HTN Guidelines Flashcards by Michaela Dansereau

What is the proper patient position for BP reading?

Sitting position, back supported, arm bare and supported at heart level, legs uncrossed and feet flat on the floor

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How should the cuff be positioned for BP reading? How do you know the right size of cuff?

Middle of cuff at heart level, lower edge of cuff 3 cm above elbow crease

Cuff bladder width should be close to 40% of arm circumference and length should cover 80-100% of arm circumference

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T/F: Resistant hypertension is defined as BP above target despite 2 or more BP lowering drugs at optimal doses.

False, Resistant hypertension is BP above target despite 3 or more BP lowering drugs at optimal doses

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Which three class of drugs would likely be prescribed for resistant hypertension?

usually a diuretic, RAAS blocker and Ca Channel blocker

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What is the purpose of out-of –office BP measurements?

To rule out white-coat hypertension

Also to diagnose suspected masked hypertension

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Single-pill combination (SPC) are recommended where possible, why?

To improve treatment efficacy, adherence and tolerability

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AOBP. What does it stand for and how is it done?

Automated Office BP. Automated device takes a series of BP measurements without the provider or others present. Patient is left unattended in a private area while 3-6 readings are taken. First reading discarded, others averaged.

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OBPM. What does it stand for and how is it done?

Office blood pressure measurement. BP measured using upper arm device with provider in the room.

Electronic or oscillometric devices are preferred to auscultatory devices

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ABPM. What does it stand for and how is it done?

Ambulatory BP monitoring. Using a validated oscillometric device worn for 24 hours. BPs taken at 20-30 minute intervals

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HBPM. What does it stand for and how is it done?

Home BP monitoring. Self-monitoring, patient measures BP for 7 days, twice in the morning and twice in the evening

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Which method of BP monitoring is preferred for in-office measurement?

AOBP – Automated office BP

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Which method of BP monitoring is preferred for diagnosis?

ABPM – Ambulatory BP monitoring

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BP should be taken in both arms on at least one visit, if one arm has consistently higher pressure, which arm should be used for BP measurement?

The arm with higher BP should be used

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How long should a patient rest before BP is measured?

Should rest comfortably for 5 minutes prior to BP measurement

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What is the threshold for diagnosis of hypertension using OBPM?

SBP greater than or equal to 140

And/or

DBP greater than or equal to 90

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What group of patients has a different threshold for diagnosis of hypertension? What is the threshold?

Patients with Diabetes

SBP greater than or equal to 130

And/or

DBP greater than or equal to 80

What is the threshold for diagnosis of hypertension using HBPM?

Using home BP monitoring, the threshold changes to

SBP greater than or equal to 135

And/or

DBP greater than or equal to 85

What is the threshold for diagnosis of hypertension using ABPM?

Using ambulatory BP monitoring, the threshold changes to

Mean 24 hour
SBP greater than or equal to 130

And/or

DBP greater than or equal to 80

Mean daytime

SBP greater than or equal to 135

And/or

DBP greater than or equal to 85

When would you do a seated vs. Standing BP

Seated used to determine and monitor treatment decisions

Standing used to examine for postural hypotension, which may modify treatment

Do you recall how to auscultate a BP?

Inflate to 30mmHg above loss of radial pulse

Listen over brachial artery

Deflate slowly

Systolic = appearance of first Korotkoff sound

Diastolic = point when sounds disappear

An office BP of ___/___ or greater allows for immediate diagnosis of HTN

180/110

What preliminary investigations are indicated for patients with hypertension?

Urinalysis

Blood chemistry (K, Na, creatinine)

Fasting glucose or A1c

Serum total cholesterol, LDL, HDL, non-HDL, triglycerides, lipids

12 lead ECG

T/F: diabetes develops in 1-3% per year of those with drug-treated HTN

True!

Screen adults with HTN with annual fasting plasma glucose testing

Target organ damage (TOD) should be assessed in patients with HTN, presence of any TOD puts patient in medium-high or high risk category for therapy. What are some TOD examples?

Cardiovascular disease: CAD, HF, left ventricular hypertrophy

Cerebrovascular disease: aneurysms, hemorrhages, ischemic stroke, TIA, etc.

Hypertensive retinopathy

Peripheral Artery Disease

Renal disease: albuminuria, CKD

Another tool for risk assessment is the Global Cardiovascular Risk Assessment

HTN Canada stratifies patients by risk level and threshold for treatment and BP treatment targets depend on the risk level... For high-risk patients what is the threshold for initiation of treatment and what is the BP treatment target?

Threshold for treatment: SBP greater than or equal to 130 BP target: SBP<120

For diabetic patients what is the threshold for initiation of treatment and what is the BP treatment target?

Threshold for treatment: SBP greater than or equal to 130, DBP greater than or equal to 80 BP target: SBP<130, DBP<80

For medium-risk patients what is the threshold for initiation of treatment and what is the BP treatment target?

Threshold for treatment: SBP greater than or equal to 140, DBP greater than or equal to 90 BP target: SBP<140, DBP<90

For low-risk patients what is the threshold for initiation of treatment and what is the BP treatment target?

Threshold for treatment: SBP greater than or equal to 160, DBP greater than or equal to 100 BP target: SBP<140, DBP<90

What are some health behavior recommendations for HTN?

Being more physically active Weight reduction Moderation in alcohol intake Healthy eating Relaxation/stress management Smoking cessation

What are helpful dietary recommendations for prevention and management of HTN?

DASH-like diet – high in fresh fruits and vegetables, dietary fiber, non-animal protein (ex. Soy), and low-fat dairy products. Low in saturated fat and cholesterol. To decrease BP in hypertensive pts consider increasing dietary potassium (!?)

What is first-line therapy for HTN?

After health behavior management, lists all of the things as first line: thiazide/thiazide-like diuretic, ACE-I, ARB, long-acting CCB, B-Blocker, single-pill combination ** There are some more specific recommendations for first line drugs in certain situations, but even then there are often multiple choices. Hint: ACE-I are almost always on the list of first line drugs! (except in pregnancy/lactation and isolated systolic HTN without other compelling indications)

T/F: it is ok to prescribe your patients multiple drugs for HTN

True! May require multiple drugs, especially in T2DM Low doses of multiple drugs may be better tolerated than higher doses of fewer drugs Aim for combination pills when able

Which two classes of BP meds should not be combined?

ACE-I and ARBs

What are some possible reasons for poor response to anti-hypertensive therapy?

Inaccurate BP measurement Suboptimal treatment (dose too low or inappropriate drug combinations) Poor adherence Associated conditions: obesity, tobacco, excessive alcohol, OSA, chronic pain, depression Drug interactions Volume overload Secondary hypertension

What are some drug interactions that can cause poor response to HTN therapy?

NSAIDs Oral contraceptives Corticosteroids and anabolic steroids Cocaine, amphetamines Erythropoietin Cyclosproine, tacrolimus Licorice Oral decongestant (pseudoephedrine) Monoamine oxidase inhibitors, certain SSRIs

How often should follow-up occur with HTN patients?

Every 1-2 months if uncontrolled Once 2 consecutive visits are below target, every 3-6 months