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Fall 2024 > Gentile - HTN packet > Flashcards

Gentile - HTN packet Flashcards

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1
Q

What is the lifetime risk of HTN

A

> 90%

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2
Q

What fraction of US adults have HTN

A

1/3

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3
Q

What fraction of those diagnosed with HTN meet their BP goal

A

<50%

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4
Q

What fraction of people are unaware that they have HTN

A

1/6

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5
Q

What populations have worse outcomes with HTN control

A

African americans
Smokers

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6
Q

What are the risk factors for primary HTN (13)

A

Old age
Family history
Obesity
Insulin resistance/DM
Hyperlipidemia
Decreased nephron numbers: restricted intrauterine growth/prematurity
AA
Social determinants
Smoking
High sodium diet (>3g/day)
Excessive alcohol consumption
Physical inactivity
Insufficient sleep (<7hours)

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7
Q

How does someone get primary HTN

A

Multifactorial: genetics and environmental factors

Compounding effects on kidney structure and function

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8
Q

BP = __ x __

A

CO X SVR

Most patients have normal cardiac output but increased peripheral resistance

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9
Q

Where is the peripheral resistance most pronounced

A

small arterioles

Prolonged smooth muscle constriction = irreversible thickening of the vessel wall

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10
Q

What are the primary determinants of BP

A
  1. Sympathetic nervous system
  2. Renin-angiotensin-aldosterone system
  3. Plasma volume (largely mediated by kidneys)
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11
Q

Medications that can cause secondary HTN

A

Oral contraceptives
NSAIDs
Antidepressants: tricyclics, SSRIs, MAOIs
Corticosteroids
Decongestants (pseudoephedrine)
Some weight loss meds
Sodium-containing antacids
Erythropoietin
Cyclosporine/tacrolimus
Stimulants (methylphenidate/amphetamines)
Atypical psychotics - clozapine, olanzapine
Angiogenesis inhibitors - bevacizumab
Tyrosine kinase inhibitors - sunitinib, sorafenib

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12
Q

Causes of secondary HTN (not meds)

A

Illicit drug use
primary kidney disease
Primary aldosteronism
Triad - HTN, unexplained hypokalemia, metabolic acidosis
Renovascular HTN
Obstructive sleep apnea
Pheochromocytoma
Cushing’s syndrome
Endocrine disorders (hypothyroid, hyperthyroid, hyperparathyroid)
Coarctation of the aorta

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13
Q

Three general categories of HTN complications

A

CV
Neurovascular
Renal

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14
Q

CV complications of HTN

A

LVH
HF
Ischemic heart disease

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15
Q

Neurovascular complications of HTN

A

Ischemic stroke
Intracerebral hemorrhage

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16
Q

Renal complications of HTN

A

Chronic kidney disease
End stage kidney disease

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17
Q

HTN is the most prevalent modifiable risk factor for _______

A

premature CV disease

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18
Q

Risk doubles with __ mm Hg increase in systolic and __ mm Hg increase in diastolic

A

20
10

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19
Q

What parts of BP have the biggest influence on CV risk depending on age?

A

<50 years - diastolic
50-60 years - systolic pressure and pulse pressure

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20
Q

When should BP be taken?

A

Every clinical encounter

at minimum, annually and semiannually if risk factors or previous systolic BP was 120-129

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21
Q

In what case can HTN be diagnosed with one reading?

A

> =180/120 or >=160/100 with known end organ damage

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22
Q

What is the common scenario of HTN diagnosis?

A

elevated BP confirmed with average BP taken on >= 2 readings obtained on >= 2 occassions

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23
Q

What is the gold standard for HTN diagnosis?

A

Ambulatory 24 hour blood pressure monitoring

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24
Q

Self monitoring is especially useful in what cases?

A

White coat syndrome
Masked HTN

And to monitor response to treatment

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25
What needs to be evaluated with HTN diagnosis?
Extent of target organ damage if any Presence of established CV or kidney disease Presence or absence of other CV risk factors Potential lifestyle contributing factors Potential interfering substances
26
What medical history much be taken with HTN diagnosis
Presence of precipitating/aggravating factors Duration of HTN Previous attempts at treatment Extent of target-organ damage Presence of other known CV disease risk factors
27
What must be assessed on physical exam for HTN diagnosis
Signs of end-organ damage or established CV disease Evaluate for potential causes of secondary HTN Fundoscopic exam for HTN retinopathy
28
What lab tests should be ordered for HTN
Electrolytes Serum creatinine Fasting glucose Urinalysis Complete blood count Thyroid-stimulating hormone Lipid profile EKG 10-year ASCVD disease risk
29
In what patients should a urinary albumin to creatinine ratio be completed?
Diabetes and chronic kidney disease
30
In what patients should an echo be completed?
In patients you are evaluating for LVH (more sensitive than EKG)
31
In what patient should you test for secondary HTN
Unusual presentation - young age, abrupt onset, significant recent evaluation Drug-resistant HTN Presence of clinical clue for a specific cause of HTN - abdominal bruit, low serum potassium
32
What is the general treatment approach for HTN in terms of lifestyle modifications
Address at least one aspect at every office visit: Dietary salt restriction Potassium supplementation (unless CI) Weight loss (0.5-2 mmHg for each kg lost) DASH diet Exercise (3-4 sessions per week) Limit alcohol intake Smoking
33
Describe the DASH diet
High in vegetables, fruits, low-fat dairy, whole grains, poultry, fish, and nuts Low in sweets, sugar-sweetened beverages, and red meats
34
Alcohol recommendations
Increased risk of HTN: Women >= 2 drinks/day Men >= 3 drinks/day Diagnosed HTN: Women: no more than 1/day Men: no more than 2/day
35
What are the proven risk reductions with HTN treatments (pharmacologic)
50% reduction in heart failure 30-40% reduction in stroke 20-25% reduction in MI
36
Who should be treated pharmacologically?
>135/>85 out of office OR >140/>90 in office OR >130/>80 and one of the following: CV disease T2DM >65 years old 10 year risk >=10%
37
What is the biggest determinate of reduced CV risk?
Degree of blood pressure reduction; not the choice of med
38
Most patients will need
More than 1 med Multiple med classes = individualized therapy
39
What are the 4 classes of first line meds?
Thiazide diuretics ACE ARB Long-acting CCB
40
Patients with nephropathy or CKD complicated by proteinuria should use what drug?
ACE or ARB
41
What drug should not be used as monotherapy? What is the exception?
Beta blockers ischemic heart disease or HFrEF
42
Single agent therapy will not adequately control BP in most patient with systolic BP >= ___ mm Hg over goal
15
43
At what point is it indicated to initiate with 2 first line agents
SBP >20 DBP >10
44
What initial combo therapy is recommended
ACE/ARB + long-acting CCB ACE/ARB + thiazide diuretic No not combine ACE and ARB
45
What should be done if 2 therapies not meeting goal?
ACE/ARB + long-acting CCB + thiazide diuretic
46
What should be done if D-CCB not tolerated due to leg swelling?
Switch to ND-CCB
47
What should be done if thiazide diuretic is not tolerated or CI?
Use mineralcorticoid receptor agonist (spironolactone or eplerenone)
48
What should be done if 3 therapies are not enough, not tolerated, or CI
Beta blocker Alpha blocker Direct arterial vasodilator
49
What combination should be avoided other than ACE + ARB
ND-CCB + BB Could cause severe brady
50
What can be done to increase adherence to BP meds
Use fixed-dose, single pill, combo meds when feasible to reduce pill burden
51
What is actually the typical cause of drug resistant HTN
Often due to pseudoresistance: inaccurate BP measurements Poor adherence No diet/lifestyle changes Suboptimal therapy White coat syndrome
52
What could be causing true drug resistant HTN
Extracellular volume expansion (renal dz) Increased sympathetic activation Meds that elevate BP (NSAIDs, stimulants) Always be sure to R/O secondary HTN
53
What is the ultimate BP goal?
Reduction of CV events
54
What is typically the BP goal?
<130/80
55
In what groups is BP goal less aggressive at 135/80?
Labile BP or postural hypotension Side effects w/ multiple meds >75 years old with high burden of comorbidity or DBP<55
56
How should BP goal be managed/assessed?
Determine if goal is met at every visit Re-evaluate monthly after therapy is initiated Once BP goal achieved, re-evaluate every 3-6 months to ensure maintenance of control
57
What typically happens following discontinuation of therapy?
Substantial proportion remain normotensive for at least 1-2 years Larger portion do well with dose reduction More gradual tapering indicated in those well-controlled taking multiple drugs
58
Which antihypertensive drugs should never be stopped abruptly?
Short-acting BB Short-acting Alpha-2 agonists Can cause fatal withdrawal syndrome; instead, gradually reduce over weeks
59
Indicated med for HFrEF post MI
ACE or ARB, diuretic, AA
60
Indicated med for chronic kidney disease with proteinuria
ACE or ARB
61
Indicated med for angina pectoris
BB or CCB
62
Indicated med for A fib with rapid ventricular response or A flutter
BB or ND-CCB
63
Indicated med for BPH
Alpha blocker
64
Indicated med for essential tremor
Noncardioselective BB
65
Indicated med for Hyperthyroidism
BB
66
Indicated med for migraine prophylaxis
BB and CCB
67
Indicated med for osteoporosis
thiazide diuretic
68
Indicated med for Raynaud phenomenon
D-CCB
69
Contraindicated med for angioedema
ACEi
70
Contraindicated med for bronchospastic disease
nonselective BB
71
Contraindicated med for pregnancy
ACE, ARB, renin inhibitor
72
Contraindicated med for second to third degree heart block
BB or ND-CCB unless pacemaker is present
73
Which drug classes can cause depression
BB and central alpha-2 agonists
74
Which drug classes can cause gout
Loop and thiazide diuretics
75
Which drug classes can cause Hyponatremia
thiazide diuretics
76
Which drug classes can cause Hyperkalemia
AA, ACE/ARBs, renin inhibitors
77
Which drug classes can cause renovascular disease
ACE/ARB, renin inhibitor

Fall 2024 (34 decks)

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