Hypertension

Question 1

Blood pressures that qualify as “HTN”

Answer 1

BP is 140/90 in office multiple times or 135/85 at home= HTN

Question 2

Blood pressures that qualify as “HTN”

Answer 2

BP is 140/90 in office multiple times or 135/85 at home= HTN

Question 3

Prehypertension

Answer 3

120-139 mmHg SBP or

DBP 80-89 mmHg

Question 4

Prehypertension

Answer 4

120-139 mmHg SBP or

DBP 80-89 mmHg

Question 5

Stage 2 HTN

Answer 5

> 160 mmHg SBP or

> 100 mmHg DBP

Question 6

Prehypertension

Answer 6

120-139 mmHg SBP or

DBP 80-89 mmHg

Question 7

Etiology of HTN

Answer 7

1. Overactivitation of SNS and RAAS
2. Blunting of pressure-natriuresis relationship
3. Variation in CV/renal development
4. Elevated intracellular Na+/Ca+
5. Exacerbating factors

NSAIDs cause hypertension, too much salt intake, family history, smoking, alcohol can all cause HTN
**Sleep apnea is a MAJOR cause of CV problems, A-Fib, HTN

Question 8

Stage 2 HTN

Answer 8

> 160 mmHg SBP or

> 100 mmHg DBP

Question 9

Higher BP and left untreated= higher incidence of

Answer 9

kidney disease

Question 10

Another major cause of Secondary HTN……

Answer 10

Renal/renovascular causes:

1. FMD (fiber musculodysplasia) in young women (young woman with refractory HTN, reversible cause of high BP in young women; “beads on a string”)
2. Refractory HTN
3. Bruits, PAD, Cr increase with ACE-I
4. Pulmonary edema

OR primary renal disease

Question 11

Clinical Example- If Creat is 1.2, give ACE inhibitor, creat goes up to 2.0; suspect _________

Answer 11

bilateral renal artery stenosis

*Flash pulmonary edema with HTN (recurrent), think renal artery stenosis

Question 12

Other random causes of Secondary HTN

Answer 12

• Oral contraceptives, NSAIDs, cocaine/stimulants, antidepressants, calcneuriun inhibitors
• Pheochromocytoma, primary aldosteronism, Cushing’s syndrome, Sleep apnea Syndrome, Coarctation of the aorta, Hypothyroidism, Primary hyperparathyroidism

Question 13

Other cases of Secondary HTN

Answer 13

Renal/renovascular causes:

1. FMD (fiber musculodysplasia) in young women (young woman with refractory HTN, reversible cause of high BP in young women; “beads on a string”)
2. Refractory HTN
3. Bruits, PAD, Cr increase with ACE-I
4. Pulmonary edema

Question 14

Clinical Example- If Creat is 1.2, give ACE inhibitor, creat goes up to 2.0; suspect _________

Answer 14

bilateral renal artery stenosis

Question 15

HTN may cause episodic presentations of

Answer 15

Pheochromocytoma

-Anxiety, palpitations, profuse perspiration, tremor, HA

Question 16

Most cases of HTN are

Answer 16

asymptomatic (“silent killer”)

• Headaches
• If severe can cause encephalopathy with N/V, confusion, vision changes (retinopathy)

Question 17

During HTN, optho exam will show

Answer 17

Cotton wool spots, AV nicking, hemorrhage, papilledema

-flame hemorrhages, hard exudates too

Question 18

_________ should be in every treatment plan

Answer 18

Diet and exercise should always be in treatment- every 10 kg of weight loss BP can drop 10-20 mmHG

Fruits veg, Mediterranean diet can drop it 10 mmHg; low sodium intake; moderate alcohol; DASH diet; physical activity and weight loss

Question 19

What meds to start with for treatment?

Answer 19

ALL race/age groups receive lifestyle modification

AA: CCB and thiazide
White (ISOLATED HTN): ACE-I and BB

However, many pts have comorbidities which should prompt targeted therapy
ie: AA pt with DM should receive ACE-I first

Question 20

What meds to start with for treatment?

Answer 20

ALL race/age groups receive lifestyle modification

AA: CCB and thiazide
White (ISOLATED HTN): ACE-I and BB

However, many pts have comorbidities which should prompt targeted therapy
ie: AA pt with DM should receive ACE-I first

Question 21

Who gets ACE inhibitor?

Answer 21

Whites with isolated HTN, pts with systolic heart failure, post MI, proteinic chronic kidney disease

Question 22

Who gets Beta Blocker?

Answer 22

Pts with angina pectoris, a fib and flutter rate control

Question 23

Don’t use alpha blocker if

Answer 23

EF is low

-use alpha blocker for pt with BPH

Question 24

Don’t use alpha blocker if

Answer 24

EF is low

-use alpha blocker for pt with BPH

Question 25

TEST: If patient has angioedema, don’t use

Answer 25

ACE inhibitor

pregnancy don’t use ACE inhibitor, ARB, or renin inhibitor

Question 26

For patient in ER with HTN, don’t give _________, give ________

Answer 26

hydrochlorothyazide

give Lasix (furosemide)- loop diuretic

**can give thiazides for more long term care after

Question 27

Side effects of Diuretics (Thiazides, loop)

Answer 27

• Initially lower plasma volume but decrease SVR (systemic vascular resistance) long-term
• electrolytes, gout, ED, hyperkalemia

Question 28

Renin inhibitors

Answer 28

Lack efficacy data over ACE-I/ARB

Question 29

Renin inhibitors

Answer 29

Lack efficacy data over ACE-I/ARB

Question 30

ACE-I

Answer 30

Inhibits RAAS, prevents degradation of bradykinin

Question 31

Aldosterone receptor blockers

may cause

Answer 31

• CHF, cirrhosis

- Can lead to gynecomastia, hyperkalemia, breast pain

Question 32

Aldosterone receptor blockers

may cause

Answer 32

• CHF, cirrhosis

- Can lead to gynecomastia, hyperkalemia, breast pain

Question 33

CCBs

Answer 33

Peripheral vasodilation with less reflex tachy/fluid retention
**Caution in CHF

Question 34

Alpha Blockers

Answer 34

-Lower PVR; useful with BPH

**First-dose hypotension, caution in CHF (have to start slowly and use at nighttime, cant use of EF is low)

Question 35

Central sympatholytic (clonidine, methyldopa)

Answer 35

• Stimulate alpha in CNS thus reducing efferent peripheral SNS outflow
• ED, rebound HTN, dry mouth, caution in pregnancy with methyldopa

Question 36

Direct vasodilators (list 2)

Answer 36

Hydralazine/minoxidil

Question 37

HTN Urgencies

Answer 37

• Treat when acute end-organ damage or BP > 220/125*

- Reduce ~ 25% in first 1-2 hrs and then target

Question 38

HTN Urgencies

Answer 38

• Treat when acute end-organ damage or BP > 220/125*

- Reduce ~ 25% in first 1-2 hrs and then target