Hypertension 2

Question 1

How often should follow-up visits be scheduled until BP is at goal?

Answer 1

Every 4-6 weeks

Question 2

How much of a BP reduction should you see per added agent?

Answer 2

10 mmHg

Question 3

What are the 2 categories of hypertensive crises?

Answer 3

Hypertensive urgency, hypertensive emergency

Question 4

What constitutes hypertensive urgency?

Answer 4

BP >180 and/or 120 without evidence of acute target-organ damage typically due to poorly controlled chronic HTN

Question 5

How is hypertensive urgency assessed?

Answer 5

Rarely emergent therapy/monitoring
Thorough H&P to evaluate for signs/symptoms of organ damage
BMP, UA, EKG

Question 6

What is the goal of hypertensive urgency treatment?

Answer 6

Reduce BP within hours
Give in office agent if available

Question 7

What in office agents can be given for hypertensive urgency?

Answer 7

Clonidine, captopril, metoprolol tartrate, hydralazine, nifedipine

Question 8

What is the action of clonidine?

Answer 8

Central sympatholytic

Question 9

How fast is the onset of clonidine?

Answer 9

30-60 minutes

Question 10

How long does clonidine last?

Answer 10

6-8 hours

Question 11

What are adverse effects of clonidine?

Answer 11

Sedation

Question 12

What is the mechanism of action of captopril?

Answer 12

ACEI

Question 13

What is the onset of captopril?

Answer 13

15-30 minutes

Question 14

How long is the duration of captopril?

Answer 14

4-6 hours

Question 15

What are adverse effects of captopril?

Answer 15

Excessive hypotension

Question 16

What is the action of metoprolol tartrate?

Answer 16

Beta blocker

Question 17

What is the onset of metoprolol tartrate?

Answer 17

20-60 minutes

Question 18

What is the duration of metoprolol tartrate?

Answer 18

5-6 hours

Question 19

What are adverse effects of metoprolol tartrate?

Answer 19

Excessive hypotension, bradycardia

Question 20

What is the action of hydralazine?

Answer 20

Vasodilator

Question 21

What is the onset of hydralazine?

Answer 21

10-80 minutes

Question 22

What is the duration of hydralazine?

Answer 22

Up to 12 hours

Question 23

What are adverse effects of hydralazine?

Answer 23

Tachycardia, headache, GI
Often given with beta blocker due to risk of heart attack

Question 24

What is the action of nifedipine?

Answer 24

CCB

Question 25

What is the onset of nifedipine?

Answer 25

15 minutes

Question 26

what is the duration of nifedipine?

Answer 26

2-6 hours

Question 27

What are adverse effects of nifedipine?

Answer 27

Excessive hypotension, tachycardia, headache, angina, myocardial infarction, stroke

Question 28

Severe HTN with signs and/or symptoms of end-organ damage. True medical emergency and must start lowering BP ASAP to preserve function

Answer 28

Hypertensive emergency

Question 29

What is the typical BP with hypertensive emergency?

Answer 29

220/130

Question 30

What is the initial evaluation of hypertensive emergency?

Answer 30

Problem-focused H&P (kidneys, heart, stroke, eyes, pulmonary) CBC, CMP, EKG, CXR, CT head, UA, UDS

Question 31

What is the goal of treatment for hypertensive emergency?

Answer 31

Use parenteral therapy to lower BP no more than 25% per first 2 hours then goal BP of 160/100 over next 2-6 hours

Question 32

How do you determine specific goals for managing BP in hypertensive emergency?

Answer 32

Organ involved

Question 33

What is the BP goal of ischemic CVA in hypertensive emergency? Hemorrhagic?

Answer 33

SBP between 180-200 mmHg with slow reduction Hemorrhagic- target SBP is <140 mmHg

Question 34

What is the goal BP for aortic dissection?

Answer 34

SBP <120 mmHg

Question 35

What is the goal BP for MI?

Answer 35

Need anticoagulation and oxygen; typically use NTG for BP reduction, but no set goal

Question 36

What calcium channel blockers can be used for hypertensive emergency?

Answer 36

Nicardipine, clevidipine

Question 37

How fast is the onset of calcium channel blockers used in hypertensive emergency?

Answer 37

Within minutes

Question 38

What are adverse effects of nicardipine?

Answer 38

Hypotension, tachycardia, headache

Question 39

What medications are 1st line for african americans?

Answer 39

CCB or thiazide

Question 40

What medications are first line for non-african americans?

Answer 40

ACEI/ARB, CCB, or thiazide

Question 41

If a patient has elevated BP, how should they be managed?

Answer 41

Lifestyle changes ## Footnote Trick question :)

Question 42

If a patient has stage 2 hypertension, how would you manage them?

Answer 42

nonpharmacologic therapy and BP lowering medication Follow up in 1 month

Question 43

What is the only time that you would give a beta blocker or a aldosterone antagonist first line?

Answer 43

Heart failure or post-MI/CAD

Question 44

How often should an EKG be obtained on a patient with hypertension?

Answer 44

every 2-4 years

Question 44

What are adverse effects of clevidipine?

Answer 44

headache, nausea, vomiting

Question 44

what are clevidipine contraindications?

Answer 44

allergy to soy or egg

Question 45

what are adverse effects of labetalol?

Answer 45

GI, hypotension, bronchospasm, bradycardia, heart block

Question 46

which patients should you avoid using labetolol in?

Answer 46

Avoid in acute LV systolic dysfunction, asthma

Question 47

what are the adverse effects of esmolol?

Answer 47

bradycardia, nausea

Question 48

you should not give esmolol to patients with what?

Answer 48

LV systolic dysfunction, asthma

Question 49

what are adverse effects of fenoldopam?

Answer 49

reflex tachycardia, hypotension, increased intraocular pressure

Question 50

what is the mechanism of action of enalprilat?

Answer 50

ACE inhibitor

Question 51

what are adverse effects of enalaprilat?

Answer 51

excessive hypotension

Question 52

how is enalaprilat used?

Answer 52

additive with diuretics

Question 53

What is the mechanism of action of furosemide?

Answer 53

diuretic

Question 54

what are adverse effects of furosemide?

Answer 54

hypokalemia, hypotension

Question 55

How is furosemide used?

Answer 55

adjunct to vasodilator

Question 56

what is nitroglycerin?

Answer 56

vasodilator

Question 57

what are adverse effects of nitroglycerin?

Answer 57

headache, nausea, hypotension, bradycardia

Question 58

what do you need to keep in mind with nitroglycerin?

Answer 58

Can develop tolerance most useful with myocardial ischemia

Question 59

what is the mechanism of action of nitroprusside?

Answer 59

vasodilator

Question 60

what are adverse effects of nitroprusside?

Answer 60

GI, CNS, thiocyanate and cyanide toxicity, especially iwth renal and hepatic insufficiency; decreased cerebral blood flow, increased intracranial blood pressure

Question 61

what are treatment options for hypertensive emergency?

Answer 61

* nicardipine * clevidipine * labetolol * esmolol * fenoldopam * enalaprilat (additive with diuretics) * furosemide (adjunct to vasodilator) * nitroglycerin * nitroprusside (no longer first-line agent)

Question 62

How much is HR expected to change during pregnancy?

Answer 62

increase by 10 bpm during 3rd trimester

Question 63

How does pregnancy impact BP?

Answer 63

Tends to decrease during 2nd trimester due to decrease in systemic vascular resistance

Question 64

when is a BP considered abnormal during pregnancy? Why?

Answer 64

>140/90 >associated with increased risk in perinatal morbidity and mortality

Question 65

what does diagnosis of hypertension during pregnancy require?

Answer 65

2 elevated readings at least 4 hours apart

Question 66

What are classifications of hypertension during pregnancy?

Answer 66

* Preeclampsia * Gestational * Chronic * Preeclampsia superimposed on chronic hypertension

Question 67

What is classified as preeclampsia?

Answer 67

New onset HTN (BP >140/90) and proteinuria (24 hr urinary protein >300 mg/24 h or creatinine ratio >.3) after 20 weeks gestation

Question 68

What is classified as gestational HTN?

Answer 68

HTN (BP 140/90) after 20 weeks gestation without pre-existing HTN or proteinuria

Question 69

What is considered chronic HTN in a pregnant patient?

Answer 69

HTN before 20 weeks gestation or longer than 12 weeks postpartum

Question 70

what HTN medications are contraindicated during pregnancy?

Answer 70

ACEI and ARBs

Question 71

How is acute chronic/gestational HTN treated?

Answer 71

IV labetolol, IV hydralazine, oral immediate-release nifedipine

Question 72

How is chronic HTN managed during pregnancy?

Answer 72

labetalol, ER nifedipine, or methyldopa

Question 73

what is the target BP during pregnancy?

Answer 73

130-150/80-100 ## Footnote not recommended to reduce BP by more than 25% over 2 hours

Question 74

failure to reach BP control in patients who are adherent to full doses of an appropriate 3-drug regimen, including a diuretic

Answer 74

Resistant HTN

Question 75

What could be an issue leading to resistant HTN?

Answer 75

medication noncompliance

Question 76

What would you do if a patient has resistant hypertension?

Answer 76

Refer to nephrology or cardiology to rule out secondary causes consider switching diuretic to aldosterone receptor blocker

Question 77

What are causes of resistant HTN?

Answer 77

* Improper blood pressure measurement * volume overload and pseudotolerance: excess sodium intake, volume retention from kidney disease, inadequate diuretic therapy * Obesity * Excess alcohol intake * Secondary causes of hypertension

Question 78

What are drug-induced causes of resistant HTN?

Answer 78

* Inadequate doses or inappropriate combinations * NSAIDs * Cocaine, amphetamines, other illicit drugs; sympathomimetics * oral contraceptives * adrenal steroids * erythropoietin * licorice * selected OTC supplements and medicines (ephedra, ma huang, bitter orange)