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Hypertension > HTN module > Flashcards

HTN module Flashcards

1
Q

what is the most common primary diagnosis in the US?

A

Hypertension

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2
Q

what is the definition of hypertension?

A

systolic >140 OR

diastolic >90

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3
Q

how many elevated blood pressure measurements do you have to get from your patient before being able to diagnose hypertension?

A

at least two elevated measurements, one in each arm, made on 2 or more visits

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4
Q

what is the USPSTF recommendation for high blood pressure screening?

A

should begin at age 18, optimal interval unknown

JNC 7: every two years 120/80, every year systolic 120-129, diastolic 80-90

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5
Q

what are proper office techniques when measuring BP?

A

1) having pt seated quietly in chair for 5 min, feet on floor, arm supported at heart level
2) using auscultatory method with a properly calibrated and validated instrument
3) using appropriate size cuff-length of the bladder should wrap around 80% of the arm circumference and the width of the cuff should be at least 40% of the arm circumference
- if too larger BP will be low, too small BP will be high

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6
Q

what are the objectives of the evaluation of patients with hypertension?

A
  1. to assess lifestyle and identify other cardiovascular risk factors or concomitant disorders that affects prognosis and guides treatment
  2. to reveal identifiable causes of high blood pressure (secondary htn)
  3. to assess presence or absence of target organ damage and cardiovascular disease
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7
Q

what are the elements of a proper initial history in a pt with new HTN per JNC 7?

A

does pt have:
PMhx: htn, congestive heart failure symptoms, PVD, diabetes (metabolic syndrome), cardiovascular disease, renal disease, cholesterol issues,
family history: premature heart attack/stroke, diabetes, hypercholesterolemia
currents meds
weight changes, smoking hx, etoh drug hx, diet hx, psychosocial stressors

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8
Q

what are impt physical exam elements and what you are looking for?

A

two BP measurements 2 min apart on each arm (coarctation of the aorta)
BMI
fundoscopic: AV nickin, papilledema (in HTN emergency), cotton wool spot, hemorrhages
thyroid exam: (hyperthyroid is 2ry cause of HTN)
neck bruits (CVD)
auscultate heart: murmurs, rate
PMI: hypertrophy or cardiomegaly
abd bruits: cardiovascular disease
peripheral veins: CVD or DB
lower extremity edema: CVD
neuro: stoke

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9
Q

what is prehypertension?

A

120-139 systolic or

80-89 diastolic

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10
Q

what is stage 1 hypertension?

A

140-159 systolic or

90-99 diastolic

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11
Q

what is stage 2 hypertension?

A

> 160 systolic or

>100 diastolic

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12
Q

what does a “diagnosis” of prehypertension mean?

A

at increased risk of adverse outcomes compared to normotensive patients, at high risk of progression to hypertension
-Pt with diabetes or renal disease and prehypertension should be treated as hypertensive if their SBP =130 or DBP = 80
50% will eventually develop HTN

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13
Q

What initial laboratory testing do you order for a newly diagnosed Stage 1 HTN pt?

A

EKG (looking for rate, rhythm, ischemia, LVH)
Urinalysis: proteinuria (nephropathy) glucosuria (DB)
serum K: need baseline prior to meds
serum ca: hyperparathyroidism raises BP
serum cr: nephropathy
fasting cholesterol panel: lipid co morbidities
urinary alb excretion or alb/cr ratio: microalbuminuria has some prognostic implications

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14
Q

what is the best prognosticator of death?

A

LVH

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15
Q

what are the CVD risk factors?

A

HTN, cig smoking, obestiy BMI>30, physical inactivity, dyslipidemia, Diabetes Mellitus, microalbuminuria or EGFR <60, age (older than 55 men 65 women), family hx of premature CVD (men under 55 women under 65)

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16
Q

what are the identifiable causes of HTN, aka secondary HTN?

A

sleep apnea, drug induced or related causes, CKD< primary aldosteronism, renovascualr disease, chronic steroid therapy and Cushing’s syndrome, pheochromocytoma, coarctation of the aorta, thyroid or parathyroid disease

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17
Q

what % of htn in US is “essential”?

A

95-99%

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18
Q

what is a hypertensive emergency?

A

marked hypertension with evidence of end-organ damage that requires immediate blood pressure control

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19
Q

what is malignant hypertension?

A

marked hypertension with papilledema, retinal hemorrhages or exudates and is considered a subset of a hypertensive emergency

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20
Q

what is hypertensive urgency?

A

marked hypertension that requires blood pressure control within hours but without evidence of end organ damage

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21
Q

what are the JNC 8 recommendations for adults >/= 60?

A

<150/90

grade A strong reccomendation

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22
Q

what are the JNC 8 recommendations for adults <60?

A 
DBP<140 
grade E (expert opinion, insufficient evidence but committee recommends)
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23
Q

what are the JNC 8 recommendations for adults with CKD >/= 18 years?

A 
<140/90 
grade E (expert opinion, insufficient evidence but committee recommends)
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24
Q

what are the JNC 8 recommendations for adults with Diabetes >/= 18?

A 
<140/90 
grade E  (expert opinion, insufficient evidence but committee recommends)
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25
Q

what objectives do lifestyle modifications achieve?

A

reduce blood pressure, enhance anti hypertensive drug efficacy, decrease cardiovascular risks

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26
Q

how can weight reduction reduce SBP?

A

5-20 mmHg/10kg weight loss

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27
Q

how can DASH eating plan reduce SBP?

A

8-14mmHg

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28
Q

how can dietary Na reduction reduce SBP?

A

2-8 mmHg

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29
Q

how can physical activity reduce SBP?

A

4-9 mmHg

30
Q

how can moderation of alcohol consumption reduce SBP?

A

2-4mmHg

31
Q

what are the lifestyle modification recommendations?

A

adopt DASH, dietary Na reduction, physical activity of moderate to vigorous aerobic physical activity 3-4 times a week for 40 minutes, and limiting etoh intake to no more than 2 drinks a day in men and no more than 1 drink a day in women

32
Q

what are the starting drug recommendations for non-black population including those with diabetes?

A 
thiazide type diuretic
CCBs
ACEi
ARBs 
(grade B recommendation-moderate)
33
Q

what are the starting drug recommendations for general black population including those with diabetes?

A

thiazide type diuretics
CCBs
(grade B (moderate) for general black population and grade C (weak) for black patients with diabetes)

34
Q

what are the starting drug recommendations for CKD pts of all races with or without DM?

A

ACEi
ARB
-either of these as initial or added to existing regimen-improve kidney outcomes
(grade B (moderate))

35
Q

what are the starting drug recommendations patients presenting with SBP >160 or DBP >100?

A

usually 2 medications from different classes simultaneously

recommended by some committee members

36
Q

what is the first line agent of choice for most pts? (minus CKD) and why?

A

thiazide type diuretics

  • have been found to have the best reduction in morbidity and mortality in regards to hypertension
  • have known benefits and side effect profiles with >70 years of data
  • are extremely inexpensive drugs (estimated cost $5 for 30 day supply)
37
Q

what should be done if the thiazide diuretic does not optimize BP?

A

continue thiazide but add another agent: ACEi, ARBs, Beta blockers or CCBs

38
Q

what is recommended first line for patients with CKD?

A

ACEi or ARB

39
Q

are beta blockers recommended for initial drug therapy?

A

NO, only used as add on

40
Q

What is generally needed to treat stage 2 hypertension?

A

bp: systolic >160, diastolic >100
generally requires two drug combination -usually thiazide type diuretic and ACEI or ARB or BB or CCB
-combination pills have been made to reduce the burden for pts

41
Q

what needs to be looked out for in pts beginning combination therapy?

A

orthostatic hypotension in elderly, diabetic pts and in pts with autonomic dysfucntion (ie paraplegic pts)

42
Q

what are the three goals that we aim to achieve by treating hypertension?

A
  • reduce cardiovascular and renal morbidity and mortality

- treat BP 60 years of age

43
Q

what are the three strategies to combine and titrate antihypertensive drugs to achieve goal blood pressure?

A

A: start one drug titrate to max, and then add 2nd
B: start one drug and then add 2nd before max initial drug
C: start 2 drugs at the same time as 2 separate drugs or as combination therapy

44
Q

what is the main objective of hypertension treatment?

A

to attain and maintain goal BP

45
Q

when should the dose of initial therapy be altered?

A

if goal BP is not reached after one month of treatment

-increase initial drug or add second drug

46
Q

when should a third drug be added?

A

when BP cannot be reached with 2 drugs

-***do not use and ACEi and an ARB together in the same patient

47
Q

what defines maximum dose for pts?

A

either:
- max dose set by pharm company, determined by drug’s side effect profile on the pt, patient preference,
* always cite why a pt reached max dose of a certain drug

48
Q

are generic drugs less effective than their brand name counterparts?

A

no

49
Q

how does tobacco effect blood pressure?

A

nicotine increases blood pressure and reduces the efficacy of blood pressure medications
-HTN patients should be vigorously encouraged towards smoking reduction and cessation at every visit by their physicians

50
Q

what should we tell a pt when starting them on a thiazide type diuretic?

A

take the medication in the morning, they will urinate much more than before

51
Q

how often should HTN pts be seen if they are not controlled?

A

monthly until the BP goal is reached

-more frequent with stage 2 or with complicating co morbid conditions

52
Q

how often should serum K and Cr be measured?

A

1-2 times a year

53
Q

how often should HTN pts be seen if they are at their BP goal?

A

every 3-6 months

54
Q

what are the initial therapy options for HTN in pts with heart failure?

A

thiazide type diuretics (reduce heart failure), BB (reduce cardiac work), ACEi, ARB (reduce afterload), aldo ant (reduce morbidity and mortality but should not be titrate to higher levels)

55
Q

what are the initial therapy options for HTN in patients with postmyocardial infarction?

A

BB, ACEi, ALDO ant

56
Q

what are the initial thearpy options for HTN in pts with high CAD risk?

A

thiaz, ACEi, CCB

57
Q

what are the initial therapy options in diabetic pts wtih HTN?

A

ACE, ARB initial

thiaz, BB and CCB as add ons

58
Q

what art the intial therapy option in CKD pts for HTN?

A

ACEi or ARB

59
Q

what are the initial therapy options for HTN pts with recurrent stroke or prevention?

A

Thiaz, ACEi

60
Q

what needs to be considered regarding thiazides diuretics?

A
  • may be a problem in urine incontinent patients
  • doses above 25mg/day of HCTZ do not decrease BP or morbidity and mortality
  • chemistry levels need to be watched esp for hyponatremia
  • AVOID in gout pts-cause attacks
  • start lower doses in elderly
  • may slow bone demineralization in osteoporosis
61
Q

what needs to be considered in loop diuretics?

A
  • electrolytes and creatinine need to be monitored

- start low in the elderly

62
Q

what needs to be considered in beta blockers?

A
  • check initial EKG and pulse
  • dont have to avoid in diabetes
  • excellent for use in tachyarrhythmias/fibrillation, migraines, essential tremor, and perioperative HTN
  • usually avoided in patients with asthma and third degree heart block (RA signal does not propagate to ventricles-compete heart block, caused by coronary ischemia)
63
Q

what needs to be considered when starting an ACEi?

A
  • watch K, Na, Creat
  • great for renal protection
  • reduces microalbuminuria
  • first line in renal disease
  • shown to have direct heart remodeling effects
  • a rise of up to 35% above baseline in creatinine is acceptable
  • ACEi cough common side effect due to bradykinin production causes ACE cough in15-20% of pts
  • angioedema is a serious side effect to monitor in pts (esp in black pts)
  • avoid in pregnant women–> category C drugs
64
Q

what needs to be considered when starting a pt on an ARB?

A
  • reduces microalbuminuria AND MACROalbuminuria
  • heart remodeling effects
  • avoid in pregnant patients, category C drugs
  • less bradykinin production–> not as much of a cough
65
Q

what needs to be considered when starting a pt on a calcium channel blocker?

A
  • May be useful in Raynaud’s syndrome
  • may be useful in certain arrhythmias
  • often causes leg edema in 15-30% of pts (from mild to very debilitating)
  • short acting CCBs are contraindicated for use in essential hypertensive urgencies or emergencies–> increase morbidity and mortality of these
66
Q

what needs to be considered with aldosterone antagonists and potassium sparing diuretics?

A
  • may cause hyperkalemia
  • avoid in pts with K>/=5 prior to starting meds
  • low dose aldosterone antagonists reduce morbidity and mortality in congestive heart failure pts but increase sudden death at higher doses (dont titrate up)
67
Q

are alpha blockers efficacious in treating HTN?

A
  • ***no proven decrease in morbidity and mortality demonstrarted in research study
  • not mentioned in JNC7 or 8 for treatment of essential HTN
  • only useful as adjunct in hard to control blood pressure
  • may be useful in prostatism but should not be used as a first line antihypertension with BPH
68
Q

what are the causes of resistant HTN?

A

improper BP measurement
excess NA intake
inadequate diuretic therapy
medication (inadequate doses, drug actions and interaction ie NSAIDs, OCPs, sympathomimetics, OTC drugs and herbal supplements) excess alcohol intake, underlying identifiable causes of hypertension

69
Q

what is resistant hypertension?

A

failure to achieve goal BP in pts who are adhering to full doses of an appropriate three-drug regimen that includes a diuretic, clinicians should first review the causes of resistant HTN before referring to a specialist

70
Q

how often should women on OCPs have their blood assessed?

A

every 6 months

71
Q

do antihypertensive drugs effect fertility?

A

not proven but ACEi and ARBs god choice in women reproductive age/trying to get pregnant-not contraindicated in pregnancy

Hypertension (1 decks)

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