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Internal Medicine (IM platinum) > Hypertension > Flashcards

Hypertension Flashcards

1
Q

Blood Pressure Classification

A
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2
Q

Secondary Hypertension

A
  • A specific, remediable cause of hypertension can be identified in ~10%
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3
Q

Clues in suspecting Secondary hypertension

A
  • Abrupt onset of hypertension or eacerbation of previously controlled hypertension
  • Age of onset <20 or >50 years old
  • No family history of HPN
  • DBP >110-120 mmHg
  • Sudden increase in BP in a patient with stable 1 HPN
  • Poor BP control (despite good compliance to adequate drug therapy) or malignant HPN
  • Systemic findings
    • weight loss/gain
    • unprovoked or excessive hypokalemia
  • Disproportionate target organ damage for degree of hypertension
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4
Q

Renal cause of Hypertension

A
  • CLINICAL CLUES
    • Hematuria, urinary symptoms, elevated creatinine, casts on urinalysis
    • Abdominal mass (in Polycystic kidney disease), pallor
  • DIAGNOSTIC TESTS
    • Renal ultrasond
    • Tests to evaluate renal disease
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5
Q

Renovascular disease causing Hypertension

A
  • CLINICAL CLUES
    • Abrupt onset of hypertenson or worsening or difficult to control
    • Flash pulmonary edema
    • Early-onset hypertension (such as in fibromuscular dysplasia)
    • Abdominal bruits
  • DIAGNOSTIC TESTS
    • ​Renal dplex Doppler UTZ
    • Abdominal CT or MRA
    • Angiography
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6
Q

Primary Hyperaldoteronism causing hypertension

A
  • CLINCAL CLUES
    • Hypertension with spotaneous hypokalemia
    • Adrenal mass
    • Arrhytmias from hypokalemia
  • DIAGNOSTIC TESTS
    • Plasma aldosterone/renin ratio
    • Oral sodium loading test
    • IV saline infusion test
    • Adrenal CT scan
    • Adrenal vein sampling
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7
Q

Obstructive Sleep Apnea causing hypertension

A
  • CLINICAL CLUES
    • Resistant hypertension
    • Snoring, apnea during sleeping, day-time sleepiness
    • Obesity
  • DIAGNOSTIC TESTS
    • Berlin Questionnaire
    • Epworth Sleepiness score
    • Overnight oximetry
    • Polysomnography
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8
Q
  • At least 3 separate clinic based measurements >140/90 mmHg and at least 2 non clinic based measurements <140/90 mmHg in the absence of any evidence of target organ damage
A

White coat hypertension

  • Use amblatory BP monitoring for more accurate diagnosis
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9
Q

Defined as:

  • Officce BP >130/80 and with 3 drugs at optimal doses (including a diuretic), or
  • Office BP <130/80 but requires >4 drugs
A

Resistant Hypertension

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10
Q

Fall in SBP >20 mmHg or in DBP >10 mmHg within 3 minutes of assuming upright posture from a a supine position

A

Orthostatic hypertension

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11
Q

Normal or even low BP, bu with evidence of hypertensive end organ damage

A

Masked hypertension

  • Consider severe peripheral arterial disease causing masked hypertension
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12
Q

Screening for hypertension

(US PREVENTIVE TASK FORCE)

A
  • Screening for high BP in adults >18 years old
  • Screening:
    • Every 2 years if BP <120/80
    • Yearly if BP 120-139/80-89 (pre-hypertensive)
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13
Q

Non pharmacologic Management for Hypertension

A
  • Weight Reduction
    • Attain and maintain BMI <25 kg/m2
  • Salt and Potassium in diet
    • For adults, reduction of Na intake by 1 g/day lowers SBP by 3-4 mmHg 9aim to consume no more than 2.4 g/day of Na)
    • Increased K intake may lower BP
  • Adapt Dietary Approaches to Stop hypertension (DASH) type dietary plan
    • Diet rich in fruits, vegetables,low-fat dairy products, whole grains poultry, fish, nuts
    • Diet low in sweets, red meat and saturated/total fat
  • Moderation of alcohol consumptions
    • <2 standard drinks/day in men
    • <1 standard drink/day in women
  • Physical Activity
    • Regular aerobic activity 93-4 sessions a week lasting 40 mins per session)
    • Aerobic physical activity reduces SBP by up to 5 mmHg
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14
Q

Thresholds and Goals of Pharmacological therapy in Patients with Hypertension

A
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15
Q

DIURETICS

A
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16
Q

BETA BLOCKERS

A
17
Q

Calcium Channel Blockers

A
18
Q

RAAS blockers

A
19
Q

Alpha Blockers

A

Blocks the post synaptic A1-receptors found in capacitance and resistance vessels

Adverse effects:

  • Postural hypotension
  • Reflex tachycardia

DRUGS:

  • Prazosin 2-20 mg/d (BID or TID)
  • Terazosin 1-20 mg/d (OD or BID)
  • Doxazosin 1-8 mg/d (OD)
20
Q

Central Sympatholytics

A

Activaion of A2-receptors in the CNS

ADVERSE EFFECTS:

  • Sedation
  • Xerostomia
  • Impotence
  • CNS side effects
  • Rebound HPN on withdrawal (therefore not recommended as emergency meds for crisis/ emergencies)

DRUGS:

  • Clonidine 75-150 mcg/d (BID-TID)
  • Methyldopa 250-1000 mg/d (BID-TID)
21
Q

Direct Vasodilators

A

Release of nitric oxide, leading to arterial vasodilation

ADVERSE EFFECTS:

  • Reflex tachycardia
  • headache
  • Hypotension
  • Lupus-like syndrome (for hydralazine)
  • Hypertrichosis (for minoxidil)

DRUGS:

  • Hydralazine 200-250 mg/d (BID or TID)
  • Minoxidil 5-100 mg/d (OD to TID)
22
Q

Differentiation Between types of Uncontrolled Hypertension

A
23
Q

General Recommendation from 2017 Hypertension Gidelines for hypertensive crisis

A
  • For adults with a compelling condition (aortic dissection, severe preeclampsia/eclampsia, pheochromocytoma crisis), SBP should be reduced to <140 mmHg during the 1st hour and to <120 mmHg in aortic dissection
  • For adults without a compelling condition, SBP should be reduced by no more than 25% within the 1st hour, then if stable, to 160/100 mmHg within the next 2-6 hours, and then cautiously to normal during the following 24-48 hours
24
Q

Nicardipine for hypertensive emergencies)

A
  • DOSE
    • 5-15 mg/hr as continuous infusion
    • Staring dose 5 mg/hr, increase q5 mins by 2.5 mg/hr until goal BP is achieved; therefore decrease to 3 mg/hr
  • CONTRAINDICATIONS and SIDE EFFECTS
    • ​Liver failre
    • Severe aortic stenosis
25
Q

Nitroglycerin for hypertensive emergencies

A
  • DOSE
    • 5-20 mcg/min
    • Initial 5 mcg/min, then increase in increments of 5 mcg/min q3-5 mins
  • CONTRAINDICATIONS and SIDE EFFECTS
    • Can cause headaches
26
Q

Nitroprusside for hypertensive Emergency

A
  • DOSE
    • 0.3-10 mcg/min
    • Initial 5 mcg/min, then increase in increments of 5 mcg/min q3-5 mins
  • CONTRAINDICATIONS
    • Liver/kidney failure
    • Can cause cyanide toxicity
27
Q

Esmolol for Hypertensive Emergency

A
  • DOSE
    • 0.5-1 mg/kg as bolus
    • 50-300 mcg/kg/min as infusion
  • CONTRAINDICATIONS
    • 2nd or 3rd degree AV block, systolic heart failure, bradycardia, COPD
28
Q

Labetalol for hypertensive emergency

A
  • DOSE
    • Initial 0.3-1 mg/kg dose (maximum of 20 mg) slow IV every 10 minutes, or
    • 0.4-1 mg/kg/hr IV infusion (up to 3 mg/kg/h). Adjust rate up to total cumlative dose of 300 mg. This dose can be repeated every 4-6 hours
  • CONTRAINDICATIONS
    • ​2nd or 3rd degree AV block, systolic heart failure, bradycardia, COPD
29
Q

Hydralazine for Hypertensice Emergency

A
  • DOSE
    • Initial 10 mg via slow IV infusion (maximum initial dose of 20 mg)
    • Repeat every 4-6 hours as needed
  • CONTRAINDICATIONS
    • Unpredicatble response and prolonged duration (not a desirable first-line agent)
30
Q

TREATMENT FOR HYPERTENSIVE EMERGENCIES BASED ON END-ORGAN INVOLVEMENT

A

Internal Medicine (IM platinum) (14 decks)

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