B4.041 Hypertension

Question 1

what are some factors that contribute to abnormal lipid values?

Answer 1

high saturated fat and trans fat intake
high simple carb intake
genetic factors
overweight and inadequate exercise

Question 2

EKG findings consistent with hypertension

Answer 2

LAD, high QRS voltage, left ventricular hypertrophy

Question 3

interaction between high salt diet and hydrochlorothiazide

Answer 3

increased excretion of potassium

can lead to development of hypokalemia

Question 4

interaction between caffeine and hydrochlorothiazide

Answer 4

augmented diuretic effect leading to dehydration

Question 5

discuss the dose dependent effects of hydrochlorothiazide

Answer 5

effects n HTN level off around 12.5 mg

any dose above 12.5 mg furthers K+ excretion effects but doesn’t help HTN anymore

Question 6

what is the “cornerstone of management” in HTN

Answer 6

therapeutic lifestyle change

Question 7

categories of BP measurements

Answer 7

normal
elevated
stage 1 HTN
stage 2 HTN

Question 8

how many measurements do you need to make a diagnosis of HTN?

Answer 8

> 2 readings on >2 occasions
out of office and self monitoring measurements are recommended to confirm diagnosis and for medication titration purposes

Question 9

old HTN definition

Answer 9

diastolic > 90

systolic > 140

Question 10

summarize epidemiology of HTN in the US

Answer 10

1 in 3 adults have high BP, only 54% have it under control
1 in 3 have prehypertension
$46 billion in health care costs per year

Question 11

new HTN definition

Answer 11

diastolic > 80

systolic > 130

Question 12

what is prehypertension under the new definition

Answer 12

120-129/<80

increased risk of developing HTN and cardiovascular complications, but benefits of treatment undertain

Question 13

what is malignant HTN

Answer 13

extremely high BP that develops rapidly and causes some type of organ damage
typical BP above 180/120
treated as a medical emergency

Question 14

risk factors and prevalence of malignant HTN

Answer 14

rare, 1% of people with history of high BP

greater risk if man, black, lower economic status, or poor access to health care

Question 15

causes of malignant HTN

Answer 15

collagen vascular disease (scleroderma)
kidney disease
spinal cord injuries
adrenal gland tumors
use of birth control pills or MAOIs
use of illegal drugs, such as cocaine, amphetamines

Question 16

for an adults 45 years old without HTN, what is the 40 year risk of developing HTN

Answer 16

93%, African American
92% Hispanic
86% white
84% chinese

Question 17

association between CVD and BP

Answer 17

20 mm Hg higher SBP and 10 mm Hg higher DBP are each associated with a doubling in the risk of death from stroke, heart disease, or other vascular disease

Question 18

medical diagnoses which have higher risks that are associated with higher SBP and DBP

Answer 18

CVD
angina
MI
heart failure
stroke
peripheral arterial disease
abdominal aortic aneurysm

Question 19

other CVD risk factors to screen for in adults with HTN

Answer 19

smoking
diabetes
dyslipidemia
excessive weight
poor fitness
unhealthy diet
psychosocial stress
sleep apnea

Question 20

basic testing for primary HTN

Answer 20

fasting blood glucose
CBC
lipids
BMP (electrolytes and creatinine)
TSH
urinalysis
EKG w/ optional echo
uric acid
urinary albumin to creatinine ratio

Question 21

cause of HTN

Answer 21

underlying mechanism(s) responsible for the increase in CO, TPR, or both that results in high BP
knowing that CO, TPR or both are elevated does not define the cause of HTN

Question 22

factors which contribute to the development of HTN

Answer 22

aging
genetics
obesity
smoking
salt sensitivity
high, frequent alcohol consumption
high fat diet
low fiber diet
lifestyle/environmental influences

Question 23

primary HTN

Answer 23

underlying cause is unknown
likely an interaction of multiple defects in BP regulation w environmental stressors
may be genetic predisposition
more than 95% of cases

Question 24

secondary HTN

Answer 24

underlying cause is known

5% of cases

Question 25

2 possibilities of primary HTN causes

Answer 25

1. abnormal function of the Na/K ATPase resulting in elevated cytosolic Ca2+ level 2. microvascular dysfunction: decreased levels of NO and increased endothelin-1

Question 26

result of decreased NO or increased endothelin 1

Answer 26

arteriolar constriction increased TPR increased MAP

Question 27

discuss the trends in essential HTN and aging

Answer 27

at younger age, CO contributes most to HTN and decreases as patient ages at old age, TPR contributes most to HTN and decreases as patients are younger

Question 28

why does TPR contribute more to HTN as people age

Answer 28

heart and vessels adapt to chronically high pressure - arterioles hypertrophy which reduced lumen diameter and increase contractile force (progressive increase in TPR over time) - decreased ventricular compliance due to ventricular hypertrophy, impairs diastolic filling of the heart

Question 29

examples of conditions causing secondary HTN

Answer 29

``` renal parenchymal disease renovascular disease pheochromocytoma primary hyperaldosteronism hypothyroidism hyperthyroidism ```

Question 30

discuss the pathophys of HTN in renal parenchymal disease

Answer 30

nephron damage leads to impaired renal excretion of sodium and thus water increased blood volume > increased venous pressure > increased venous return > increased preload > increased SV > increased CO > increased MAP

Question 31

discuss the pathophys of HTN in renovascular HTN

Answer 31

atherosclerotic plaques in renal arteries > impaired renal blood flow > activation of renin-angiotensin system

Question 32

what are the effects of increased renin and thus angiotensin II formation?

Answer 32

arteriolar constriction > increased TPR venous constriction > increased CO aldosterone secretion > increased blood volume > increased CO

Question 33

discuss the pathophys of HTN in pheochromocytoma

Answer 33

catecholamine secreting tumor in the adrenal medulla > increased epi and NE in the blood

Question 34

what are the effects of increased epi and NE in the blood?

Answer 34

arteriolar constriction > increased TPR venous constriction > increased CO increased inotropic state> increased CO increased HR > increased CO

Question 35

what is primary hyperaldosteronism?

Answer 35

Conn's syndrome 66% of cases due to enlargement of both adrenal glands 33% of cases due to an adrenal adenoma that produces aldosterone

Question 36

discuss the different layers of the adrenal glands and their function

Answer 36

outermost > innermost zona glomerulosa (cortex) - mineralcorticoids - aldosterone zona fasiculata (cortex) - glucocorticoids - cortisol, corticosterone, cortisone zona reticularis (cortex) - androgens - dehydroepiandrosterone adrenal medulla - stress hormones - epi, NE

Question 37

what are 2 causes of primary hyperaldosteronism and how do treatments differ

Answer 37

adrenal gland tumor- gland is removed | adrenal hyperplasia- aldosterone antagonist given

Question 38

discuss the pathophys of HTN in primary hyperaldosteornism

Answer 38

increased aldosterone > increased sodium and water reabsorption from kidneys > increased blood volume > increased CO increased aldosterone> increased potassium excretion > hypokalemia > skeletal muscle weakness

Question 39

discuss the pathophys of HTN in hypothyroidism

Answer 39

decreased metabolic rate > decreased production of metabolic vasodilators in systemic organs > increased TPR

Question 40

discuss the pathophys of HTN in hyperthyroidism

Answer 40

increased metabolic rate > increased O2 demand by systemic organs > increased CO

Question 41

discuss the baroreflex

Answer 41

homeostatic mechanism that helps to maintain BP at nearly constant levels elevated BP > causes decrease in HR and thus BP decreased BP > causes HR to increase and restore BP

Question 42

how does baroreceptor desensitivity occur

Answer 42

cause is unknown after chronic increases in arterial pressure, baroreceptor sensitivity to changes in arterial pressure is decreased compared to a normotensive person

Question 43

physiologic dysfunction of the heart in development of HTN

Answer 43

high CO due to abnormal neuronal or hormonal stimulation may contribute to HTN

Question 44

physiologic dysfunction of blood vessels in development of HTN

Answer 44

1. greater than normal sym vasoconstrictor responses 2. abnormal reg of vascular tone by local metabolic vasodilators 3. ion channel defects in vascular SM 4. endothelial dysfunction 5. increased circulating levels of vasoconstrictors

Question 45

physiologic dysfunction of kidney in development of HTN

Answer 45

1. impaired renal blood flow 2. inappropriate hormone regulation (increased aldosterone release) 3. ion channel defects causing sodium retention 4. increased renin resulting in higher circulating angiotensin II

Question 46

physiologic dysfunction of baroreceptor in development of HTN

Answer 46

in a person with HTN, MAP will be maintained at a pressure higher than normal

Question 47

physiologic dysfunction of adrenal gland in development of HTN

Answer 47

1. increased release of aldosterone will raise blood volume and CO 2. in pheochromocytoma, excessive NE and epi will increased TPR and CO

Question 48

heart damage from HTN

Answer 48

workload is increased and oxygen delivery is compromised ventricular hypertrophy and higher arterial pressure significantly increases myocardial O2 consumption, reduced ventricular compliance, increases filling pressures, and can lead to systolic or diastolic dysfunction and ultimately heart failure

Question 49

arterial damage from HTN

Answer 49

combined effects of elevated pressure and accelerated atherosclerosis high pressure may cause endothelial dysfunction endothelial damage will promote plaque and thrombus formation physical rupture of an artery (aneurysm) can also occur due to high arterial pressures

Question 50

lifestyle changes to reduce HTN risk factors

Answer 50

``` decrease body weight reduced salt intake exercise reduced alcohol consumption and smoking reduce chronic stress biofeedback interventions ```

Question 51

first line therapy for stage 1 HTN

Answer 51

thiazide diuretics CCBs ACE inhibs or ARBs

Question 52

therapy for stage 2 HTN

Answer 52

2 first line drugs of different classes

Question 53

how can improved adherence to therapy be obtained

Answer 53

once daily dosing | combination therapy

Question 54

preferred diuretic

Answer 54

chlorthalidone | long half life and proven reduction of CVD risk

Question 55

what should not be used in combo

Answer 55

ACE inhib, ARBs, and direct renin inhib

Question 56

which drugs increase risk of hyperkalemia in CKD or with supplemental K+ or K+ sparing drugs

Answer 56

ACE inhib and ARBs

Question 57

which drugs should be discontinued during pregnancy

Answer 57

ACE inhib and ARBs

Question 58

which drugs cause edema

Answer 58

CCBs and dihydropyrodines

Question 59

side effects of non-dihydropyridine CCBs

Answer 59

bradycardia and heart block | avoid in HFrEF

Question 60

when are loop diuretics preferred

Answer 60

in HF and when GFR is < 30