pre-reading

Question 1

primary hypertension

Answer 1

• 95% of adult cases due to primary hypertension (5% secondary to other disorders
o Presentation can be associated by symptoms (e.g. headache, weariness) but disease is often ‘silent’ as patients have little to no symptoms due to body acclimation to higher and higher pressures over time

Question 2

• Diagnosis typically (not always) requires readings on 2 separate occasions

Answer 2

o Consider white-coat hypertension (high readings when in healthcare setting)—can utilize at-home measurements or 24-hour measurement to differentiate
o Assume primary blood pressure unless history/physical exam/other screenings suggest alternative cause)

Question 3

• ASH/ISH and JNC 8

Answer 3

Normal	<120	And <80
Prehypertension	120-139	Or 80-89
Stage 1 hypertension	140-159	Or 90-99
Stage 2 hypertension	≥160	Or ≥ 100
Hypertensive Urgency	≥ 180	≥ 110
Hypertensive Emergency	≥ 180	≥ 120 (with target organ damage)

Question 4

• ACC/AHA

categoreis of BP in adults

Answer 4

Normal <120 and <80
elevated 120-129 and <80
hypertension 
stage 1: 130-139 or 80-89
stage 2: >= 140 or >= 90

Question 5

• Lifestyle modifications

Answer 5

o Weight reduction if BMI ≥ 25 kg/m2: SBP lowering by 5-20 mm Hg for every 10 kg of weight loss
o Healthy diet (F/V, whole grain emphasis, limit fats, sweets and red meat): SBP lowering by 8-14 mm Hg
o Na restriction ≤ 2.4 gm sodium daily : SBP lowering by 5-6 mm Hg
o K 3.5-5 gms per day
o Exercise: 90-150 minutes aerobic per week SBP lowering by 4-9 mm Hg, resistance 3 times per week
o Alcohol: men ≤ 2 drinks, women ≤ 1 drink per day SBP lowering by 2-4 mm Hg
o Tobacco Cessation
o Limit/Eliminate caffeine
 Energy drinks: as little as one per day can raise SBP by 3.5 mm Hg
o Following drug classes can exacerbate HTN: alcohol, stimulants, antidepressants (except SSRI’s), atypical antipsychotics, oral contraceptives

Question 6

80 or 60 older

Answer 6

 Patients 80 years or older (ASH/ISH) or 60 years or older (JNC8) target of <150/90 may provide CV and stroke protection

Question 7

under 50

Answer 7

 Data lacking for blood pressure targets for patients under 50, lower targets could be appropriate

Question 8

CKD- goal of ash/ish and jnc

Answer 8

 Goal of < 140/90 although some experts still recommend < 130/80 in patients with CKD and albuminuria

Question 9

monitoring

Answer 9

• Every visit

• Drug ADE (see table/Pharmacology notes)
• Yearly
• Causes of resistant HTN (failure to achieve goal BP on 3-drug, diuretic-including regimen)

Question 10

urgency

Answer 10

often treated in clinic

Question 11

Hypertensive Urgency

Answer 11

≥ 180 ≥ 110

 Goal: Reduce BP to 160/110 mm Hg over several hours to days

after controlled
 Resume usual blood pressure regimen with enhanced monitoring or add additional medication if appropriate

Question 12

drugs for urgency

Captopril

Answer 12

• Captopril: onset of action 15-30 minutes
o Maximum drop in BP: 30-90 minutes
o 25 mg initial dose, followed by 50-100 mg 90-120 minutes later

Question 13

drugs for urgency

nicardipine

Answer 13

• Nicardipine: onset of action 30-120 minutes
o Usual dose: 30 mg every 8 hours until target BP achieved
o Use of short-acting nifedipine should be avoided due to stroke risk

Question 14

drugs for urgency

labetalol

Answer 14

• Labetalol: onset of action within 60-120 minutes

o Starting dose 200 mg, repeated every 3-4 hours

Question 15

drugs for urgency

clonidine

Answer 15

• Clonidine: onset of action within 15-30 minutes
o Peak effect: 2-4 hours
o Typical regimen: 0.1-0.2 mg loading dose, followed by 0.05-0.1 mg every hour until target BP achieved (max dose 0.7 mg)

Question 16

emergency

Answer 16

 Defined by Numbers and/or target organ damage
 Send to ER (not treatable in clinic)

 Ideal rate of blood pressure reduction unclear, proposed decrease to BP by 25% during first hour and to 160/100-100 mmHg over the next 2-6 hours

Question 17

Hypertensive Emergency

Answer 17

≥ 180 ≥ 120

(with target organ damage)

Question 18

monitoring every visit

Answer 18

o Blood pressure and pulse
o Lifestyle modifications
o Symptoms of elevated BP (HA, blurred vision, chest pain, SOB, epistaxis, tinnitus, tremor, weakness)

Question 19

monitoring yearly

Answer 19

o Eye exam
o Physical
o sCr and microalbumin

Question 20

monitoring

Causes of resistant HTN

Answer 20

o	Medication nonadherence
o	Volume overload
o	Improper BP measurement
o	Excessive sodium intake
o	Volume retention
o	Ineffective medication regimens (selection and doses)
o	Obesity
o	Alcoholism
o	Medications (NSAIDS, Cocaine, amphetamines, Sympathomimetics, Adrenal steroids, Cyclosporin or tacrolimus, Erythropoietin)

Question 21

resistant HTN

Answer 21

failure to achieve goal BP on 3-drug, diuretic-including regimen