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Family Medicine > Case 8: Hypertension > Flashcards

Case 8: Hypertension Flashcards

1
Q

USPSTF screening recommendation for hypertension

A

Screen in patients with no known HTN starting at 18

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2
Q

Normal blood pressure

A

SBP: <120
DBP: <80

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3
Q

Prehypertension

A

SBP: 120-139
DBP: 80-89

  • technically a higher subset of normal blood pressure
  • used to identify pts in whom early intervention of healthy lifestyles could reduce blood pressure
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4
Q

HTN (<60 yrs old)

A

SBP: >140
DBP: >90

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5
Q

HTN (>60 yrs old)

A

SBP: >150
DBP: >90

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6
Q

JNC8 update

A

Updated EBM recs for management of high BP

Defaulted recommendations for Dx and prevention of high BP to earlier JNC7 report

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7
Q

3 questions to ask someone with new diagnosis of hypertension

A
  1. Presence of end organ damage (brain, heart, kidneys, vasculature, eyes)
  2. Presence of cardiovascular risk factors or other co-morbid conditions
  3. Reveal potential causes of hypertension

Also can ask

  • Family hx of diabetes, hypercholesterolemia
  • pt’s diet history
  • review of psychosocial stressors (stress causes direct release of Ag2 and norepi)
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8
Q

Signs of end organ damage due to hypertension (brain, heart, kidneys, vasculature, eyes)

A

Heart
- LVH, angina, prior MI, prior coronary revasc, CHF

Brain
- stroke, TIA

Kidney
- chronic renal failure

Vasculature
- peripheral artery disease

Eyes:
- retinopathy

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9
Q

Patient with X number of years of HTN probably already has end organ disease

A

10

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10
Q

Major cardiovascular RFs or concomitant disorders that affect prognosis/treatment of HTN (11)

A
  • diabetes
  • high cholesterol
  • obesity
  • family Hx of premature CV disease or death (<55 in men, <65 in women)
  • smoking
  • alcohol
  • cocaine, ketamine, narcotic withdrawel
  • age (>55 in men, >65 in women)
  • physical inactivity
  • microalbuminuria
  • GFR = 60
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11
Q

Causes of high blood pressure

A
  • sleep apnea
  • renovascular disease
  • CKD
  • primary aldosteronism
  • pheochromocytoma
  • coarctation of aorta
  • thyroid disease
  • parathyroid disease
  • OCPs, amphetamines, steroids
  • pseudophedrine, NSAIDs, appetite suppressants
  • St John’s Wart, ginseng, licorice, ma huang, bitter orange, ginkgo
  • smoking, alcohol, cocaine, ketamine, narc w/drawal
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12
Q

Causes of hypertension

A 
Essential hypertension (95%)
Secondary hypertension (5%): sleep apnea, CKD, renovascular, drug, pheo, aldosteronism, chronic steroids, Cushings, thyroid/parathyroid dz, coarc of aorta
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13
Q

How to accurately dx HTN

A

2 elevated measurements 5 minutes apart, one in each arm on 2 or more visits (can’t be Dx if acutely ill or in pain)

  • pt should be seated quietly for at least 5 min
  • support back, arm at heart level
  • need correct size cuff: length should be 80% arm circumference and width should be 40% arm circumference (bc cuff that is too small will give erroneously high BP) – with obese - need to use XL or thigh cuff instead of adult sized cuff
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14
Q

BMI Underweight

A

<18.5

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15
Q

BMI Normal

A

18.5-24.9

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16
Q

BMI Overweight

A

25.-29.9

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17
Q

BMI Obese

A

30-40

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18
Q

BMI Extreme obesity

A

> 40

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19
Q

People with white coat HTN should..

A
  1. check BP at home

2. still receive ongoing surveillance for development of essential HTN

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20
Q

Hypertensive retinopathy fundoscopy

A

Cotton wool spots
Flame hemorrhages
Exudates

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21
Q

Hypertensive emergency fundoscopy

A

Papilledema

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22
Q

Signs on PE that point to progression of HTN

A
  • carotid, abdominal, femoral bruits
  • crackles, diminished breath sounds (CHF)
  • AAA pulsation
  • enlarged PMI
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23
Q

How to monitor HTN

A

Only need ONE measurement in ONE arm for ongoing monitoring

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24
Q

Patient’s explanatory model of illness/health may overlap or diverge from…

A

Physician’s biomedical model of disease

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25
Q

What tests are indicated in the initial workup of HTN?

A
  1. EKG
  2. UA
  3. Blood glucose
  4. Blood hematocrit
  5. Serum potassium
  6. Serum calcium
  7. Serum creatinine and corresponding GFR
  8. urine albumin/creatinine
  9. Fasting lipids

(do not need TFTs, echo, LFTs, Na, Cl)

26
Q

EKG for initial evaluation of HTN

A

To assess rate and rhythm
- beta blockers and CCBs are contraindicated in people with abnormal R/R
To assess LVH
- 2nd indicator of death prognosis (first is age)

27
Q

UA for initial evaluation of HTN

A

To assess glucosuria (look for diabetes as co-morbid)

To assess proteinuria (evidence of HTN nephropathy)

28
Q

Blood glucose for initial evaluation of HTN

A

To assess for diabetes as co-morbid condition

29
Q

Blood hematocrit for initial evaluation of HTN

A

To assess for anemia

  • anemia makes major CV events (MI, stroke) more likely
  • can also be product of end organ damage in moderate/severe renal disease
30
Q

Serum K for initial evaluation of HTN

A

Obtain baseline because several anti HTN make pts hyperkalemic (ACEIs, ARBs, K sparing diuretics)

Also some secondary causes of HTN cause hyperK: primary aldosteronism, Cushings

31
Q

Serum Ca for initial evaluation of HTN

A

33% of pts with hyperparathyroidism + HTN have illness that can be attributed to renal parenchymal damage due to nephrolithiasis

32
Q

Serum creatinine and GFR for initial evaluation of HTN

A

Can point to hypertensive nephropathy

Also some anti HTN raise serum creatinine (ACEIs, ARBs, diuretics)

33
Q

Urine albumin/creatinine ratio for initial evaluation of HTN

A

To assess for microalbuminuria

34
Q

Fasting lipids (total cholesterol, HDL, LDL, triglycerides) for initial evaluation of HTN

A

Look for lipid co-morbidities

35
Q

Management of HTN involves (4)

A
  1. Lifestyle modifications
  2. Pharmaceutical management according to JNC 8 guidelines, all which apply to pts > 18 - choose agent based on age, diabetes status, CKD status
  3. If BP not at goal, max first or add second
  4. If BP not at goal w 2 meds maxed out, continue adding from other classes (but never ACEI + ARB together)
36
Q

Age < 60

General non black population

A

ACEI
ARBs
CCBs
Thiazide diuretics

Goal: 140/90

37
Q

Age < 60

General black population

A

CCBs
Thiazide diuretics

Goal: 140/90

38
Q 
Age > 60
General population (non black or black)
A

ACEI
ARBs
CCBs
Thiazide diuretics

Goal: 150/90

39
Q

Any age + any race + CKD

A

ACEI
ARBs

Goal: 140/90

40
Q

Any age + any race + diabetes

A

ACEI
ARBs
CCBs
Thiazide diuretics

Goal: 140/90

41
Q

Are beta blockers and alpha blockers first line therapies for HTN?

A

No

Poor support in clinical trials

42
Q

Thiazide diuretics

A

Most cost effective anti HTN drug

  • marked reduction in M/M from HTN in comparison to never, more expensive anti HTN medications
  • diminished returns when increase dose to 50 mg (low dose inexpensive thiazide diuretics are the best and should be used as first choice drug in most HTN pts except those with CKD)
  • may slow demineralization in osteoporosis
43
Q

Thiazide complications

A
  • can cause hyponatremia: monitor electrolytes
  • can precipitate gout flares: avoid in pt w Hx of gout
  • can exacerbate urinary incontinence
  • can cause elderly to be hypotensive if used at too high doses
44
Q

Starting dose for thiazides in normal adult

A

25 mg

45
Q

Starting dose for thiazides in elderly

A

6.25 or 12.5mg and then titrate up

46
Q

Lifestyle modifications that lower BP in order of increasing SBP reduction range

A 
Weight reduction
DASH eating plan
Physical activity
Sodium restriction
Moderation of alcohol consumption
47
Q

Sodium restriction is defined by

A

<100 mmol/day = 2.4 Na or 6 g NaCl

48
Q

Moderation of alcohol consumption is defined by

A

no more than 2 drinks/day for men

no more than 1 drink/day for women

49
Q

USPSTF aspirin recommendations

A

Start aspirin to reduce risk of MI in

a) men 45 to 79
b) women 55 to 79

50
Q

JNC7 aspirin recommendations

A

In pts with HTN, only judiciously prescribe aspirin when BP in normal range (otherwise, risk of hemorrhagic stroke)

51
Q

Alpha blockers in management of HTN

A
  • no evidence that shows the decrease M/M
  • only utilized as adjunct in hart to control blood pressure
  • often prescribed in prostatism but shouldn’t be used as first line anti HTN in pts w BPH
52
Q

In which ethnicities are BP control rates the lowest?

A

Native Americans

Mexican Americans

53
Q

African Americans and HTN

A
  • reduced BP responses to monotherapy with ACEIs, ARBs, and BB (but still reduce M/M in AA)
  • 2-4x more likely to develop angioedema from ACEIs
  • ACEIs/ARBs only recommended as first line treatment in blacks if they have CKD (can be used as third, fourth line treatment in general black population however)
54
Q

Beta blockers special considerations

A
  • check EKG and pulse prior to starting because should be avoided in patients with third degree heart block
  • avoid in asthma patients
  • do not mask hypoglycemic episodes in diabetics (myth)
  • good for use in pts with tachy/fibrillation, migraines, essential tremor, perioperative HTN
55
Q

ACEIs special considerations

A
  • first line in diabetics and CKD pts (renal protective)
  • monitor Na, K, creatinine (rise above 35% baseline in creatinine is acceptable)
  • Category C drug in pregnancy: avoid
  • have direct heart remodeling effects
  • Cough common side effect (bradykinin)
  • Angioedema is serious side effect)
  • reduces microalbuminuria
56
Q

ARB special considerations

A
  • Category C drug in pregnancy: avoid
  • have direct heart remodeling effects
  • Cough common side effect (bradykinin) but less
  • reduces microalbuminuria and macroalbuminuria
57
Q

CCB special considerations

A
  • useful in Raynauds and certain arrhythmias
  • can cause leg edema
  • only use long acting (short acting contraindicated)
58
Q

Loop diuretic special considerations

A
  • monitor electrolytes

- start at lower doses in elderly

59
Q

Aldosterone antagonist and K sparing diuretic special considerations

A
  • can cause hyperkalemia so avoid in pts with K>5
  • low dose aldo antagonist reduces M/M in CHF
    but high dose aldo antagonist increases sudden death
60
Q

Alpha blocker special considerations

A
  • not mentioned in JNC for Tx of HTN - only useful as adjunct in hard to control BP
  • can be used in prostatism but not as first line anti HTIN in pts with BPH
61
Q

Refer to specialist when…

A

Fail to control BP in pts maxed out on 3 drug regimen that includes a diuretic

Family Medicine (10 decks)

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