Hypertension Flashcards
(154 cards)
1
Q
5 major forms of cardiovascular disease
A
- hypertension
- atherosclerosis
- ischemic heart disease
- peripheral vascular disease
- heart failure
2
Q
what are the 3 leading causes of death in canada
A
- cancer
- diseases of the heart
- cerebrovascular diseases
3
Q
what is a major risk factor of hypertension? how can we establish this?
A
Age
prevalence increases with age (higher in males vs females)
and at 65+ equal for male and females, still with a higher prevalence
-> linear relationship
4
Q
what is the leading reason for visits to physicians in canada?
A
hypertension
5
Q
____ are one of the most expensive drug categories
A
antihypertensives
6
Q
the lifetime risk for developing hypertension among adults aged 55 to 65 years with normal blood pressure is ___
A
90%
7
Q
which population have the highest rate? lowest rate?
A
- highest: african-americans (44%)
- lowest: Chinese, Koreans (17%)
8
Q
what are the 2 phases of the cardiac cycle?
A
systolic (contraction) and diastolic (resting)
9
Q
cardiac output formula
A
stroke volume x heart rate
10
Q
peripheral resistance formula
A
(length of vessel x viscosity of the blood)/radius^4
11
Q
relationship between vasoconstriction and resistance
A
in vasoconstriction - resistance increases
12
Q
relationship between vasodilation and resistance
A
in vasodilation - resistance decreases
13
Q
mean arterial pressure MAP formula
A
cardiac output x peripheral resistance
14
Q
what are the 4 factors regulating blood pressure (MAP)
A
- sympathetic nervous system
- renin-angiotensin aldosterone system
- renal function
- hormones involved: epinephrine, vasopressin, angiotensin 2
15
Q
which factors modulate heart rate + direction
A
- parasympathetic activity decreases HR
- sympathetic activity and epinephrine increase HR
16
Q
the kidneys sense _____ which causes the release of ____
A
decrease in sodium, extracellular fluid, and arterial blood pressure which causes the release of RENIN
17
Q
the liver releases ____ which reacts with ____ to make _____
A
angiotensinogen which reacts with renin to make angiotensin 1
18
Q
the lungs produce ____ which reacts with ____ making ____
A
angiotensin-converting enzyme reacts with angiotensin 1 making angiotensin 2
19
Q
angiotensin 2 positively regulates: (4)
A
- adrenal cortex
- vasopressin
- thirst
- arteriolar vasoconstriction
20
Q
adrenal cortex release ___ which stimulates ___. what are the consequences
A
aldosterone stimulates kidneys which results in sodium reabsorption by kidney tubules which osmotically holds more water in ECF -> water conserved and helps correct low ECF volume
21
Q
effects of vasopressin
A
water reabsorption by kidney tubules
22
Q
____ + ____ + _____ = increase osmolality, increase blood volume and blood pressure
A
water reabsorption + fluid intake + vasoconstriction
23
Q
what are the target organ damage related to hypertension
A
- heart: left ventricle hypertrophy, coronary heart disease, congestive heart failure
- kidneys: renal failure, proteinuria
- bigger vessels: peripheral vascular disease/atherosclerosis
- eyes: retinopathy
- brain: hemorrhage, stroke, dementia
24
Q
how do you measure blood pressure
A
sphygmomanometer in mmHg (millimetres of mercury)
25
causes of hypertension can either be ___ or ___
primary/essential or secondary
26
what are primary/essential/idiopathic causes of HTN
they represent 95% of cases
- unknown etiology
- interaction from environmental and genetic factors (predisposition)
- influenced by dietary and behavioural factors (PA, smoking, sleeping)
27
what are secondary causes of HTN
they represent 5% of cases
| - occurs secondary to another condition such as renal, endocrine, or neurological disorders
28
why do we refer to HTN as the "silent killer"
because HTN is typically asymptomatic - you die from HTN due to target organ damage
29
which are non-modifiable risk factors of HTN
- age >60y
- men, postmenopausal women, ethnicity
- family history of CVD: women <65y or men <55y
30
which are modifiable risk factors of HTN
- smoking
- sedentary lifestyle
- abdominal obesity, insulin resistance
- excess sodium intake
- poor diet quality
- stress
31
why are excessive secretion of vasopressin and angiotensin 2 contributing factors to HTN
increased vasoconstriction and fluid retention - high blood pressure
32
mechanism of smoking on HTN
interferes with nitric oxide which impairs endothelial vasodilation
33
mechanisms of renal disease/atherosclerosis on HTN
reduced blood flow -> increased angiotensin 2 -> vasoconstriction + sodium/chloride/water retention -> increase in blood volume
34
mechanism of adrenal disorders on HTN
adrenal disorders that increase secretion of epinephrine and norepinephrine causes vasoconstriction and increases cardia output
35
____ is associated with HTN but the mechanisms are unclear
hyperinsulinemia
36
what is the normal range of systolic blood pressure and diastolic blood pressure
90-119 mmHg and 60-79 mmHg
37
Blood pressure
systolic/diastolic
38
how does hypertension canada stratify patients?
by cardiovascular risk and based on that risk, there are different threshold and targets for treatment
39
what are the 4 stratification categories?
- low risk
- moderate-to-high risk
- diabetes mellitus
- hypertension canada high risk patient
40
characteristics of a person categorized as "low risk" for hypertension
- person with some HTN
| - no target organ damage or cardiovascular risk factors and 10-year global risk inferior to 10%
41
characteristics of a person categorized as "medium-to-high risk" for hypertension
multiple cardiovascular risk factors and 10-year global risk 10-14%
42
characteristics of a person categorized as "diabetes mellitus" for hypertension
- higher chronic blood glucose
| - higher risk at cardiovascular risk
43
characteristics of a person categorized as "high-risk patient" for hypertension
- >50y
- AND with systolic blood pressure between 130-180 mmHG [normal 90-119mmHg]
- AND with one or more of the following CV risk factors should be considered for intensive BP management:
. clinical or subclinical cardiovascular disease
. chronic kidney disease (non-diabetic nephropathy, proteinuria)
. estimated 10-year global cardiovascular risk >15%
. age >75y
44
threshold for initiation of antihypertensive therapy and targets for LOW risk patients
- threshold: SBP >160 DBP >100
| - treatment: SBD <140 DBP <90
45
threshold for initiation of antihypertensive therapy and targets for MODERATE TO HIGH risk patients
- threshold: SBP >140 DBP >90
| - treatment: SBD <140 DBP <90
46
threshold for initiation of antihypertensive therapy and targets for DIABETIC patients
- threshold: SBP >130 DBP >80
| - treatment: SBD <130 DBP <80
47
threshold for initiation of antihypertensive therapy and targets for HIGH RISK patients
- threshold: SBP >130
| - treatment: SBD <120
48
observation made when looking at threshold and treatment between low risk and high risk patients
threshold is higher for low risk patients but lower for high risk - you need to start treating high risk patients as soon as possible even if BP is not that high
=> concept of overall risk for cardiovascular diseases
49
what is the preferred method for blood pressure measurement
Oscillometric (electronic) - patients can do it themselves [having BP measured by doctor can be stressful - influence BP]
50
benefits of ambulatory BPM
measure BP out of the doctor's office which could be stressful in itself and influence BP - used when the BP is just at a limit that could be diagnosed as HTN + measures throughout day and night time - more representative of overall BP
51
what is the threshold value for diagnosis of HTN for a patient with diabetes?
OBPM > 130/80 -> lower threshold value than for a patient with no diabetes [140/90]
52
what is the threshold value for a patient with no diabetes that has a mean office BP lower than 180/110?
OBPM >140/90
53
what is WCHT
white coat hypertension - hypertension related to stress of being at the doctors
54
what is the general threshold for diagnosis of HTN
>135/85
55
what are the hypertension therapy goals?
- reduce risk of CVD and renal disease
| - Lower BP to clinically appropriate level
56
what does the comprehensive plan for HTN therapy include?
- physical activity
- weight reduction
- nutrition therapy
- moderation in alcohol, relaxation therapy, smoking cesation
- pharmacological interventions
57
what are the pharmacological interventions available for treating HTN
- loop diuretics;
- thiazides;
- carbonic anhydrase inhibitors;
- potassium sparing diuretics
58
what si the basis for HTN therapy?
lifestyle modifications, if not sufficient then you add medication
59
what are the dietary factors involved in HTN
- high calories, excess weight, obesity
- sodium
- potassium
- calcium
- magnesium
- alcohol
60
in adults <55y there is a direct link between ___ and ___
excess weight and hypertension
-> 60% of those with excess weight [abdominal obesity more specifically] and normal BP will develop HTN in the next 4 years
61
what are the causes of HTN associated with obesity
- insulin resistance/hyperinsulinemia
- overactivity of sympathetic nervous system with obesity
- alteration of RAAS [overproduction of aldosterone]
- leptin increases sympathetic activity [in obesity there is some form of leptin resistance - satiety function isn't working properly]
62
what is the most potent non-pharmacological approach to treating HTN
weight loss - greatest decrease in BP among all of the interventions that are not drugs
63
what is the reduction of BP per 10kg loss
5-20mmHg per 10kg loss
64
weight loss is indicated both in ___ and ___ of HTN
treatment and prevention
65
all overweight patients should achieve a weight loss of ___ why?
5kg -> reduce SBP by 4.4 mmHg and DBP by 3.6mmHg to reduce BP and risk for organ damage
66
what are some weight loss approaches in HTN treatment
- diet education and instruction
- increase in PA
- behavior modification
67
weight loss may be more difficult in patient using ____. why?
beta-blockers for cardiac disease because these will lower sympathetic activity -> lower metabolism and weight gain
68
what is the relationship between systolic BP and urinary sodium excretion
linear relationship
69
measuring serum sodium is a good reflection of sodium intake. True or false?
False, when sodium intake increases the RAAS system maintains sodium concentration in a very tight range therefore any excess is excreted which is why sodium excretion is the best method to reflect sodium intake
70
lower sodium intake ____ SBP
reduces
71
which population is more responsive to diet lower in sodium
hypertensive people although normotensive also see an improvement in SBP
african-american
middle-aged
diabetic, renal disease
72
high sodium intake increases risk of complications in hypertensive patients such as
Coronary heart disease death, Cardiovascular disease death and all death
73
when comparing American diet and DASH diet with the same amount of sodium intake, which diet shows a greater reduction in BP when lowering the sodium intake?
American diet
74
which is better: American diet with reduced sodium intake or DASH diet with more liberal sodium intake?
DASH with more liberal sodium intake -> DASH diet associated BP lines are much lower than the control diet regardless of sodium intake
75
what can explain the heterogeneity observed regarding salt sensitivity
- familial/genetic factors
- age
- severity of HTN
- degree of restriction
- renin-angiotensin-aldosteron (low renin)
- sympathetic response (high NE response)
- duration of trials
76
salt sensitivity is largely influence by ____
POTASSIUM: high potassium intake - lower sodium sensitivity
77
good ___ intake is protective against BP
potassium
78
if diet is high in ___, higher ___ won't affect much the increase of BP
potassium
| sodium
79
dietary sodium DRI
adequate intake
14-50: 1500mg Na/day
51-70: 1300mg/day
80
what is the upper limit of sodium
2300 mg Na/day for all adults
81
to decrease blood pressure, consider reducing sodium intake towards ____ per day
2000 mg Na per day aka 5g of salt
82
80% of average sodium intake is ____
processed foods
83
breads are ___ in sodium but are _____
lower in sodium but are big contributors because they are eaten in higher amounts
84
choose foods with less than ___ per serving
120mg Na
85
choose foods with sodium that have a % daily value of ____
5% or less
86
to whom are sodium control diets bets for?
hypertensive people and those with renal diseases
87
overall, reducing sodium intake:
- reduces BP in most cases
- prevents HTN
- has an additive effect to antihypertensive medications -> lower doses and better control
- reduces risks of complications
88
relationship between potassium intake and BP
- inverse relationship
- decrease in mean blood pressure
- decreased prevalence in HTN with higher K intake
89
what are the mechanisms involved in potassium decreasing BP?
- natriuresis [sodium secretion in urine]
- suppressed renin
- attenuates vascular contraction -> vasodialtion
- may reduce sympathetic activity and angiotensin
90
higher sodium intake favours ___
potassium excretion
91
our kidneys and RAS system are programmed to ____ [basis of our physiology]
conserve sodium and excrete potassium if in excess
92
recommended daily dietary intake of potassium
>60mmol (2300mg) -> associated with decreased risk of stroke mortality (+50mmol reduced BP)
93
potassium supplementation above daily dietary intake of 60mmol/day os recommended as a treatment for hypertension. true or false
false - emphasize fruit and vegetable + dairy intake which will allow for sufficient potassium intake
94
what are the risk factors for hyperkalemia
- patients using RAAS inhibitors
- patients receiving other drugs causing hyperkalamia [retention of K]
- chronic kidney disease
- baseline serum potassium >4.5mmol/L
95
___ intake is inversely associated with BP
calcium
96
what are the mechanisms of increased calcium itnake
- increased sodium excretion
- increased sensitivity to nitric oxide -> vasodilation
- reduced production of superoxyde and prostanoids (vasoconstrictors)
97
calcium supplementing above daily recommended dietary intake is not recommended as a treatment for ___
hypertension
98
relationship between magnesium and BP
inverse relationship
99
mechanism of magnesium on BP
relates to vascular structure and function: regulates vascular reactivity and contractility
100
what are the recommendations for magnesium intake
increase dietary intake to reach DRI (menL 420mg/d; women 320mg/d)
101
alcohol intake has an immediate _____ effect but followed by ____ in the next 10-15h
vasovagal (decrease BP)
| elevated BP
102
effect of moderate alcohol consumption
does not raise BP and has cardioprotective effects
103
recommendations for alcohol consumption
- limit to 2 drink per day for men
| - limit to 1 drink per day for women
104
what are the routine lab tests done for assessment fo HTN
- urinalysis to see excretion of electrolytes
- blood chemistry (K+, Na+, creatinine)
- fasting blood glucose or Arc1 [hemoglobin Arc1 - marker for longer term blood glucose]
- serum lipid profile [stratification of HTN - overall cardiovascular risk]
105
how is hypertension assessed
- routine lab testing
- electrocardiogram (ECG)
- target organ damage
- cardiovascular risk score
- physical activity
106
which are the possible nutrition diagnoses for HTN
- excessive energy intake
- excessive or inappropriate intake of fats
- excessive sodium intake
- inadequate calcium, fibre, potassium, or magnesium intake [inverse relationship with those nutrients and HTN]
- overweight/obesity
- food and nutrition knowledge deficit
107
which are the health behaviour recommendations for treatment of HTN
- weight reduction [BP decreased by 5-10mmHg/10kg loss]
- eating healthier [DASH-like]
- being more physically active
- moderation in alcohol intake [abstain or limit to <2/day]
- relaxation therapies
- smoking cessation
108
what are the recommendations for exercise and hypertension
- accumulation of moderate PA of 30-60min/day on most days IN ADDITION to daily activities
- higher intensities are NOT more effective at reducing BP
- for HTN up to 160/99 mmHg: resistance exercise does not negatively impact BP
- recommend gradual increase to 30-60min/day of moderate intensity
109
what does DASH diet stand for
dietary approach to stop hypertension diet
110
what is the rational behind the DASH diet
negative correlations between blood pressure and certain nutrients intake (potassium, calcium, magnesium, fibres and proteins) therefore you increase intake in these
> combine a diet that contains a lot of fruits and vegetables, whole grains, low fat dairy, restriction on total fat, saturated fats, dietary cholesterol, and salt
111
what are the results/benefits of the DASH diet
- average reduction of 5.5 mmHg SBP and 3 mmGh DBP more in DASH vs control
- further decrease in hypertensive subjects
- half of the DASH effects were observed for the high F&V diet vs control
112
what is the carbohydrate goal in the DASH diet
55%
113
what is the protein goal in the DASH diet
18%
114
what is the total fat goal in the DASH diet
27%
115
what is the saturated fat goal in the DASH diet
6%
116
what is the sodium goal in the DASH diet
2300mg
117
what is the potassium goal in the DASH diet
4700mg
118
what is the calcium goal in the DASH diet
1250mg
119
what is the magnesium goal in the DASH diet
500mg
120
what is the fiber goal in the DASH diet
30g
121
which foods are major sources of energy and fiber
whole wheat bread and rolls, whole wheat pasta, English muffin, pita bread, bagel, cereals, oatmeal, brown rice, unsalted pretzels and popcorn
122
rich sources of potassium magnesium and fiber (vegetables)
broccoli, carrots, collards, green beans, green peas, kale, lima beans, potatoes, spinach, squash, sweet potatoes, tomatoes
123
important source of potassium magnesium and fibre (fruits)
apples, apricots, bananas. dates, grapes, oranges, grapefruit, mangoes, melons, peaches, pineapple, strawberries
124
major sources of calcium and protein
fat free or low fat milk or buttermilk, fat free, low fat or reduced fat cheese, fat free or Low fat regular frozen yogurt
125
rich sources of protein and magnesium
select only lean, trim away visible fats, broil, roast, poach, remove skin from poultry
126
rich sources of energy, magnesium, protein, and fiber
almonds, hazelnuts, mixed nuts, peanuts, walnuts, sunflower seeds, peanut butter, kidney beans, lentos, split peas
127
27% of calories as fat including fat in or added to foods which include
soft margarine, vegetable oil (canola, corn, olive, safflower), low fat mayo, light salad dressing
128
sweets should be low in fat. examples
fruit flavoured gelatin, fruit punch, hard candy, jelly, maple syrup, sorbet and ices, sugar
129
what is the main difference between DASH and mediterranean diet
Medi diet is low in dairy
130
observations of healthy diets similar to DASH-sodium diets rich in CHO, rich in protein, rich in UFA
all diets reduced BP, LDL-C and cardiovascular risk
| diets high in protein and unsaturated FA further decreased blood pressure in hypertensive individuals
131
comparing typical DASH-diet vs. higher-fat/low CHO DASH diet
- similar decrease in blood pressure
- decrease triglycerides and large and medium VLDL particle concentrations
- did not decrease LDL-c but increased LDL peak particle diameter [LDL particle size increased - less atherogenic, less cholesterol esters in larger LDL particles]
=> depends on type of fat
132
Benefits of DASH diet
improves:
- BP
- LDL
- VLDL
- TG
133
examples of antihypertensive drugs
- thiazide diuretics
- distal tubular diuretics
- angiotensin converting enzyme (ACE) inhibitors
- angiotensin 2 receptor blockers (ARB)
- calcium channel blockers (CCB)
- beta blockers
- single pill combination (SPC) [combine 2 different medications that act through different mechanisms of action aka ACE inhibitor with calcium blocker]
134
what is the mechanism of diuretic treatments
> more urine produced
- decreased reabsorption of Na and K
- production of osmotic diuresis
- increased excretion of Na and K
- inhibit action of aldosterone
135
about loop diuretics
- excrete more potassium, diet should be providing alot of potassium + supplementation
- i.e. furosemide
- most prescribed drug
- side effects: hypokalemia, hyperglycemia [pb of insulin secretion]
136
about thiazides diuretics
- potassium excretion
- hydrochlorothiazide
- side effects: hypokalemia, hyperglycemia
137
for both loop and thiazides, what is the dietary approach
- provide potassium rich foods
| - provide potassium supplements
138
about potassium sparing diuretic
- spironolactone, triamterene, amiloride
- avoid excess dietary potassium and supplements
- avoid salt substitutes [potassium chloride]
- avoid excess water consumption
- take with food
- avoid natural licorice
139
why should one avoid natural licorice
natural licorice interacts with medication
it comes from root and contains an acid that acts by stimulating cortisol production. effect on creating a state of production of aldosterone
-> plays against antihypertensive medication
140
about ACE inhibitors
- ramipril
- inhibits conversion of angiotensin 1 to angiotensin 2 -> decrease vasoconstriction, vasopressin, inhibits aldosterone release
- side effects/interactions: hypotension, dry cough, side effects are more prevalent in African Americans, avoid salt substitutes, avoid natural licorice
141
about angiotensin 2 receptors blockers (ARB)
- valsartan, losartan
- usually used when ACEi are not tolerated
- block angiotensin 2 receptor and therefore decrease its activity -> vasodilation, reduced vasopressin and aldosterone
- side effects/interactions: hyperkalemia, avoid salt substitutes and natural licorice, caution with grapefruit for Losartan
142
why should one be cautious when eating grapefruit whilst taking losartan (ARB) or felodipine (CCB)
it contains a molecule that can interact with cytochrome P4-50 involved in drug metabolism
P4-50 is slightly inhibited by grapefruit molecule and drug will be found in higher levels in blood than what is normally expected
143
about calcium channel blockers
- amlodipine
- affect the movement of calcium through calcium channels causing blood vessel relaxation, especially large vessels
- side effects/interaction: deem, avoid natural licorice, limit caffeine/alcohol, avoid grapefruit with felodipine
144
what si the contraindication associated with calcium channel blockers
heart failure
145
about beta blockers
- propanolol
- block adrenergic beta-receptors in the heart (B1) -> decrease rate and cardiac output
- prescribed fro treating heart problems
- side effects/interactions: dizziness, fatigue, bradycardia, hallucinations, avoid natural licorice
146
to whom are beta-blockers recommended for
not recommended as initial therapy in those over 60y
147
why is fasting glucose monitored when using beta-blockers
the symptoms experienced by beta-blockers could mask some symptoms of hypoglycaemia (dizziness, fatigue)
148
where is the drug metabolized and excreted
liver and kidney
149
with all HTN drug avoid ____
natural licorice because it contains glycyrrhinic acid
150
why should one consider the nutritional status of patient taking medication
low albumin may increase drug effect because of more free drug in the blood
151
which physiological status should be considered before medication use
pregnancy, lactation, presence of disease
152
when patient has diabetes, which drug do you prescribe
- with complications: ACEi or ARB
| - without complications: ACEi ARB CCB or diuretics
153
when patient has coronary artery disease, which drug do you prescribe
ACEi or ARB
| beta-blockers or CCB for stable angina
154
when patient has heart failure, which drug do you prescribe
ACEi or ARB + beta-blockers
| AVOID CCB
