Clinical Approach To Hypertension

Question 1

HTN contributes to greater than ______ deaths per day in the US.

Answer 1

1000

Question 2

At best, only ____% of adults with HTN are controlled.

Answer 2

57

Question 3

In 2017, the AHA/ACC changed their classification for stage 1 hypertension from ________ to ________.

Answer 3

140/90; 130/80

Question 4

____% of adults in the US are classified as hypertensive.

Answer 4

46

Question 5

For every _____mmHg increase in ____ or ____mmHg increase in ____, the risk of death from heart attack, stroke, heart failure, and/or aortic aneurysm ________.

Answer 5

20; SBP
10; DBP
Doubles

Question 6

Why do the AAFP, ACP, and European Union not follow the new AHA guidelines?

Answer 6

A meta-analysis done showed that only patients primarily with high risk of CVD benefitted from stricter screening.

Question 7

Primary HTN vs Secondary HTN

Answer 7

Primary HTN accounts for 90-95% of all cases (caused by genetics, age, high salt/low potassium diet, insulin resistance/diabetes, inactivity, alcohol, and obesity)

Secondary HTN accounts for 5-10% of all cases (cause identified and may be curable: medications/drugs, CKD, endocrine causes, coarctation of aorta, apnea)

Question 8

Etiologies of secondary HTN between 0-18 yrs (2)

Answer 8

1. Renal parenchymal disease

2. Aortic coarctation

Question 9

Etiologies of secondary HTN between 19-39 yrs (4)

Answer 9

1. Thyroid dysfunction
2. Fibromuscular dysplasia
3. Renal parenchymal disease
4. Endogenous Cushing’s syndrome

Question 10

Etiologies of secondary HTN between 40-64 yrs (5)

Answer 10

1. Hyperaldosteronism
2. Thyroid dysfunction
3. OSA
4. Exogenous (iatrogenic) Cushing’s syndrome
5. Pheochromocytoma

Question 11

Etiologies of secondary HTN greater than 65 yrs (3)

Answer 11

1. Renal artery stenosis
2. CKD
3. Hypothyroid

Question 12

Insuffciently-treated ________ is one of the most common causes of resistant HTN.

Answer 12

OSA (obstructive sleep apnea)

Question 13

Research suggests that the heritable portion of “essential” HTN may be up to ____%

Answer 13

65

Question 14

Research also suggests that there are genetic components of HTN that may account for up to ____% of cases

Answer 14

27

Question 15

There is a ________% drop in BP during sleep.

Answer 15

10-20

Question 16

The DASH diet includes what parameters? (4)

Answer 16

1. Limit salt to <1500mg per day
2. Eat potassium-rich foods
3. Small amounts of lean meat
4. High veggie and fruit intake, whole grains, and nuts

Question 17

HTN Medications for diabetics with neuropathy (2)

Answer 17

ACE-I and ARB because they are renal protective

Question 18

HTN Medications for diabetics without neuropathy (4)

Answer 18

ACE-I, ARB, diuretic, and CCB

*Don’t use diuretic as first line as it can raise glucose levels.

Question 19

HTN Medications for CKD (2)

Answer 19

ACE-I and ARB

Question 20

HTN Medications for CAD (5)

Answer 20

Beta-blocker (first line after MI), ACE-I/ARB (for stable CAD or LVHF), and thiazide diuretic or CCB (add on if not at goal BP yet).

Question 21

HTN Medications for migraines (2)

Answer 21

Beta-blocker and CCB.

Question 22

HTN Medications for gout (4)

Answer 22

ACE-I, ARB, BB, and CCB okay.

Avoid diuretics!

Question 23

What are the 4 types of HTN associated with pregnancy?

Answer 23

1. Chronic HTN
2. Pre-eclampsia or eclampsia
3. Pre-eclampsia or eclampsia superimposed on chronic HTN
4. Gestational HTN

Question 23

HTN complicates ____% of all pregnancies

Answer 23

10

Question 24

What are the ACOG’s criteria for Pre-eclampsia?

Answer 24

BP >160/110 mmHg +
Any one of the following:
1. Low platelets
2. Elevated liver enzymes
3. Elevated creatinine
4. Severe, persistent RUQ pain
5. Pulmonary edema
6. New onset cerebral or visual changes

Question 25

____% increased incidence of pre-eclampsia in the US since 2000.

Answer 25

25

Question 26

_______% of patients with chronic HTN will develop pre-eclampsia during pregnancy

Answer 26

35-40

Question 27

True/False: For treatment of chronic HTN during pregnancy, recommendations suggest continuing or initiating anti-HTN meds during pregnancy only if the SBP is >160 mmHg or DBP > 110 mmHg.

Answer 27

True

Question 28

What is HELLP syndrome?

Answer 28

Hemolysis, elevated liver enzymes, low platelets
Considered a subset of pre-eclampsia
Up to 30% mortality rate

Question 29

Safe-to-use anti-HTN meds in pregnancy (3)

Answer 29

Labetolol (BB)
Methyldopa (centrally-acting agent)
Nifedipine (CCB)

Question 30

___% of children in the US have stage 1 or 2 HTN

Answer 30

14

Question 31

HTN Urgency vs HTN Emergency

Answer 31

HTN urgency: Severe asymptomatic hypertension. SBP greater than 180 mmHg OR DBP greater than 110 mmHg. No acute, end-organ injury. Affects men 2x more than women.

HTN emergency: Crisis. SBP > 180 mmHg OR DBP > 110 mmHg. With acute, end-organ injury. Symptoms include severe chest pain, SOB, headache with confusion or blurred vision, severe back pain, nausea/vomiting, seizures, unresponsiveness, severe anxiety or sense of impending doom.

Malignant HTN: is a subset of HTN emergency with widespread arteriolar injury of at least 3 organs commonly involving the retina, kidneys, and brain, leading to death if inadequately untreated.

Question 32

What end-organ damage occurs in HTN emergencies?

Answer 32

45% cerebral

49% cardiac

Question 33

True/False: In an HTN emergency, bring blood pressures down SLOWLY unless the cause is stroke, eclampsia, or aortic dissection.

Answer 33

True

Question 34

The 3 exceptions of recommended guidelines for treatment of HTN emergencies are what?

Answer 34

1. Aortic dissection: Lower HR to less than 60 bpm within minutes and SBP to 120 mmHg within 20 minutes. Use BB.
2. Ischemic/hemorrhage: Use IV antihypertensives when thrombolytics are indicated and BP is > 220 mmHg. Aggressively lower SBP between 140-160 mmHg within 2-4 hours of hemorrhagic stroke.
3. Eclampsia