Hypertension Flashcards
(96 cards)
1
Q
How many Americans are affected by hypertension? How many are adequately controlled?
A
50 million
25% adequately controlled
2
Q
Where is there an increased prevalence of HTN?
A
Elderly
3
Q
What BP would make you consider a patient to be hypertensive?
A
140/90 or greater
4
Q
What are the 4 different types of HTN?
A
Essential (Primary/idiopathic)
Secondary
Malignant
Hypertensive urgencies and emergencies
5
Q
95% of all HTN cases, etiology unknown. 2X prevalence in black populations
A
Essential HTN
6
Q
5% of HTN cases. Renal, renovascular, endocrine, and congenital etiologies
A
Secondary HTN
7
Q
What are the contributing factors to HTN? (7)
A
- Genetic
- Environmental (diet, smoking, alcohol, weight)
- Sympathetic nervous system hyperactivity
- Renin – Angiotensin – Aldosterone system
- Defect in natriuresis
- Intracellular Na+ and Ca++
- Insulin resistance and metabolic syndrome
8
Q
What factors exacerbate HTN?
A
Obesity Excess Na intake Cigarette smoking (norepinephrine) NSAIDS Excess alcohol intake
9
Q
How does estrogen use cause HTN? What type of HTN is this?
A
Increases activity of the RAA system which causes volume expansion
2ndry HTN
10
Q
Renal disease, renal vascular HTN, endocrine HTN, and HTN in pregnancy are all what type of HTN?
A
2ndry
11
Q
What type of insufficiency does HTN accelerate?
A
Renal
12
Q
How does intrinsic renal disease result in HTN?
A
Volume expansion and/or increased activity of RAA system
13
Q
What does renal artery stenosis cause?
A
Increased renin
14
Q
What are the two forms of renal artery stenosis?
A
Fibromuscular hyperplasia (FMH) Atherosclerosis
15
Q
Presents in young adults - BP markedly elevated; renal function preserved; arteriography diagnostic
A
FMH
16
Q
What type of treatment do FMH patients benefit from?
A
Angioplasty/stent
17
Q
Older patents - BP elevated and unresponsive to meds; renal function often impaired; intervention may or may not help
A
Atherosclerosis
18
Q
What type of treatment helps patients with atherosclerosis decrease their BP?
A
Long term medication Rx
19
Q
Decreased LV compliance results in ???
A
Diastolic dysfunction
20
Q
What is associated with increased morbidity and mortality in patients with HTN?
A
LVH
21
Q
What is the test of choice to diagnose LVH?
A
Cardiac ultrasound (echocardiography)
22
Q
What methods can you use to get LVH to regress?
A
Aggressive treatment
23
Q
What causes LVH?
A
It is a compensatory mechanism to LV pressure overload
24
Q
Why is hypertrophy an issue?
A
It takes much higher pressure in diastole to relax a ventricle that is hypertropied
25
What is the major predisposing cause of stroke?
HTN
26
What causes cerebral infarction in patents with HTN/
Atherosclerosis/small vessel disease
27
What causes an intracerebral hemorrhage?
Rupture of micro aneurysms from increased BP
28
Strokes are more closely associated with _____ pressure
Systolic
29
The average anti-hypertensive medication titrated to the appropriate dose decreases systolic BP by ____mmHg?
10-15
30
HTN accelerates all other causes of ??
Chronic renal insufficiency
31
Progressive renal insufficiency; more common in black populations, especially in the presence of DM
Neprhosclerosis
32
Clinical findings for HTN are usually?
Asymptomatic - maybe some AM headaches
33
What are some symptoms related to LVH and diastolic dysfunction?
SOB, DOE
34
What are some symptoms related to cerebral involvement?
TIA, stroke, hemmorhage
35
What are some symptoms related to cardiac involvement?
MI, angina, HF
36
What are some abnormals you might find on a cardiac exam of a patient with HTN?
Bruits from atherosclerotic disease
Different upper/lower pulses
Mostly unremarkable
37
Symptoms of hypertensive retinopathy
```
A/V narrowing
AV nicking
Silver/copper wired appearance
Hemorrhages or exudates
Papilledema
```
38
What are some labs you should pay attention to when assessing a patient for HTN?
Creatinine/BUN for renal function
K for electrolytes
39
According to JNC 8 guidelines, what BP should you Rx with meds in a patient older than 60?
150/90
40
If you are treating a patient for HTN that is older than 60 yo and their blood pressure is lower than 140/90 on medications, do you need to adjust the medications?
Do not need to adjust meds if BP is well tolerated
41
According to JNC guidelines, in a patient younger than 60 when should you RX meds? What should the goal of treatment be?
140/90
Goal should be under 140/90
42
According to JNC guidelines, when should you Rx a patient older than 18 with diabetes or chronic kidney disease? What should the goal be?
140/90
Under 140/90
43
What should the initial treatment in a nonblack patient with HTN (including patients with diabetes)?
Thiazide-type diuretic
CCB
ACE inhibitor or ARB
44
What should the initial treatment be in black populations with HTN?
Thiazide-type diuretic or CCB
45
What should the additional or add-on therapy be in a patient over 18 with chronic kidney disease and HTN?
ACE or ARB to improve kidney outcomes regardless of race or diabetes status
46
What is no longer indicated as the initial RX for HTN?
Beta blockers
47
When is it okay to initiate 2 drugs at onset of therapy in a patient with HTN?
BP S greater than 160 or D greater than 100
48
Diuretics with HTN almost always ??
Requires multiple (average 3) meds
49
What drugs should be a part of a diuretic regimen for a patient with HTN?
Thiazide diuretic + ACEI (or ARB) + CCB
50
What is the main goal of therapy with HTN?
Decrease endpoints, not BP alone
Reduce cardiovascular risk for CHD
51
MI, Stroke, LVH, PAD are all _______
Endpoints
Cause cardiac mortality, HF, and renal failure
52
What is the most important target for reducing morbidity and mortality?
Systolic BP
53
What is the equation for calculating BP?
CO X Systemic vascular resistance (SVR)
54
What is the recommended 1st choice medications for HTN and should be part of any multi-drug combination?
Thiazide diuretics
55
What are the initial effects of thiazide diuretics? Chronic effects?
Initial: Decreased plasma volume (Decreased preload)
Chronic: Decreased SVR!
56
Diuretics are more potent in ___ and more effective in ___
Potent: Blacks, elderly, obese
Effective: Smokers
57
_____ is more potent than HCTZ
Chlorthalidone
58
Who should you not prescribe a diuretic to?
Patient with hyponatremia or gout
59
Adverse effects of thiazides
Hypokalemia, Hyperuricemia, Lipid abnormalities
60
How do beta blockers work to decrease BP?
Decreasing cardiac output by decreasing HR
61
With beta blockers, ____ increases but ____ levels decrease
SVR increases
Renin levels decrease
62
Who are beta blockers less effective in?
Black population and elderly
63
When would a beta blocker be useful?
In a patient with HTN and other co-morbid conditions (Post MI, migraines, arrhythmias, etc.)
64
The mortality and end point benefits of beta blockers are mostly applicable to what type of beta blocker?
Lipid soluble
65
Beta blockers are less effective for ____ vs other agents
LVH
66
In patients with chronic compensated and stable HF with a low ejection fraction, what is clearly beneficial to decrease mortality?
Beta blockers
67
What are some side effects of beta blockers?
```
May worsen PAD
Masks hypoglycemia
Exacerbation of bronchospasm
Bradycardia
CNS issues - nightmares, fatigue, depression, etc.
```
68
Beta blockers should NOT be used as??
1st line mono therapy in patients with HTN
69
What do ACE inhibitors inhibit?
Renin-angiotensin-aldosterone system
70
ACE inhibitors inhibit ____ degradation
Bradykinin
71
ACE inhibitors stimulate
Vasodilating prostaglandin synthesis
72
What increases the anti-hypertensive efficacy of ACE inhibitors?
Improved when combined with a diuretic
73
ACEIs are the antihypertensive of choice in ____
Diabetics
74
What other diseases do ACEIs help with?
HTN, LV dysfunction, HF (when given with loop diuretic)
75
What do ACEIs help with in patients with LV dysfunction?
Prevents remodeling
76
When should someone take an ARB? What is the downside?
They are useful for HF patients who can't take ACEI but don't inhibit bradykinin breakdown
77
ARBs are ____ in diabetics
Renoprotective
78
ARBs do not have the side effect of ____ that ACEIs have
Cough
79
Act by peripheral vasodilation (after load) and other mechanisms; effective in demographic groups
CCB
80
What groups are CCBs preferable in?
Blacks and elderly
81
CCBS provide additional protection against ____
Stroke
82
Significant vasodilation, reduction in SVR; can cause fluid retention and REFLEX TACHYCARDIA
Dihdyropyridine agents
83
Vasodilation and negative inotropic, chronotropic, and dromotrophic effects
Non-dihydrophyridine agents
84
What is the downside to nondihydropyridines?
Exacerbate HF and cause SA and AV nodal dysfunction
85
Can you use diltiazem with B blockers?
Cautiously, avoid verapamil
86
Side effects of dihydropyridines
Headaches and peripheral edema
87
Which CCBs cause bradycardia?
Verapamil and diltiazem
88
Post-synaptic alpha receptor blockers that relax smooth muscle, decrease SVR
Alpha receptor blockers (terazosin, doxazosin)
89
When is an alpha receptor blocker useful?
Benign prostatic hyperplasia
90
Stimulates CNS presynaptic alpha-2 receptors resulting in reduced efferent peripheral sympathetic flow
Central acting agents: Methyldopa, clonidine
91
Why would someone want to use clonidine?
Compliance benefits - patches are effective for 7 days
92
What is the initial Rx for treating HTN?
Thiazide diuretics (with some exceptions)
Remember - multiple agents are often needed!
93
What should you do to a dose of an HTN medication before adding a second agent?
Titrate to moderate/high doses first
Exception = thiazide
94
What would additional drug therapy include?
Beta blocker
ACEI
CCB
Look at comorbid conditions!!
95
If initial average BP is greater than 160/90, what should you do when RXing?
Start with dual Rx!
96
What is the common 3 drug combination that HTN patients are on?
Diuretic, ACEI, and CCB (or beta blocker)
