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clinical medicine II > HTN > Flashcards

Flashcards in HTN Deck (72):
1

HTN is most prevalent in which race

blacks > whites > hispanics

2

normal blood pressure values

  • systolic pressure < 120 mmHg
  • diastolic pressure < 80 mmHg

3

what blood pressure values classify as pre-hypertension 

  • systolic pressure 120-139 mmHg OR
  • diastolic pressure 80-89 mmHg

4

what blood pressure values classify as stage 1 HTN

  • systolic 140-159 mmHg OR
  • diastolic 90-99 mmHg

5

what blood pressure values classify as stage 2 HTN

  • systolic > or = 160 mmHg OR
  • diastolic > or = 100 mmHg

6

equation for blood pressure 

BP = CO x systemic vascular resistance 

7

what are the major factors that determine BP

  • sympathetic nervous system
  • Renin angiotensin aldosterone system
  • plasma volume 

8

what are the modifiable risk factors for primary HTN

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

9

primary HTN accounts for what percentage of diagnosed HTN

90-95% of all HTN

10

what is secondary HTN

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

11

what are the major conditions that are associated with secondary HTN

  • 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 

12

united states preventive services task force recommendation for screening for HTN

  • 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 

13

gold standard for diagnosing HTN

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

14

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

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

15

Physical exam for a person who is hypertensive 

  • 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 

16

what tests should you always order when evaluating for HTN

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

17

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

Lifestyle modifications

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

18

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

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

19

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

  • beta blockers
  • alpha blockers
  • central alpha agonist
  • direct renin inhibitor 

20

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

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

21

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

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

22

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

  • thiazide-type diuretic OR
  • Calcium channel blockers 

23

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

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

24

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

  • 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

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