Blood Pressure

Question 1

What are the four systems that regulate blood pressure?

Answer 1

Heart
Blood vessel tone
Hormones
Kidney

Question 2

Most powerful hormone system for regulating body volumes and BP is what?

Answer 2

Renin-Ang system

Question 3

What component of the Renin-Ang system is a powerful vasoconstrictor?

Answer 3

Angiotensin II

Question 4

What percentage of cases are essential HTN?

Answer 4

95%

Question 5

HTN is a major modifiable risk fact for what disease?

Answer 5

cardiovascular

Question 6

List some risk factors for essential hypertension

Answer 6

Insulin resistance
Glucose intolerance
Hyperinsulinemia
Body Weight
Gender
Age
Low socioeconomic class
Smoking
Family history
Medications
African American

Question 7

What is a major determinate of BP?

Answer 7

body weight

Question 8

List some exacerbators of essential hypertension

Answer 8

Obesity
Increased Na+ intake
Alcohol
Cigarette smoking
Polycythemia vera
Low K+ intake
NSAIDs
Sleep apnea
Metabolic syndrome

Question 9

What is the most frequent symptom in HTN?

Answer 9

Headache

Question 10

What are the main organs that suffer in HTN?

Answer 10

Heart
Brain
Kidney
Blood vessels

Question 11

What are some physical exam findings suggestive of
secondary or potentially reversable causes of HTN?

Answer 11

Abdominal or flank bruits (renovascular issue)

Absent or diminished femoral pulses (coarctation)

Flank or abdominal masses (AAA of Polycystic kidney disease)

Question 12

What lab is a marker of asymptomatic renal dysfunction in HTN
patients?

Answer 12

Microalbuminuria

Question 13

What are the monitoring guidelines in HTN patients?

Answer 13

Annual urine microalbumin (UA)

Annual BMP

Annual lipids (HLD, LDL, triglycerides)

Baseline EKG (Repeat every 2-4 years)

Annual BUN/Creatinine

A1c or fasting glucose

Question 14

What is the blood pressure goal in patients with no comorbidities?

Answer 14

<140/<90

Question 15

What is the blood pressure goal in patients with DM or chronic kidney disease?

Answer 15

<130/<80

Question 16

What is the blood pressure goal in patients 60 and older?

Answer 16

<150/<90

Question 17

What lifestyle modifications in all patients needs to be addressed and encouraged?

Answer 17

Weight loss
Exercise
Diet (DASH)
Decreased Na+ intake
Decreased alcohol intake (1 drink a day: females; 2 drinks a day: males)
Tobacco cessation
Decrease stress

Question 18

What class of medications for HTN is the DOC?

Answer 18

Thiazides

Question 19

What is the creatinine clearance level that you need to discontinue Thiazides?

Answer 19

can’t use once CrCl <30

Question 20

What class of medications for HTN must be avoided in pregnancy and renal artery stenosis?

Answer 20

ACE/ARBs

Question 21

What class of medications for HTN has a questionable role in the treatment of essential HTN unless patient also have CHF or history of MI?

Answer 21

Beta Blockers

Question 22

What class of medications for HTN is contraindicated in COPD/asthma patients?

Answer 22

Beta Blockers

Question 23

What class of medications for HTN should never be used as monotherapy?

Answer 23

Alpha blockers

Question 24

What medication is the DOC for HTN in pregnancy?

Answer 24

Methyldopa

Question 25

What class of medications for HTN is a good addition for resistant HTN?

Answer 25

Calcium Channel Blockers

Question 26

What class of medications for HTN is contraindicated in heart failure?

Answer 26

Calcium Channel Blockers

Question 27

What class of medications for HTN can cause heart failure?

Answer 27

Direct vasodilators

Question 28

What class of medications for HTN is protective against strokes?

Answer 28

Calcium Channel Blockers

Question 29

What is the most common cause of secondary hypertension?

Answer 29

Renal Parenchymal Disease

Question 30

If you see these signs and symptoms in a patient with secondary HTN, which underlying cause should you suspect? HTN is resistant to 3+ drugs Renal artery bruits Abrupt deterioration in kidney function after ACE initiation Excess renin and aldosterone (unexplained hypokalemia)

Answer 30

Renal Artery Stenosis

Question 31

If you see these signs on imaging in a patient with secondary HTN, which underlying cause should you suspect? Xray: Indention of aorta Rib notching

Answer 31

Coarctation of Aorta

Question 32

This secondary HTN condition is associated with bicuspid aortic valve

Answer 32

Coarctation of Aorta

Question 32

Catecholamine secreting tumor on adrenal medulla

Answer 32

Pheochromocytoma

Question 32

If you see these signs on imaging in a patient with secondary HTN, which underlying cause should you suspect? Lab: 24hr urine 🡪 catecholamines and their metabolites Vanillylmandelic acid (VMA) and metanephrine

Answer 32

Pheochromocytoma

Question 33

If you see these signs on imaging in a patient with secondary HTN, which underlying cause should you suspect? Autonomic attacks – periodic, surges of severe throbbing HAs, profuse sweating, palpitations, tachycardia, severe retinopathy

Answer 33

Pheochromocytoma

Question 34

If you see these signs on imaging in a patient with secondary HTN, which underlying cause should you suspect? Rounded face Central obesity Proximal muscle weakness Hirsuitism “buffalo hump” Purple straie on abdominal wall

Answer 34

Cushing’s Syndrome

Question 35

What is the pathophysiology of Cushing’s Syndrome resulting in secondary HTN?

Answer 35

Excessive cortisol 🡪 blood expansion and stimulated synthesis of components of renin-angiotensin system

Question 36

Severely elevated blood pressure and symptomatic Life threatening Acute end organ damage DBP >130

Answer 36

Hypertensive Crisis

Question 37

What is the goal in a Hypertensive Crisis?

Answer 37

Drop blood pressure rapidly! Reduce blood pressure within first 2 hours by 15-25%

Question 38

If a hypertensive crisis is Catecholamine induced, what is the DOC?

Answer 38

Phentolamine

Question 39

Severely elevated blood pressure with minimal or no symptoms Not life threatening No end organ damage DBP>115

Answer 39

Hypertensive Urgency

Question 40

What is the goal in a Hypertensive Urgency?

Answer 40

Reduce blood pressure within first 24-48 hours

Question 41

Which part of the blood pressure reading is a better predictor of morbid events?

Answer 41

Systolic blood pressure

Question 42

Characterized by encephalopathy or nephropathy with accompanying papilledema Progressive kidney disease ensues if not treated Treat like other hypertensive emergencies

Answer 42

Malignant Hypertension

Question 43

List some potential causes of resistant hypertension

Answer 43

Improper blood pressure measurement Excessive Na+ intake Inadequate diuretic therapy Excessive EtOH intake Medications

Question 44

In cases of resistant hypertension, what workup needs to be done?

Answer 44

Start looking into secondary causes!

Question 45

A palpable brachial or radial artery when the cuff is inflated above systolic pressure Falsely elevated blood pressure reading due to atherosclerosis of blood vessels that won’t compress

Answer 45

Osler’s Sign (Pseudohypertension)

Question 46

Excessive fall in blood pressure on assuming upright position Typically >20/>10 mm Hg

Answer 46

Orthostatic Hypotension

Question 47

List some causes of orthostatic hypotension

Answer 47

Diuretics (most common) Vasodilators (most common) Dehydration Bradycardia Heart failure Diabetes Nervous system disorders

Question 48

What are the two most common causes of orthostatic hypotension?

Answer 48

Diuretics Vasodilators

Question 49

What are some complications of orthostatic hypotension?

Answer 49

Stroke Falls Brain damage (Repeated episodes of hypotension) Increased risk of some forms of dementia