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533 > Week 1 HTN > Flashcards

Week 1 HTN Flashcards

1
Q

how is BP diagnosed

A

2 measurements on 2 separate visits

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2
Q

Antihypertensives for African Americans

A

CCB (amlodipine, cardiezem, diltiazem)

and/or

thiazide (chlorthalidone or HCTZ)

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3
Q

antihypertensives for Asians

A

CCB (amlodipine, diltizem, cardizem)
ARBs

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4
Q

JNC 8 guidelines to start on HTN:
Whites

A

ACE
Diuretics
Beta blockers
CCB

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5
Q

ANYONE with Chronic kidney disease or diabetes, regardless of age or ethnicity

A

Start on ACE or arb to protect kidneys
Monitor K and renal function in initial workup and f/u in 1 month
Recheck BP, renal function, and electrolytes

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6
Q

elevated hypertension

A

120-129 / < 80

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7
Q

stage 1 hypertension

A

130-139/ 80-89

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8
Q

stage 2 hypertension

A

> 140/>90

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9
Q

If have elevated or stage 1 HTN with estimated 10 year ASCVD risk of LESS < than 10%

A

recommend non pharm therapy, lifestyle modifications

repeat BP in 3-6 months

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10
Q

If have stage 1 with estimated 10 year ASCVD risk > 10%

A

Recommend 1 drug treatment + life style mod

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11
Q

If have stage 2 HTN and has tried lifestyle modification

A

Recommend 2 drugs from 2 different classes (combine into 1 pill)

Recheck BP in 1 month

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12
Q

lifestyle modifications to manage elevated BP and HTN?

A
  • lose weight
  • Adopt a heart-healthy diet, (DASH) diet (fruits, vegetables, and low-fat dairy products with reduced total and saturated fat)
  • Reduce dietary sodium < 100 mEq/L daily
    • 2.4 g sodium or 6 g sodium chloride
  • Supplement potassium (preferably from diet) unless contraindicated by the presence of chronic kidney disease or drugs that reduce potassium excretion
  • Increase physical activity
  • no more than 2 drinks/day in men and no more than 1 drink/day in women
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13
Q

if stage 2 HTN and/or signs of target organ dysfunction:

A
  • Retinopathy, hemorrhages in fundus exam, alternated mental, visual deficits, focal neuro deficits, cardiopulmonary (rales, S3, variations in bilateral arm or leg BP measurements, decrease peripheral pulses)
  • Send to ER ASAP
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14
Q

if stage 2 HTN and NO evidence of end organ damage/normal PE:

A
  • Can be managed outpatient with 2 medications
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15
Q

orthostatic hypotension

A

Decrease in SBP at least 20 mmgh or decrease in diastolic BP at least 10 mmg w/in 3 minutes of moving to standing position

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16
Q

when to increase dose of statin if goal is not achieved with initial prescribing

A

in 4-6 weeks

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17
Q

first line statin

A

atorvastatin (Lipitor) 80 mg daily (reduces acute coronary syndrome)

first line

avoid grapefruit juice

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18
Q

what is a good indicator of coronary risk

A

LDL

every 1% reduction of LDL, there is a 1% decrease in coronary risk

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19
Q

moderate intensity statin

(daily dose lowers LDL ~30-50%)

A
  • Atorvastatin 10-20 mg
  • Rosuvastatin 5-10 mg
  • Simvastatin 20-40 mgPravastatin 40-80 mg
  • Lovastatin 40 mg
  • Fluvastatin 40 mg bid
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20
Q

high intensity statins

(daily dose lowers LDL >50%)

A
  • atorvastatin (Lipitor) 40-80 mg
  • rosuvastatin (Crestor) 20-40mg
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21
Q

what other meds if can’t tolerate statins

A
  • Bile acid sequestrants - cholestyramine
  • Nicotinic acid - Niacin
  • Fibrates – fenofibrate (Tricor)
  • Cholesterol absorption inhibitors – ezetimibe (Zetia)
  • Liposoluble antioxidants – omega-3 fatty acids
  • PCSK9 – alirocumab
    • subcutaneous injection
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22
Q

5 A’s of motivational interviewing

A
  • Ask permission to discuss topic
  • Assess BMI and obesity
  • Advise health risk a/s with obesity
  • Agree with realistic goals and tx options
    • Assist resources and barriers
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23
Q

what % of weight loss is associated with decreased risk of morbidity and mortality, esp with cardiovascular events?

A

A 10% weight loss, with 7% kept off during maintenance

benefits start at 5% loss

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24
Q

if have BMI 25+

A

use diet, exercise, and behavior modification techniques alone

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25
Q

if BMI >27 with comorbidity OR BMI 30+….

A

start pharmacology for weight loss

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26
Q

if have BMI > 35 with comorbidity or BMI 40+…

A

consider bariatric surgery

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27
Q

Patients may be candidates for weight loss medications if

A

they have a history of lack of success with weight loss and maintenance of the weight loss and if they meet medication label requirements.

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28
Q

metabolic syndrome diagnosis adults

A

need 3 out of 5:

  • Waist
    • male: > 40 inches
    • women: > 35 inches
  • Triglyceride >150 +
  • Reduced HDL cholesterol
    • < 40 males
    • < 50 in females,
  • SBP > 130/> 85
  • Fasting glucose >100
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29
Q

metabolic syndrome in children (age 10-16)

A
  • same as adults
  • except waist > 90% for age, gender, race
30
Q

how to properly take a blood pressure

A
  • recheck BP with manual cuff using proper techniques (2 mins in between readings)
    • Pt seated, feet flat on floor, leaning back against something & rest for 5 mins before taking BP
    • empty bladder, no clothing under arm, neither me or pt should be talking while it’s being taken. Choose appropriate size cuff (too large can give lower)
    • Bare arm level of heart
    • Cuff is placed at bladder of the cuff over brachial artery
  • Rapidly inflate cuff 70 mmHg, increase to 10 increments while palpating radial pulse
    • Note pressure at which radial pulse disappears and reappears during cuff deflation
    • (“palpatory method” to better estimate adequate inflation—avoiding overinflation in persons with low blood pressure and underinflation in those with an auscultatory gap)
  • Use either the bell or the diaphragm of the stethoscope over the brachial artery and below the cuff (not wedged under the cuff)
  • Inflate the cuff to 20 to 30 mm Hg above the palpated pulse disappearance pressure and deflate the bladder at 2 mm Hg/sec while listening for the appearance and disappearance of the Korotkoff sounds.
  • Phase I = appearance of the first sounds = systolic blood pressure (SBP)
  • Phase V = disappearance of the Korotkoff sounds =diastolic blood pressure (DBP)
  • Take the proper measurement needed for diagnosis and treatment of elevated BP or hypertension.
  • use arm with higher reading for subsequent readings.
  • Separate measurements by one to two minutes.
  • Round off (upward) to the nearest even number
  • Measurement should be repeated after one to two minutes and the two readings averaged
  • Properly document accurate BP readings.
  • Average the readings.
  • Average more than two readings obtained on more than two occasions to estimate the BP
  • Provide BP readings to the patient.
  • SBP and DBP readings should be provided verbally and in writing to the patient.
31
Q

initial primary hypertension workup

A
  • EKG (ischemic heart dz or L ventricular hypertrophy)
  • CMP
  • Renal function
  • UA
  • Fasting blood glucose
  • CBC
  • Lipid profile
  • Serum creatinine with GFR
  • Na, K, Ca
  • TSH
  • Cholesterol
32
Q

rec what med if have HTN and congestive heart failure:

A

thiazides, BB, ACE inhibitors, ARB, aldosterone antagonist

33
Q

rec what class of med if have HTN and post MI

A
  • BB, ACE
34
Q

rec what class of meds if have HTN and high cardiovascular risk

A

thiazides, BB, ACE inhibitor, CCB

35
Q

rec what med if have HTN and diabetes

A

ACE inhibitors/ARB = renal protective

thiazides

CCB

36
Q

rec what med if have HTN and chronic kidney disease

A

ACE/ARB (renal protective)

goal: < 140/90

37
Q

rec what med if have HTN and recurrent stroke prevention

A

HCTZ, ACE (neuro protective)

38
Q

rec what med if have HTN and BPH

A

alpha blocker

39
Q

risk factors for secondary hypertension

A
  • No family history
  • Drug resistance/induced HTN
  • Abrupt on set of HTN
  • Onset before 30 or after 65 yrs
  • Exacerbation of previously controlled HTN
  • Accelerated HTN or malignant HTN
  • Unprovoked or excessive hypokalemia
40
Q

11 Causes of secondary hypertension

A

“ABCDE”

  1. Apnea
  2. Aldosteronism (primary hyperaldosteronism)
  3. Bruits
    1. Renovascular disease (renal artery stenosis or fibromuscular dysplasia)
  4. CKD (bad parenchymal disease)
  5. Catecholamines release from decongestants, herbal preparations
    1. ​pheochromocytoma (5 H’s: HTN, Headache, hyperhidrosis, hypermetabolic state, hyperglycemia)
  6. Coarctation of aorta
  7. Cushing’s syndrome and other excess glucocorticoid states
  8. Drug induced
  9. Diet (excess Na, alcohol, black licorice)
  10. Erythropoietin excess (exogenous or secondary to COPD/polycythemia)
  11. Endocrine disorders
    1. hypothyroidism, hyperthyroidism, hyperparathyroidism, pregnancy-induced hypertension, pheochromocytoma, acromegaly
41
Q

goals of therapy for antihypertensive therapy

A

reduce stroke, heart failure, and CAD

get SBP below 130 and diastolic < 80

42
Q

favorable effects of thiazide diuretics besides for HTN

A

slow down demineralization in osteoporosis

43
Q

favorable effects of beta blockers (besides for HTN)

A
  • useful for atrial tachyarrhythmias or atrial fibrillation
  • migraine prophylaxis
  • thyrotoxicosis (short-term)
  • essential tremor
  • CCBs – useful for Raynaud syndrome and certain arrhythmias
44
Q

common side effects of chlorthalidone, chlorothiazide, hydrochlorothiazide, indapamide, and metolazone

A

thiazide/diuretic

  • HypoK, hypoMg, hypoNa
  • hypERcalcemnia
  • worsens or precipitates gout (increases reabsorption of urate)
  • elevated cholesterol
  • pancreatitis, rash, photosensitivity
  • erectile dysfunction
45
Q

common side effects of bumetanide, ethacrynic acid, furosemide, and torsemide,

A

loop diuretics
Volume depletion, hypokalemia, hyponatremia (less likely than with thiazides), hypomagnesemia, hyperglycemia, metabolic alkalosis, hyperuricemia, elevated cholesterol and triglycerides, rash, blood dyscrasias

46
Q

common side effects of amiloride and triamterene spironolactone and eplerenone

A

K sparing

HypoN, HyperK

Spironolactone: mastodynia, gynecomastia, sexual dysfunction, abnormal menses

Hyperkalemia, rash, headaches, gastrointestinal disturbances, nephrolithiasis

47
Q

common side effects of amlodipine, felodipine, isradipine, nicardipine, nifedipine, nisoldipine

A
  • Dihydropyridines CCB*
  • Dizziness, headache, peripheral edema (worse with the dihydropyridines than it is with the non-dihydropyridine CCBs), flushing, tachycardia, rash, gingival hyperplasia*
48
Q

common side effects of diltiazem and verapamil

A

Non-dihydropyridines

Dizziness, headache, edema (less common than with the dihydropyridine CCBs), bradycardia, atrioventricular (AV) blockade, heart failure
- diltiazem is also associated with a lupus-like rash.

49
Q

common side effects of enazepril, captopril, enalapril, fosinopril lisinopril, moexipril, perindopril, quinapril, ramipril, and trandolapril

A

Angiotensin converting enzyme inhibitors

  • Chronic nonproductive cough, hypotension (especially use with a diuretic or if used in the setting of volume depletion), rash, acute kidney injury (especially w bilateral renal artery stenosis or in patients with limited blood flow to a solitary kidney), angioedema, hyperkalemia, mild to moderate taste disturbance, hepatotoxicity, pancreatitis, and blood dyscrasias.*
  • NO in pregnant women or women likely to become pregnant*
50
Q

common side effects of azilsartan, candesartan, eprosartan, irbesartan, losartan, olmesartan, telmisartan, and valsartan

A
  • Similar to ACE inhibitors but not not really chronic cough*
  • less likely to cause angioedema*
51
Q

common side effect of aliskiren

A

direct renin inhibitor

similar to ARB

diarrhea

52
Q

if started on a diuretic and ACE or aldosterone or ARB, when should pt come back for follow up?

A

2 weeks to check his potassium, creatinine, and evaluate his BP control. Apart from these considerations, it is the recommendation of the 2017 guidelines that the patient be reevaluated for his BP in a month’s time.

53
Q

what med used for pregnant women with hypertension?

A

CCB (nifedipine) and beta blockers (labetalol)

diuretics may be used but can increase risk of maternal volume loss

54
Q

which hypertensive medication should be avoided in patients with poorly uncontrolled asthma?

A

beta blockers - may cause bronchoconstriction

55
Q

what is not considered first-line with essential hypertension and no other medical conditions?

A

beta blockers

56
Q

Patients at very high-risk for ASCVD with a LDL > 70 mg/dL

A
  • consider addition of ezetimibe if LDL > 100 mg/dL
57
Q

what in the lipid profile is okay if non fasting?

A

direct LDL

HDL

Total cholesterol

58
Q

MUST be fasting to show what in lipid panel

A

corrected LDL

triglycerides

59
Q

if have abnormal lipid screening,

A

repeat screening test

average both results to assess patient risk

60
Q

what lipid value drives the statin treatment?

A

LDL cholesterol value (if > 190) drives the statin treatment

61
Q

6 drug class options available to treat hyperlipidemia

A
  • HMG-CoA reductase inhibitors (statins)
  • Bile acid sequestrants
  • Cholesterol absorption inhibitors
  • Fibrates
  • Niacin
  • Fish oil capsules
  • Monoclonal antibodies that inhibit proprotein convertase subtilisin/kexin type 9 (PCSK9)
62
Q

what are the LDL treatment goals?

A

To reduce the ASCVD risk

high-intensity statin therapy lower LDL by ≥50%, moderate-intensity statin therapy by 30-49%, and low-intensity statin therapy by <30%.

63
Q

contraindications to statins

A

pregnancy

active liver disease

Transaminitis (high levels of liver enzymes)

cholestatic liver disease

64
Q

statin side effects

A

myopathy

elevated liver transaminases (dose dependent, usu in first 3-4 months)

65
Q

if have only elevated triglycerides but normal lipid levels, does she need drug treatment for dyslipidemia?

A

No, guidelines do not specifically address treating elevations in the triglycerides.

if elevated triglycerides (>500 mg/dL) consider secondary causes of hyperlipidemia: diet, certain drugs, nephrotic syndrome, chronic renal failure, lipodystrophies, poorly controlled diabetes, hypothyroidism, obesity, and pregnancy.

benefit from a high fiber, low cholesterol (less than 200 mg/day) diet, with less than 7% of calories from saturated fat; increase physical activity and weight reduction

66
Q

universal screening for dyslipidemia for adolescents

A

fasting lipid checked once between ages 9 - 11 years and once again ages 17-21

If ages 2-8, should have fasting lipid profile checked twice if:

  • parent, grandparent, aunt/uncle, or sibling with MI, angina, stroke, or CABG/stent/angioplasty when younger than 55 years in males and 65 years in females
  • Any child with a parent who has a TC >240 mg/dL or known dyslipidemia
  • Any child with diabetes, hypertension, BMI > 95th percentile or who smokes cigarettes
  • Any child who has one of the following moderate- or high-risk medical conditions:
    • High Risk
      • Type 1 or type 2 diabetes mellitus
      • Chronic kidney disease, end-stage renal disease (ESRD), history of renal transplant
      • History of orthotopic heart transplant
      • Kawasaki disease with current aneurysms
    • Moderate Risk
      • Kawasaki disease with regressed coronary aneurysms
      • Chronic inflammatory disease (systemic lupus erythematosus, juvenile rheumatoid arthritis)
      • HIV infection
      • Nephrotic syndrome
67
Q

if children lipid profile abnormal, do you start on med?

A
  • No. For children 10 years old and older who have elevated LDL a cholesterol lowering medication “should be considered.”
  • focus on weight loss, increased activity (play outside an hour a day), and nutritional counseling.
  • rec reduced-fat dairy products if > 1 year of age.
68
Q

Which of the following lab values are the most likely to be affected by eating within an hour of lab draw?

A

triglycerides

69
Q

nezetimibe (Zetia) MOA

statins MOA

fibrates MOA

bile acid sequestrates MOA

A
  • Ezetimibe blocks absorption of cholesterol in the brush border of the small intestine.
  • Statins (atorvastatin and pravastatin)
    • HMG-CoA reductase inhibitors,
    • limiting the rate of hepatic cholesterol synthesis = leading to increased peripheral LDL receptor expression and LDL uptake from the blood.
  • Fibrates (gemfibrozil)
    • activate peroxisome proliferator-activated receptor alpha (PPAR-alpha), a nuclear transcription factor that regulates lipid metabolism,
    • for severe hypertriglyceridemia
  • Bile acid sequestrants (cholestyramine, colestipol)
    • resins bind cholesterol in the gastrointestinal tract and increase cholesterol excretion in the stool.
70
Q

statin therapy indications

A

1) If already have atherosclerotic cardiovascular disease (ASCVD) [high statin]
2) Have LDL _>_190 [high statin]
3) 40-75 yrs old with diabetes AND LDL 70-189 [moderate statin]
4) 40-75 yrs old with 10 yr risk of ASCVD of _>_7.5%[moderate statin]

71
Q

lipid screening in adults

A

ALL adults > 20 yrs old every 5 years get fasting lipid panel

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