Lecture 3 - Hypertension & Dyslipidemia Guidelines Flashcards Preview

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1

Cardiovascular Mortality Risk Doubles with each ______ increase in BP

20/10 mm Hg

2

Hypertension can be diagnosed using one of the
following three acceptable measurement strategies:

1. Ambulatory blood pressure monitoring (ABPM)
2. Home blood pressure monitoring (HBPM)
3. Office-based blood pressure measurements

3

Diagnosis of Hypertension: Home Measurement
Why do we like it?
What are some drawbacks?

Why do we like it?
• Available
• Inexpensive
• No white coat syndrome
• Can improve BP control and compliance


What are some drawbacks?
• Training/BP technique
• Access to appropriate/accurate device

4

Diagnosis of Hypertension: ABPM
Why do we like it?
What are some drawbacks?

Why do we like it?
• Detects morning bp surge • Quick results
• Dippers v. non-dippers
• If treatment is working at the best time

What are some drawbacks? • Availability
• Expense

5

Dippers v. non-dippers

Dipper blood pressure dips at night where as non-dippers

(Non-dippers are more at risk as BP should dip when you sleep...natural surges in the am)

6

Non-dippers or dippers need ambulatory BP monitoring

Non-dippers

7

The proper measurement of office-based BP requires attention to all of
the following:
(6)

- Time of measurement
- Type of measurement
- Cuff placement
- Patient condition
- Technique of measurement
- Number of measurment

8

Oscillometric method

Analyzes pulse waves collected
from the cuff during constricted
blood flow

(Automated one at most doctors offices)

9

Auscultatory method

Listening to the internal sounds of the body, usually using a stethoscope

(Most efficient way uses ear)

10

Correct Office Based Measurement:

Cuff Placement

• Bladder midline over brachial artery • Two finger lengths above “elbow bend”

11

Correct Office Based Measurement:

Type of Measurement Device

Oscillometric method

Auscultatory method

12

Correct Office Based Measurement:

Patient Condition

• Patient position (sitting, feet on floor etc)

• Extraneous variables (caffeine, smoking etc)

13

Correct Office Based Measurement:

Technique of Measurement

Depends on skill of operator

14

Correct Office Based Measurement:

Alternative Sites for Measurement

Radial artery
Brachial artery
Dorsalis pedis artery
Popliteal artery
Posterior tibial artery

15

Postural Hypotension

AKA?
What is it?
Add what to diet?

- Aka orthostatic hypotension
- Low BP when you stand up from sitting/laying down

- Add sea salt to diet to increase BP

16

Pathophysiology of Postural Hypotension

Normal

- Stand up
- Gravity moves blood to legs
-** Baroreceptors in neck and heart arteries sence low BP
- Send signals to brain
-** Signals heart to breat faster and vessels to constrict to increase BP

17

**_____ in neck and heart arteries sense low BP

Signals heart to beat ____ & vessels to ____

Baroreceptor

faster & constrict

18

**Pathophysiology of Postural Hypotension

Abnormal

- Stand up
- Gravity moves blood to legs
-**Interruption of natural process
- Less blood circulating to heart
- Decreased BP

19

Risk Factors for Postural Hypotension
Risk Factors for Postural Hypotension

-Age
-Postprandial hypotension
-Dehydration
-Medications
-Pregnancy
-Certain disease
-Bed rest
-Alcohol

20

Postprandial hypotension

A condition in which a person’s blood pressure drops after they eat

21

Classification of Hypertension
Sys/Dia

- Normal
- Stage 1
- Stage 2

- Normal = 120/80
- Stage 1 = >130-139 / 90
- Stage 2 = >140/90

22

Non-Pharmacologic Treatment for hypertension
(6)

1. Weight reduction
2. Adopt DASH eating plan
3. Dietary sodium reduction
4. Physical activity
5. Moderation of aalcohol consumption
6. Stop smoking

23

Recommended sodium intake

less than 1500 mg/day

24

Hypertension BP goals for general population with no diabetes or CKD:

- Older than 60
- Younger than 60

<150/90
<140/90

25

Hypertension BP goals for population with diabetes or CKD:

- All Ages Diabetes present and no CKD
- All Ages and races with CKD present with or without diabetes

140/90

26

Treatment for nonblack

- Thiazide
- ACEI
- ARB
- CCB

(alone or in combo)

27

Treatment for black

- Thiazide
- CCB

28

Blood pressure reduction is less with ______ or _____ compared with other drug classes in African Americans

What's the exception

ACE inhibitors or ARBs

Exception: If they have chronic kidney disease (start on ACE and ARB)

29

If ACEI, ARB, CCB and Thiazide are not working what is the next step?

- Reinforce lifestyle and adherence
- Add medication class (beta-blocker, aldosterone antagonist)

30

What are the four
main classes of drugs that are recommended for use as initial monotherapy:

- ACE Inhibitor (ACEI)
- Angiotensin receptor blocker (ARB)
- Thiazide diuretic
- Calcium channel blocker (CCB)

31

ACE Inhibitors work to prevent ________ being converted to __________

Angiotensin I to Angiotensin II

(This prevents the retention of fluid + vasoconstriction that would raise the BP)

32

Volume Regulating Hormones drugs

ARBs = targets vasoconstriction
Aldosterone antagonist = aldosterone
Thiazide diuretic = targets Na+ and water retention

33

ARBs

Vasoconstriction

34

HTN Drug Classes:
-pril

ACE Inhibitor

35

HTN Drug Classes:
-pine

CCBs

36

HTN Drug Classes:
sartans

ARBs

37

HTN Drug Classes:
ACE Inhibitors

Inhibits ACE, preventing conversion of ang I to ang II (see RAAS pathway)

38

HTN Drug Classes:
ARBs

Blocks ang II from binding to receptor on vascular smooth muscle

39

HTN Drug Classes:

Inhibits Ca movement through Ca channels --> vasodilation and decreased BP

40

How do you calculate estimated VLDL?

TG/5

41

What cholesterols are measurable?

- T-C (total cholesterol)
- HDL (HDL cholesterol)
- LDL (LDL cholesterol)

42

How do you calculate estimated LDL?

LDL = TC - HDL - VLDL

(Not to be used when TG > 400mg/dl)

43

LDL Cholesterol desirable range

< 100

44

HDL Cholesterol desirable range

< 40 males
< 50 women

45

Non-HDL Cholesterol (TC-HDL) desirable range

< 130

46

Four Major Statin Benefit Groups

1. Individuals with clinical ASCVD (Atherosclerotic vascular disease)

2. Primary elevation of LDL > 190mg/dL

3. Diabetes & 40-75 years of age with LDL between 70-189mg/dl

4. Patient 40-75 with LDL between 70-189 with estimated 10 years ASCVD risk of 7.5

47

We want 10 year ASCVD rate to be ______

> 7.5%
(less)

48

10 year ASCV Risk Calculator

Provides an estimate of an individual’s risk of having a cardiovascular event during the next 10 yrs

49

What is the BMI range one should aim for?

18.5 - 24.9 kg/m2

50

Saturated fats

• Molecules
“saturated” with hydrogen molecules

• Typically solids
at room temperature

(High LDL..example coconut oil)

51

Trans fat

• Industrial
process that
adds hydrogen to
liquid vegetable
oils to make
them more solid

• **AKA: ____ partially hydrogenated oils

52

Unsaturated fats

• Monounsaturated
• Polyunsaturated
• Usually liquid at room temp

(Healthy body can't make these)

53

Cholesterol

• Waxy substance

• Most of what we require is produced by our bodies

54

____________ aka “statins”
are the primary pharmacologic agent used

HMG- CoA Reductase Inhibitors

55

Statins

Inhibit the enzyme HMG-CoA reductase, which prevents the conversion of HMG-CoA to mevalonate..the rate limiting step in cholesterol synthesis

(decrease LDL + TG; increase HDL)

56

Bile Acid Sequestrants/Bile Acid Binding Resins

Binds bile acids in intestine forming a complex that is excreted in the feces

↓LDL

↑HDL

No change or ↑TG

57

Fibrates

↓LDL, but can ↑LDL if TG are high

↓ TG

↑HDL

58

Fish oils

↓TGs

↑HDL, can ↑LDL

59

Statins target what?

Inhibit HMG- CoA reductase which limits cholesterol

60

Pharmacologic agents used to
decrease TG include:
(4)

• Fibric Acids
• Fish Oils
• Nicotinic acid
• Statins

61

Only add a pharmacologic agent to treat TG once LDL goal is reached and if TG remain ______-

≥ 200mg/dL

62

Epidemiologic data suggest that ___% to ___% of the population believed to have hypertension may have lower blood pressure outside of the office setting

15% to 30%

63

The average nocturnal blood pressure is approximately ___% lower than daytime values in both normotensive and hypertensive patients

15%

64

Adverse fish oil effect

Increase LDL

65

Adverse bile acid effect

No change in TG

66

Adverse Fibrate effect

Increase LDL (if TG is high)