HTN Flashcards

Question

How do you manage a hypertensive patient

Answer 1

### **Management of Hypertension (HTN)** Management of hypertension involves a stepwise approach to confirm the diagnosis, find underlying causes, and assess the overall risk to the patient. Here’s how it’s done: 1. **Management of HTN (1):** - **Confirm HTN & determine its level:** First, the diagnosis of high blood pressure must be confirmed with accurate measurements. The level of hypertension is then classified based on these readings. - **Identify secondary causes:** Secondary hypertension occurs when high blood pressure is caused by another condition, such as kidney disease or hormonal disorders, so it's important to identify if there's an underlying cause. - **Find other cardiovascular (CV) risk factors:** Other risk factors, like smoking, high cholesterol, or diabetes, should be identified as they can increase the likelihood of complications. - **Investigate:** Conduct tests to understand the patient’s overall health and look for signs of complications. - **Determine presence of end-organ damage:** Look for damage to organs such as the heart, kidneys, brain, and eyes, which are commonly affected by prolonged high blood pressure. - **Stratify the risk:** Once all factors are considered, the risk of future complications (like heart attack or stroke) is assessed and categorized as low, moderate, or high. 2. **Management of HTN (2):** This is done through: - **Full History:** Taking a detailed medical history helps identify risk factors, previous illnesses, and family history of hypertension or heart disease. - **Thorough Physical Exam & Fundoscopy:** A full physical examination, including checking the blood pressure, heart sounds, and conducting an eye exam (fundoscopy), helps detect signs of hypertension-related damage. - **Investigations:** Laboratory tests (e.g., kidney function tests, lipid profiles) and imaging studies (e.g., echocardiogram, renal ultrasound) are done to assess the impact of hypertension and check for secondary causes.

Answer 2

**Threshold for Starting Treatment:** The decision to start antihypertensive treatment is based on the **risk of complications**: - **Without Target Organ Damage (TOD) or risk factors:** - JNC-7, WHO-ISH, and European guidelines suggest starting treatment at **140/90 mmHg**. - British guidelines recommend starting at **160/90 mmHg**. - **With risk factors or TOD:** - All guidelines agree to start treatment at **140/90 mmHg**. - **With diabetes or chronic kidney disease (CKD):** - JNC-7 and WHO-ISH recommend starting at **130/80 mmHg**. - British guidelines suggest **140/90 mmHg**. - European guidelines recommend **130/85 mmHg**.

Answer 3

**Drug Classes, Compelling Indications, and Contraindications:** 1. **Diuretics:** - **Compelling Indications (Indicated for use):** - **CCF (Congestive Cardiac Failure)** - **Elderly patients** - **Contraindications (Avoid use):** - **Gout** (diuretics can increase uric acid levels, worsening gout)

Answer 4

2. **β-blockers (Beta-blockers):** - **Compelling Indications:** - **Angina** (chest pain due to reduced blood flow to the heart) - **High Heart Rate** - **Post Myocardial Infarction (M.I.)** (after a heart attack) - **Contraindications:** - **Asthma** and **COPD (Chronic Obstructive Pulmonary Disease)** (beta-blockers can cause bronchoconstriction) - **Heart Block** (a slow or blocked electrical signal in the heart)

Answer 5

3. **ACE Inhibitors/ARBs (Angiotensin-Converting Enzyme Inhibitors/Angiotensin Receptor Blockers):** - **Compelling Indications:** - **Congestive Cardiac Failure (CCF)** - **Post M.I.** (for heart recovery) - **Diabetic Nephropathy** (kidney protection in diabetes) - **Left Ventricular Dysfunction** - **Contraindications:** - **Pregnancy** (ACE inhibitors/ARBs are teratogenic) - **High potassium levels** (can worsen hyperkalemia) - **Renal Artery Stenosis** (narrowing of the kidney arteries)

Answer 6

4. **Calcium Channel Blockers (CCB):** - **Compelling Indications:** - **Angina** - **Systolic Blood Pressure (SBP)** control - **Elderly** (especially in isolated systolic hypertension) - **Contraindications:** - **Heart Block** (due to risk of exacerbating conduction issues) 5. **α-blockers (Alpha-blockers):** - **Compelling Indication:** - **Prostatic Hypertrophy** (enlarged prostate, which can cause urinary issues)

Answer 7

### **Other Drugs:** 1. **Renin Antagonists/Inhibitors** (e.g., Aliskiren): These block the renin-angiotensin-aldosterone system, reducing blood pressure. 2. **Central Alpha-2 Blockers** (e.g., Aldomet, Guanabenz, Guanadrel, and Clonidine): These work in the brain to lower blood pressure by reducing sympathetic nervous system activity. 3. **Peripheral Adrenergic Inhibitors** (e.g., Reserpine, Guanethidine): These block nerve signals that cause blood vessel constriction. 4. **Vasodilators** (e.g., Hydralazine): These relax blood vessels and reduce resistance, lowering blood pressure. ---

Answer 8

- **WHO/ISH (2003):** Recommends starting with a **low-dose diuretic**, unless contraindicated. - **EHS/ESC (2003):** Suggests starting with any of the **5 major drug classes** (Diuretics, Beta-blockers, ACE inhibitors, ARBs, Calcium Channel Blockers). - **BHS (British Hypertension Society):** The choice is based on **age** and **risk factors**. - **British National Institute for Clinical Excellence (NICE):** Recommends starting with **thiazide diuretics**. - **Canadian Hypertension Education Program (CHEP):** Suggests using any class, but if combination therapy is required, it should include a **thiazide diuretic**. ---

Answer 9

1. **Diuretics + ACE Inhibitors (ACEI) or ARB (Angiotensin Receptor Blockers)** 2. **Diuretics + β-blockers** 3. **Calcium Channel Blockers (CCB) + ACEI** 4. **CCB + β-blockers** The **NHS (National Health Service) recommendations** for combinations are similar, with the addition of options like: - **Diuretics + Central Acting Drugs** - **Diuretics + Alpha-blockers** --- **Preferred Combinations (American Society of Hypertension - ASH):** **Preferred 2-drug combinations:** - **ACE Inhibitors/Diuretics** - **ARB/Diuretics** - **ACEI/Calcium Channel Blockers (CCB)**

Answer 10

**Acceptable combinations:** - **β-blocker/Diuretics** - **CCB/Diuretics** - **Renin Inhibitor/Diuretics** **Unacceptable combinations:** - **ACE Inhibitors/ARBs** (using both together can cause dangerous side effects) - **ARB/β-blocker** (less effective) - **CCB (non-dihydropyridine)/β-blocker** (increases the risk of heart block) - **Centrally Acting Agent/β-blocker** (can cause significant side effects like bradycardia)

Answer 11

**Special Considerations:** 1. **Blacks:** Often require more aggressive treatment and **diuretics** should be emphasized. 2. **Pregnant Women:** Specific medications should be used (avoid ACE inhibitors/ARBs). 3. **Elderly:** Often have **Isolated Systolic Hypertension (ISH)**; **Calcium Channel Blockers** are preferred. 4. **Athletes:** Should avoid drugs that cause drowsiness (like beta-blockers and some central agents). 5. **Diabetics:** Should use **ACE inhibitors** or **ARBs** for kidney protection. 6. **Patients with CAD (Coronary Artery Disease), CCF (Congestive Cardiac Failure), CVD (Cerebrovascular Disease), or PVD (Peripheral Vascular Disease):** Require specific tailored treatment based on their conditions. 7. **Hypertensive Pilots:** Special consideration due to occupational needs. 8. **Resistant Hypertension:** May need combination therapy or investigation for secondary causes.

Answer 12

--- ### **Drug Classes for Chronic Hypertension in Pregnancy:** 1. **Methyldopa:** - **Comments:** Methyldopa is **preferred** in treating chronic hypertension during pregnancy because of its **long-term safety profile**. It has been shown to be safe for both the mother and fetus, especially based on long-term follow-up studies. It is also commonly used in **eclampsia** cases, making it a reliable option for hypertensive crises in pregnancy. 2. **β-Blockers (Beta-blockers):** - **Comments:** These drugs are generally considered **safe**, but there have been reports of **intrauterine growth retardation** (restricted fetal growth) in some cases. This risk must be balanced with the benefit of controlling high blood pressure. - **Labetalol**, a specific β-blocker, is becoming increasingly preferred over methyldopa because it has **fewer side effects**, making it a better tolerated option for pregnant women. 3. **Clonidine:** - **Comments:** Clonidine is not commonly used in pregnancy due to **limited data** on its safety for both mother and fetus. Thus, its use is reserved for specific cases when other treatments are not suitable. 4. **Calcium Channel Blockers (CCB):** - **Comments:** These drugs have **limited data** available, but current studies have not shown an increase in **major teratogenicity** (birth defects). This means they are not linked to significant harm when the fetus is exposed during pregnancy, making them an option for treating high blood pressure. 5. **Diuretics:** - **Comments:** Diuretics are **not first-line** treatments for hypertension in pregnancy. They are likely **safe in low doses**, but because they can affect blood volume and electrolyte balance, they are used cautiously in pregnant women. They are typically avoided unless necessary. 6. **ACE Inhibitors & ARBs:** - **Comments:** These drugs are **strongly contraindicated** in pregnancy. They are classified as **Category C** in the 1st trimester (meaning risk to the fetus cannot be ruled out) and **Category D** in the 2nd and 3rd trimesters (there is evidence of fetal risk). Exposure to these drugs during pregnancy has been associated with **major teratogenicity**, including **fetal toxicity** and **death**. Therefore, they should be avoided in all pregnant women. --- ### **Conclusion:** The prevalence of hypertension is increasing, and **genetics** play a significant role. Pregnant women with chronic hypertension should have their **SBP (Systolic Blood Pressure)** kept below **140 mmHg** and **DBP (Diastolic Blood Pressure)** below **90 mmHg** to reduce the risk of complications. Other cardiovascular risk factors should also be identified and treated appropriately. Combination drug therapy may be used to control blood pressure, but the chosen medications must be safe for both the mother and fetus. **Failure to manage hypertension** during pregnancy can lead to severe complications such as **cerebrovascular accidents (stroke)**, **acute myocardial infarction (heart attack)**, and **chronic renal failure**.

Answer 13

2. What are the key clinical features and complications of untreated hypertension? 3. Explain the diagnostic workup for a patient presenting with suspected hypertension. 4. Describe the pharmacological management of hypertension, including drug classes and their mechanisms. 5. Discuss the management of hypertension in special populations, including pregnancy.

Answer 14

**Essential (primary) hypertension** is the most common form of hypertension, and its pathophysiology involves multiple interconnected factors: - **Genetic predisposition:** Family history plays a major role. Variations in genes related to blood pressure regulation (such as those controlling RAAS components) make certain individuals more susceptible. - **Renin-Angiotensin-Aldosterone System (RAAS):** RAAS is crucial for blood pressure regulation. Angiotensin II, a potent vasoconstrictor, increases systemic vascular resistance and aldosterone release, which enhances sodium and water retention, raising blood volume and pressure. - **Sympathetic Nervous System (SNS):** Overactivity of the SNS leads to vasoconstriction and increased cardiac output, contributing to chronic hypertension. This occurs because of abnormal signals from the brainstem, which causes over-stimulation of peripheral sympathetic nerves. - **Endothelial dysfunction:** The endothelium (inner lining of blood vessels) normally produces vasodilators like nitric oxide (NO). In essential hypertension, there’s reduced NO availability, leading to vasoconstriction and increased peripheral resistance. - **Salt and water retention:** Excessive salt intake, especially in salt-sensitive individuals, leads to fluid retention and elevated blood volume. This increases cardiac output and leads to sustained high blood pressure. - **Other contributing factors:** Obesity, insulin resistance, and lifestyle factors (e.g., stress, alcohol, physical inactivity) all contribute to the development and progression of essential hypertension. This multifactorial interplay results in increased peripheral vascular resistance (systemic vasoconstriction) and/or increased cardiac output, leading to persistently elevated blood pressure.

Answer 15

Both hypertensive urgency and emergency are situations where blood pressure rises significantly, but they differ in their clinical presentation and required management. - **Hypertensive Urgency:** - **Definition:** Severe elevation in blood pressure (usually >180/110 mmHg) without acute end-organ damage. - **Presentation:** The patient is usually asymptomatic or may present with headaches, dizziness, or nosebleeds. - **Management:** It does not require immediate IV treatment. Instead, oral antihypertensives are used, and the goal is to lower the BP gradually over 24-48 hours. Common drugs include clonidine or captopril. - **Hypertensive Emergency:** - **Definition:** Severe hypertension (typically >180/120 mmHg) associated with acute end-organ damage (e.g., stroke, myocardial infarction, pulmonary edema, renal failure). - **Presentation:** Symptoms vary depending on which organ is affected. For example, hypertensive encephalopathy can cause confusion or seizures, while myocardial ischemia presents with chest pain. - **Management:** This is a medical emergency requiring rapid blood pressure reduction using intravenous agents (e.g., sodium nitroprusside, labetalol). The goal is to reduce the mean arterial pressure by no more than 25% within the first hour to avoid ischemia from sudden BP drops

Answer 16

Managing **chronic hypertension in pregnancy** requires a careful balance to protect both the mother and fetus. Treatment strategies include: - **First-line medication:** - **Methyldopa** is commonly used as it has a long-established safety profile in pregnancy. It’s also favored in cases of pre-eclampsia and eclampsia. - **Labetalol** is increasingly preferred due to fewer side effects compared to methyldopa. It combines alpha- and beta-blocking effects, helping to lower blood pressure without excessive reflex tachycardia. - **Other drugs:** - **Calcium channel blockers (CCBs):** These are generally safe, although data is limited. Nifedipine is used in some cases without significant risks of teratogenicity. - **Diuretics** are not first-line but may be used in low doses for fluid management. - **Drugs to avoid:** - **ACE inhibitors and ARBs** are contraindicated due to the risk of fetal malformations, particularly in the second and third trimesters (category D). They can cause fetal renal damage and death. - **Complications if untreated:** Untreated hypertension can lead to severe complications such as pre-eclampsia, eclampsia, fetal growth restriction, and preterm birth. Thus, close monitoring and careful drug selection are vital throughout the pregnancy

Answer 17

Chronic hypertension affects multiple organ systems, leading to both structural and functional damage: - **Heart:** - **Left Ventricular Hypertrophy (LVH):** Chronic pressure overload increases myocardial wall thickness, leading to LVH. Over time, this results in diastolic dysfunction and heart failure. - **Coronary Artery Disease (CAD):** Hypertension accelerates atherosclerosis in coronary arteries, increasing the risk of myocardial infarction. - **Heart failure (HF):** Both systolic and diastolic heart failure can occur due to the increased workload and ischemic damage. - **Kidneys:** - **Hypertensive nephropathy** occurs when hypertension damages renal arteries and glomeruli. This can lead to progressive kidney damage, proteinuria, and eventually chronic kidney disease (CKD). - **Brain:** - Hypertension increases the risk of **ischemic strokes**, transient ischemic attacks, and **intracerebral hemorrhages (ICH)**. - **Hypertensive encephalopathy** is an emergency that presents with confusion, seizures, and even coma, caused by cerebral edema. - **Eyes:** - Hypertensive retinopathy results from chronic pressure on retinal vessels. There are different grades of retinopathy, ranging from mild vessel narrowing to severe retinal hemorrhages, cotton wool spots, and even papilledema

Answer 18

Non-pharmacological interventions are essential for managing hypertension: - **Salt reduction:** Reducing sodium intake to <100 mmol/day (around 6 g of NaCl) decreases water retention, thus lowering blood volume and blood pressure. This is particularly effective in salt-sensitive individuals. - **Weight loss:** A body mass index (BMI) between 18.5–24.9 kg/m² is associated with reduced cardiovascular risk. Each kilogram of weight loss can reduce systolic BP by 1-2 mmHg. - **Exercise:** Engaging in moderate physical activity (e.g., brisk walking) for at least 30 minutes on most days lowers BP by enhancing endothelial function and reducing peripheral vascular resistance. - **Diet:** A diet rich in fruits, vegetables, low-fat dairy, and whole grains (as seen in the **DASH diet**) lowers BP by providing essential nutrients (e.g., potassium, magnesium) and limiting saturated fat. - **Limiting alcohol:** Reducing alcohol intake can lower systolic BP by 2-4 mmHg, particularly in individuals who consume excessive amounts.

Answer 19

- **Diuretics:** Thiazide diuretics (e.g., hydrochlorothiazide) reduce blood volume and are often first-line therapy, especially in older adults. - **ACE Inhibitors (ACEI):** Drugs like enalapril inhibit the conversion of angiotensin I to angiotensin II, reducing vasoconstriction and aldosterone production. They’re useful in patients with diabetes and chronic kidney disease. - **Angiotensin II Receptor Blockers (ARBs):** ARBs (e.g., losartan) block angiotensin II receptors, offering similar effects to ACE inhibitors, with fewer side effects like cough. - **Calcium Channel Blockers (CCBs):** These drugs (e.g., amlodipine) block calcium influx in vascular smooth muscle, reducing vascular resistance. They are particularly useful in elderly patients and those with isolated systolic hypertension. - **Beta-Blockers:** These reduce heart rate and cardiac output and are especially useful in post-myocardial infarction patients and those with arrhythmias

Answer 20

Combination therapy is often necessary for patients who cannot achieve adequate blood pressure control with a single drug: - **Advantages:** - Combination therapy targets different mechanisms involved in blood pressure regulation, such as combining a diuretic with an ACE inhibitor. This approach is more effective and reduces the need for higher doses of individual drugs, minimizing side effects. - WHO recommends combinations like diuretics and ACE inhibitors, or calcium channel blockers and beta-blockers, to manage complex hypertension cases. - **Risks:** - Some combinations (e.g., ACE inhibitors with ARBs) are not recommended because they may increase the risk of hyperkalemia or renal impairment without improving outcomes. - Careful monitoring is necessary to avoid interactions and manage potential adverse effects like hypotension or electrolyte imbalances. This approach maximizes efficacy while minimizing side effects, making it a preferred strategy for patients with resistant hypertension.

Answer 21

**Answer:** The first-line antihypertensive medications in diabetic patients are **ACE inhibitors** or **angiotensin II receptor blockers (ARBs)**. These drugs not only lower blood pressure but also provide renal protection by reducing proteinuria and delaying the progression of diabetic nephropathy.

Answer 22

**Answer:** Resistant hypertension is when blood pressure remains elevated despite the use of three or more antihypertensive medications, including a diuretic, at optimal doses. Management includes ruling out secondary causes (e.g., renal artery stenosis), optimizing treatment with additional drug classes (e.g., aldosterone antagonists), and lifestyle modifications.

Answer 23

**Answer:** **Target organ damage** refers to the damage caused by prolonged high blood pressure to critical organs, including the heart (e.g., left ventricular hypertrophy), kidneys (e.g., chronic kidney disease), brain (e.g., stroke), and eyes (e.g., hypertensive retinopathy). Detection of such damage indicates severe or poorly controlled hypertension and increases the risk of complications.

Answer 24

**Answer:** Isolated systolic hypertension (ISH) is when only the systolic blood pressure (SBP) is elevated (>140 mmHg) while the diastolic blood pressure (DBP) remains normal (<90 mmHg). It is common in the elderly due to decreased arterial elasticity, leading to stiffening of the large arteries. As a result, systolic pressure increases, while diastolic pressure remains stable or decreases

Answer 25

**Answer:** ACE inhibitors are contraindicated in pregnancy because they can cause significant fetal harm, particularly during the second and third trimesters. They are associated with fetal renal dysgenesis, oligohydramnios, skull hypoplasia, and even fetal death due to their teratogenic effects on the developing renin-angiotensin system

Answer 26

**Answer:** The **DASH diet** (Dietary Approaches to Stop Hypertension) helps lower blood pressure by promoting a diet rich in fruits, vegetables, whole grains, and low-fat dairy, while limiting saturated fats, cholesterol, and sodium. This diet provides essential nutrients like potassium, magnesium, and calcium, which help regulate blood pressure

Answer 27

**Answer:** **White-coat hypertension** refers to elevated blood pressure readings in a clinical setting but normal readings at home or in a non-clinical environment. It is diagnosed through **ambulatory blood pressure monitoring (ABPM)** or home blood pressure monitoring, which tracks the patient's blood pressure over 24 hours or in their everyday setting

Answer 28

**Answer:** The kidney plays a central role in hypertension through its regulation of blood volume and the renin-angiotensin-aldosterone system (RAAS). Impaired sodium excretion, excessive activation of RAAS, and renal artery stenosis can lead to fluid retention, increased blood volume, and elevated systemic vascular resistance, all contributing to sustained hypertension