Week 2 - Respiratory and Cardiac Disorders Flashcards
Pharmacological treatment for hypertention should be started in those over 60 when BP is…
150/90 or higher
First line treatment for hypertension in those over 60
- diuretics and dihydropyridine calcium channel blockers (amlodipine) are the recommended initial choices for older adults.
- Most older adults with hypertension need two or more drugs to effectively lower their blood pressure
American Heart Association
BP Goal for adults over 65 with hypertension
less than 130 mmHg
Factors to consider when commencing hypertension medication in older adults
Factors to consider when weighing the risks and benefits of treatment for hypertension in older adults
- Clinical judgment
- patient preference
- comorbidities
- life expectancy are
- Blacks at higher risk for HTN than whites (also increased stroke risk)
People with hypertension have a higher risk for
- Stroke
- PAD
- MI
- HF
- risk of cardiovascular disease increases markedly with age
HTN risk factor for alzheimers and vascular dementia due to cumulative damaged to cerebral blood vessels of the brain
Physiological changes that cause hypertension
- increase in stiffness of vessels, waves move faster and reflect back during systole augmenting systolic BP and lowering diastolic BP
- widening the pulse pressure (this is a better predictor of heart disease rather than SBP or DBP
- Blood vessels less responsive to B-adrenergic stimulation
- Plasma renin activity declines with ages
- Decreased aldosterone leads to greater risk of hyperkalemia
Essential hypertension
raise in BP with unknown cause (likely interaction of environmental and genetic factors – usually associated with aging, obesity, physical inactivity, insulin resistance, diabetes, HLD)
Secondary hypertension
HTN caused by another condition like kidney disease. Uncommon in older adults but should be considered if there is a sudden rise in BP or lack of response to drug therapy. Other causes in older adults are obesity, thyroid disease, parathyroid disease
What medications can increase blood pressure?
NSAIDs, steroids, decongestants
Resistant hypertension
BP that remains above goal despite treatment with 3+ medications at optimal doses including a diuretic or 4 HTN meds. Commonly caused by nonadherence to medication.
Psuedohypertension
peripheral arteries so stiff and rigid that measuring BP in the arm cuff may overestimate arterial pressures due to incomplete compression of brachial artery. Consider with patients who have symptoms that don’t respond to treatment or who have postural symptoms.
Severe asymptomatic hypertension
SPB >180 and DBP >110 without symptoms of acute target injury (may have headaches, nausea, palpitations, SOB)
How to diagnose hypertension
Two different high readings on two separate occassions
Blood pressure cuff effects
Cuff too small may produce a high reading
Physical exam for people with hypertension
Eyes - evaluate the optic fundi for arteriolar narrowing, hemorrhage
Palpate thyroid gland
Neuro exam for signs of stroke
Memory testing for cognition
Heart – murmur, displaced apical impulse, arrhythmia
Auscultate the lungs
Peripheral circulation – abdominal pulsation or bruit, carotid bruit, peripheral pulses, jugular venous distention
Total cholesterol
Below 200 mg/dL
HDL
Above 60 mg/dL
LDL
Below 100 mg/dL (below 70 for diabetics)
Triglycerides
Below 150 mg/dL
Tests for end organ damage and CV risk factors
- CBC
- lipid panel
- creatinine
- sodium
- potassium
- CA
- TSH
- UA
- EKG
Which patients over 60 should be treated to attain BP <130/80?
patients with ischemic heart disease or heart failure
Lifestyle changes to improve BP
- Weight loss
- Physical activity
- Reduce salt intake
- Heart healthy diet (DASH “dietary approaches to stop hypertension” – low fat with fruits and veg, whole grains, poultry, fish, nuts. Reduce intake of fats, red meats, sweets and sweetened beverages rich in K, phos and protein, not recommended for CKD 3 or 4)
- Potassium supplementation
- Smoking cessation
- Moderation of alcohol (less than 2 per day for men and 1 per day for women)
If reducing salt intake, the effects are most pronounced in what populations?
blacks, older individuals with DM, HTN, and CKD
When to follow-up after starting BP medication?
Start medication and follow-up in 1 month. If target BP not reached then increase dosage or start a second medication
First line of treatment for HTN in individuals over 60
CCB or diuretics
What conditions have increased risk for a widened pulse pressure?
stroke, heart attack and other CV disease
What medications are most effective at reducing widened pulse pressure?
Thiazide diuretics
Resistant hypertension
most common cause of inability to control BP despite 4+ medications is noncompliance to medications
Treatments for resistant hypertension
- Focus on lifestyle factors, obesity, exercise, alcohol intake and diet
- Reduced meds that elevate BP – NSAIDS, stimulants, decongestants
- Consider secondary cause of hypertension
- Maximize diuretic therapy, add a mineralocorticoid receptor agonist, agents from class fo BP med not tried, loop diuretic
Acute coronary syndrome
Ddevelopment of plaque in the vessels which then erodes, fissures or ruptures. Vascular inflammation has been shown to have a pivotal role in the development of ACS
Percutaneous coronary intervention
stent placement
Complex atheroma
– plaques in the descending aorta if they are greater than 4mm thick or have mobile debris
Clinical risk factors for CAD
- Smoking
- HTN
- DM
- HLD
- CKD
- Family history CV disease
- PAD
CAD risk reduction strategies
- smoking cessation
- lipid management
- BP control
- diet and nutrition counseling
- diabetes management
- use of cardiac rehabilitation
- exercise instructions
