HTN

Question 1

Primary HTN

general

Answer 1

Genetic predisposition
Onset is usually between ages 30 and 50 years
Environmental factors – overweight & obesity, OSA, diet (↑ salt intake, ↓ potassium intake), physical inactivity, excessive alcohol, smoking

Question 2

Secondary HTN

general

Answer 2

Secondary may be curable…
Suspect if:
Onset of HTN at early age (< 30 yo)
Abrupt onset of HTN
Exacerbation of previously
drug resistant HTN

Question 3

Stages of BP according to ACC

Answer 3

ACC/AHA
Normal < 120/80mmHg
Elevated 120-129/80mmHg
Stage 1 130-139/80-89mmHg
Stage 2 > 140/90mmHg

Question 4

HTNs

First line med

Answer 4

ACE or ARB

Question 5

Complications of HTN

Answer 5

Coronary heart disease, heart failure, LVH, ischemic and hemorrhagic stroke, CKD, end-stage renal disease, and acute hypertensive emergencies such as hypertensive encephalopathy and acute aortic dissection, etc.

Question 6

Symptoms of HTN

Answer 6

Head ache, blurred vision, dizziness, nausea, fatigue, chest pain, shortness of breath, confusion

Question 7

HTN

PE findings: (5)

Answer 7

abn eye exam, left ventricular heave, abdominal bruit, radial-femoral delay, pulsatile abd mass

Question 8

What is the most frequent symptom of HTN?
A) nausea
B) headache
C) somnolence
D) chest pain

Answer 8

B) headache

Question 9

HTN Diagnostic findings (2)

Answer 9

LVH on ECG or echocardiogram

proteinuria on UA

Question 10

HTN nutshell

1- What is BP goal

Answer 10

Is this primary or secondary?
Goal < 130/80 unless hx Chronic Kidney Disease (then < 120/80)
Calculate 10-year risk (high-risk patients start rx BP > 130/80; lower-risk start rx BP > 140/90)

Question 11

HTN

Work Up:

Answer 11

BMP (sodium/potassium/calcium)
Serum creatinine & GFR
Fasting glucose or A1C
Urinalysis (if + protein consider UACR)
CBC
Lipid profile
TSH
Calculate 10-year ASCVD risk
*consider sleep apnea
*consider echocardiogram

Question 12

Secondary Hypertension

common causes(5)

Answer 12

Question 13

secondary HTN

OCRAPH3

Answer 13

Question 14

Fantastic 4 for HTN

Answer 14

1st line: ace or arb 2nd line: add on calcium channel blocker 3rd line: Thiazide diuretic 4th line: spironolactone; next step refer

Question 15

Steps

Answer 15

1- check BP and define
2- if > 120/80 TLCs 3-6 months
3-if >130/80:
Calculate 10-year ASCVD risk
+ Dx: CAD, DM, CKD, PAD, CVA, age > 65?
If “yes” or > 10% risk 1-month, TLCs then Rx
If “no” or < 10% 3-6 months TLCs
4- >140/90 TLCs 3-6 months then Rx (2 drugs)

Question 16

Answer 16

Question 17

TLC

Answer 17

therapeutic lifestyle change

Question 18

ACE/ARB compelling indications 4

Answer 18

DM, CKD, Cardiomyopathy, proteinuria

Question 19

Beta Blockers compelling indications

Answer 19

post-ACS, Cardiomyopathy

Question 20

HTN

Clonidine compelling indications

Answer 20

indicated for CKD and ESRD
can cause rebound HTN

Question 21

Calcium Channel Blockers:

Answer 21

preferred for black pts, Raynaud’s, vasospastic angina

Question 22

10 year risk

Very high Risk

Answer 22

Question 23

10 year risk

High Risk

Answer 23

Question 24

10 year risk

Moderate and Low Risk

Answer 24

Question 25

38 yo Female PMH: Type 2 Diabetes, HTN presents for Office Visit.   What is BP goal? 10 year risk? Drugs compelling indication?

Answer 25

< 130/80 High Ace and arb

Question 26

55 yo Male; 148/90  PMH: CAD, HTN, hyperlipidemia, presents in office. What is his bp goal? Do you need to calculate 10 year risk? Drugs compelling indication? What Rx consider?

Answer 26

Bp goal < 130/80 Do NOT need to calculate risk bc has ASCVD Compelling indication for cad- ace/arb/bb Consider he is > 140/90 so possible two drug tx

Question 27

what is the benefit of Ca channel blocker Contraindications

Answer 27

work well for black pts Contraindicated In CHF

Question 28

# HTN Lifestyle modifications

Answer 28

Question 29

Initial monotherapy in uncomplicated HTN

Answer 29

Question 30

What drugs what disease?

Answer 30

## Footnote End Stage Renal Disease

Question 31

Question 32

# HTN Thiazide Diuretics meds

Answer 32

Hydrochlorothiazide (HCTZ)12.5-25 mg po daily Chlorthalidone 12.5-25 mg po daily Drug of choice: 1st line Tx HTN (if no compelling indications)

Question 33

# HTN Thiazide diuretics MOA

Answer 33

Inhibits sodium reabsorption in distal renal tubules, resulting in increased excretion of water and of sodium, potassium, and hydrogen ions

Question 34

# HTN Thiazide Adverse effects

Answer 34

Hypokalemia, Hyperglycemia, Hyperuricemia, Hypercalcemia, hypocalciuria, Hyponatremia, Hypomagnesemia Do not use if GFR < 30, NA < 130, gout

Question 35

ACE-Inhibitors MOA

Answer 35

Prevent the conversion of angiotensin I to angiotensin II (potent vasoconstrictor), inhibit bradykinin degradation, stimulate the synthesis of vasodilating prostaglandins, and can reduce sympathetic nervous system activity

Question 36

ACE/ARB Adverse effects

Answer 36

Dry cough (↑ bradykinin levels) tickle in back of throat Hyperkalemia Skin rash, headache, renal impairment, angioedema ***contraindicated in pregnancy**

Question 37

ACE prefered for

Answer 37

prefered in heart failure, DM, CKD

Question 38

Calcium Channel Blockers meds

Answer 38

For HTN use dihydropyridines!! Amlodipine (Norvasc) 5-10 mg po daily Nicardipine (adalact/Procardia) 15-180 mg po daily

Question 39

Ca channel blocker MOA

Answer 39

Inhibits transmembrane influx of extracellular calcium that inhibits cardiac and vascular smooth muscle contraction

Question 40

Ca channel blocker Adverse effects

Answer 40

Constipation Peripheral edema Headache, Heart block, Gingival overgrowth

Question 41

Ca channel blockers are contra for

Answer 41

CHF

Question 42

Beta-blockers MOA

Answer 42

Blocks response to beta-adrenergic stimulation; reduce cardiac output and decrease release of renin from kidney

Question 43

Beta blockers drug of choice for

Answer 43

Drug of Choice: CM EF < 45%, aortic dissection, SVT, MI, hyperthyroid

Question 44

Cardioselective (beta-1 receptors) 

Answer 44

Atenolol 25-50 mg po BID Metoprolol 12.5 -100 mg po BID (IV) Bisoprolol 2.5-10 mg po BID Nebivolol 5-20 mg po daily

Question 45

Noncardioselective (beta-2 receptors)

Answer 45

Propranolol 40-180 mg po BID Carvedilol 3.125-25 mg po BID Labetalol 5-150 mg po BID (IV)- strongest for HTN

Question 46

beta blockers do NOT use

Answer 46

Do NOT use cocaine MI or pheochromocytoma until alpha blockage established

Question 47

beta blocker adverse effect

Answer 47

Fatigue Can mask hypoglycemia S/Sx Depression, sexual dysfunction, insomnia Decreases HR

Question 48

Special population Patient

Answer 48

Pregnancy Drug of choice HTN: labetalol, nifedipine, HCTZ, methyldopa Black patient Respond more favorably to CCB and hydralazine/isosorbide than whites Advance CKD ( hyperK, creatinine > 2.0) Calcium channel blocker, clonidine, hydralazine, alpha blocker

Question 49

when do you treat pregnant pts?

Answer 49

In pregnancy do not treat unless symptomatic or BP > 150/90

Question 50

if you start pt on ACE or ARb and kidney function drops

Answer 50

think about renal artery stenosis

Question 51

55 yo black male reports to office for primary HTN. No PMHX. What is most appropriate first line anti HTN for this patient? A) metoprolol (BB) B) valsartan (ARB) C) amlodipine (CCB) D) lisinopril (ACE)

Answer 51

C) amlodipine (CCB)

Question 52

48 yo Female presents f/u HTN. Meds:  lisinopril 20 mg po BID,  amlodipine 5 mg po daily BP 138/88, HR 55 A) increase amlodipine 10 mg/d B) continue current rx C) add metoprolol 25 mg po BID D) add HCTZ 25 mg qd

Answer 52

A) increase amlodipine 10 mg/d | BP goal < 130/80

Question 53

Black patient with hyperkalemia and HTN presents in office with elevated BP. What is most appropriate add on therapy? A) diltiazem ( non-dihydropyridine ccb) B) amlodipine ( dihydropyridine ccb) C) spironolactone ( MRA) D) atenolol ( bb)

Answer 53

**Amlodipine- good bp reduction, will not affect K, counsel side effect edema** Diltiazem not good for BP reduction side effect GI Spironolactone contraindicated hyperK Atenolol poor choice for HTN esp in black patient

Question 54

Resistant Hypertension possible causes

Answer 54

Question 55

Hypertensive Crises

Answer 55

Question 56

HTN crisis classification

Answer 56

Question 57

# Hypertensive Crises In emergency ( + end-organ damage) Tx

Answer 57

admit and treat with IV rx goal reduce BP 10-20% first hour In urgency ( no evidence end-organ damage) treat outpatient, close follow up, oral rx. Usually start/titrate “baseline” rx : Amlodipine/HCTZ Clonidine ( transdermal, po) ACE/ARB hydralazine (IV,PO)

Question 58

A patient presents to ED with agitation/HA bp 210/110 a. What diagnosis is this ? b. HTN urgency c. HTN emergency d. Malignant HTN

Answer 58

Pt has evid of end organ damage. This is htn emergency.

Question 59

A patient presents to ED with agitation/HA bp 210/110 a.your goal is to reduce BP_ % in first hour a.10%  b.10-20% c.25%

Answer 59

Goal is to reduce BP 10-20% in 1 hour

Question 60

A patient presents to ED with agitation/HA bp 210/110 Which of the following is best choice for this patient? Clonidine 0.1 mg po Amlodipine 10 mg po Labetalol 10 mg IVP Enalapril 5 mg IVP

Answer 60

Labetalol 10 mg IVP

Question 61

Blood Pressure (BP) =

Answer 61

Blood Pressure (BP) = CO x SVR Cardiac Output (CO) Systemic Vascular Resistance (SVR)

Question 62

BP considered elevated if

Answer 62

Elevated BP on three separate occasions ( > 120/80)

Question 63

HTN Nutshell | 4

Answer 63

1- What is BP goal Is this primary or secondary? Calculate 10 year risk 2- TLCs +/- Rx 3-Drugs w compelling indications 4-Drug/dose/side effects/follow up