Determine HTN Flashcards
(36 cards)
-Arterioles are thin-layer vessels
-Compared to veins arteries have a larger layer of smooth muscle as well as a larger dense outer layer.
Pertinent Anatomy HTN
Maintenance of _________ pressure is essential for organ perfusion and nutrients.
arterial blood
(1) Have the patient relax for>5 minutes without having them talk
(2) patient’s arm at the level of their heart.
(3) appropriately sized cuff
(4) Use either the diaphragm or the bell for auscultation listening over the brachial artery.
(5) Inflate the cuff 20-30 mm Hg above the level where the auscultatory sound disappears.
(6) Deflate the cuff pressure to 2 mm Hg per second and listen for the Korotkoff sounds to appear
How to appropriately measure blood pressure
SBP: 120-129
DBP: < 80
Elevated BP
SBP: 130-139
DBP: 80-89
Stage I
Hypertension
SBP: ≥140
DBP: ≥ 90
Stage II
Hypertension
(a) Sympathetic hyperactivity, abnormal cardiovascular development, renin-angiotensin, and/or defects in natriuresis (sodium)
(b) Exacerbated by smoking, obesity, and/or excessive alcohol intake.
A mix of genetic and environmental factors:
(1) Renal Disease
(2) Renal Artery Stenosis
(3) Pregnancy
(4) Pheochromocytoma (tumor)
(5) Cushing Syndrome
(6) Hyperthyroidism
(7) Estrogen Use
(8) Drug-Induced
Secondary hypertension has an identifiable cause.
(1) Essential hypertension is usually asymptomatic.
(2) Blood pressure will be elevated on 3 or more separate occasions.
(3) In patients with long term uncontrolled HTN.
(a) Can have displaced PMI.
(b) Can hear mitral valve murmurs
(c) Can hear S4
Physical Findings: HTN
As the LV has to pump against such high Aortic pressures, the mitral valve starts having all that force upon it, which can lead to insufficiency. What sound is this?
mitral valve murmurs
This is a low-frequency sound so best heard with the bell. It
occurs just before S1 when the atria contract to force blood into the left ventricle. If the LV is non-compliant (thickened for example), the atrial contraction forces blood through the atrioventricular valves, and an _______ is produced by the blood striking the left ventricle. What sound is this?
S4
Lab/Imaging: HTN
To evaluate new diagnoses of HTN (looking specifically for evidence of end-organ damage or comorbidities).
(a) Fasting glucose
(b) UA for proteinuria, hematuria, casts
(c) CBC
(d) Chemistry
(e) TSH
(f) Lipid panel
(g) EKG
(h) Calculate 10-year atherosclerotic cardiovascular disease risk (if over age 40).
Assessment: HCL
Patients must have elevated blood pressure recordings on 3-5 separate visits.
(1) Lifestyle modifications: Yields modest results
(a) Diets rich in fruits and vegetables and low in saturated fats
(b) Weight reduction (10 kg can lower SBP 5-20 mm Hg)
(c) Reduced alcohol consumption
(d) Increase in physical activity
(f) Medications
Treatment: HCL
Goal BP for most pt and diabetes pt
< 140/90 in most patients
< 130/80 in patients with diabetes or kidney disease
(a) Diuretics (First line):
Hydrochlorothiazide (HCTZ)
- 12.5-25 mg daily and can titrate to a maximum of 50 mg
-Syncoped association
(b) Angiotensin Converting Enzyme Inhibitors (ACEi) (First Line)
–pril
- work well in younger white patients and are less effective in black patients.
Lisinopril (Prinivil, Zestril), Enalapril (Vasotec), Captopril
- a) Initial dose 5-10 mg daily max 50mg
- cough
(c) Angiotensin Receptor Blockers (ARBs)
- sartan
Losartan (Cozaar): Initial dose 50mg daily max 100mg
- cough
(d) Calcium Channel Blockers (CCB)
1. Diltiazem
- Initial dose 180 mg daily max 360mg
- second or third-degree heart block
2. Amlodipine (Norvasc) 2.5 mg daily max 10mg
(e) Alpha Blockers
Terazosin: 1 mg once daily; 20 mg daily in 1 or 2 divided doses.
Pharmacological: HCL
Pt taking AntiHTN should manage and f/u:
- should be taking their blood pressure at home at least 3 times per week and keeping a log of their readings
- re-evaluate them 1 month after any medication change, usually, give it 3 months before adjusting doses of medication.
(1) Referral to MO to work up accompanying cardiovascular disease or 2nd hypertension on discovery and have had 3-5 readings that qualify as HTN.
(2) You may renew the medication if they are well controlled. Need to document each visit any side effects of medication and any symptoms or signs of end-organ damage.
(3) Should have blood work (chemistry) every year to evaluate for kidney dysfunction.
Initial Care for HTN as an IDC:*
(1) This arises due to sustained elevations of BP with consequent structural changes in the heart and vasculature.
(2) Cardiovascular disease: CAD, CHF, LVH
(3) Renal: Chronic renal failure
(4) Aortic dissection
(5) Cerebrovascular disease: Ischemic and hemorrhagic stroke, dementia, and Alzheimer’s.
(6) Peripheral vascular disease
(7) Eyes: Retinal damage, hemorrhage
Complications: HTN*
(a) SBP > 220 mm Hg or DBP > 125 mm Hg
(b) +/- optic disk edema, progressive target organ complications.
(c) NO SIGNS OF END ORGAN DAMAGE (nephropathy,
encephalopathy, etc.)
(d) Blood pressure must be reduced within a few hours.
Hypertensive Urgency
(a) Blood pressure is usually strikingly elevated DBP > 130 mm Hg, but the correlation between pressure and end-organ damage is poor.
(b) SIGNS OF END ORGAN DAMAGE is occurring:
Hypertensive Emergency
1) Hypertensive **[brain] encephalopathy (mental status changes,
confusion, headache).
2) Intracranial hemorrhage
3) Ischemic stroke
4) **Hypertensive nephropathy (proteinuria, hematuria, and progressive kidney dysfunction).
5) Unstable angina, AMI, CHF, or Aortic dissection.
(8) Secondary causes of HTN
(9) Pre-eclampsia
(10) Heavy alcohol use
NOTE: theses are usually acute and they look sick
SIGNS OF END ORGAN DAMAGE is occurring:
-Signs of end organ damage
(stroke, CHF, acute kidney injury, AMI, pulmonary edema, aortic dissection, papillary edema, retinal hemorrhage).
-Neurological examination for deficits, mental status changes, changes in vision, headache, nausea/vomiting.
-Cardio/Pulmonary exam looking for signs of heart failure (S3, new murmurs), auscultate for carotid bruits, pulmonary edema (rales, crackles), complaints of sudden onset SOB, chest pain.
-Fundoscopic examination looking for papilledema or hemorrhage.
Physical Findings: Hypertensive Emergency
(1) UA looking for proteinuria or hematuria.
(2) Comprehensive metabolic panel looking for renal or liver dysfunction.
(3) Troponins is looking for signs of myocardial injury.
(4) EKG looking for signs of AMI.
(5) CXR looking for widened mediastinum (aortic dissection) or pulmonary
edema.
(6) CT Head or Aorta if indicated.
Labs/Imaging - Remember you are looking for signs of end organ damage:
