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Flashcards in HTN - Brown Deck (32):
1

Reduced Sodium Intake

 

Describe the management of HTN according to lifestyle modifications including recommendations and objective support.

  • Recommend moderate restriction:
    • 2400 mg/day (2.5-5 grams)
    • 6 grams of Na/Cl (normal 6-12)
    • < 1500 mg is ideal
  • greatest benefit in: African Americans and elderly
  • read food labels

1

Prevention of HTN

5 Ways:

Describe the management of HTN according to lifestyle modifications including recommendations and objective support.

  1. reduction of salt intake
  2. diet rich in fruits, vegetables, low-fat dairy products, reduce saturated fat, total fat and cholesterol
  3. reduction of excess body weight
  4. regular physical exercise
  5. moderation of alcohol intake

2

HTN Retinopathy

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  • Keith-Wagner Barker System
  • can determine the level of retinopathy caused by HBP
  • features
    • hemorrhage
    • exudates
    • papilledmia
  • HTN retinopathy has some reversibility

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2

Relative Risk of HTN for CAD, CHF, CVA

Normal BP: 1x

140-160/90: 2x

>160/95: 4x

2

Renovascular Hypertension

Summarize the pathophysiology, secondary causes, and differential diagnosis of HTN.

  • unilateral or bilateral stenosis of renal artery
  • clinical clues:
    • abdominal bruit
    • rapid new onset of HTN
    • rapid loss of renal function
    • difficult to control HTN
  • screening studies: MRI, CT
  • confirmatory: renal arteriography

3

Role of Renin in HTN

 

Summarize the pathophysiology, secondary causes, and differential diagnosis of HTN.

volume status (as related to changes in dietary sodium intake) affects the amount/rate of renin secreted

Angioteninogn -----RENIN-------> Angiotensin 1 ----- ACE ----> Angiotensin 2 (vasoconstricts and increases BP)

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5

Definition of Hypertension

 

Describe the classification and definition of blood pressure

any of the following:

Systolic BP > 140 mm Hg

Diastolic BP > 90 mm Hg

taking antihypertensive medications

5

Blood Pressure Technique

  • measure after 5 minutes of rest in a seated position
  • patient should refrain from smoking or ingesting caffeine 30 minutes prior to measurement
  • appropriate cuff size (bladder of cuff ~ 80%  of arm)

6

Weight Loss HTN

 

Describe the management of HTN according to lifestyle modifications including recommendations and objective support.

  • direct linear relationship to increasing BP
  • 1-2 mm Hg fall in BP seen with each kg of weight loss
  • weight regain accompanied with elevated BPs
  • overweight patients: 2-6x increase risk of developing HTN

6

Pseudohypertension

 

 

Summarize the pathophysiology, secondary causes, and differential diagnosis of HTN.

increased stiffness of larger arteries = artificially elevated systolic blood pressure

8

Pathophysiology of HTN

 

Summarize the pathophysiology, secondary causes, and differential diagnosis of HTN

  • cause of primary HTN unknown
  • hemodynamic fault of established hypertension - INCREASED PERIPHERAL VASCULAR RESISTANCE
  • renal defect in sodium excretion
  • heredity
  • abnormal CV or renal development

 

**EXACERBATING FACTORS:

  • obesity
  • sleep apnea
  • alcohol

9

Isolated Systolic HTN

 

Summarize the pathophysiology, secondary causes, and differential diagnosis of HTN.

  • defined as a systolic > 160 mmHg while diastolic is < 90 mmHg
  • common among older persons
  • SBP is a better predictor of CV events than DBP

 

9

Renal Parenchymal Disease

Summarize the pathophysiology, secondary causes, and differential diagnosis of HTN.

  • most common secondary cause
  • responsible for 20% of end stage renal disease in whites; 50% - African Americans

10

HTN High Risk Groups

  • Prehypertension
  • Family history
  • African-Americans
  • Overweight
  • Excess consumption of sodium
  • Physical inactivity
  • Alcohol consumption

12

Describe the impact hypertension has on individuals and populations.

JNC 7 Goals for Specific Group Management of HTN:

patients < 60

patients > 60

diabetics or kidney disease

patients < 60 140/90

patients > 60 150/90

diabetes or kidney disease 140/90

13

Exercise

 

Describe the management of HTN according to lifestyle modifications including recommendations and objective support.

  • regular isotonic exercise 40 min, 4x/week
  • avoid isometric exercise -may cause reflex rise

14

Evaluation of Hypertension: History

 

Describe the clinical presentation, history, PE, and diagnostic work-up of HTN.

  • risk factors for CAD
  • social history
    • diet (salt)
    • alcohol
    • caffeine
    • smoking
    • exercise
  • drugs
    • OTC (anti-histamines)
    • prescription
  • past medical and family histories
  • ROS to secreen for secondary causes

15

DASH Diet

 

Describe the management of HTN according to lifestyle modifications including recommendations and objective support.

Dietary Approaches to Stop Hypertension

  • consume a diet rich in fruits, vegetables and low-fat dairy products
  • 8-14 mmg Hg reduction in BP

 

16

JNC 7 - High Blood Pressure Prevention, Detection, Evaluation and Treatment Recommendations

Normal, Prehypertension, Hypertension (Stage 1 and 2)

Describe the classification and definition of blood pressure

Normal

  • Systolic < 120 
  • Diastolic < 80

Prehypertension

  • Systolic 120-139
  • Diasstolic 80-89
  • at risk (50% will develop HTN within 4 years) 

Stage 1 Hypertension

  • Systolic 140-159
  • Diastolic 90-99

Stage 2 Hypertension

  • Systolic > 160
  • Diastolic > 100

*use the highest risk group

17

Diagnostic Tests HTN

 

Describe the clinical presentation, history, PE, and diagnostic work-up of HTN.

  • Hematocrit & Hemoglobin
  • electrolytes, glucose, BUN, creatinine, cholesterol, calcium
  • lipid profile
  • urinalysis: dipstick and microalbumin (kidney issues)
  • EKG
  • As Indicated
    • CXR
    • TSH (esp. in patients over 50)
    • 24 hr urine for protein (kidney issues)

** can identify secondary causes of hypertension

18

Clinical Objectives for Diagnosing HTN

 

Describe the clinical presentation, history, PE, and diagnostic work-up of HTN.

  • appropriate diagnosis - BP on 2 or more separate occasions
  • assess for secondary causes
  • determine presence of end-organ disease
  • assess other coronary risk factors
  • institute appopriate managment to control BP

19

HTN in African Americans

 

Describe the impact hypertension has on individuals and populations.

  • develops earlier
  • average BP is higher
  • higher rates of stage 2 disease
  • 80% higher stroke, 50% higher heart disease mortality
  • screen early and often
  • ? response with ACE, ARBs, BetaBlockers

20

Factors Implicated in HTN

 

Summarize the pathophysiology, secondary causes, and differential diagnosis of HTN

  • salt intake
  • obesity
  • occupation
  • alcohol intake
  • family size
  • crowding

21

Types of Hypertension

 

Summarize the pathophysiology, secondary causes, and differential diagnosis of HTN

  • Primary, Essential or Idiopathic (95%)
  • Secondary (5%)
    • look at secondary causes if the patient is young, has unusual symptoms, or doesn't respond to conventional therapy

23

Secondary Causes of Hypertension

 

Summarize the pathophysiology, secondary causes, and differential diagnosis of HTN.

Renal Diseases

  • Renal Parenchymal Disease (2-3%)
    • acute glomerulonephritis
    • polycystic disease
    • diabetic neuropathy
  • Renovascular (1%)
    • renal artery stenosis

Endocrine Disorders

  • hypo/hyperthyroidism
  • hyperparathyroidism
  • adrenal
  • exogenous hormones
  • acromegaly

Coarctaton of Aorta

Primary Hyperaldosteronism

Alcohol

  • excessive consumption

Drugs

25

Lifestyle Modifications

 

Describe the management of HTN according to lifestyle modifications including recommendations and objective support.

Documented Efficacy:
  • weight loss
  • DASH diet
  • reduced sodium intake
  • reduced alcohol intake

 

Limited Efficacy:

  • stress management
  • potassium
  • fish oil
  • clacium
  • magnesium

26

Pheochromocytoma

Summarize the pathophysiology, secondary causes, and differential diagnosis of HTN.

  • rare
  • wildly episodic hypertension
  • peculiar spells: profuse sweating, tremor, palpitations, headache and other symtpoms
  • lab: single voided urine metanephrine, CT of abdomen
  • tx: surgery

27

Management of HTN

  • Goals: BP < 140/90 (60)
  • reverse end organ manifestations
  • maintain quality of life
  • improve risk stratification for CAD
  • lifestyle modifications

28

Evaluation of Hypertension: Exam

 

Describe the clinical presentation, history, PE, and diagnostic work-up of HTN.

  • vital signs:
    • bp x 3 and leg
    • pulse
    • weight
    • height
  • fundoscopic exam on all HTN patients
  • bruits:
    • carotid
    • renal
    • aortic
  • heart and lungs
  • extremities:
    • edema
    • pulse
    • signs of PVD

30

White Coat HTN

 

Summarize the pathophysiology, secondary causes, and differential diagnosis of HTN.

  • many patients have higher blood pressure levels when taken in the office than when out of the office
  • may explain as much as 20% of elevated diastolic BPs in office
  • utilize home monitoring or ambulatory monitoring to further define HTN

31

Describe the impact hypertension has on individuals and populations.

  • 78 million Americans affected - 1000 deaths/year
  • African Americans >> Caucasians
  • frequency increases with age
    • diastolic doesn't change much after 45
  • level of BP direct risk factor for premature CV disease
  • earlier onest - greater likelihood of CV dieases
  • men >> women

32

Primary Essential HTN

 

Summarize the pathophysiology, secondary causes, and differential diagnosis of HTN

increased arterial blood presssure with no definable cause

common presentation - asymptomatic

readily detectable

easily treated

often leads to lethal complications if untreated