Hypertension

Question 1

Complications of HTN

Answer 1

• END ORGAN DISEASE
• Premature cardiovascular disease
  
  • CHF, LVH, ventricular arrhythmia (PMI may be displaced laterally; you WILL see this on EKG), MI
• CVA, intracranial HTN
  
  • Especially with significant fluxuations in BP
  • Headache, blurred vision, slurred speech
• Retinopathy - they need to be seen by an ophthalmologist yearly
• Chronic renal insufficiency, ESRD - decreased urine output - Check serum Cr for elevations
• Peripheral vascular disease - claudication (pain or cramping with walking or exercise)
  
  • Also think about ED
  • Also look for skin breakdown (painful and dry, over bony areas)
  • Extremities will be colder
• Hypertensive emergencies
• With pts with high BP, you want to make sure that they aren’t at cardiovascular risk
  
  • These pts usually feel completely fine because there are no noticeable symptoms

Question 2

• Screening for BP

Answer 2

• USPSTF recommends BP screening adults starting at age 18 years
  
  • Every year for patients >40 years
  • Every year for high risk patients
  • Every 3-5 years for normotensive, average risk patients
  • Recommends obtaining BP readings outside clinical setting for diagnostic confirmation, treatment

Question 3

How to treat Stage II HTN

Answer 3

(>140/>90) = lifestyle modification, CV risk reduction, begin 1 medication

Question 4

leading COD in women

Answer 4

CAD and CVA over all other causes combined

Question 5

Essential (primary) HTN

Answer 5

• pathogenesis is poorly understood but a variety of factors are implicated:
  
  • Increased sympathetic neural activity, with enhanced beta-adrenergic responsiveness.
  • Increased angio II activity and mineralocorticoid excess.
  • Genetic: twice as common in subjects who have one or two hypertensive parents
    
    • genetic factors account for ~ 30% of incidence
  • Reduced adult nephron mass may predispose to hypertension
  • Perinatal factors:
    
    • intrauterine: hypoxia, drugs, nutritional deficiency
    • post-natal environment: malnutrition, infections
• The syndrome of apparent mineralocorticoid excess (AME), a genetic disorder, and chronic ingestion of licorice or licorice-like compounds (such as carbenoxolone) can result in findings similar to those in primary aldosteronism: hypertension, hypokalemia, metabolic alkalosis, and low plasma renin activity
• 90-95% of patients have essential hypertension

Question 6

Secondary HTN

Answer 6

• Renovascular disease
  
  • Renal artery stenosis à MOST COMMON CAUSE OF SECONDARY HTN
• Obstructive Sleep Apnea - STOP BANG
• Primary renal HTN
• Coarctation of the Aorta
• Pheophromocytoma - Catecholamine-secreting tumors from chromaffin cells of adrenal medulla and sympathetic ganglia
• Primary hyperaldosteronism - elevation in blood pressure is dependent upon the mild volume expansion that occurs
• Cushing’s syndrome - moderate diastolic hypertension d/t Increased peripheral vascular sensitivity to adrenergic agonists, increased production of angiotensinogen
• Other endocrine
  
  • Hyper/Hypothyroidism - changes in hypothyroidism include decrease in contractility, reduction in HR, and increase in peripheral vascular resistance
  • Hyperparathyroidism
• You start thinking of secondary HTN if you put them on medication and BP is not coming down with medications

Question 7

Ace Inhibitors

Answer 7

• Highly effective, well tolerated, most patients develop a dry cough
• Block the formation of angiotensin II, decreasing the amount of angiotensin available to both AT1 and AT2 receptors
  
  • Arterial dilation, decreasing resistance to blood flow and consequently decreasing blood pressure
• First-line therapy for heart failure or asymptomatic LV dysfunction, MI, anterior infarct, diabetes, systolic dysfunction, proteinuric chronic kidney disease
• Side effects:
  
  • Approximately 10% of patients develop a chronic nonproductive cough
  • Angioedema: Rarely, ACE inhibitors produce a sudden swelling of the lips, face, and cheek areas in an allergic reaction that can occur at any time during therapy
  • May affect renal function and raise the potassium level

Question 8

USPSTF 2015 guidelines for treatment

Answer 8

• For nonblack patients, initial treatment consists of a thiazide diuretic, calcium-channel blocker, angiotensin-converting enzyme inhibitor, or angiotensin-receptor blocker.
• For black patients, initial treatment is thiazide or a calcium-channel blocker.
• Initial or add-on treatment for patients with chronic kidney disease consists of either an angiotensin-converting enzyme inhibitor or an angiotensin-receptor blocker (not both).

Question 9

• Comparison of Guidelines

Answer 9

• JNC 7 (2003)
  
  • Defined HTN, pre-HTN
  • Recommended goal BP <140/90 or <130/80 for DM, CKD
  • Recommended treatment goals and medication class based on risk categories, “compelling indications”
  • Very specific algorithm and recommendations to follow
• JNC 8 (2014)
  
  • Recommends goal BP <140/90 for everyone <60 yrs, <150/90 for >60 yrs
  • Recommends treatment goals, medication class based on pt characteristics (race) or CKD
  • Hedges recommendations – “use clinical judgment”
• In persons older than 50 years, SBP > 140 mmHg is a much more important CVD risk factor than DBP.
• The risk of CVD beginning at 115/75 mmHg doubles with each increment of 20/10 mmHg
• Individuals who are normotensive at age 55 have a 90% lifetime risk for developing hypertension.

Question 10

leading causes of renal failure

Answer 10

DM and HTN

Question 11

Ambulatory blood pressure monitoring devices

Answer 11

-small, portable machines that record blood pressure at regular intervals over 12-24 hrs while patients go about their normal activities and are sleeping

Question 12

hypertensive urgency

Answer 12

BP >180/>120 in asymptomatic patient, start on 2 medications

Question 13

most common reason for medical office visits and use of prescription drugs in the United States

Answer 13

HTN

Question 14

How to treat BP >160/100

Answer 14

begin 2 medications, ideally a combo pill to improve compliance

Question 15

Acute Hypertensive emergency (malignant HTN)

Answer 15

• Marked hypertension with retinal hemorrhages, exudates, or papilledema
• May be associated with hypertensive encephalopathy
  
  • Seizure
  • Altered mental status
  • Headache with visual changes
• Decreased urinary output with rapid increase in renal failure
• Eclampsia in pregnancy/postpartum

Question 16

Evaluation of HTN pt

Answer 16

• Hx: FH, CVD risk factors, PMH (ever had problems with kidney, any prenatal or postnatal issues), ROS for end organ damage/complications
• PE: VS (RR, BMI), Eyes (look at fundus), Brain, Neck, Heart, Lungs (listening for crackles for evidence of heart failure), Abdomen (listening for bruits), PV (look at feet looking for ulcers, pulses, hair distribution)
• Labs
  
  • CBC, BMP, UA
    
    • CBC - wont really tell you much
    • BMP - looking at kidneys, glucose
    • UA - specific gravity, glucose
  • Fasting (9 to 12 hours) lipid profile
  • Electrocardiogram
  • Urine microalbuminuria for patients with diabetes to screen for early nephropathy
• Consider TSH, toxicology screen, other labs as dictated by H&P

Question 17

Assessing CV risk

Answer 17

• AHA/ACC 2013 Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults
• Calculated 10 year risk based on age, gender, race, lipid profile, BP, DM, smoking
  
  • Use q 4-6 yrs in pts 20-79 yrs

Question 18

hypertensive emergency/malignant HTN

Answer 18

BP >180/>120 with specific symptoms

Question 19

Treatment goals

Answer 19

• Reduction of cardiovascular and renal morbidity and mortality
• primary focus should be on achieving the SBP goal - most ppl (esp >50yo) reach DBP goal by achieving SBP goal
• Treating SBP and DBP to target <130/80 mmHg is associated with a decrease in CVD complications
  
  • New goal for persons ≥60 yrs is <140/90 mmHg
• Pts <30 yrs old with DBP >90mmHg should be treated
• Many patients with hypertension will require two or more antihypertensive medications to achieve goal blood pressure
  
  • Start 1 drug, titrate to max dose, then add 2^nd drug
  • Start 1 drug, add 2^nd drug to regimen before max 1^st drug
• If BP is >20/10 mmHg above goal, or SBP >160 mmHg or DBP >100 mmHg, consider initiating therapy with two agents at the same time
• BP goals controversial: <130/80 mmHg for most patients, <140/90 mmHg for patients >75 y/o or with increased risk

Question 20

Combination therapy

Answer 20

• A patient who is relatively unresponsive to one drug has almost 50% likelihood of becoming normotensive on a different drug - if partial response but suboptima, add a drug
  
  • an ACEI/ARB, β-blocker, or calcium channel blocker can be sequentially added or substituted in uncomplicated pts
• If NO response with initial agent, switch rather than add second drug
  
  • 70-80% of patients with mild hypertension will be controlled with a single agent
• Combination of a low dose of a thiazide diuretic with a β-blocker, ACEI/ARB has a synergistic effect

Question 21

Summary Treatment Goals

Answer 21

• Target BP:
  
  • Pts age <60, DM, CKD, goal is BP <140/90 mmHg
  • Pts age > 60, goal BP <150/90 mmHg
• Diastolic BP should not be reduced to <65 mmHg in elderly patients to attain the target systolic pressure
• Acute lowering of BP in patients with severe HTN can lead to serious cerebrovascular and coronary events
• Pre-HTN often controlled with lifestyle modifications
  
  • increasing physical activity
  • reducing dietary salt intake
• If medication indicated, begin therapy in uncomplicated hypertensive pts with a thiazide diuretic, ACEI, ARB, CCB
  
  • Start with 1 drug, max dose, then add 2^nd drug

Question 22

Metabolic syndrome

Answer 22

• Metabolic risk factors for both DM and CVD
  
  • Abdominal obesity, hyperglycemia, dyslipidemia, HTN
• Insulin resistance apparent underlying pathophysiology
• NCEP/ATPIII Guidelines: 3 of the following
  
  • Abdominal obesity: waist circumference ≥40 inches men, ≥35 inches women
  • Serum TG ≥ 150 mg/dL or drug treatment
  • Serum HDL <40 mg/dL men, <50 mg/dL women or treatment for cholesterol
  • BP ≥130/85 mmHg or treated HTN
  • FPG ≥100 mg/dL or treated for blood glucose

Question 23

Definitions of normal BP, prehypertension, and hypertension for JNC 7 and ACC/AHA

Answer 23

• JNC 7 Definitions (2003)
  
  • Normal blood pressure:
    
    • systolic <120 mmHg and diastolic <80 mmHg
  • Prehypertension:
    
    • systolic 120-139 or diastolic 80-89
  • Hypertension:
    
    • Stage 1: systolic 140-159 or diastolic 90-99
    • Stage 2: systolic ≥160 or diastolic ≥100
• ACC/AHA Definitions (2017)
  
  • Normal blood pressure:
    
    • Systolic <120 mmHg and diastolic <80 mmHg
  • Elevated blood pressure:
    
    • Systolic 120-129 mmHg and diastolic <80 mmHg
  • Hypertension:
    
    • Stage 1: systolic 130-139 or diastolic 80-89
    • Stage 2: systolic 140 or higher or diastolic 90 or higher

Question 24

Ethnic variation in Rx Response

Answer 24

• Ace inhibitors don’t work as well in AA

Question 25

Leading cause of stroke

Answer 25

HTN

Question 26

Pre HTN

Answer 26

* **Systolic blood pressure of 120–139 mmHg or diastolic blood pressure of 80–89 mmHg considered pre-hypertensive** * At increased risk for CVD * *What about the metabolic syndrome?* * out-of-office blood pressure (mean home or daytime ambulatory) ≥130 mmHg systolic or ≥80 mmHg diastolic w/ one or more of the following: * cardiovascular disease (eg, stable ischemic heart disease, heart failure, carotid disease, previous stroke, PAD) * Type 2 diabetes mellitus * Chronic kidney disease * 65 years or older * estimated 10-year risk of atherosclerotic CVD of at least 10 percent * pts w/ stage 1 hypertension (130 to 139/80 to 89 mmHg) withhold antihypertensive therapy if 75 years or older or those who do not have established cardiovascular disease, diabetes, or chronic kidney disease IF they have recurrent falls, dementia, multiple comorbidities, orthostatic hypotension, residence in a nursing home, or limited life expectancy

Question 27

* Prevalence of hypertension

Answer 27

* Menopause is usually when the cardiovascular risks go up * 31% incidence of hypertension in the \>18 yo population of the United States * About 1 in 4 American adults have high blood pressure * 1 in 3 African Americans, * 1 in 5 Hispanics and Native Americans, * 1 in 6 Asians/Pacific Islanders * 31.6% of pts with high BP don't even know they have it * Prevalence of hypertension in African American females (23%) is nearly double that of white females (12%) * The higher prevalence and earlier onset of hypertension in African American women = more severe course and a higher incidence of CV morbidity and mortality at younger ages

Question 28

* HOW TO OBTAIN ACCURATE BP MEASUREMENT

Answer 28

* Persons should be seated quietly for at least 5 minutes in a chair (rather than an exam table), with feet on the floor, and arm supported at heart level. * An appropriate-sized cuff (cuff bladder encircling at least 80 percent of the arm) should be used to ensure accuracy. At least two measurements should be taken * Blood pressure should be taken over skin, not over clothes * Clinicians should provide to patients, verbally and in writing, their specific BP numbers and BP goals

Question 29

How to treat elevated BP

Answer 29

(120-129/\<80) = lifestyle modification, CV risk reduction

Question 30

Diagnosis of HTN

Answer 30

- meeting one criteria using ABPM qualifies as HTN - day (awake) mean \>130/80 - diagnosis made by multiple ABPM readings

Question 31

Unfavorable Combinations

Answer 31

* ACEI with β-blocker, or diuretic with CCB * similar mechanisms of action * angiotensin II formation and renin secretion are respectively reduced by the two medications * calcium channel blockers may act in part by inducing a natriuresis, which could contribute to a lesser additive value when used with a diuretic * Combinations with additive side effects * β-blocker used with caution in combination with CCB * potentiates the cardiac depressant effect of the beta blocker, possibly leading to bradycardia or heart block

Question 32

BP goal for most patients

Answer 32

130/80

Question 33

How to treat Stage I HTN

Answer 33

(130-139/80-89) = lifestyle modification, CV risk reduction, treat high risk patients (DM, CKD, CHF, previous CV event, elderly) with 1 medication

Question 34

Angiotensin Receptor Blockers

Answer 34

* Similar in action and effect to ACE inhibitors * Selectively block binding of angiotensin II to the AT1 receptor * Indicated in patients who do not tolerate ACE inhibitors * Improve congestive heart failure symptoms, decrease hospitalizations for heart failure, and decreased morbidity

Question 35

HTN risk factors

Answer 35

* African Americans * more common and more severe * Sodium intake (?) * _Excess_ alcohol intake à a little alcohol is actually good for you * Smoking * Obesity and sedentary lifestyle * Dyslipidemia à can cause heart attacks, strokes, etc. * Personality traits / Stress * hostile, anxious, type A

Question 36

Hypertensive Urgency

Answer 36

* Severe hypertension in asymptomatic patients * SBP ≥180 mmHg * DBP ≥120 mmHg * No proven benefit from rapid reduction in BP in asymptomatic patients without evidence of acute end organ damage * Reduce BP to ≤160/100 mmHg over hours to days with conventional oral meds * Adjust patient’s meds; if not on meds, start 2 drugs * Recheck BP and sx every 1-2 days

Question 37

Calcium Channel Blockers

Answer 37

* Angiotensin or calcium channel blockers should be first line for african american pts * Decrease BP by decreasing the force of myocardial contractions, dilating the arteries, decreasing resistance to blood flow * Newer CCBs primarily dilate arteries and have little effect on myocardial contractions * May be preferred in patients with obstructive airway disease * Rate control in patients with atrial fibrillation or for angina * Side effects: * May occasionally worsen congestive heart failure symptoms * Verapamil may cause constipation, especially in elderly patients * Headache and LE edema

Question 38

Managing HTN

Answer 38

* Lifestyle modifications / nonpharmacologic therapy * Reduction of dietary sodium intake, DASH diet * Potassium supplementation (MVI) - 90-120 milliequivilants a day has been shown to reduce risk (multivitamin is sufficient) * If someone is on a diuretic, often times we supplement with potassium supplements * Increased physical activity, weight loss * Recommended amount = 30 mins, 5x/wk * Stress management * Reduction of alcohol intake * Primary CVD prevention * ASA 81mg daily * Statin therapy\* * Smoking cessation * Screen for DM, OSA * KCl supplementation seems to be more helpful in patients with a high salt diet and has been shown to lower BP; due to potential for toxicity, KCl supplements beyond a MVI are generally not used without another reason (diuretic medication, hypokalemia, etc). * Don’t forget to manage and prevent end organ damage: yearly EKG, urine microalbumin, ophthalmology exam; check for bruits, distal pulses, ask about ED, HA, vision changes, etc

Question 39

Thiazide diuretic - target population, ADE, examples

Answer 39

* Low dose thiazide diuretic in both younger and older patients provides better cardioprotection than an ACE inhibitor or a calcium channel blocker in patients with risk factors for coronary artery disease * Mechanism: increase kidney excretion of sodium and water, decreasing fluid volume and arterial pressure * Oldest and most studied antihypertensive class * ADE: urinary frequency, hypokalemia, hyperglycemia * HCTZ, chlorthalidone are examples of drugs in this class * Most people use ACE inhibitors as first line therapy

Question 40

Therapy: Age and Race

Answer 40

* Younger patients: β-blockers and ACEI/ARB * Older patients: diuretics and CCB * Avoid using beta blockers in elderly because it could have consequences for the heart * AA patients: respond better to monotherapy with a thiazide diuretic or calcium channel blocker * relatively poor control with ACEI or β-blockers * Different Tx response may be related to the baseline plasma renin activity (PRA) level * Older / AA hypertensives usually have lower PRA levels than younger / white patients * Drugs that act to lower renin-angiotensin effects, such as ACE inhibitors, ARBs, would be more effective in those with higher PRA levels

Question 41

how to calculate MAP and what constitutes HTN

Answer 41

MAP = DBP + PP/3 PP = Systolic - Diastolic HTN = MAP \>110