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Flashcards in Hypertension Deck (36):
1

History in confirmed hypertension

1. Duration and Previous treatment
2. Past/current symptoms
IHD
Heart failure
Cerebrovascular disease
Peripheral arterial disease
3. Symptoms of CKD
Oliguria
Nocturia
Hematuria
4. Suggestions of secondary cause
Cushings: weight, mood, acne, myopathy, menstrual
Conns: fatigue, headA, parasthesia
Phaeochromocytoma: sweating, headA, tachyC
Sleep apnea: daytime sleep, snoring, obesity
Nephrogenic: PCKD, RAS, GN
HyperPTH: stones, bone, groans, psychic moans
5. Other chronic conditions influencing management/+CV risk
Asthma, COPD
Diabetes
Lipids
DM
CKD
Alcoholism
Heart failure
6. Lifestyle
Smoking
Alcohol
Diet
Physical activity
Weight
7. Medication, FHx, occupation etc

2

Physical examination

1. Vitals
2. Evidence of underlying cause
Endocrine
Focal neurological
3. Complications
CVS: ++pulse, CCF, bruits, PVD, aneurysms
Palpable kidneys, bruits
Optic fundi: nipping, hemorrhage, exudates, cotton wool, papilloedema

3

Goals of HTN evaluation

1. Identify all risk factors
2. Detect end organ damage
3. Identify secondary causes

4

Overview of management

1. Lifestyle
Weight reduction
Diet
Limit alcohol
Physical activity
Smoking cessation
2. Pharmacotherapy
3. Manage comorbidities
Low dose aspirin
Lipid management
Diabetes management

5

Principles of drug treatment

1. Start with lowest does
2. If not tolerated->change
3. If not managed 6 weeks->add second drug
4. Still not, tolerated->+dose of one type
5. Can add third drug
6. Consider other reasons for non-responding

6

When is pharmacotherapy intervention required immediately

When >180/110, >160/15% CVD risk
ATSI w/ hypertension

7

Associated conditions

PVD
+Cholesterol >7.5
CKD
Diabetes
Aortic
FHx of premature CVD
Cerebrovascular
CAD

8

Evidence of end organ

1. CKD: proteinuria:creatinin >30mg/mmol, >300mg protein, eGFR a:cr >2 M, >2.5 F
3. LVH on ECG
4. Vascular disease->bruits, HTN retinopathy

9

Options for pharmacotherapy

1. ACEi
2. ARB
3. B blocker
4. CCB
5. Diuretics

10

Defining

High normal 130-139/85-89
Mild 140-159/90-99
Moderate 160-179/100-109
Severe >180/110

11

Grading HTN retinopathy

1. Tortuous silver/copper wiring
2. AV nipping
3. Flame hemorrhages and cotton wool spots
4. Papilloedema

12

Define malignant hypertension

Systolic >200/130 + bilateral retinal hemorrhages and exudates +papilloedema (may or may not)

13

Management of malignant and why

Renal failure, cardiac failure, encephalopathy
Fibriniod necrosis

14

Investigations in HTN

1. Quantify risk
Glucose
Cholesterol
2. End organ damage
ECG
Urinalysis
UEC
FBC and Hct
3. Exclude secondary
UEC (low K in conns), +Ca in hyperPTH
Consider other secondary tests
TSH

15

Treatment resistance

1. Volume overload->CKD
2. White coat
3. Medications that +BP
4. Secondary causes
5. Non-adherence
6. Undisclosed alcohol/drug use
7. Sleep apnea
8. High salt

16

Treatment with comorbidities: angina, AF, Asthma/COPD, bradyC, Depression, HF, diabetes w/ albumin, post stroke, pregnancy, CKD

1. Angina->ACEi, BB, CCB
Atenolol/metoprolol
Peridopril
Amlodipine
2. Asthma/COPD->Cardioselective CCB
Verapamil
Diltiazem
XBB
3. AF->BB, ACEi, cardio CCB
4. BradyC/heart block
Verapamil
Diltiazem
XBB
5. Depression
Avoid BB, clonidine, methyldopa

17

Treatment with HF, diabetes w/ albumin, post stroke, pregnancy, CKD

1. HF
ACEi, ARB
Thiazide
BB->bisoprolol, carvedilol
Spirinolactone
2. Diabetes
ACEi, ARB
Avoid BB, thiazide diuretics
3. Post-stroke
ACEi, ARB,
low dose thiazide (hydrochlorthiazide)
4. Pregnancy
Methyldopa
Nifedipine
5 CKD
ACEi
ARB->candesartan

18

Combinations of anti-hypertensives to avoid

ACEi +ARB
ACEi+K sparing
Verapamil + beta blocker

19

Good combination anti-HTN

ACE- + CCB or thiazide

20

Side effects of thiazide diuretics

Low potassium, low sodium, postural hypotension, impotence

Not in gout!

21

Side effects of CCB

Flushes
Fatigue
Gum hyperplasia
Ankle edema

22

Side effects of ARB

Urticaria
Vertigo
Pruritus

23

Side effects of beta blocker

Bronchospasm
Heart failure, block
Cold peripheries
Lethargy
Impotence

Caution in asthma, heart failure, heart block

24

Features of hypertensive emergency

BP >210/130
Neurological, cardiovascular
Oliguria, polyuria
Abnormal fundoscopic examination
Abnormal neurological examination

25

Investigations in HTN emergency

ECG
FBC w/ smear
UEC
Urinalysis MCS
CXR
CT without contrast
MRI
Spot urine or plasma metanephrine

26

Management of HTN emergency

1. Labetolol
2. If LVF-> GTN + frusemise
3. Aortic dissection->Labetolol or esmolol
4. ARF->fenoldopam
5. Hyperandrogenic->Benzodiazepines
6. Eclampsia->Hydralazine, labetolol or nicardipine

27

Contraindications to diuretic

Hypokalemia
Hyponatremia
Hyperuricemia
Hyperlipidemia (thiazide)
Gout (Loop)

28

Side effects of clonidine

Postural hypoT
Dry mouth
Rebound HTN with abrupt withdrawal

29

Side effects of ACEi

Leukopenia
Pancytopenia
Hypotension
Cough
Angioedema
Urticarial rash
Hyperkalemia
Acute renal failure (if RAS)

30

Secondary causes

1. Renal
PCKD
RAS
GN
2. Endocrinology
Cushings: weight, mood, acne, myopathy, menstrual
Conns: fatigue, headA, parasthesia
Phaeochromocytoma: sweating, tachyC. headA, palpitations
HyperPTH: stones, bone, groans, psychic moans
Hyperthyroidism
3. Drugs: caffiene cocaine, sympathomimetic,TCA
4. Sleep apnea: daytime sleep, snoring, obesity
5. Coarctation of the aorta
6. Carcinoid

31

Hypertensive encephalopathy

Severely elevated BP
Confusion
+ICP
+/- seizures

32

DIfferentiate HTN urgency vs emergency

Emergency is associated with end organ damage

33

Normal range of cerebral autoregulation

MAP of 60-120 mm

34

Goal reduction in hypertensice emergency in chronic HTN

Reduction in MAP no more than 25% or to diastole 100-110

35

Why is labetolol good in HTN emergency

Combined alpha and beta->lowers resistance and prevents reflex tachC

36

Should people with HTN crises and stroke have immediate lowering of BP and why

No, may worsen ischemia