Special Considerations Flashcards
Left Ventricular Hypertrophy (LVH)
Independent risk factor that increases risk of CVD
Regression occurs with aggressive BP management: wt loss, sodium restriction, and tx with all classes of drugs except direct vasodilators hydralazine and minoxidil
Peripheral Artery Disease (PAD)
equivalent risk to ischemic heart disease
Any class of drug can be used
Should use ASA
Other risk factors should be managed aggressively
Postural HTN
Decrease in standing SBP >10 mmHg, when associated with dizziness/fainting, more frequent in older SBP patients with diabetes, taking diuretics, venodilators, and some psychotropic drugs.
BP in these individuals should be monitored in the upright position.
Avoid volume depletion and excessively rapid dose titration of drugs.
HTN in Women
Oral contraceptives may increase BP, and BP should be checked regularly. In contrast, HRT does not raise BP.
Development of HTN—consider other forms of contraception.
Pregnant women with HTN should be followed carefully. Methyldopa, BBs, and vasodilators, preferred for the safety of the fetus. ACEI and ARBs contraindicated in pregnancy.
HTN in <18 yo
1-3% of the pediatric population
Pre-hypertension
Average systolic BP and/or diastolic BP greater than the 90th but less than the 95th percentile for gender, age, and height on 3 separate occasions.
Hypertension
Average systolic BP and/or diastolic BP >95th percentile for gender, age, and height on 3 separate occasions
Stage I
Average BP ranging from >95th to 5 mmHg above the 99th percentile for gender, age, and height
Stage 2
Average BP >5 mmHg above the 99th percentile for gender, age, and height. These patients require further evaluation within 1 week.
Tx <18yo
Use lifestyle interventions first, then drug therapy for higher levels of BP or if insufficient response to lifestyle modifications.
Drug choices similar in children and adults, but effective doses are often smaller.
Uncomplicated HTN not a reason to restrict physical activity.
Lifestyle therapy
Low salt diet, DASH diet, exercise, and weight loss
Medications
ACE I, ARB, B-blocker, CCB, diuretics
Causes of Resistant HTN
Improper BP measurement Excess sodium intake Inadequate diuretic therapy Medication Inadequate doses Drug actions and interactions (e.g., nonsteroidal anti-inflammatory drugs (NSAIDs), illicit drugs, sympathomimetics, oral contraceptives) Over-the-counter (OTC) drugs and herbal supplements Excess alcohol intake Identifiable causes of HTN
Secondary HTN Causes
Chronic ETOH use Renal disease Endocrinopathies Sleep apnea Medications Coarctation of the aorta Hyperthyroidism Pheochromocytoma Primary Hyperaldosteronism Cushing’s Syndrome Coarctation of the Aorta Sleep Apnea Medications
Hypertensive Urgencies and Emergencies
Patients with marked BP elevations and acute TOD (e.g., encephalopathy, myocardial infarction, unstable angina, pulmonary edema, eclampsia, stroke, head trauma, life-threatening arterial bleeding, or aortic dissection) require hospitalization and parenteral drug therapy.
Patients with markedly elevated BP but without acute TOD usually do not require hospitalization, but should receive immediate combination oral antihypertensive therapy.
Hypertensive Urgency
Severe BP elevation with mild or no target organ damage
Must be reduced in hours
Hypertensive Emergency
Severe BP elevation with target organ damage
Must be reduced in minutes
Hypertensive Emergency Damage
Neurologic Hypertensive encephalopathy Acute CVA Intracranial bleeding Cerebral embolism/thrombotic stroke Subarachnoid hemorrhage Acute head trauma/injury Cardiac Cardiac ischemia/ M.I. Pulmonary edema/CHF Vascular Aortic dissection Recent Vascular Injury Epistaxis unresponsive to ant./post. packing Acute Renal Damage Pregnancy-related: Eclampsia Catecholamine excess states: Pheochromocytoma Drug related: MAO-related, clonidine or aldomet withdrawl, cocaine or phencyclidine
Drug Tx Acute Renal Damage Pregnancy-related Pheochromocytoma Drug-related
Acute Renal Damage Pregnancy-related: Eclampsia Catecholamine excess states: Pheochromocytoma Drug related: MAO-related, clonidine or aldomet withdrawl, cocaine or phencyclidine Clonidine withdrawl: Clonidine Postop hypertension: Nipride Post-CABG hypertension: NTG Subarachnoid Hemorrhage: Nimodipine
Hypertensive Urgencies Tx
ACE inhibitors (enalapril 1.25 mg q 6 hr i.v. available)
Labetalol (r/o asthma, CHF due to LV systolic dysfx., heart block)
Nitrates
Clonidine
Goal: Lower BP to 110-100 range and RTC in 24-48hrs for recheck
