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clinical medicine II > HTN > Flashcards

HTN Flashcards

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1
Q

HTN is most prevalent in which race

A

blacks > whites > hispanics

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2
Q

normal blood pressure values

A
  • systolic pressure < 120 mmHg
  • diastolic pressure < 80 mmHg
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3
Q

what blood pressure values classify as pre-hypertension

A
  • systolic pressure 120-139 mmHg OR
  • diastolic pressure 80-89 mmHg
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4
Q

what blood pressure values classify as stage 1 HTN

A
  • systolic 140-159 mmHg OR
  • diastolic 90-99 mmHg
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5
Q

what blood pressure values classify as stage 2 HTN

A
  • systolic > or = 160 mmHg OR
  • diastolic > or = 100 mmHg
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6
Q

equation for blood pressure

A

BP = CO x systemic vascular resistance

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7
Q

what are the major factors that determine BP

A
  • sympathetic nervous system
  • Renin angiotensin aldosterone system
  • plasma volume
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8
Q

what are the modifiable risk factors for primary HTN

A
  • smoking
  • high sodium diet
  • excess alcohol intake
  • obesity/weight gain
  • physical inactivity
  • dyslipidemia
  • vitamin D deficiency
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9
Q

primary HTN accounts for what percentage of diagnosed HTN

A

90-95% of all HTN

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10
Q

what is secondary HTN

A
  • increased BP resulting from an identifiable medication or medical condition
  • must be addressed to achieve adequate BP control
  • 5-10% of all HTN
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11
Q

what are the major conditions that are associated with secondary HTN

A
  • renal disease
  • medication induced: estrogen, NSAIDS, steroids
  • Thyroid, Parathyroid disease
  • Coarctation of aorta
  • primary hyperaldosteronism
  • Cushing’s syndrome
  • Pheochromocytoma (hypertensive emergency: HA, sweating, tachycardia)
  • obstructive sleep apnea
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12
Q

united states preventive services task force recommendation for screening for HTN

A
  • all individuals 18 or older should be screened
  • adults 40 yo or older should be measured at least annually
  • adults betwwen 18-39 should be screened annually if they have risk factors or previously measured BP was elevated
  • adults betwwen 18-39 without risk ractors and high BP should be screened at least every 3 years
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13
Q

gold standard for diagnosing HTN

A
  • ambulatory blood pressure monitoring
    • if BP elevated at screening, the diagnosis should be confirmed using out of office BP measurement
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14
Q

general principles you should tell patient when having them check BP outside of office

A
  • serial measurements required
  • measure on both arms
  • comfortable, quiet setting
  • avoid eating, exercise, smoking, and caffeine
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15
Q

Physical exam for a person who is hypertensive

A
  • vitals
    • BMI, waist circumference
    • BP both arms
    • pulses
  • general
    • body fat distribution
    • skin lesions
    • muscle strength
    • alertness
  • HEENT
    • fundoscopy for hemorrhage
    • cotton wool spots
  • Neck
    • carotids, thyroid
  • Respiratory: rales
  • Cardiac
    • displaced PMI or new murmur
  • Abd
    • renal masses
    • abdominal aorta
  • Neuro
    • visual disturbance
    • focal weakness
    • confusion
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16
Q

what tests should you always order when evaluating for HTN

A
  • LUBE
    • Lipid panel
    • UA
    • Basic metabolic panel
      • fasting glucose
      • creatinine, electrolytes, GFR
    • EKG
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17
Q

what is the first line treatment for all patients with essential HTN

A

Lifestyle modifications

  • Diet
    • lower sodium intake
    • DASH diet
    • alcohol reduction
  • Exercise
    • 3-4x/week (40 min, mod-vigorous)
  • healthy weight
  • smoking cessation
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18
Q

What are the BIG FOUR medications when it comes to treating HTN

A
  • Diuretics
  • Angiotensin Converting Enzyme inhibitors (ACE-I)
  • Angiotensin II receptor blockers (ARB)
  • calcium channel blockers
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19
Q

What other four medications can be used to treat HTN if the BIG FOUR aren’t working

A
  • beta blockers
  • alpha blockers
  • central alpha agonist
  • direct renin inhibitor
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20
Q

What is everybody’s treatment threshold/goal for BP. What is the exeption

A
  • 140/90
  • exception is people over 60 yo who don’t have kidney disease or diabetes, in which case their goal is 150/90
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21
Q

In the general nonblack population, including those with diabetes, initial antihypertensive treatment should include

A
  • One of BIG FOUR
    • thiazide type diuretic
    • calcium channel blocker
    • angiotensin-converting enzyme inhibitor
    • Angiotensin II receptor blockers
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22
Q

In the general black population, including those with diabetes, initial antihypertensive treatment should include

A
  • thiazide-type diuretic OR
  • Calcium channel blockers
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23
Q

Adults with chronic kidney disease should be put on which drugs regardless of race or diabetes status

A
  • angiotensin II receptor blocker (ARB)
  • angiotensin converting enzyme inhibitor (ACE-I)
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24
Q

Medication recommendation summary (put CKD, race recommendations all together)

A
  • if you have CKD, start with ACEI or ARB
  • if you are black, start with thiazide or CCB
  • neither? start with any one of BIG FOUR
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25
if a single antihypertensive drug doesn't work, what should you do
* add a second drug from another class * if that doesn't work, add another from one of the remaining classes * \*\*Don't use ACEI and ARB together * ex: * ACE, thiazide, CCB * ARB, thiazide, CCB
26
If the patient is taking three out of the four BIG FOUR classes of antihypertensives and still hasn't reached the target goal, what should you do
* consider other classes of medications or refer to specialist
27
what is resistant hypertension. How should you manage it
* blood pressure that is not controlled despite adherence to an appropriate three drug regimen or requires at least four medications to achieve control * ensure adherence to lifestyle changes, medication regimen, and accurate measurement * consider referral
28
How would you treat * 65 yo white male with BP 170/90
1. lifestyle management 2. target goal BP: \< 150/90 3. place him on ACEI, ARB, CCB, or Thiazide
29
How would you treat * 65 yo black female with DM and BP 162/98
1. lifestyle modification 2. target BP: \< 140/90 3. CCB or Thiazide
30
What are the side effects of Thiazide type diuretics
* Hypokalemia * Gout * Dyslipidemia
31
Contraindication to taking Thiazide type diuretics
sulfa sensitivity
32
MOA of Thiazide type diuretics
* decrease body's sodium stores by inhibiting sodium reabsorption in the nephron * reduces plasma volume and peripheral vascular resistance
33
Name the four types of Diuretics
* _Thiazide type diuretics_ * Loop diuretics * Potassium sparing diuretics * aldosterone antagonist
34
Hydrocholorthiazide (HCTZ) is a part of which class of drugs
Thiazide-type diuretics
35
Side effect of ACE inhibitors
* hyperkalemia * acute renal failure * angioedema
36
Which patient populations greatly benefit from being put on an ACE inhibitors
* DM * CKD * post MI * Heart failure
37
contraindications to give ACE inhibitors
* renal artery stenosis * pregnancy * angioedema
38
The "Pril"s (e.g. lisinopril, enalapril) are a part of which drug class
ACE inhibitors
39
MOA of ACE inhibitors
* inhibit the RAAS system and stimulate bradykinin (which has a vasodilatory effect)
40
MOA of angiotensin II receptor blockers
inhibit the RAAS system
41
The "..sartan"s (e.g. Losartan, valsartan etc..) fall into which drug class
angiotensin II receptor blockers
42
Side effects of angiotensin II receptor blockers
* hyperkalemia * acute renal failure * angioedema
43
which patient populations greatly benefit from being placed on an angiotensin II receptor blocker
* CKD * DM * heart failure
44
contraindications to give angiotensin II receptor blockers
* pregnancy * renal artery stenosis * angioedema
45
What are the two types of calcium channel blockers. Which is used to treat HTN?
* Non-dihydropyridine * dihydropyridine: more selective as vasodilators, less cardiac depressant effect
46
"..pine"s (e.g. amlodipine, felodipine..etc) are a part of which drug class
dihydropyridine
47
side effects of calcium channel blockers
* cardiodepressant -\> bradycardia * dizziness * HA
48
which patient populations greatly benefit from being put on a calcium channel blocker
black population
49
contraindications to give calcium channel blocker
* several types of cardiac dysfunction * acute MI
50
MOA of calcium channel blocker
inhibit calcium influx into arterial smooth muscle cells, which reduces peripheral vascular resistance
51
What are the types of Beta blockers
* cardioselective (B1 receptors) * Noncardioselective (B1 and B2 receptors
52
"..olol"s (e.g. propranolol, nadolol etc) are in which drug class
beta blockers
53
side effects of beta blockers
* bradycardia * bronchospasm
54
which patient populations benefit from being on beta blockers
* post MI * stable heart failure * high CAD risk * often used in pregnancy
55
contraindications for beta blockers
* bronchospastic disease * heart block * acute decompensation heart failre * \*\*avoid abrupt cessation
56
side effect of central alpha agonists
* hepatitis * hemolytic anemia * anticholinergic effects
57
clonidine and methyldopa are a part of which drug class
central alpha agonists
58
MOA of central alpha agonists
* stimulate a2 adrenergic receptors in the brain which reduces CNS sympathetic outflow
59
what is the most commonly used anti-HTN in pregnancy
Methyldopa: central alpha agonists
60
contraindications for central alpha agonists (specifically methyldopa)
liver failure
61
"zosin" (e.g. doxazosin, terazosin, etc) are a part of which drug class
alpha blockers
62
MOA of alpha blockers
targets alpha 1 receptors on vascular smooth muscle, causing peripheral vascular resistance to decrease, thus decreasing BP
63
side effects of alpha blockers
* orthostatic hypotension * reflex tachycardia
64
which patient population benefits from being on a alpha blockers
BPH
65
aliskiren (tekturna) is a part of which drug class
direct renin inhibitors
66
side effects of direct renin inhibitors
* hyperkalemia * renal impairment * hypersensitivity reaction (anaphylaxis, angioedema)
67
contraindications for direct renin inhibitors
* with ACE-I or ARB in diabetics * pregnancy
68
Hypertensive urgency
* **asymptomatic** severe HTN (diastolic \> 120 mmHg) and **NO** evidence of end organ damage * usually nonadherence to chronic antihypertensive medication * nonadherence to low sodium diet and/or high salt load
69
hypertensive emergency
severe HTN (diastolic \> 120 mmHg) and evidence of **acute end-organ damage**
70
Causes of hypertensive crisis (urgency and emergency)
* abrupt d/c of BP meds * high salt load * neurological emergencies (stroke, trauma) * cardiac emergencies (HR,MI) * vascular emergencies (aortic dissection) * pregnancy * renal emergencies
71
Treatment for hypertensive urgency
* Goal: reduce BP \< 160/120 mmHg (achieved over hours-days) * treatment * rest * increase dose of current meds * add meds * f/u
72
treatment for hypertensive emergency
* hospitalized in ICU * address underlying cause * reduce BP * no more than 25% within minutes to 1 hour * BP goal, 160/100-110 mmHg over 2-6 hours * \*sublingual nefidipine is contraindicated

clinical medicine II (8 decks)

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