Cardio-clinical-HTN-Bennet Flashcards by Melanie Athens

HTN is considered what bp level :

>130/80

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HTN trends have increased/decreased just about everywhere.

increased

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The number one modifiable risk to early death is :

High BP or HTN

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What is the average pressure within the patient’s arteries through one cardiac cycle?

MAP

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What is a better predictor of stress on arterial walls?

MAP

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What is a normal MAP?

70-100

>60 needed to maintain cerebral/renal/cardiac; MAP >100 is high)

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For every mmHg increase in SBP or a mmHg increase in DBP: the risk of death from heart attack & stroke, and the risk of heart failure and aortic aneurysm

20; 10; DOUBLES; DOUBLES

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What 3 things can lead to HTN:

Too much volume, renin, catecholamines

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Pheochromocytoma increases which catecholamine? which can increase BP?

Norepinephrine

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Primary HTN causes include:

Genetics

Age

High salt,

low potassium diet

Insulin resistance/diabetes

Inactivity

ETOH

Obesity

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Secondary HTN (known cause) which may be reversible causes include:

Meds/drugs

Chronic kidney disease (RAS, FMD, PKD)*

Endocrine causes

Coarctation of Aorta

Sleep Apnea

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Major causes of HTN for 0-18:

Renal parenchymal disease

Aortic coarctation

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Major causes for HTN for ages 19-39

Thyroid dysfunction

Fibromuscular dysplasia

Renal parenchymal disease

Endogenous Cushing’s Syndrome

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major causes for HTN in ages 40-64

Hyperaldosteronism

Thyroid dysfunction

OSA

Exogenous (Iatrogenic) Cushing’s Syndrome

Pheochromocytoma

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Major causes of HTN in ages >65

Renal Artery Stenosis

Chronic Kidney Disease (CKD)

Hypothyroid

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Cushing’s (iatrogenic) is caused by which drug?

steroids

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Testosterone supplements can increase EPO which can lead to slurrying of blood and lead to:

HTN

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What is a cause for resistant HTN caused by low K+ levels?

Aldosteronism (Conn’s Syndrome)

adrenal tumor
bilateral adrenal hyperplasia

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What is the most common cause of resistant HTN?

sleep apnea

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Obstructive sleep apnea (OSA) is also a common cause of :

hypertension

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Fibromuscular dysplasia (string of pearls narrowed renal arteries) and tortuosity is a cause of HTN in which population?

younger women

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Diffucult to control HTN involving renal arteries in older age?

renal artery stenosis

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If treating FMD or Renal artery stenosis with ACE inhibitors, what happens to Cr lab values?

Serum creatinine rises 30%, significantly

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FMD (renal string of pearls) and renal artery disease both can compromise sufficient to the glomerular complex and lead to kidney injury.

blood pressure

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Kidney' s issues lead to HTN problems in what manner?

messing with Na+ altered RAS system increased endothelin (vasoconsticor) inhib NO

Endocrine disorders -Pheochromocytoma, Carcinoid and other neuroendocrine tumors producing excess: and have what effect on BP

EPI/NE/DOPAMINE/ SEROTONIN; SSRI/SNRI/TCA (ie antidepressants)-can also raise BP

Coarctation is another cause of HTN , there is a 75% mortality by age

Where do you listen for a possible coarctation of the aorta?

posterior, L inferior scapula

What is endogenous cushing's syndrome?

excess cortisol production (due to tumor on adrenal gland-\>10-15%); overproduction of **ACTH** by **pituitary tumor** ( ie Cushing’s Disease -70% or extra-pituitary, ACTH-producing tumor-\>10-15%)

Exogenous (iatrogenic Cushing’s): leading to resistant HTN, truncal obesity, striae, elevated glucose, easy bruising, osteoporosis at young age. is more or less common than endogenous Cushing's and is caused by?

more common, steroids

Which top 3 diet involved issues can affect blood pressure (not including cholesterol)?

High salt, low potassium, and high ETOH

Alcohol has a biphasic affect with BP, how?

low BP ( vasodilation) for the first few hours, followed by vasoconstiction (while sleeping)

EPO is a treatment for chronic renal failure, however, it can worsen HTN in 2 ways:

increases blood viscosity has direct pressor effect

**Hyperthyroidism/hypothroidism** can cause HTN?

both actually, via different mechanisms

Other endocrine issues that can cause HTN other than cushings and throid issues include:

hyperparathyroidism and acromegaly-growth hormones excess (fluid retention)

Normally, there is about a 10-20% drop of BP while you sleep which is called the nocturnal dip except which two populations: of which both have a higher risk of HTN

African americans and those with sleep apnea

What are the things we do clinically when someone is diagnosed with HTN:

look at optic discs for HTN retinopathy auscultate for cardiac murmurs or bruits palpate thyroid check peripheral pulses directed neuro exam (visual and cognitive changes)

First choice antihypertensives include which 4? and of those 4, are usually started first because of cost and they are highly tolerated

ace inhibitors (-pril) angiotensin receptor blockers (-aratns) CCBs diuretics (thiazides) diuretics are used

What diuretic is most commonly prescribed for treatment of HTN?

Hydrochlorothiazide

Though Hydrochlorothiazide is more often prescribed, which diuretic is most effective?

chlorthalidone more expensive

Continually and repetitively emphasize which lifestyle changes for treatment of HTN:

a diet low in Na+ & high in K+ (DASH), aerobic exercise 3-5 x/wk, limit ETOH, stress management, sleep adequacy

Labs to check and why when diagnosed with primary HTN:

Chem panel: gluclose, electrolytes CBC: polycythemia lipids: hyperlipidemia TSH: thyroid function UA- leaking protein, renal dz EKG

If you suspect secondary HTN, what are some important labs to consider:

1. BNP (brain natriuretic peptide) and/or echo (ie heart failure) 2. Aldosterone/Renin Ratio (hyperaldosteronism) 3. Urinary catecholamines (pheo), 5-HIAA (carcinoid) 4. Sleep study (OSA) 5. AM Cortisol (Cushing’s) 6. Magnetic Resonance Angiography of renal arteries (RAS, FMD)

What is the first line treatment for African Americans for HTN as they dont respond as well to ACE inhib, and angiotensin receptor blockers (ARBs)?

start off with diurectics and CCB

What is the first line therapy with diabetics?

ACE ihibs, and ARBs (especially with kidney disease)

Which first line therapy is not used for diabetics?

diuretics, as they can raise blood gluclose levels

Those with kidney disease (like many diabetics) we use:

ACEs and ARBs because they are renal sparing

What is first line HTN therapy for coronary artery disease sufferers:

BBlockers (especially after MI) , add ACE or ARB if BP not at goal, or have LV heart failure

What is the first line therapy for those with or without HTN for those with migraines?

BB and CCB, this can be with or w/o HTN

What first line HTN therapy is contraindicated for those with GOUT?

**diuretics**, as they can **increase uric acid** and worsen gout

At what age in kids should one follow ACC/AHA guidelines for treating HTN?

you should suspect secondary HTN if child has symptoms under the age of , with no fam hx of HTN, failure to , and thin body

6; thrive; habitus

Common conditions that cause HTN in kids under six with no fam hx of HTN are which 3 conditions:

Suspected or known **kidney disease,** **endocrine disorder** or **congenital cardiac disorder**

What end organ damage can be caused by poorly controlled or undiagnosed HTN?

Stroke or TIA Vascular dementia (#2 cause of dementia)-“silent strokes” Chronic kidney disease/renal failure Myocardial infarction Left ventricular hypertrophy Heart failure (diastolic and systolic) Aortic aneurysm Retinopathy and retinal artery thrombosis

What do we consider HTN urgency (a type of HTN crisis)?

severe but asymptomatic HTN SBP ≥ 180 OR DBP ≥ 110 mmHg NO ACUTE, END-ORGAN INJURY **often caused by noncompliance** **men 2:1**

What do we consider a hypertensive emergency?

end organ damage SBP ≥ 180 OR DBP ≥ 110 mmHg severe chest pain, SOB, headache with confusion or blurred vision, severe back pain, nausea/vomiting, seizures, unresponsive, severe anxiety or sense of impending doom

What is malignant HTN?

subset of HTN Emergency with **widespread arteriolar injury** of at least **3 organs** commonly involving **retina, kidneys and brain** —\>death rates approach 100% if inadequately treated ## Footnote **worst hypertensive emergency**

What end organ damage is most common?

cardiac then cerebral

if there is a 20mmhg difference in BP when measuring both arms, asymmetrical bilateral pulses, what pathology would you consider?

aortic dissection

What are some things to look for in a retinal exam with someone in HTN crisis?

(exudates, cotton wool spots

A new S3 sound during auscultation could indicate what?

Heart failure or torn chordae tendinae

How would you treat HTN urgency (no end organ failure, asymptomatic)?

compliance with medications and followup within 24 /48 hours if compliant, increase dose and/or add another med and f/u

How would you treat a HTN emergency?

Lower BP SLOWLY by 25% in first 60min; Then 10-15% more over next 6-23 hrs with the goal: 160/100-110mmHg) ICU admission

What are the 3 exceptions to the normal treatment of HTN emergency: Lower BP SLOWLY by 25% in first 60min; Then 10-15% more over next 6-23 hrs with the goal: 160/100-110mmHg) ICU admission

Aortic Dissection \* Stroke (Hemorrhagic or Ischemic) \* Eclampsia(HTN+Seizure+Pregnancy

How to treat the HTN emergency aortic dissection: Lower HR to \<60 bpm within + SBP to \<120 mmHg within minutes start on an IV if BP still not at \<120 add or nitroprusside or NTG

minutes; 20; BB (esmolol, labetolol); nicardipine

Why is it so important to focus on HR first if an aortic dissection is suspected/occuring?

slow down the amount of blood getting into the pocket to prevent tearing and/or occlusion

How do we treat hypertension emergency with acute **ischemic** stroke if using tPA?

If **thrombolytics indicated** (ie tPA) and **BP is \>220 mmHg:** then use IV antihypertensives to lower BP to \<185/110 **before** tPA and maintain BP \<180/105 mmHg for 24 hrs after tPA

When do we not treat hypertensive emergent acute ischemic stroke with IV antihypertensives:

if **not using tPA** and **BP less than 220/100**

What is the BP range that we need to get to in order to treat ischemic stroke with tPA to lower risk of hemorrhagic stroke?

\<180-185/110-105

If acute ischemic stroke with \>220 mmHg and not using tPA, then tx to get a 15% reduction in 24 hours

slowly

What are the recommendations of high BP (over 220) with hemorrhagic stroke?

Aggressively lower SBP to between 140-160mmHg within first 2-4 hours, but not lower so as not to compromise perfusion

CV risks rise **linearly/nonlinearly** with BP elevations over 115/75 mmHg

linearly

What effect do NSAIDS have on BP?

they can elevate BP

In a HTN emergency, it is important to bring BP down slowly, with three exceptions:

stroke, eclampsia and aortic dissection

Cardio-clinical-HTN-Bennet Flashcards

(75 cards)