Hypertension (8 questions) Flashcards
(142 cards)
1
Q
What percent of patients with diagnosed HTN are controlled?
A
25%
2
Q
Relationship between age and HTN
A
HTN increases w/age
3
Q
At what age does pulse pressure change and how
A
PP increases d/t decreased diastolic pressure
after age 50
4
Q
Hypertension incidence: blacks vs whites
A
more common in blacks
5
Q
Difference between primary and secondary hypertension
A
- Primary HTN = “essential HTN”. No identifiable cause. Probably mix of environment & genetic
- **Secondary HTN: **identifiable cause
6
Q
Most common cause of HTN before age 50
A
primary HTN
7
Q
Primary HTN accounts for ___ percent of all HTN
A
95%
8
Q
Age range for typical onset of primary HTN
A
25-55yo
9
Q
Some multifactorial causes of HTN: contribution by arterioles
A
- Constriction of resistance arterioles
10
Q
Some multifactorial causes of primary HTN: contribution by baroreceptors
A
decreased Baroreceptor sensitivity
11
Q
Some multifactorial causes of primary HTN: contribution by endothelium
A
Endothelial dysfunction
12
Q
Some multifactorial causes of HTN: contribution by sympathetic nervous system activity
A
Increased Sympathetic nervous system activity
13
Q
Some multifactorial causes of primary HTN: contribution by α and β-adrenergic receptors
A
Decreased α and β-adrenergic receptor response
14
Q
Some multifactorial causes of HTN: contribution by plasma renin
A
Low plasma renin activity
15
Q
Some multifactorial causes of primary HTN: contribution by insulin system
A
Insulin resistance
16
Q
Some multifactorial causes of primary HTN: contribution by neurohormonal factors
A
Neurohormonal factors that decrease vascular response (poor dilation)
17
Q
Causes of secondary HTN
A
- Medications of drugs
- Pheochromocytoma (rare)
- Coarctation of the aorta
- Primary renal disease
- Primary aldosteronism
- Renocvscular disease
- Cushing’s syndrome
- Obstructive sleep apnea
- Increased intracranial pressure
18
Q
JNC 7: normal BP
A
SBP <120
DBP <80
19
Q
JNC 7: prehypertension
A
SBP 120-139
DBP 80-89
20
Q
JNC 7: stage I HTN
A
SBP 140-159
DBP 90-99
21
Q
JNC 7: Stage 2 HTN
A
SBP: > 160
DBP: > 100
22
Q
HTN: presentation (initial and late)
A
- Usually silent
- Occasionally headache
- End organ disease symptoms: renal, cardiac, ophthalmologic, cognitive impairment
23
Q
Goals of JNC7 assessment
A
- Stage BP: how high is it?
- Determine CVD risk
- Determine if secondary HTN is present
- Determine if any end organ damage is present
24
Q
Diagnosis of HTN
A
- Hypertension should never be diagnosed based on only one reading in the office.
- 2 or more readings, taken at 2 or more visits at least 2 weeks apart. (calculate and average)
- Measure twice, keep patient sitting and relaxed, use the correct cuff, big arm, big cuff.
- Inflate cuff 20mm higher than the level that obliterates the radial pulse (esp in older)
- Both arms, sitting and standing
25
BP relationship to risk of CVD
continuous, consistent, and independent of other risk factors.
26
How many increments of BP increase to double risk of CVD?
Each increment of 20/10 mmHg doubles the risk of CVD across the entire BP range starting from 115/75 mmHg.
27
Risk factors for CVD
* HTN **\***
* Smoking
* Obesity **\*:** BMI ≥30kg/m2
* Physical inactivity
* Dyslipidemia **\***
* Diabetes **\***
* Age \>55 for men or \> 65 for women *– applies more to white women. Black women develop earlier, 55/45*
* Family history of heart disease— women \<65 and men \<55
* Microalbuminuria *– indicates renal damage*
* GFR \<60ml/min
**\***components of metabolic syndrome
28
HTN exam: what should you check?
* Weight gain or loss
* Retinas: exudate, hemorrhages, papilledema
* Lung Sounds
* Heart Sounds
* Check lower legs/ankles
* BP & HR :supine-sitting-upright *(esp geriatric)*
29
Baseline diagnostic tests for primary causes of HTN
* Comprehensive Metabolic Panel
* *CBC *
* Lipids
* TSH
* HbA1C
* UA (Urine MicroAlbumin)
* EKG
* Echocardiogram
30
components of CMP
* [Alkaline phosphatase](http://www.nlm.nih.gov/medlineplus/ency/article/003470.htm): 44 to 147 IU/L
* [ALT](http://www.nlm.nih.gov/medlineplus/ency/article/003473.htm) (alanine aminotransferase): 8 to 37 IU/L
* [AST](http://www.nlm.nih.gov/medlineplus/ency/article/003472.htm) (aspartate aminotransferase): 10 to 34 IU/L
* [Total bilirubin](http://www.nlm.nih.gov/medlineplus/ency/article/003479.htm): 0.2 to 1.9 mg/dL
* [BUN](http://www.nlm.nih.gov/medlineplus/ency/article/003474.htm) (blood urea nitrogen): 7 to 20 mg/dL
* [Creatinine](http://www.nlm.nih.gov/medlineplus/ency/article/003475.htm): 0.8 to 1.4 mg/dL
* [CO2](http://www.nlm.nih.gov/medlineplus/ency/article/003469.htm) (carbon dioxide): 20 to 29 mmol/L
* [Potassium test](http://www.nlm.nih.gov/medlineplus/ency/article/003484.htm): 3.7 to 5.2 mEq/L
* [Sodium](http://www.nlm.nih.gov/medlineplus/ency/article/003481.htm): 136 to 144 mEq/L
* [Calcium](http://www.nlm.nih.gov/medlineplus/ency/article/003477.htm): 8.5 to 10.9 mg/dL
* [Chloride](http://www.nlm.nih.gov/medlineplus/ency/article/003485.htm): 96 - 106 mmol/L
* [Glucose test](http://www.nlm.nih.gov/medlineplus/ency/article/003482.htm): 70 to 100 mg/dL
* [Total protein](http://www.nlm.nih.gov/medlineplus/ency/article/003483.htm): 6.3 to 7.9 g/dL
* [Albumin](http://www.nlm.nih.gov/medlineplus/ency/article/003480.htm): 3.9 to 5.0 g/dL
31
Components of BMP
* BUN: 7 to 20 mg/dL
* Creatinine: 0.8 to 1.4 mg/dL
* CO2 (carbon dioxide): 20 to 29 mmol/L
* Glucose: 64 to 128 mg/dL
* Serum chloride: 101 to 111 mmol/L
* Serum potassium: 3.7 to 5.2 mEq/L
* Serum sodium: 136 to 144 mEq/L
32
Components of CBC
RBC count:
* Male: 4.7 to 6.1 million cells/mcL
* Female: 4.2 to 5.4 million cells/mcL
WBC count:
* 4,500 to 10,000 cells/mcL
Hematocrit:
* Male: 40.7 to 50.3%
* Female: 36.1 to 44.3%
Hemoglobin:
* Male: 13.8 to 17.2 gm/dL
* Female: 12.1 to 15.1 gm/dL
Red blood cell indices:
* MCV: 80 to 95 femtoliter
* MCH: 27 to 31 pg/cell
* MCHC: 32 to 36 gm/dL
33
WBC w/differential
* Neutrophils: 40% to 60%
* Lymphocytes: 20% to 40%
* Monocytes: 2% to 8%
* Eosinophils: 1% to 4%
* Basophils: 0.5% to 1%
* Band (young neutrophil): 0% to 3%
34
Diagnostic studies for secondary causes of HTN
* 24hr urine free cortisol and plasma metanephrine levels
* Renal ultrasound
* Abdominal imaging: ultrasound, CT Scan, MRI
* Renal Arteriography
35
Benefits of lowering BP
**Average Percent Reduction**
Stroke incidence
35–40%
Myocardial infarction
20–25%
Heart failure
50%
36
What to explain to PT about end organ damage
* Heart: explain to the patient. This is a silent killer
* Left ventricular hypertrophy
* Angina or prior myocardial infarction
* Prior coronary revascularization
* Heart failure
* Brain : once again need to partner with the patient
* Stroke or transient ischemic attack
* Chronic kidney disease
* Peripheral arterial disease
* Retinopathy
37
JNC 8 target goals for BP
* General population aged ≥ 60 years: 150/90 mmHg (140/90 mmHg for everybody else)
* Population aged 18 years with DM or CKD: 140/90mmHg
* *Note: Diabetes and renal disease need more aggressive treatment --\> 130/80mmHg (JNC 7)*
38
JNC 8: General nonblack population (including those with diabetes), initial antihypertensive treatment
a thiazide-type diuretic, CCB, ACEI or ARB.
39
JNC 8: General black population (including those with diabetes), initial antihypertensive treatment
a thiazide-type diuretic or CCB
40
JNC 8: Population aged18 years with CKD, initial (or add-on) antihypertensive treatment, regardless of race or diabetes status
ACEI or ARB
41
Treatment guidelines for prehypertension:
No risk factors or target organ disease--lifestyle changes
42
Treatment guidelines for stage 1 HTN
Lifestyle change but newer approach is aggressive--one drug needed
43
Tx guidelines stage 2 HTN
start with 2 drug therapy
44
Tx guidelines: diabetes & renal dz
need more aggressive treatment--\> à 130/80mmHg
45
Summary of general treatment goals, HTN
* Reduce CVD and renal morbidity and mortality
* * Lower if preserving renal function
* Lower to slow heart failure progression
46
Can Hypertension Be Prevented?
* Blood pressure rise is not inevitable with age--prospective follow up study (to DASH?)
* However, Framingham data suggest that normotensive 55 year olds have a 90% lifetime risk for developing hypertension!
* Treatment for over one year did not prevent the onset of hypertension only delayed it
47
Important findings on relationship between diet, weight loss, and BP
* Diet rich in fruits, vegetables, and low-fat dairy foods, with reduced fats lowers BP in a randomized trial (DASH)
* Population wide--reduce salt in processed food, reduced caloric intake (obesity and sleep apnea directly correlated with HTN)
* Weight loss (~2.5 kg or 5 lbs) can reduce BP similar to monotherapy
48
For what populations is low sodium diet especially effective?
middle-aged and older individuals, African Americans, and those who already had high BP
49
Components of DASH diet
**Nutrient**
**Amount**
**Nutrient**
**Amount**
**Total Fat**
27 % of calorie
Sodium
2,300 mg**\*\***
**Saturated Fat**
6 % of calorie
Potassium
4,700 mg
**Protein**
18 % of calorie
Calcium
1,250 mg
**Carbohydrate**
55 % of calorie
Magnesium
500 mg
**Cholesterol**
150mg
Fiber
30 g
**\*\*** 1,500mg sodium was a lower goal tested and found to be even better for lowering BP. It was particularly effective for middle-aged and older individuals, African Americans, and those who already had high BP.
50
Lifestyle Modifications to Manage Hypertension
* Weight reduction
* Adopt DASH eating plan
* Dietary sodium reduction
* Physical activity
* Moderation of alcohol consumption
51
HTN mgmt: Weight reduction - recommendation & approximate reduction in SBP
* Maintain normal body weight (body mass index, 18.4-24.9 kg/m2)
* 5-20 mm Hg; 10-kg weight loss
52
HTN mgmt: Adopt DASH eating plan - recommendation & approximate reduction in SBP
* Consume diet rich in fruits, vegetables, low-fat dairy products, with reduced content of saturated and total fats
* 8-14 mm Hg
53
HTN mgmt: Dietary sodium reduction - recommendation & approximate reduction in SBP
* Reduce dietary sodium intake to no more than 100 mmol/day (2.4 g sodium or 6 g sodium chloride)
* 2-8 mm Hg
54
HTN mgmt: Physical activity - recommendation & approximate reduction in SBP
* Engage in regular aerobic physical activity (e.g., brisk walking) at least 30 min/day, most days of the week
* 4-9 mm Hg
55
HTN mgmt: Moderation of alcohol consumption- recommendation & approximate reduction in SBP
* Most men: limit consumption to no more than two drinks/day‡ Most women and those who weigh less than normal: no more than one drink/day
* 2-4 mm Hg
56
Classes of oral antihypertensive drugs
* Diuretics (Thiazide)
* ACE inhibitors
* ARBS
* Calcium Cannel Blockers (CCBs)
* Beta Blockers
* Alpha Blockers
* Beta Blockers
* Direct renin inhibitor
* Sympatholytic Types
* Diuretics (Loop and K sparing)
* Central Sympatholytic
* Direct Vasodilators
57
If taking a K sparing or ACE/ARB, how often check electrolytes?
Q3 mths
58
How long trial lifestyle modifications before moving to pharm therapy?
"can try 6mth trial. 1 year is too long/negligent"
59
1st line antihypertensives
* Diuretic (Thiazide): in uncomplicated HTN (JNC)-inexpensive and effective
* ACEIs
* ARBs
* CCBs
60
What if BP goal is not achieved on monotherapy?
Combine different 1st line agents
61
White males may do better with ___ as first line
ACEi
62
Most patients need 2+ antihypertensives. What are recommended combinations?
* ACE WITH DIURETIC
* ARB WITH DIURETIC
* BB WITH DIURETIC
* CCB WITH DIURETIC
Add a second drug from a different class
63
First line pharm for black population
thiazide or CCB, but may start w/ACE if diabetic
64
HTN management: BP is 160/100 or greater
consider starting with 2 drugs (or combination product)
65
JNC algorithm: first intervention
lifestyle modification
66
JNC 7: you've tried lifestyle modification. Why would you move to drug therapy?
Not at goal BP (
"6 mth trial at most"
67
JNC 7 algorithm: Initial drug choice for stage 1 HTN w/o "compelling indications"
thiazide for most
may consider ACEi, ARB, BB, CCB, or combo
68
JNC 7 algorithm: Initial drug choice for stage 2 HTN w/o "compelling indications"
2 drug combo for most (usually thiazide type diuretic & ACEi, ARB, BB, or CCB)
69
JNC 7 algorithm: Initial drug choice HTN with "compelling indications"
other antihypertensive drugs (diuretics, ACEi, ARB, BB, CCB) - chart w/appropriate meds for each "compelling indication" - e.g., recent MI (BB), Diabetes (ACEi), etc...
70
"Compelling indications"
Angina + HTN, treat with....
β-blocker or CCB
71
"Compelling indications"
Atrial tachycardia or A Fib + HTN, treat with....
β-blocker, non-DHP CA
72
"Compelling indications"
Essential tremor + HTN , treat with....
–β-blocker
73
"Compelling indications"
Heart failure + HTN, treat with....
Carvedilol [Coreg]
74
"Compelling indications"
Hyperthyroidism + HTN, treat with....
β-blocker
75
"Compelling indications"
Migraine + HTN, treat with....
β-blocker, non-DHP CA
76
"Compelling indications"
Osteoporosis + HTN , treat with....
Thiazides
77
"Compelling indications"
Preop Hypertension, treat with...
β-blocker
78
"Compelling indications"
BPH + HTN, treat with...
α-blocker
79
"Compelling indications"
Raynaud’s Syndrome + HTN, treat with...
CCB
80
Bronchospasm, avoid which med(s)?
avoid β -Blocker
81
Depression, avoid which med(s)?
avoid central α-agonist, reserpine
82
Diabetes and dyslipidemia, avoid which med(s)?
avoid High dose diuretics
83
Gout, avoid which med(s)?
avoid thiazides
84
Heart bock, CHF: avoid which med(s)?
β-blocker, non-DHP CCB
85
Liver Dz, avoid which med(s)?
Avoid labetalol, methyldopa
86
PVD, avoid which med(s)?
Avoid β-blocker
87
Pregnancy, avoid which med(s)?
Avoid ACE I, Angiotensin II blocker
88
Angioedema, avoid which med(s)?
avoid ACEi
89
Renal insufficiency, avoid which med(s)?
Avoid K+-sparing agents
90
Bilateral renovascular dz, avoid which med(s)?
Avoid ACE I, ARB
91
natural products that raise BP
* Blue Cohosh (*Caulophyllum thalictroide*)
* Dong quai Ephedra increases BP
* Licorice (*Glycyrrhiza glabra*)
* Yohimbe (*Pausinystalia yohimbe*)
* Coltsfoot (*Tussilago farfara*)
* Ginseng (*Panax ginseng*) increases or decreases BP
92
Natural Products that Lower BP
* Coenzyme Q (*Ubiquinone*) lowers 2-7%
* Garlic (*Allium sativum*) may or may not
* Ginkgo (*Ginkgo biloba)*
* Ginseng (*Panax ginseng*) may lower depending on preparation
* Hawthorn (*Crataegus laevigata)*
* St. John’s Wort (*Hypericum perforatum*)
* Black Cohosh (*Cimifuga spp*.)
* Omega 3 Fatty Acids
93
Adherence--contributes to lack of control in __ of patients!
2/3
94
Tips for managing adherence
* Involve patient in their treatment
* Maintain contact--email? Telephone?
* Integrate into routine activities of living
* Inexpensive and simple pharmacologic choice
* Combination Products
* Health literacy (teaching back methods)
* Establish trusting relationship
*ask pharmacist to monitor refills; call and ask; ask at each visit in nonjudgmental way*
95
Besides adherence, why might medications fail?
* Smoking
* Increasing obesity
* Sleep apnea
* Insulin resistance/hyperinsulinemia
* Ethanol excess
* Anxiety, panic attacks, chronic pain
* TRUE SECONDARY CAUSE OR RESISTANCE
96
What is true resistance?
* Can’t meet goal with 3 agents including a diuretic
* At maximal doses
* Suspect secondary causes
97
What is metabolic syndrome
* 3 of following:
* Abdominal obesity
* Glucose intolerance (fasting glucose \> 109)
* High triglycerides
* Low HDL (
## Footnote
*treat each component !*
98
Obesity: BMI & waist
BMI \>30 (waist \>39 in. men, \>34 in. women)
99
HTN present in \_\_\_\_% of patients with DM
75%
100
Goal BP for diabetic (JNC7, JNC8, ADA 2015)
101
Recommended classes of drug for HTN with DMI and DMII w/renal insufficiency
(and what if they have CHD too?)
DMI: ACEi
DMII: ARB
Usually also need loop diuretic and CCB (start after ACEI/ARB), add β-blocker if has CHD
102
Pharm mgmt of HTN in post-MI patients
* Use non-selective beta blocker if at all possible
* Use ACE I or ARB if LVH or Left Ventricular Dysfunction
* ASA
* Lipid lowering agents
103
Mgmt of HTN w/ LVH
* Find LVH on EKG or Echo
* Salt reduction, weight loss, aggressive BP treatment
* All classes of antihypertensive cause regression except direct vasodilators
* *Post MI + LVH: Use ACE I or ARB if LVH or Left Ventricular Dysfunction*
104
Pharm mgmt: HTN + Congestive Heart Failure
* After MI, ACE I prevents heart failure
* ACE inhibitors and Beta Blockers--reduce
morbidity and mortality
* Hydralazine and Isosorbide
* Symptomatic dysfunction/end stage—ACE I, Beta
blocker, ARB, spironolactone, loop diuretics
* Only amlodipine or felodipine CA in CHF
105
Treatment of HTN + renal dz
(+ goal BP and what measures of renal dz?)
Creatinine \> 1.5 (GFR 60), or albuminuria \> 300mg
* Lower BP goal
* All classes of antihypertensives work
* ACE/ARB with T1DM/T2DM
* ACE/ARB with non-diabetic renal disease
106
Treatment: HTN + dyslipidemia
* Lifestyle modifications first
* Low dose thiazides, no metabolic effects
* β-blockers reduce HDL but also reduce mortality, MI
* Alpha-blockers lower cholesterol and increase HDL
107
Treatment of HTN + respiratory dz
* Sleep apnea can reduce HTN control
* Beta blockers and alpha-beta-blockers can exacerbate asthma
* ACE I- safe with asthma--if cough, try ARB
* Avoid sympathomimetic decongestants
* Cromolyn, atrovent, inhaled steroids OK
108
Treatment of HTN + gout
* Hyperuricemia is common finding-- decreased renal blood flow
* Diuretics can increase uric acid
* Diuretics rarely cause acute gout
* If gout, avoid Thiazide
109
Blacks & HTN: global incidence, stroke rate, MI rate, relative ESRD risk
* Highest incidence in the world
* 80% **** stroke rate
* 50% **** heart attack rate
* 320% **** ESRD (end stage renal disease)
110
Blacks & HTN: first line w/ckd & proteinuria
ACEI or ARB as initial tx
111
Blacks & HTN: first line w/CKD but no proteinuria:
Thiazide diuretics, CCB, ACE or ARB (? as initial tx)
112
Blacks and HTN: response to BBs or ACEi as monotherapy
decreased responsiveness
113
Blacks and HTN: relative frequency of angioedema
2-4x more frequent
114
Women and HTN: difference in response to Tx
none
115
Women & HTN: effect of OC on BP
increases BP esp w/smoking, age \>35
116
Women & HTN: If pt needs OCPs and has HTN?
treat the HTN
117
Women & HTN: effect of HRT on BP
does not increase BP
118
Women and HTN: considerations in drug selection
No ACE inhibitors if child bearing age
119
Pregnancy & HTN: when is HTN considered chronic?
present at
120
Pregnancy & HTN: considerations in choosing drug therapy
* Methyldopa [Aldomet] safest choice or vasodilators
* Beta blockers after 20 weeks- may retard growth if used early in pregnancy
* Diuretics OK if started before pregnancy
* ACEIs and ARBs avoided (neonatal renal failure risk)
121
Elderly & HTN: which is better predictor of adverse events, SBP or DBP?
SBP
122
New onset HTN in elderly. What two secondary causes of HTN should you consider?
Renovascular hypertension and primary aldosteronism more common-especially w/ new onset
123
Elderly & HTN: do salt reduction and weight loss work?
yes (TONE trial)
124
Elderly and HTN: considerations in dosing agents
Start low (1/2 usual dose) and go slow
## Footnote
Assess for postural hypotension, if present, back off on meds
125
HTN drug of choice in elderly
thiazide diuretics
126
HTN and elderly: drug of choice if isolated systolic HTN
Thiazide, DHP CCB, ACEI, ARB
127
Elderly & HTN: which meds more likely to cause OH?
adrenergic blockers, alpha-blockers, Viagra, diuretics
128
F/U of treated HTN
* Once stabilized limit office visits (3-6 months) and lab work/tests to what is appropriate for the individual patient
* Consider co-morbid conditions
* Step-down therapy if achieved favorable lifestyle changes, weight loss, etc…
* decrease doses or D/C of medications occasionally feasible
129
Important aspects of history in PT w/HTN
130
Important aspects of PE w/HTN
131
BP assessment: caffeine, exercise, smoking
avoid at least 30min before BP measurement
132
BP measurement: The inflatable part of the blood pressure cuff should cover about \_\_\_% of the circumference of your upper arm.
80
133
BP measurement: The cuff should cover \_\_\_of the distance from your elbow to your shoulder
2/3
134
Secondary HTN clues:
Onset: at age 55 yrs
fibromuscular dysplasia, athelosclerotic renal artery stenosis, sudden onset-- thrombus or cholesterol embolism
135
Secondary HTN clues: Severity
Grade II, unresponsive to treatment.
136
Secondary HTN clues:
Episodic, headache and chest pain/palpitation
pheochromocytoma, thyroid dysfunction
137
Secondary HTN clues:
Morbid obesity with history of snoring and daytime sleepiness
sleep disorders
138
Secondary HTN clues:
Increased creatinine, abnormal urinalysis
renovascular and renal parenchymal disease
139
Secondary HTN clues:
Unexplained hypokalemia
hyperaldosteronism
140
Secondary HTN clues:
Impaired blood glucose
hypercortisolism
141
Secondary HTN clues:
Impaired TFT
Hypo-/hyper- thyroidism
142
Give an ACEi or ARB and they get worse, consider...
secondary HTN
