) Calcium (hypercalcemia)
What are the 3 things with increased excretion with thiazide diuretics?
1) Na: hyponatremia
2) K: hypokalemia … especially if patient not salt restricted
3) Magnesium: hypomag can make it difficult to correct for hypo K
Why should you avoid thiazide diuretics with lithium use?
Increasing risk of lithium toxicity
1) What can happen with thiazide diuretics if the pt has hyperlipidemia?
2) When are thiazide diuretics not effective?
3) What is the exception to this lack of efficacy?
1) Elevate TG
2) If eGFR < 30-40 mL/min (CKD stage 3B)
3) Metolazone (Zaroxolyn); not useful for monotherapy but improves diuresis when used with loop diuretic (furosemide, torsemide, bumetanide, ethacrynic acid)
List the initial and max doses for the following:
1) Hydrochlorothiazide
2) Chlorthalidone
1) 12.5-25mg/ day; 25mg
2) 12.5-25mg/ day; 50mg
List 3 thiazide diuretics
1) Hydrochlorothiazide
2) Chlorthalidone
3) Indapamide
What are the diuretics sites of action? (from proximal to distal)
MALTS
1) Mannitol (proximal convoluted)
2) Acetazolamide (proximal convoluted)
3) Loop diuretics (ascending loop)
4) Thiazide diuretics (distal convoluted)
5) Spironolactone (collecting duct)
1) What are the 4 clinical indications for ACE inhibitors and ARBs?
2) Are ACEis and ARBs initial or add-on Txs?
3) In patients 18 and older with _____, treatment should include ACEi or ARB
1) HTN, HF, previous MI, CKD
2) Can be used for both
3) CKD
ACEi and ARBs do what in diabetic patients?
Slows progression of microalbuminuria
(all DM patients should be screened for microalbumin and treated with ACEi or ARB if present)
1) Why do ACEis cause a cough in 10-20% of patients?
2) What should you do if this happens?
1) Elevated bradykinin in lungs (site of action of ACEi)
2) Substitute ARB (works at receptors peripherally)
ACEis and ARBs:
1) What can they increase?
2) What has an absolute contraindication?
3) What has a relative contraindication?
1) Lithium levels
2) Pregnancy
3) Pts with RAS and hyper K+
ACEis and ARBs:
1) How do black patients respond?
2) What is 2-4x more common in black patients?
1) Relatively reduced BP response to monotherapy with ACEi or ARBs
2) ACEi induced angioedema
Can ACEis and ARBs be used together in the same pt?
No; never ever
What are the ACEis? What do they end in?
End in -pril
1) Fosinopril
2) Lisinopril
3) Qinapril
4) Ramipril
What are the ARBs? What do they end in?
end in -sartan
1) Candesartan
2) Irbesartan
3) Losartan
4) Olmesartan
5) Valsartan
1) What group of Ca+ channel blockers (CCBs) may cause some dependent edema and reflex tachycardia?
2) What group may exacerbate HF, bradycardia, or conduction blocks?
1) Dihydropyridine
2) Non-dihydropyridine
Ca+ channel blockers (CCBs):
1) What may all of them cause
2) When are they generally avoided?
1) Postural hypotension, HA, fatigue, weakness
2) In HF in most patients
Hypertension Geriatric (65+) considerations:
1) What is common?
2) What is the JNC-8 Threshold ?
3) What abt with either CKD or DM?
4) ACC threshold SBP is what?
1) Isolated systolic HTN common
2) SBP 150/90 mm Hg (without CKD or DM)
3) 140/90 mm Hg
4) ~ 130/80 mmHg
Side effects to medications more frequent
Any of the 3 classes appropriate
CCB for isolated systolic HTN
HTN & Ischemic heart disease: Beta blockers
1) When should you avoid?
2) What may they lead to?
1) In Asthma, COPD, heart block
2) Bronchospasm, bradycardia, HF, fatigue, decreased exercise tolerance, elevated TG
1) What represent a spectrum of disease that affects women throughout pregnancy and the immediate postpartum period?
2) What 3 things are warranted in these cases?
1) Hypertensive disease of pregnancy
2) Close blood pressure (BP) monitoring, laboratory evaluation, and fetal assessment are warranted
What does the spectrum of hypertensive disease of pregnancy include?
1) Gestational hypertension (HTN)
2) Preeclampsia, eclampsia, HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome
3) Chronic HTN, and chronic HTN with superimposed preeclampsia
HTN of pregnancy:
1) What are first-line oral antihypertensives for outpatient BP management of chronic HTN?
2) What has long h/o use and appears safe alternative (monitor LFT’s)?
3) What should you do postpartum?
1) Labetalol and nifedipine extended release (Procardia XL)
2) Methyldopa (alpha-2 agonist)
3) Continued vigilance (6-8 wks)
Resistant HTN refers to a BP that stays above the target in spite of the Tx with ___ drugs (among one of them is a diuretic)
3
What are the two caveats to the general rule of “3 or more drugs and still high= resistant HTN”?
1) One must be a diuretic
2) Adequate dosing of all 3 classes of medications
What are examples of exogenous substances?
1) Caffeine – energy drinks, supplements
2) Excessive alcohol, smoking, cocaine
3) NSAIDS, OCP, Steroids
4) EPO
5) Herbal agents
How can you make sure resistant HTN is real?
Verify with clinic and out of office BP measurements
How do you measure BP correctly in-office?
Quietly sitting 5 minutes, back supported, feet comfortably on the ground
Cuff correct size – 80% of biceps
Support arm at heart level
Average minimum of 2 readings at least a minute apart
Check BP in both arms
Check BP standing for orthostasis
Give examples of causes of secondary HTN
1) OSA
2) CKD – renal parenchymal disease and RAS
Resistant HTN: How can you ensure a pt’s regimen is appropriate? (3 things)
1) Appropriately dosed as tolerated
2) Typically, it’s inadequate diuresis; consider longer acting diuretic
3) Change thiazide type diuretic to chlorthalidone
Resistant HTN: Adjunctive therapy
1) What is a potential 4th drug?
2) Could you switch from ACEi to ARB or vice versa to help?
3) What other b-blockers could you consider? Why? Which increases nitric oxide levels?
4) What are 2 other meds to consider and their MOAs?
1) Spironolactone - potassium sparing & aldosterone antagonist
2) No benefit changing from ACEi to ARB or vice versa
3) Vasodilating B-blocker: Carvedilol, labetalol – both block alpha and beta receptors
-Nebivolol increases nitric oxide levels
4) Clonidine: central alpha-2 receptor blocker
Prazosin (Minipress): peripheral alpha -1 receptor blocker
Stopping ___________ suddenly can cause rebound HTN
Clonidine
1) What groups tend to be sensitive to diuretics?
2)
1) Obese, AA, or elderly patients
2)
Tolerance to thiazides or “braking” effect: What are 3 things you should do?
1) Restrict salt intake
2) Increase dose
3) Add aldosterone inhibitor – spironolactone (Aldactone)
Other Treatment considerations for HTN:
1) What are 2 reasons to consider aldosterone inhibitors?
2) What should you do for OSA?
1) PA, Cushing syndrome
2) CPAP (+ lifestyle modifications)
Renal vascular disease causing HTN:
1) What did not improve outcomes over Rx alone in atherosclerotic RAS?
2) What is tx of choice for fibromuscular dysplasia
ACEi and ARB relatively contraindicated?
1) Stenting
2) Angioplasty
1) What is “the 4th BP medication”?
2) What is it the appropriate choice for?
3) At initiation eGFR should be what? What abt K+?
4) Resistant HTN is associated with higher levels of what? What does this lead to?
1) Aldosterone antagonist
2) Resistant HTN
3) eGFR should be > 30 mL/min (CKD 3 or better) and K+ < 4.5 mEq/dL
4) Higher levels of aldosterone, leading to secondary pharyngeal edema, increasing upper airway obstruction and making this a good choice for patients with OSA
Give an example of a direct arterial vasodilator (i.e. combines with receptors in endothelium of arterioles and can cause palpation + tachy)
Hydralazine
Give an example of a group of drugs that oppose effects of the sympathetic nervous system (decrease smooth muscle contraction)
Alpha-1 and alpha 2 adrenergic agonists
Rx induced renal funct. decline:
1) What is the normal change?
2) What also dilate efferent arteriole, exaggerating decline in IG pressure?
3) What should you do if the change is abnormal?
1) Physiologic (normal) – up to 30% increase in creatinine, stabilizes
Ex: 1.0 to 1.3 mg/dL
2) ACEi/ARB
3) If creatinine increases by more than 30%, agent should be reduced or discontinued
True or false: Renal dysfunction may occur with any antihypertensive agent
True
List the 5 steps you should take if BP is not controlled
1) Alter thiazide to chlorthalidone or indapamide
2) Add spironolactone or eplerenone
3) Add B-blocker. Alternative is alpha-blocker or diltiazem Qday.
4) Add hydralazine (3x/day). Add isosorbide if HFrEF
5) Substitute minoxidil. Involve specialist if not effective.
Give examples of end-organ damage that may occur with a hypertensive emergency
1) CNS – dizziness, confusion, encephalopathy, TIA, ischemic or hemorrhagic stroke
2) Eyes – vision changes - papillary edema, retinal changes
3) Heart – angina, ACS, aortic dissection
4) Renal – ARF – hematuria and proteinuria
A pt has a BP of 190/120 and no end organ damage. What do they have and what do you do?
Severe asymptomatic HTN; outpatient management
1) Define severe asymptomatic HTN
2) What do these pts often have and what is the use of immediate diagnostic testing?
1) Defined as SBP > 180 or DBP > 110 (120) mmHg without symptoms of target organ injury
2) Often have pre-existing poorly controlled chronic HTN; immediate diagnostic testing rarely alters short term management
Severe asymptomatic HTN:
1) >180/110 (120) mmHg is also the goal BP for what?
2) Describe when it most often occurs in patients previously Dx with HTN
1) rtPA in ischemic stroke)
2) In patients previously Dx with HTN:
60% chronically uncontrolled HTN
65% Medication noncompliance
Rarely: unrecognized secondary HTN
Severe HTN:
1) What is essential?
2) What parts of history definitely need to be asked?
3) What does ROS need to include?
4) Why is an exam needed?
1) Comprehensive history is essential
2) Medication history:
New Rx and/or OTC
Recreational drugs and alcohol excess
Compliance with current prescriptions
3) For end organ damage
4) Look for end organ damage
Describe how you should look for target organ injury (6 steps)
1) Neuro exam for focal deficits
2) Eye exam with fundoscopic exam
3) Retinal bleeding, papillary edema
4) Cardiovascular – bruits, pulses, JVD, abnormal heart sounds
5) Pulmonary - rales
6) Abdominal exam – pulsating abdominal bruits
Recent study of outpatients of patients referred to ER for HTN urgency found that ~_____% of test were abnormal and ~____% had evidence of target organ injury
~5%; ~2%
HTN urgency:
1) What can routine testing include?
2) How often is EKG done?
1) Routine? - CMP, UA, cardiac enzymes, CXR, CT head
2) EKG performed in < 1%
True or false: No validated policies or nationally recognized clinical guidelines for HTN urgency
True
List 4 questions to ponder in Severe Asymptomatic HTN
1) Does acute Rx management affect short term adverse outcomes?
2) How quickly should BP be lowered?
3) Who should be admitted?
4) How should admitted patients with HTN urgency be managed?
1) Most outpatient clinicians hesitant to send patients home with severe hypertension. Why is this an issue?
2) Studies support a “conservative” approach; describe this
1) Lack of evidence of immediate increase in risk of major adverse outcomes
-Common practice to acutely lower BP with short acting antihypertensives
2) Outpatient management
PO antihypertensive Rx and follow up
Acutely lowering BP may not be necessary or beneficial
Asymptomatic severe HTN:
1) Gradually lower BP over ________to ________ to goal
2) Use GDMT, typically require at least ______ medications
3) If patient was stable on medications in the past, you should do what?
1) days; weeks
2) 2
3) Return to same medications
Give the severe asymptomatic HTN BLUF
Patients with HTN urgency should have a history and exam to distinguish between severe asymptomatic hypertension and hypertensive emergency
A 30-minute rest period is recommended when the initial BP is severely elevated. In more than 30% of patients, the BP will lower to an acceptable level without intervention after the rest period (<180/110 mmHg)
An immediate diagnostic evaluation is not required in the initial management of severe asymptomatic hypertension
Aggressive lowering of BP can be harmful and should be avoided in patients with severe asymptomatic hypertension. Gradual reduction over several days to weeks is recommended
Describe HTN emergency Tx (covered in detail in emergency med)
1) Gradually lower BP by 10-20% in the 1st hour and a further 5-15% over the next 23 hours
-Initial goal 1st hour is < 180/120 mm Hg
-Goal for next 23 hours is < 160/110 mm Hg
2) Typically admitted and IV meds are used
B-Blockers: Labetalol
Nitrites: Nitroprusside
CCB: Nicardipine
True or false: syncope is generally not a brain issue
True
1) Define syncope
2) What is the immediate cause? What are 2 potential causes of this?
1) Abrupt, transient complete loss consciousness associated with inability to maintain postural tone with rapid spontaneous recovery (not just MS changes such as intoxication or opioid OD)
2) Transient cerebral hypoperfusion
-Systemic vasodilation, decreased cardiac output, or both
What are 3 MOAs of syncope?
Usually a combination:
1) Cardiac: decreased cardiac output (CO), most often associated with sudden cardiac death
2) Reflex (neurogenic): most common type affecting systemic vascular tone and CO
-Provoking factor: fear, pain, emotional distress, cough, micturition
3) Orthostatic: usually associated with positional changes
-Dehydration, anemia, medication use
1) Dehydration, anemia, medication use are examples of what types of syncope causes?
2) What is the most common type affecting systemic vascular tone and CO?
3) Fear, pain, emotional distress, cough, micturition can provoke what type?
1) Orthostatic
2) Reflex (neurogenic)
3) Reflex (neurogenic)
What should you do for each of the following types of syncope?
1) Cardiac
2) Reflex
3) Orthostatic
1) Treat underlying issue
2) Pt education (trigger avoidance) and reassurance
3) Pt education and reassurance + anticipating triggers
1) Define orthostatic hypotension
2) Define the criteria for Dx
1) Drop in BP after assuming a standing position from supine
2) Dx: drop of 20 mm Hg or more SBP or drop of 10 mm Hg or more DBP
(Similar BP changes 60 degrees head up on tilt table)
Symptoms (not required for Dx) of orthostatic hypotension are due to what?
Inadequate physiologic compensation and organ hypoperfusion
List the following Sx for orthostatic hypotension:
1) Constitutional
2) CNS
3) Retina
4) CV
5) Pulmonary
6) GI
7) MSK
1) Fatigue
2) HA, lightheaded, presyncope/syncope
3) Visual disturbance
4) CP, palpitations, pallor, weakness
5) Dyspnea
6) Nausea
7) Shoulder and neck pain (coat hanger syndrome)
1) How do you measure orthostatic hypotension BP?
2) What should you do if the pt can’t safely stand?
1) Take BP and heart rate five minutes after supine and 3 minutes after standing
+ test = drop in 20 or more mm Hg SBP or 10 or more mm Hg DBP
2) Head up tilt table test
List 3 risk factors for orthostatic hypotension
1) Prevalence increased in elderly – decreased baroreceptor sensitivity and increasd autonomic neurodegenerative disease
2) Peripheral neuropathy - T2DM
3) Postural symptoms that only occur when standing
What is the significance of orthostatic hypotension?
Significant increase in CV risk, all cause mortality, and falls
For neurogenic causes of orthostatic hypotension, list the following:
1) Change in HR/change in SBP
(HR compensation ratio)
2) Symptoms of autonomic failure
3) Neurologic deficits
1) < 0.5 BPM/mm Hg
2) Dysfunction of urinary, GI
Postprandial hypotension
Symptoms worse in morning
3) Parkinsonism, cognitive dulling, cerebellar signs, peripheral sensory findings
For non-neurogenic causes of orthostatic hypotension, list the following:
1) Change in HR/change in SBP
(HR compensation ratio)
2) Symptoms of autonomic failure
3) Neurologic deficits
1) Marked increase in ratio
0.5 or more
2) None
3) None
Orthostatic hypotension management:
1) What are the goals?
2) How is this done?
3) What is especially important in elderly? (per Beers Criteria 2024)
1) Reduce Sx, improve QOL
2) ID and Tx underlying conditions
3) Medication review
Describe how to avoid aggravating activities with orthostatic hypotension (3 things)
1) Post prandial hypotension = smaller more frequent meals
2) Avoid hot humid conditions which leads to cooling via vasodilation
3) Proper hydration
What 2 groups of medications can you use in orthostatic hypotension Tx? Give examples of each and their MOAs
1) Adrenergic receptor agonists
a) Midodrine: short acting alpha-1 agonist
b) Droxidopa: short acting prodrug of norepinephrine
2) Mineralocorticoids
a) Fludrocortisone: increases salt reabsorption, IV volume, and vascular tone
