Case 8: Hypertension Flashcards Preview

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Flashcards in Case 8: Hypertension Deck (61):
1

USPSTF screening recommendation for hypertension

Screen in patients with no known HTN starting at 18

2

Normal blood pressure

SBP: <120
DBP: <80

3

Prehypertension

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

4

HTN (<60 yrs old)

SBP: >140
DBP: >90

5

HTN (>60 yrs old)

SBP: >150
DBP: >90

6

JNC8 update

Updated EBM recs for management of high BP

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

7

3 questions to ask someone with new diagnosis of hypertension

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)

8

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

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

Brain
- stroke, TIA

Kidney
- chronic renal failure

Vasculature
- peripheral artery disease

Eyes:
- retinopathy

9

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

10

10

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

- 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

11

Causes of high blood pressure

- 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

12

Causes of hypertension

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

13

How to accurately dx HTN

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

14

BMI Underweight

<18.5

15

BMI Normal

18.5-24.9

16

BMI Overweight

25.-29.9

17

BMI Obese

30-40

18

BMI Extreme obesity

>40

19

People with white coat HTN should..

1. check BP at home
2. still receive ongoing surveillance for development of essential HTN

20

Hypertensive retinopathy fundoscopy

Cotton wool spots
Flame hemorrhages
Exudates

21

Hypertensive emergency fundoscopy

Papilledema

22

Signs on PE that point to progression of HTN

- carotid, abdominal, femoral bruits
- crackles, diminished breath sounds (CHF)
- AAA pulsation
- enlarged PMI

23

How to monitor HTN

Only need ONE measurement in ONE arm for ongoing monitoring

24

Patient's explanatory model of illness/health may overlap or diverge from...

Physician's biomedical model of disease

25

What tests are indicated in the initial workup of HTN?

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

EKG for initial evaluation of HTN

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

UA for initial evaluation of HTN

To assess glucosuria (look for diabetes as co-morbid)
To assess proteinuria (evidence of HTN nephropathy)

28

Blood glucose for initial evaluation of HTN

To assess for diabetes as co-morbid condition

29

Blood hematocrit for initial evaluation of HTN

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

Serum K for initial evaluation of HTN

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

Serum Ca for initial evaluation of HTN

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

32

Serum creatinine and GFR for initial evaluation of HTN

Can point to hypertensive nephropathy
Also some anti HTN raise serum creatinine (ACEIs, ARBs, diuretics)

33

Urine albumin/creatinine ratio for initial evaluation of HTN

To assess for microalbuminuria

34

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

Look for lipid co-morbidities

35

Management of HTN involves (4)

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

Age < 60
General non black population

ACEI
ARBs
CCBs
Thiazide diuretics

Goal: 140/90

37

Age < 60
General black population

CCBs
Thiazide diuretics

Goal: 140/90

38

Age > 60
General population (non black or black)

ACEI
ARBs
CCBs
Thiazide diuretics

Goal: 150/90

39

Any age + any race + CKD

ACEI
ARBs

Goal: 140/90

40

Any age + any race + diabetes

ACEI
ARBs
CCBs
Thiazide diuretics

Goal: 140/90

41

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

No
Poor support in clinical trials

42

Thiazide diuretics

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

Thiazide complications

- 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

Starting dose for thiazides in normal adult

25 mg

45

Starting dose for thiazides in elderly

6.25 or 12.5mg and then titrate up

46

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

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

47

Sodium restriction is defined by

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

48

Moderation of alcohol consumption is defined by

no more than 2 drinks/day for men
no more than 1 drink/day for women

49

USPSTF aspirin recommendations

Start aspirin to reduce risk of MI in
a) men 45 to 79
b) women 55 to 79

50

JNC7 aspirin recommendations

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

51

Alpha blockers in management of HTN

- 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

In which ethnicities are BP control rates the lowest?

Native Americans
Mexican Americans

53

African Americans and HTN

- 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

Beta blockers special considerations

- 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

ACEIs special considerations

- 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

ARB special considerations

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

57

CCB special considerations

- useful in Raynauds and certain arrhythmias
- can cause leg edema
- only use long acting (short acting contraindicated)

58

Loop diuretic special considerations

- monitor electrolytes
- start at lower doses in elderly

59

Aldosterone antagonist and K sparing diuretic special considerations

- 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

Alpha blocker special considerations

- 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

Refer to specialist when...

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