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Primary Care Exam 2 > Hypertension > Flashcards

Hypertension Flashcards

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1
Q

How do you calculate blood pressure?

A

Blood pressure = cardiac output x peripheral resistance

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2
Q

What changes in the blood pressure formula cause hypertension?

A

Hypertension = increased cardiac output and/or increased peripheral resistance

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3
Q

What is the most common conditions seen in primary care?

A

Hypertension

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4
Q

Who do we screen for hypertension?

A

All adults over 18 years old

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5
Q

What are some major complications of uncontrolled hypertension?

A

Myocardial infarction, stroke, renal failure, death

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6
Q

What is another name for primary hypertension?

A

Essential hypertension

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7
Q

What are some risks for hypertension?

A
  • Age
  • Race
  • Obesity
  • Diet: ETOH, sodium
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8
Q

What causes secondary hypertension?

A

Medical problems

A: Apnea, aldosteronism
B: Bruit, bad kidney
C: Catecholamine, coarctation, Cushing
D: Drugs (ETOH)
E: Endocrine disorders
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9
Q

Which puts you at higher risk for a cardiac event: Elevated SBP or DBP?

A

Elevated SBP

  • Isolated elevation of systolic blood pressure (>140 mmHg) is related to significant cardiac risk
  • Widening pulse pressure is a significant risk factor for cardiovascular event, especially in ordered adults
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10
Q

What is the most common form of high blood pressure in older Americans?

A

Isolated systolic hypertension

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11
Q

What is your white coat hypertension?

A
  • “Labile” hypertension
  • BP persistently >120/80 at the providers office, but not on home measurements
  • Systolic BP is especially elevated
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12
Q

Are people with white coat HTN at risk for cardiovascular events?

A

CV risks appear to be less than people with sustained HTN, but white coat HTN may increase risk of stroke and LV remodeling

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13
Q

What are some important instructions for your patient to heed before having their blood pressure checked in the office?

A
  • Relax, sitting in the chair, feet on floor, > 5 min
  • Avoid caffeine, exercise, smoking for at least 30 min
  • Empty bladder
  • No talking
  • No clothes under cuff
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14
Q

What are some proper techniques for getting an accurate blood pressure?

A
  • Support patient’s arm

- Use correct sized cuff

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15
Q

According to the 2017 ACC/AHA guidelines, what is considered NORMAL blood pressure?

A

< 120/80 mmHg

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16
Q

According to the 2017 ACC/AHA guidelines, what is considered ELEVATED blood pressure?

A

120-129/<80 mmHg

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17
Q

According to the 2017 ACC/AHA guidelines, what is considered STAGE 1 HTN?

A

130-139/80-89 mmHg

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18
Q

According to the 2017 ACC/AHA guidelines, what is considered STAGE 2 HTN?

A

> 140/90 mmHg

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19
Q

At what blood pressure do we treat hypertension?

A

> 130/80 (STAGE 1): Assessed 10-year ASCVD risk…

  • <10%, lifestyle changes and reassess in 3-6 months
  • > 10% or CVD, DM, CKD, start BP-lowering medication

> 140/90 (STAGE 2): BP-lowering medications (2)

Lifestyle modifications for >120/80

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20
Q

What are the risk factors that are considered when calculating ASCVD risk?

A
  • Age (40-79)
  • Gender (male)
  • Race (African American)
  • Total cholesterol (high)
  • HDL cholesterol (low)
  • SBP (high)
  • DBP (high)
  • Treated for HTN?
  • DM?
  • Smoker?
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21
Q 
What is the
- BP level
- intervention
- reassessment
for someone with a normal blood pressure?
A

<120/80
Promote optimal lifestyle habits
Reassess in 1 year

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22
Q 
What is the
- BP level
- intervention
- reassessment
for someone with elevated blood pressure?
A

120-129/<80
Nonpharmacological therapy
Reassess in 3-6 months

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23
Q 
What is the
- BP level
- intervention
- reassessment
for someone with STAGE 1 HTN?
A

130-139/80-89
Assess ASCVD risk

If ~NO~ ASCVD or 10yr risk <10%:

  • Nonpharmacological therapy
  • Reassess in 3-6 months

If ~YES~ ASCVD or 10-yr >10%

  • Nonpharmacological therapy & BP lowering medication (1)
  • Reassess in one month
  • If BP goal met, reassess in 3-6 months
  • If BP goal NOT met, assess & optimize adherence to therapy, & consider intensification of therapy
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24
Q 
What is the
- BP level
- intervention
- reassessment
for someone with STAGE 2 HTN?
A

> 140/90

  • Nonpharmacological therapy & BP lowering medications (2!)
  • Reassess in one month
  • If BP goal met, reassess in 3-6 months
  • If BP goal NOT met, assess & optimize adherence to therapy, & consider intensification of therapy
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25
What are some diagnostics we need to consider when assessing someone with hypertension?
- 12 lead ECG - BLOOD GLUCOSE (FBG) - Fasting cholesterol panel - GFR - SERUM CALCIUM - SERUM POTASSIUM - Urinalysis - Tsh - Cbc (Echo, uric acid, urinary albumin to creatinine ratio)
26
What are some diagnostics we need to consider when assessing for secondary hypertension?
- Sleep study - Hormone levels (aldosterone, cortisone) - Urine drug screen - Renal ultrasound
27
What are some lifestyle modifications that help reduce blood pressure?
- Exercise - DASH diet - Salt restriction - Weight reduction - Reduction in excess alcohol consumption - Limiting NSAIDs - Stress reduction
28
What are some of the blood pressure benefits of exercise?
- Aerobic and circuit weight training 3x/wk can reduce BP as much as a BB or CCB - Weight reduction - CV conditioning - Decrease lipids (increase HDL)
29
Who benefits the most from sodium restriction in terms of blood pressure reduction?
- African Americans | - Elderly
30
What is the difference between "no added salt" diet and "low salt" diet?
"No salt added" = 4g/day | "Low salt" = 2g/day
31
What lifestyle modification reduces blood pressure the most?
DASH diet + sodium reduction
32
What is the DASH diet?
Dietary Approaches to Stop Hypertension Goals: 2,000 cal/day Sodium: 2,300mg (standard), 1,500mg (low) ``` Whole grains (6-8 servings per day) Vegetables (4-5 servings per day) Fruits (4-5 servings per day) Fat-free/low-fat dairy (2-3 servings per day) Fats/oils (2-3 servings per day) ``` Nuts/seeds/legumes (4-5 servings per week) Meat/poultry/fish (<6 servings per week) Sweets (<5 servings per week)
33
In the general NON-BLACK population, including those with DM, what are some initial first-line antihypertensive treatments?
- Thiazide-type diuretics - Calcium channel blockers (CCBs) - Angiotensin-converting enzyme inhibitors (ACEs) or angiotensin receptor blockers (ARBs)
34
In the general BLACK population, including those with diabetes, what are some initial first-line antihypertensive treatments?
- Thiazide-type diuretic | - Calcium channel blockers (CCBs)
35
In the population aged 18+ with CKD, what are the initial antihypertensive treatments to improve kidney outcomes?
- ACEs - ARBs *This applies for all CKD patients with HTN, regardless of race or diabetes status*
36
What are some secondary antihypertensives?
- Loop diuretics - Potassium-sparing diuretics - Beta blockers - Alpha blockers - Alpha/beta blockers - Direct-acting vasodilators - Centrally acting alpha agonists
37
What are some of the uses/benefits of thiazide-type diuretics?
- First line in many patients, comparable to all other first-line agents - Safe and low-cost - Commonly used in combination
38
What is the mechanism of action of size thiazide-type diuretics?
Enhanced sodium excretion => reduce intravascular volume => reduce peripheral resistance
39
What are some side effects with thiazide-type diuretics?
- Potassium wasting - Hyperglycemia / hypercalcemia / hyperuricemia - Sexual dysfunction - Urinary frequency - Transient increase in LDL
40
What are some cautions with thiazide type diuretics?
- Sulfa allergy - Gout - Monitor hypokalemia, uric acid, calcium
41
Which is more potent: chlorthalidone or hydrochlorothiazide?
Chlorthalidone has 2x potency of HCTZ
42
What are some of the uses/benefits of calcium channel blockers (CCBs)?
- African American patients - Nondihydropyridines (Verapamil, Diltiazem) used to rate control patients with AFib or for control of angina - Preferred over BB for treatment in patients with airway disease
43
What is the mechanism of action of calcium channel blockers (CCBs)?
Block entry of calcium in the heart and vascular smooth muscle => reduces smooth muscle contraction => reduce peripheral resistance
44
What are some side effects of calcium channel blockers (CCBs)?
- Edema - Reflex tachycardia / bradycardia - Headache - Constipation - Dizziness
45
When should we be cautious with using calcium channel blockers (CCBs)?
Not recommended first line after MI
46
Which class of antihypertensive medications may improve GFR in patients with real insufficiency?
Calcium channel blockers (CCBs)
47
What class of antihypertensive medications is a good alternative for patients who have DM/CKD and a history of angioedema with ACE/ARB?
Calcium channel blockers (CCBs)
48
What are some of the uses/ benefits of angiotensin-converting enzyme inhibitors (ACEs)?
- First line in CKD, DM - Specific use after MI, to reduce heart failure and mortality - Reverse LVH and remodeling to hypertension (post MI) - Low cost
49
What is the mechanism of action of angiotensin-converting enzyme inhibitors (ACEs)?
- Blocks conversion of renin-activating angiotensin I to angiotensin II => reduces vasoconstriction => also reduces aldosterone (influences Na & water reabsorption in kidneys) - Inhibits breakdown of bradykinin (vasodilator)
50
What are some side effects of angiotensin-converting enzyme inhibitors (ACEs)?
- Dry cough (benign) - Hyperkalemia - Elevated creatinine (AKI)
51
When must we be cautious with using angiotensin-converting enzyme inhibitors (ACEs)?
- Angioedema (critical) - Must avoid in pregnancy - There are different dosage recommendations for ACE use in HTN vs renal protection - Do NOT use with ARB
52
What are some of the uses/benefits of angiotensin receptor blockers (ARBs)?
- First line in CKD, DM - Specific use after MI, to reduce heart failure and mortality - Reverse LVH and remodeling to hypertension (post MI) - Low cost - Comparable to ACEs in blood pressure control
53
What is the mechanism of action of angiotensin receptor blockers (ARBs)?
-Blocks conversion of renin-activating angiotensin I to angiotensin II => reduces vasoconstriction => also reduces aldosterone (influences Na & water reabsorption in kidneys) No effect on bradykinin (which removes the risk for cough)
54
What are the side effects of in utensil receptor blockers (ARBs)?
- Hyperkalemia - Elevated creatinine (AKI) No cough!
55
When should we be cautious with angiotensin receptor blocker (ARB) use?
- Angioedema - Avoid in pregnancy - Do NOT use with ACE
56
What is the initial antihypertensive drug selection for a black patient?
CCB or thiazide diuretic
57
What is the initial antihypertensive drug selection for a non-black patient <60yo?
ARB or ACE
58
What is the initial antihypertensive drug selection for a non-black patient >60yo?
CCB, thiazide diuretic, ARB, ACE
59
What is the initial antihypertensive drug selection for CKD?
ARB or ACE
60
What is the initial antihypertensive drug selection for CAD?
BB & | ARB or ACE
61
What is the initial antihypertensive drug selection for DM?
ARB or ACE
62
What is the initial antihypertensive drug selection for CHF?
BB & | ARB or ACE
63
What is the initial antihypertensive drug selection for a patient with a history of CVA?
ARB or ACE
64
What are some examples of thiazide-type diuretics?
- Hydrochlorothiazide (HCTZ) | - Chlorthalidone
65
What are some examples of calcium channel blockers (CCBs)?
End with -dipine - Amlodipine - Diltiazem - Nifedipine
66
What are some examples of angiotensin-converting enzyme inhibitors (ACEs)?
End with -pril - Lisinopril - Enalapril
67
What are some examples of angiotensin receptor blockers (ARBs)?
End with -sartan - Losartan - Valsartan
68
What are some examples of loop diuretics?
- Furosemide | - Bumetanide
69
What are some examples of potassium-sparing diuretics?
- Spironolactone | - Amiloride
70
What are some examples of beta blockers (BBs)?
End with -olol - Atenolol - Nadolol - Metoprolol
71
What are some examples of alpha blockers?
End with -azosin - Doxazosin - Terazosin
72
What are some examples of alpha/beta blockers?
End with just -lol - Carvedilol - Labetalol
73
What are some examples of direct acting vasodilators?
- Hydralazine | - Minoxidil
74
What are some examples of a centrally acting alpha agonists?
- Clonidine | - Methyldopa
75
According to the 2017 ACC/AHA guidelines, how do you titrate medication for Stage I HTN?
- If ASCVD risk is >10% or known clinical CVD, DM, or CKD, start 1 BP lowering medication - If goal is met after 1 month, titrate medication, reassess in 3-6 months - If goal is NOT met after 1 month, consider different medication or titration - Continue monthly follow-up until control is achieved
76
According to the 2017 ACC/AHA guidelines, how do you titrate medication for Stage II HTN?
- Start 2 BP lowering medications of different classes | - Follow titration schedule of Stage I HTN
77
What are some cautions with prescribing antihypertensive medications in older patients aged 65+?
- Start low, go slow - Carefully consider diuretics - Monitor renal function closely - Review risk of postural hypotension
78
What are some general cautions with prescribing antihypertensive medications?
- Do not use ACE and ARB together in the same patient - Is the BP goal cannot be reached due to contraindications or the need to use >3 drugs to reach goal BP, antihypertensive drugs from other classes can be used - Referral to a specialist may be indicated for patients in whom goal BP cannot be attained
79
What are some steps to work through in patients with resistant hypertension?
- Confirm resistance - Exclude environmental factors - Screen for secondary causes - Maximize pharmacologic therapy - Refer to specialist
80
Arrange these medications in order of "most affordable": 1. Lisinopril 2. Amlodipine 3. Losartan 4. Hydrochlorothiazide
1. HCTZ ($4) 2. Lisinopril ($4) 3. Amlodipine ($40-50) 4. Losartan ($40-60)
81
Arrange these medications in order of "safest for future mommy": 1. Hydrochlorothiazide 2. Nifedipine 3. Lisinopril 4. Labetalol
1. Labetalol 2. Nifedipine 3. HCTZ 4. Lisinopril
82
Which medications should be used/NOT used in women who are pregnant/planning to become pregnant?
USE: the ABCs Alpha agonist (centrally acting): methyldopa Beta/alpha blocker: labetalol CCB: nifedipine DO NOT USE: the ACEs or ARBs
83
Arrange these medications in order of "easiest regimen": 1. Chlorthalidone 2. Metoprolol 3. Hydralazine 4. Benazepril hydrochloride
1. Chlorthalidone 2. Benazepril HCT (combination medication) 3. Metoprolol 4. Hydralazine
84
What are some barriers to antihypertensives care/compliance?
- Lack of understanding of disease - Lack of access - Side effects - Cost - Lack of appropriate follow-up by provider, including not following up on missed appointments - Confusion regarding medication's language/reading barriers, pharmacy confusion - Therapeutic/clinical inertia
85
What should be documented in the HPI for hypertension?
- Diet - Exercise - Weight loss - Medication adherence - Home blood pressure measurements
86
What should be included in the ROS for hypertension?
- HEENT: vision changes - Pulm: SOB, cough, orthopnea - CV: Chest pain, palpitations - Abd: abdominal pain - Neuro: dizziness, lightheadedness, weakness - Peripheral resistance: edema, leg pain
87
What should be included in the physical exam for hypertension?
- HEENT: fundoscopic exam, thyroid, carotids - Lungs - CV: Rate, rhythm, murmurs - ABD: HSM, aorta - Neuro: cranial nerves, strength - PV: pulses, edema
88
What is the ultimate goal of into hypertensive therapy?
Reduce cardiovascular morbidity and mortality
89
What is the cornerstone of successful/sustained hypertension management?
Lifestyle changes

Primary Care Exam 2 (2 decks)

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