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Flashcards in Hypertension CIS Deck (49):
1

65 y/o F brought to ED for increasing confusion. Has been complaining of a terrible headache and blurred vision for last 2 days. Ran out of meds 2 weeks ago because insurance ran out.
PMH: HTN and tachyarrhythmia
Meds: metoprolol, 50 mg 2x/day
NKDA
97.F, BP 200/120, P 100/min
Loud S4
Lungs: bi-basilar rales
Electrocardiogram consistent with left ventricular hypertrophy

Which would be best immediate action?
A. Administer lorazepam
B. Obtain serum creatinine level
C. Observe pt in quiet room
D. Perform lumbar puncture
E. Administer intravenous nitroprusside

A. Administer lorazepam: would further cloud sensorium, suppress respirations
B. Obtain serum creatinine level: will not protect from target organ damage and would be included in initial bloodwork
C. Observe pt in quiet room: high BP with symptoms needs acute invertevention
D. Perform lumbar puncture: BP of 200/120 poses great danger, no sign of infection, and no h/o falls or worst headache of my life
*E. Administer intravenous nitroprusside* quick onset, easily titratable to avoid too quickly lowering her BP, generally well tolerated

2

Describe hypertensive urgency vs emergency

Urgency
Systolic BP>180 or diastolic BP>130 and NO evidence of end organ damage

Emergency
May occur at any BP but involves damage to at least one organ system

3

What are signs of target organ involvement in HTN?

CV: MI, angina, aortic dissection, aneurysmal dilation of large vessels, LVH, CHF

Renal: hematuria, proteinuria, AKI (ARF)

CNS: cerebral edema, altered mental status, bleed, stroke, TIA

Ophthalmologic: retinal hemorrhages or exudates, papilledema, AV nicking

4

28 y/o F is pregnant in first trimester and has just been diagnosed with hypertension with no secondary established. Her hypertension has not responded to diet, exercise, and stress reduction.

As a first line therapy, which would you recommend?
A. Thiazide diuretic
B. Magnesium sulfate
C. Enalapril
D. Diltiazem
E. Methyldopa

A. Thiazide diuretic: decreasing circulating volume is contraindicated in pregnancy due to decreased perfusion of placenta and fetus
B. Magnesium sulfate: no signs of preeclampsia
C. Enalapril: pregnancy category D: absolutely contraindicated in pregnancy. Teratogenic in 1st trimester
D. Diltiazem: pregnancy category C. Risk to fetus
E. Methyldopa: pregnancy category B, alpha agonist

5

19 y/o F otherwise healthy, comes to clinic for routine health check. Complains of episodic headaches as well as occasional palpitations. Blood pressure check reveals pressure of 190/110.
PE: abdominal bruit heard over upper right and left abdominal quadrants. Because pt has previously had normal BP as a teenager and has no family history of HTN, extensive search for secondary causes of HTN is undertaken.
Magnetic resonance demonstrates a string of beads bilaterally.

Which of the following should be used with utmost vigilance in this pt?
A. Amlodipine
B. Clonidine
C. Hydrochlorothiazide
D. Metoprolol
E. Fosinopril

E. Fosinopril
Age group likely to have sex and get pregnant. ACEIs avoided in childbearing population

ACEIs small risk of induction of kidney failure. They dilate vascular surrounding kidneys. Efferent arterioles dilated. Narrowing of afferent arterioles in pt plus ACEIs could lead to decreased blood flow and thus kidney failure.

6

Compare/contrast atherosclerosis with fibromuscular dysplasia

Atherosclerosis
>50 y/o
Male
33% bilaterally
Progressive +++
Responsive to angioplasty +
Associated risks (tobacco, lipids, diabetes) +++

Fibromuscular dysplasia

7

Describe renovascular hypertension associated with renal artery stenosis

1. Stenosis is a progressive obstructive disease
2. Stenosis rate of 1.5% per month
3. If untreated, can lead to total occlusion
4. Causes of stenosis & HTN are atherosclerosis and fibromuscular dysplasia

8

Describe the different types of fibromuscular dysplasia

Medial fibromuscular dysplasia
-most common. 85% of all stenosis
-9/1 F to M, ages 25-45
-can be seen in carotids and iliac arteries
-70% bilateral
-may appear as solitary mid and distal stenotic lesions or multiple constrictions with intervening aneruysmal dilations

Perifibromuscular dysplasia
-10-25%
-usually mid-distal portion of renal artery

Intimal fibromuscular dysplasia
-5%
-M=F
-infants and young adults more frequent

9

What are the types of renal arterial stenosis (RAS)?

1. One stenosis
-2 kidneys (unilateral renal arterial stenosis)

2. Two stenoses
-2 kidneys (bilateral renal artery stenosis)

3. One stenosis
-1 kidney (unilateral stenosis in solitary kidney)

10

Compare the 3 types of RAS

Unilateral
-decreased intravascular volume
-more renin mediated (increased) than others
-BP usually falls with ACEIs

Bilateral or one kidney
-increased intravascular volume
-renin mediation is more varied
-ACE response unpredictable and may worsen HTN

11

Describe diagnosis of renovascular hypertension

1. Renal ultrasound with arterial dopplers
2. Captopril test (reactive rise in renin and large fall in BP after administration)
3. Digital subtraction angiography
4. MRI: angiography
5. Arteriography
6. Renal vein renin ration (ratio of 1.5 or greater)

12

Describe treatment of renovascular hypertension

1. Aimed at BP control and preservation of renal function
2. Medical rx: antihypertensive meds
3. Unilateral stenosis: ACEI unpredictable, may worsen
4. Bilateral stenosis or unilateral with 1 kidney: may see renal dysfunction caused by ACEI
5. Poor response to 3 or more agents points way to nonpharmacologic interventions, eg stenting
6. Surgical treatment grafting

13

What are contraindications to ACEIs?

1. Bilateral renal artery stenosis
2. Unilateral renal artery stenosis with solitary kidney
3. Pregnancy
4. Known angioneurotic edema with prior ACE administration
5. Relative contraindication: ACE-induced cough

14

What can cause secondary hypertension?

Sleep apnea
Drug-induced causes
Chronic kidney disease
Primary aldosteronism
Renovascular disease
Steroid therapy or Cushing's syndrome
Pheochromocytoma
Coarctation of aorta
Thyroid disease
Parathyroid disease

15

72 y/o M presents to ED suffering from palpitations and headache. At time of arrival, he is found to have a BP of 210/120 mm HG, proteinuria confirmed by dipstick, and his funduscopic.
PMH: long-standing essential hypertension

1. What do you expect on his funduscopic?

2. Pt states that his systolic BP has never been greater than 175. He normally takes hypertensive meds but ran out and missed last night's dose.
Which, if abruptly stopped, is most likely to cause this pt's symptoms?
A. Atenolol
B. Clonidine
C. Felodipine
D. Hydrochlorothiazide
E. Lisinopril

1. Arteriorvenous nicking (long standing history of HTN)
Papilledema (hypertensive emergency)

2. Clonidine
Possibly hypertension urgency.
Alpha2 agonist
Decreases sympathetic outflow

16

48 y/o M presents to clinic for a return visit and has a history of adult-onset diabetes. On previous visits, a great deal of time has been spent working with pt to bring his diabetes and cardiac risk factors under control. Although blood glucose levels are better controlled and his lipids are near target, his BP remains elevated. The pt has been watching his diet and exercising for last 6 months but still has a BP of 148/92 on today's visit.

Which is most appropriate, first medication to start for this pt's HTN?
1. Acetazolamide
2. Clonidine
3. Felodipine
4. Hydrochlorothiazide
5. Lisinopril
6. Metoprolol
7. Sprionolactone
8. Terazosin
9. Triamterene
10. None, continued diet and exercise

1. Acetazolamide: glaucoma, acute mountain sickness
2. Clonidine: risky
3. Felodipine: CCB
4. Hydrochlorothiazide: affects glucose regulation
*5. Lisinopril* Good choice for diabetics with HTN and proteinuria
-Reduces pressure on glomerulus because of efferent dilation
6. Metoprolol: not as good as lisinopril
7. Sprionolactone: Not as efficacious as thiazides
-Not as much sodium at DCT
-Reduces morbidity/mortality in HF
8. Terazosin: alpha-blocker, effective in HTN with BPH
9. Triamterene: Like spironolactone
-Potassium-sparing diuretics
-Not as efficacious
10. None, continued diet and exercise

17

What are primary causes of kidney failure?

Diabetes 43.8%
High BP 26.8%
Glomerulonephritis 7.6%
Cystic diseases 2.3%
Urologic diseases 2%
Other 17.5%

18

62 y/o F presents to office to follow up on elevated BP at her annual exam 2 weeks ago. PMH negative, PSH hysterectomy for fibroids. No meds, NKDA, labs normal, ophtho normal.

Which does JNC8 recommend for management for this pt's HTN?
A. 110/50
B. 120/60
C. 130/70
D. 140/80
E. 150/90

E. 150/90

19

Describe 8th Joint National Committee and management of HBP in adults: Grades A and B

Grade A: In general population over 60 y/o, initiate treatment to achieve goal of 150/90

Grade B: in over 18 y/o with CKD, initial or add-on therapy should include ACEI or ARB

20

21 y/o M presents to ED complaining of chest pain and tightness and SOB. He was at a party when he clutched his chest, was pale, dyspneic, and diaphoretic. Recent ED visit for a broken toe. No medical problems, no allergies, no meds.
Active on tennis and basketball teams.
Father had MI at 60. Mother takes meds for hyperlipidemia.
He needs to take antibiotics before dental procedures because of a problem with a heart valve.
BP 185/105, P 120/min. O2 sat normal. 100F.
EKG shows acute ST-segment elevations in anterolateral leads.
He is hostile and mumbling incoherently, and his eye exam shows bilateral pupils dilated with minimal reaction to light.

What is most likely explanation for these findings?
A. Cardiac contusion
B. Pheochromocytoma
C. Plaque rupture
D. Valvular incompetence
E. Drug overdose

Drug overdose

21

What are cardiac causes of secondary HTN?

MI
Acute left ventricular failure
Vasculitis
Coarctation of aorta
Aortic dissection
Volume overload (including pulmonary edema)

22

What is coarctation of aorta?

Narrowing of medial layer of aorta
Commonly at ligamentum arteriosum
3 types
-interrupted
-preductal
-postductal

23

Describe diagnosis of coarctation

1. Differences in BP of upper and lower extremities
-systolic hypertension in infant
-20 mm Hg between arms

2. Heart sounds
-if isolated, a systolic ejection murmur in aortic outlet and between scapulae

3. Radiology
-cardiomegaly
-rib notching on PA chest
-3 sign on lateral chest

24

56 y/o M presents to clinic for a return visit. Last 3 visits, his BP has been in 150-160 systolic and 90-95 diastolic ranges.
Despite 3-6 months of following a healthy diet and exercise program, he has not been able to get his BP under control.
PMH: negative besides HTN
FH: Brother HTN and died from heart attack in mid-60s
BP today 162/92

What is the most appropriate, cost-effective, first-line treatment for this pt?

Hydrochlorothiazide or lisinopril

25

52 y/o F returns for follow-up visit after being discharged from hospital. She was seen 3 days ago for recently diagnosed diabetes mellitus type 2 and essential HTN. At her last visit, you switched her from hydrochlorothiazide to enalapril. Approximately 3 days after starting therapy, she began to develop facial swelling that progressed to stridorous SOB. She was admitted to hospital for close observation and was told to discontinue enalapril. She was advised to discuss medications to take.

What would you prescribe?

Hydrochlorothiazide

26

55 y/o M presents to office for annual visit. He denies chest pain, palpitations, headache, dyspnea, or lightheadedness. He is currently taking insulin for his diabetes. He has no other medical issues. He is fairly active and is able to perform all activities of daily living. NKDA.
BP 135/85, P 80/min.
Lungs clear. Heart rate regular
No pedal edema
Chemistry panel unremarkable
ECG normal sinus rhythm.
Urine studies reveal microscopic albumin in urine.

What is appropriate management at this time?
A. Encourage lifestyle modification
B. Hydrochlorothiazide 12.5 daily
C. Hydrochlorthiazide 12.5 + metoprolol 25 mg bid
D. Lisinopril 10 mg daily
E. Metoprolol 25 mg bid

D. Lisinopril 10 mg daily

27

41 y/o F referred for evaluation of long-standing HTN. First diagnosed 10 years ago on routine PE. At that time, BP of 200/100, serum potassium 2.7 even though no meds of any kind. She was started on metoprolol and hydralazine in addition to potassium sypplementation.
For ensuing 8 years, she remained hypertensive and hypokalemic. Meds were changed 2 years ago without success. She is not getting any "water pills"
BP 180/100. Na 145, K 2.6, bicarb 38.

What would most likely help diagnose her condition?
A. Dexamethasone suppression test
B. Renal artery doppler flow
C. Spiral CT scan of chest
D. Urinary catecholamines
E. Renin and aldosterone levels

A. Dexamethasone suppression test: clinical presentation doesn't suggest cortisol excess
B. Renal artery doppler flow: no bruits
C. Spiral CT scan of chest: no history to suggest pulmonary embolus or pulmonary mass
D. Urinary catecholamines: used to test for pheo, no episodic nature
*E. Renin and aldosterone levels:* hyperaldosteronism drops potassium and increases BP

28

Describe primary hyperaldosteronism

Located in adrenal gland without exogenous stimulus
Elevated aldosterone and low renin levels

29

Describe secondary hyperaldosteronism

Elevated aldosterone and elevated renin levels
Causes are
-diuretics
-CHF
-cirrhosis
-ascites
-nephrosis

30

What is the choice of drug after MI? Caution?

Beta blocker, ACEI

Caution: direct vasodilators may worsen coronary insufficiency

31

Drug of choice for CHF?

ACEI, diuretics (beta blockers with no pulm edema)

Caution: beta blockers, CCB

32

Drug of choice for hypertrophic cardiomyopathy? Caution?

Beta blocker, CCB

Caution: diuretics, ACEIs, direct vasodilators

33

Caution for bradycardia and heart block?

Beta blockers, CCB

34

Drug of choice for tachyarrhythmias?

Beta blockers, verapamil

35

Drug of choice for angina? Caution?

Beta blockers, CCB, nitroglycerin

Caution: direct vasodilators (lower afterload may lower coronary perfusion)

36

Drug of COPD/ROAD? Caution?

CCB, thiazide, ARB, ACE?

Caution beta blockers

37

Drug of choice for aortic dissection? Caution?

Nitroprusside, beta blocker

Caution: drugs that increase cardiac output (increased shear stress)

38

Caution for bilateral renal artery stenosis?

ACEIs, angiotensin blockers (may worsen renal function)

39

Drug of choice for chronic renal insufficiency? Caution?

ACEIs (with serum creatinine

40

Caution for renal transplants?

ACEIs (may worsen renal function)

41

Drug of choice for migraine headaches?

Beta blockers, CCB (may relieve symptoms)

42

Drug of choice for stroke or TIA? Caution?

ACEIs (may allow reestablishment of CNS autoregulation)

Caution: vasodilators may increase intracranial pressure

43

Drug of choice for diabetes?

ACEI (delay renal failure, decrease proteinuria)

44

Drug of choice for pregnancy (preeclampsia, eclampsia)? caution?

Methyldopa, hydralazine, beta blockers (with caution)

Caution: ACEI, angiotensin blockers (may cause renal agenesis), diuretics

45

Caution with gout?

Diuretics (worsen joint pain or precipitate gout)

46

Drug of choice with cocaine use? Caution?

Labetalol, clonidine

Caution: selective beta-blockers (unopposed cocaine induced alpha agonism)

47

Drug of choice for GI bleed?

Non-selective beta blocker (lower portal blood pressure)

Caution: beta blockers (may mask signs of acute bleeding)

48

Drug of choice for pheochromocytoma? Caution?

Alpha blocker, then beta blockade

Caution: selective beta blocker (unopposed alpha agonism)

49

Drug of choice for benign prostatic hypertrophy? Caution?

Alpha-1 antagonist

Caution: selective beta blocker (unopposed alpha agonism)