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HTN Flashcards

1
Q

What is HTN a precursor to

A

systemic dx like hypertensive retinopathy, cerebrovascular dz, renal failure, and CVD

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2
Q

What is the #1 attributable risk factor for death world wide

A

Suboptimal BP

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3
Q

What is the epidemiology of HTN

A

1/3 adults have HTN

1/3 have pre-HTN

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4
Q

Why does incidence of HTN increase in women around 55 y/o

A

Menopause! estrogens not there to protect anymore

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5
Q

What races have a higher prevalence of HTN

A

African American
White
Mexican American

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6
Q

What happens when BP hits 115/75

A

CVD risk DOUBLES for each 20/10 mmHg increase

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7
Q

What is the MOA of primary essential HTN

A

Overactive SNS
Renal Na+ retention
Inflammation, oxidative stress, vascular remodeling
RAAS damaging vascular health

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8
Q

What controls BP

A

SNS, RAAS, plasma volume mediated by kidneys

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9
Q

What are the types of HTN

A 
Primary essential HTN (90-95% of cases)
Secondary HTN (younger onset)
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10
Q

What are risk factors for Primary HTN

A

*Smoking
*Diet (high Na intake)
*Excess alcohol intake
*Obesity
*Physical inactivity
Age, race, FHx, dyslipidemia, DM

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11
Q

What disorders can cause Secondary HTN

A 
Renal disease
Meds (adderall, NSAID, OCP, steroid, decongestant)
Hypo/Hyperthyroid/parathyroid
Obstructive sleep apnea
Pheochromocytoma 
Coarctation of aorta
Primary Aldosteronism
Reno vascular dz
Cushing's
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12
Q

When should you suspect secondary HTN

A

Young onset
Diastolic HTN >50 y/o
Target organ damage at presentation (SrCr >1.5, LVH)
Secondary causes
-Hypokalemia, abdominal bruit, Labile pressure w/ tacky diaphoresis or tremor, FHx renal dz
Poor response to generally effective therapy

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13
Q

How is HTN and age related

A

Young patient= DIASTOLIC

Older pt= SYSTOLIC

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14
Q

What are positive findings for end organ damage

A

MI, Angina, coronary revascularization, HF
Ischemic stroke, cerebral hemorrhage, TIA
Retinopathy
Renal dz
PAD (claudication)

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15
Q

What symptoms during Hx should make you think of HTN

A

muscle weakness, tachycardia, sweating, tremor, thinning skin, flank pain
Sleep apnea signs (early morning HA, day time somnolence, loud snoring, erratic sleep)

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16
Q

What can increased waist circumference be indicative of

A

Cushing’s disease (Dexamethasone test)

Metabolic syndrome

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17
Q

What could you see on HTN HEENT PE

A 
Arterial diameter narrower than 50% of venous  (A:V 2:#)
Copper/silver wire appearance 
exudates
Cotton wool spots
hemorrhaged (flame hemorrhage)
Papilledema
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18
Q

What could you see on remaining HTN PE

A

Rhonchi, rales
Renal mass/bruit
Visual disturbance, focal weakness, confusion

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19
Q

What could you see on CV HTN PE

A

LVH (displaced PMI, ECG evidence)
S4 (pre systolic) gallop (decreased LV compliance)- A-Stiff—wall
Carotid, abd, femoral bruits
Extremity edema

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20
Q

USPSTF guideline for HTN

A

Screen all 18+
Every 3-5 years in 18-39, normal BP, no RF
Annual if 40+ or increased risk for HTN

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21
Q

What is required to diagnose HTN

A

2+ properly measured, seated BP readings on 2 or more office visits

  • legs uncrossed, rested, proper cuff size, arm at heart level
  • High caffeine drinker not at risk for HTN dx because HTN comes in waves for them, not steady
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22
Q

What is the JNC7 HTN goal

A

Gen. pop: 140/90

DM or renal Dz: 130/80

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23
Q

What is the JNC8 HTN goal

A

<140/90 for ALL adults (including CKD/DM)
<150/90 in adults 60+
-ACC/AHA said continue with JNC-7

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24
Q

What is the ADA target BP (diabetics)

A

<140/90

risk-based individualization to lower targets 130/80

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25
What diagnostic tests are important o order in HTN eval
``` CBC Urinalysis Blood chemistry (glucose, Ca, Cr, GFR, electrolytes) TSH (new HTN pt) Lipid profile ECG -Maybe: urine albumin, echo, sleep study ```
26
What patients did the ACC/AHA study say to initiate anti-HTN meds in
All with stage 2 HTN | Pt with Stage 1 and 1+ of following (ASCVD, T2DM, CKD, 10 year ASCVD risk 10%+)
27
What are non-pharm Diet Modification treatment options for HTN
Salt restriction= 5/3 mmHg decrease DASH diet= 6/4 mmHg decrease --High fruit/veg, then grain. low fat dairy Alcohol reduction= 2-4 decrease in SBP
28
What are other non-pharm treatment options
Weight loss (1mmHg per 1 lb lost) Exercise (4-6/3 mmHg) Smoking cessation
29
What are pharm treatment options for HTN
``` Diuretics CCB ACE-I ARB BB DRI Central alpha 2 agonist Alpha 1 blockers ```
30
Who do diuretics work better in
Black, elderly, obese, smokers
31
What are side effects/CI of diuretics (HCTZ)
``` Hypokalemia, Mg, Na Hypercalcemia Hyperurecemia Dyslipidemia Hyperglycemia** ``` -Contraindicated with Sulfa drugs
32
What are side effects in loop diuretics (Furosemide)
Hypokalemia/Na/Mg/Ca Hypercholesterolemia Glucose disturbance --Supplement potassium!
33
What is special about loop diuretics
Poor anti-HTN med, much better as diuretic | Reserved for patients with renal dz of fluid retention
34
What are side effects/CI of K Sparing diuretics (Triamterene)
Hyperkalemia Nephrolithiasis Renal dysfunction -Contraindicated in hyperkalemia, renal failure, liver Dz
35
What should you use caution combining K sparing diuretics with
Ace, Arb, DRI, K supplement -Weak anti-HTN
36
What are side effects/CI of Aldosterone Antagonists (spironolactone)
Hyperkalemia, Gynecomastia -Contraindicated in renal impairment, DM, hyperkalemia
37
What are the types of CCB and how do they work
Non-DHP (cardiac depressants, verapamil/Diltiazem) and DHP (selective vasodilator, nifedipine, amlodipine) - Inhibit the influx of calcium into myocardial and smooth muscle cells= less contractile= vasodilation - Reduce PVR
38
Who should and shouldn't use CCB
-Very effective in african american DHP Contraindicated in acute MI or emergent HTN release Non-DHP contraindicated in acute MI, AV block, HF, WPW, V-tach, etc
39
What are side effects of CCB
DHP- Peripheral deems, HA, flush | Non-DHP- brady, gingival hyperplasia, HF, constpation
40
What are side effects/CI of ACE inhibitors
Cough! Hyperkalemia, angioedema, acute renal failure - Less effective in african americans - Contraindicated in pregnancy, angioedema, renal artery stenosis
41
Who are ACE inhibitors especially good for
patients with CKD, DM, HF, post-MI
42
What are the side effects/CI of ARB's
hyperkalemia, angioedema, acute renal failure -Contraindicated in pregnancy and renal artery stenosis
43
What are the side effects/CI of Direct Renin Inhibitors (Aliskiren)
Hyperkalemia, hypersensitivity reactions, renal impairment -DO NOT combine with ACE or ARB Don't use in pregnancy
44
What are the types of BB
Cardioselective (Metoprolol, atenolol) Non-cardioselective (Propranolol, Nadolol) Combination non-selective: Carvedilol, Labetolol
45
What are side effects/CI of BB
-Exercise intolerance, bradycardia, fatigue, sexual dysfunction -Do Not use in AV block, cariogenic shock, unstable HF, hypotension Do not use if with COPD or asthma -Caution with depression/DM -AVOID abrupt cessation
46
What are side effects/CI in Central alpha-2 bockers
anticholinergic effects, bradycardia, dizziness Clonidine: constipation, blurry vision Methyldopa: hepatitis, fever, anemia -DO NOT use methyldopa in liver disease Avoid abrupt cessation (rebound HTN)
47
What are side effects of alpha-1 blockers
Reflex tacky, Dizzy, orthostatic hypotension - First Dose Effect- give at night time for elderly - Doxazosin=increased risk of HF
48
What can alpha-1 blockers be used for
treatment of BPH! | Also HTN, PTSD, Raynauds
49
How should you initiate treatment always
Lifestyle interventions (f/u 3-6 months depending on their numbers)
50
What treatment should you start if lifestyle modifications don't work
``` Pharm therapy (f/u at 1 mo) Continue med if at goal. If not at goal, increase dose or add 2nd med If 3+ meds don't work, consider HTN specialist referral ```
51
How should you monitor HTN once BP goal is met
every 3-6 months | Monitor SrCr and K+ 1-2x annually
52
What are the treatment strategies for JNC7, JNC8, and AHA/ACC
JNC7: Diuretic first, then follow indications JNC8: THIAZ, ACE, ARB, or CCB first line (in Af. Am. Thiaz or CCB first) (In CKD, ACE or ARB first) AHA/ACC: First line agents same as JNC8
53
What are first line pregnancy drugs
Methyldopa (central alpha agonist) Nifedipine (CCB) Labetolol (BB) -Avoid ACE, ARB, DRI; known teratogenic effects
54
What CVD indicators have a poor prognosis
**LVH Men >55, Women >65 smoking, dyslipidemia, DM, FHx premature CVD, Abd. obesity, high pulse pressure
55
What other indicators have poor prognosis
**Carotid wall thickening or plaque **Low GFR, Microalbuminemia **ABI <0.9 (mild marker for PAD) Retinopathy
56
What comorbid conditions have poor outcomes
``` Premature CVD HF LVH Ischemic stroke Intracerebral hemorrhage CKD/ESRD PAD Retinopathy ```
57
How can therapy benefit prognosis
Lowering BP reduces risk of: | MI, stroke, HF, CKD
58
What is Resistant HTN
failure to achieve BP goal in compliant patient with 3 drugs, including a thiazide OR at goal but requiring 4+ anti-HTN meds
59
What are causes of resistant BP
``` improper BP measurement volume overload/retention Med induced obesity excess alcohol ```
60
What is Hypertensive Urgency
SBP 180+ and/or DBP 120+ May be asymptomatic Can be due to non-adherence to anti-HTN med or non-adherence to low sodium diet
61
What is a Hypertensive Emergency
SBP 180+ and/or DBP 120+ Associated with acute end organ damage (Encephalopathy, brain infarct, hemorrhage, dissection, LV failure, MI, acute glomerulonephritis)
62
What is the goal of Hypertensive Urgency
GRADUAL reduction to safe level (<160/100) Not too rapid or will cause MI or cerebral infarct -Sublingual Nifedipine contraindicated
63
How can you reduce BP in hypertensive urgency
rest (10-20 mmHg drop) If HTN pt: increase current med dose, add med (diuretic), adhere to Na restriction If new HTN: need more aggressive treatment, several hours to reduce
64
How do you treat a hypertensive Emergency
ICU- hospitalization* Reduce no more than 25% in the first hour <160/110 in 2-6 hours Back to normal in 24-48 hours

Nayla Foundations (18 decks)

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