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Flashcards in HTN Deck (49):
1

damage from HTN

stroke
retinopathy, blindness
MI
HF
kidney failure

2

180/110

HTN emergency
see slide 4

3

consistently above 140/90 check for

end organ damage
if yes: tx for HTN

if not, diet and exercise

(home BP: 135/85)

4

HTN values

Normal: less than 120/80
pre-HTN: 120-139/80-89
stage 1: 140-159/90-99
stage 2: greater than 160/greater than 100

5

how to perform BP

slide 7, 8

6

long standing HTN

develop LVH-->higher rate of CV events
tx pressure, mass will decrease

if untx dev. ESRD

7

etiology of HTN: primary (95%)

Overactivitation of SNS and RAAS
Blunting of pressure-natriuresis relationship
Variation in CV/renal development
Elevated intracellular Na+/Ca+
Exacerbating factors (too much salt, meds: NSAIDS, cocaine, smoking, etOH, *sleep apnea*, OCPs)

8

Secondary Hypertension

Who should be screened?

Severe or resistant HTN: Persistent HTN despite use of adequate doses of three antiHTN from different classes
Acute rise in BP in a patient with previously stable values
Age less than 30 in non-obese, non-African American pt w. negative fam hx
malignant/accelerated HTN (severe HTN and evidence of end-organ damage)
age of onset before puberty

9

Genetic causes of secondary HTN

Liddle syndrome
hyperaldo
HTN in pregnancy

10

Renal/renovascular causes of secondary HTN

FMD (fibromuscular dysplasia) in young women (rev)
Refractory HTN
Bruits, PAD
Cr increase with ACE-I (bilat renal artery stenosis)
Pulmonary edema

slide 17
flash pulmonary edema

11

pheochromocytoma

paroxysmal elevations in BP
triad of pounding ha, palps, sweating

12

primary aldosteronism

unexplained hypokalemia with Ur K+ wasting (but more than 50% are normokalemic)

tx: spironalactone: aldosterone inhib

13

cushings

cushingoid facies, central obesity, prox musc wkness and ecchymoses
may have hx glucocorticoid use

14

sleep apnea

primarily in obese men, snore loudly

daytime somnolence, fatigue, morning confusion

15

coarctation of aorta

HTN in arms, diminished/delayed femoral pulses and low/unobtainable BP in legs
left brachial pulse diminished and equal to femoral pulse if origin of the left subclavian artery is distal to the coarctation

*bicuspid aortic valve, assoc. with aortapathies (tx: stent)

+ coarc. check for intracranial aneurysms if both! (MRI)

16

hypothyroidism

symptoms of hypothyr.
elevated TSH

17

primary hyperparathyroidism

elevated serum calcium

18

complications

If untreated can lead to acute complications

Chronic complications:
Hypertensive heart disease
Hypertensive cerebrovascular disease and dementia
Hypertensive kidney disease

19

HTN: Silent killer

Silent killer
Mostly asymptomatic; headache
If severe can cause encephalopathy with N/V, confusion, vision changes

20

Pheochromocytoma will have

episodic presentation
Anxiety, palpitations, profuse perspiration, tremor, HA

21

Optho exam

Cotton wool spots, AV nicking, hemorrhage, *papilledema

22

other tests/imaging

ECG, ECHO, radial-femoral delay

23

EKG

look for LVH

S wave in V3
+ R wave in AVL:
if 23 in female, 28 in male
it's HTN

S wave in V1 of V2 + R wave in V4 or V5: >35 is HTN

ST depression and asymmetrical T wave inversion

LA enlargement (HTN HD)

24

pics: heart on LVH

slide 24

25

lifestyle mods

diet, exercise
every 10 k weight lost BP drops 5-20
more slide 25

26

who should be treated?

All receive lifestyle modification

Controversial…
Persistently > *140 SBP* (if younger than 60)
Persistently > 150 SBP (if older than 60)
Persistently > 90 DBP

27

HTN meds to start with

Afr. American with ISOLATED HTN: ??

White ??


Afr. Am. pt with DM ??

AA: CCB and thiazide

White: ACE-I and BB

However, many pts have comorbidities which should prompt targeted therapy
ie: Afr. Amer pt with DM should receive ACE-I first




28

systolic HF meds

ACE-I (red. RAS, prev. breakdown of bradykinin (inflamm))
ARB (help with cough from ACE-I)
B-blocker (if used before: metoprolol succinate, carvedilol)
diuretic
aldosterone antag

29

postMI

ACE-I
B-blocker
ARB
ald antag

30

proteinuria

ACE-I
ARB

31

angina

B-blocker
CCB

32

a fib
A flutter

B block, nondihydorpyridine
CCB

33

more drugs for comorbs

benign protastic hyperplasia: a-blocker
essential tremor: B-blocker (noncardiosel)
hyperthyroidism: B-blocker
migraine: B-blocker, CCB
osteoporosis: thiazide diuretic
Raynaud's: dihydropyridine CCB

34

contraindications

angioedema: don't use ACE-inhib.
Bronchospasticity: DON'T USE B-blocker
depression: DON'T USE reserpine
liver disease: DON'T USE methyldopa (used during preg)
preggos: DON'T USE ACEinh, ARB, renin inhib
2nd/3rd degree heart block: DON'T USE B-block, nondihydropyridine CCB

35

Diuretics
how they work

Initially lower plasma volume but decrease SVR long-term

electrolytes, gout, ED, hyperkalemia

Thiazides: hydrochlorothiazide best for long-term (give lasix initially)
porthaladone: longer half-life
loop: not as good for 1st or 2nd line

36

B-blockers

not 1st line for BP anymore

Decrease HR and CO, decrease renin levels

Carvedilol decrease PVR thru alpha-blockade

Nebivolol increases endogenous NO release-->vasodilation
may cause bronchospasm, bradycardia, fatigue, ED

37

B-blocker complications


Do not use alone for tx of HTN from cocaine or for pheo unless alpha blockade (unopposed alpha is bad)

38

Renin inhibitors

Lack efficacy data over ACE-I/ARB

39

ACE-I

Inhibits RAAS, prevents degradation of bradykinin

40

ARB

Inhibit RAAS
Olmesartan can be a/w a sprue-like syndrome
Caution for ACE-I/ARB if Cr worsens > 25%, could be due to renal artery stenosis

41

Aldosterone receptor blockers

CHF, cirrhosis
Can lead to gynecomastia, hyperkalemia, breast pain

42

CCB

Peripheral vasodilation with less reflex tachy/fluid retention
do not use nondihydropyridine CCB in systolic HF (can only use norovast, amlodipine)
Caution in CHF

43

Alpha blockers

Lower PVR; useful with BPH

*First-dose hypotension* (start slow, start at night), caution in CHF
can't use if EF is too low

44

Central sympatholytic (clonidine, methyldopa)

Stimulate alpha in CNS thus reducing efferent peripheral SNS outflow

adverse: ED, rebound HTN, dry mouth, caution in pregnancy with methyldopa

45

Direct vasodilators

Hydralazine/minoxidil

hydrazine with nitrates in Afr. Am: reduces mortality

46

Peripheral Sympathetic Inhibitors

Reserpine

adverse: depression

47

HTN urgencies

Treat when acute end-organ damage or BP > 220/125

Reduce ~ 25% in first 1-2 hrs and then target less than 160/100 within 2-6 hrs

using Nicardipine, labetalol, nitroprusside, NTG

48

OMM

OA Release: increase Vagal output
Rib Raising: inhibitory (attenuate facilitation)
Cervicals: carotid baroreceptors, cervical ganglions
Thoracolumbar junction: renals and RAS
Chapman’s Reflexes: myocardium, adrenals
CV4: fluid homeostasis and decrease stress
Myofascial Trigger Points: mobilize fluids

49

certain antiHTN drugs may have adverse effects on comorbid conditions:

depression: BB, central a2 agonist
gout: diuretic
hyperkalemia: aldo anta, ACEi, ARB, renin inhib
hyponatremia: thiazide diuretic
renovascular disease: ACEi, ARB, renin inhib.