Monday HTN lecture

Question 1

What are 5 types of HTN?

Answer 1

1) Essential
2) Secondary hypertension
3) Resistant HTN
4) Asymptomatic severe HTN (HTN urgency)
5) HTN emergency (covered in Emergency Medicine)

Question 2

What are 2 types of hypertensive crisis?

Answer 2

1) Hypertensive urgency
2) Hypertensive emergency

Question 3

1) What is HTN an independent risk factor for?
2) Risk of vascular death increases from a “normal” blood pressure of < __________ mm Hg
3) What happens for every 20 mm Hg systolic or 10 mm Hg diastolic increase?

Answer 3

1) Ischemic cardiovascular events
2) 120/80
3) Risk of major cardiovascular events & stroke doubles

Question 4

Treatment of HTN reduces what?

Answer 4

All causes of mortality and results in regression of pathologic cardiac structural changes

Question 5

What does physiology help you do?

Answer 5

Helps you with identification of secondary causes of HTN and how the interventions work to reduce blood pressure.

Question 6

Physiology review:
Primary role of sympathetic system is to do what? What is the resting state?

Answer 6

Regulate BP; resting state of moderate vasoconstriction

Question 7

Physiology review:
How is vascular tone typically regulated?

Answer 7

Sympathetic stimulation = relative vasoconstriction (except?)
Decrease in sympathetic stimulation = relative vasodilation

Question 8

Physiology review:
What converts angiotensin 1 into angiotensin II?

Answer 8

ACE in lungs + renal endothelium

Question 9

Physiology review:
What is the effector chemical in the RAAS?

Answer 9

Angiotensin II

Question 10

Physiology review:
What are the effects of angiotensin II?

Answer 10

1) Increase symp. activity
2) Tubular sodium + Cl reabsorption, K+ excretion, H2O retention
3) Stimulates adrenal cortex to increase aldosterone secretion
4) Arteriolar vasoconstriction (increases BP)
5) Pituitary gland’s posterior lobe to secrete ADH (increasing H2O reabsorption)

Question 11

Give examples of modifiable and non-modifiable risk factors for HTN

Answer 11

1) Modifiable: Smoking, obesity, high-sodium diet, excessive alcohol consumption, and physical inactivity.
2) Non-modifiable: Family history, age, male sex, and ethnicity

Question 12

Give an example of a co-morbidity related to secondary HTN

Answer 12

Chronic kidney disease

Question 13

What are 4 questions you should be able to answer regarding HTN?

Answer 13

1) What is normal blood pressure?
2) Who should be screened for HTN?
3) How is blood pressure measured?
4) What blood pressure threshold is used to diagnose HTN?

Question 14

True or false: Not all guidelines agree on what normal BP is

Answer 14

True

Question 15

What are the 2 main BP guidelines?

Answer 15

ACC/AHA 2017
JNC-8 2014

Question 16

What does the USPSTF say abt screening for HTN in kids?

Answer 16

Not enough evidence to conclude

Question 17

What does the USPSTF say abt screening asymptomatic pregnant women for HTN?

Answer 17

Recommends screening for hypertensive disorders in pregnant women with BP measurements throughout pregnancy (B)

Question 18

How is HTN screened and diagnosed?

Answer 18

Office visit BP measurements to screen
Out of office BP measurements to diagnose

Question 19

Describe the diagnosis of HTN

Answer 19

-Challenging in busy practice
-Accurate diagnosis HTN is important – correct methodology of measuring BP

Question 20

Describe screening BP in the office

Answer 20

1) Patient: Sitting quietly for 5 minutes, feet and back supported
-Avoid smoking, caffeine, and exercise for 30 minutes prior to measurement
2) Equipment: BP cuff should encircle 80% of arm, arm at heart level
-Manual or automatic
3) Initial visit: Measure in both arms (highest is documented BP)
-3 measurements 1-2 minutes apart, average used to determine BP

Question 21

1) What is a reasonable alternative to ABPM for HTN Dx?
2) What are better predictors of CV disease than office BP?

Answer 21

1) Home BP monitoring is a reasonable alternative
2) Both ambulatory and home BP monitoring

Question 22

1) Describe white coat HTN
2) Describe masked HTN

Answer 22

1) HTN in office, no HTN at home. Minimal/ slight increase in CVD risk, up to 35% prevalence
2) No HTN in office, but HTN at home. Similar to sustained HTN regarding CVD risk; limited data on prevalence

Question 23

What should you do if an office BP suggests elevated BP?

Answer 23

1) Ambulatory BP measurement: GOLD STANDARD; limitations due to insurance coverage
2) Home BP measurement: initial modality to confirm for most patients
3) Out of office confirmation not practical (equipment, insurance, skill, and cost)
-Average of serial office BP measurements spaced over a period of several visits

Question 24

What are the criteria for a Dx of HTN?

Answer 24

1) Diagnosis of HTN (ICD-10 code I11.9) = serial BP measurements >130/80 mm Hg
ICD-10 code R03.0 = elevated BP w/o dx of HTN
2) At least 2 readings
3) On at least 2 different occasions
4) Out of office confirmation is recommended
-To rule out white coat HTN + capture masked HTN

Question 25

HTN crisis is quantified as what according to ACC thresholds?

Answer 25

> 180 systolic or 120 diastolic

Question 26

ACC/AHA guidelines; list them for: 1) Clinical CVD or 10yr ASCVD risk >/=10%, diabetes, HTN, CKD, CHF, CAD, PAD 2) Secondary stroke prevention

Answer 26

1) >/=130/80 threshold for Tx; goal of <130/80 2) >/= 140/90 threshold for Tx; goal of <130/80

Question 27

ACC/AHA guidelines; list them for: 1) No clinical CVD and 10yr ASCVD risk <10% 2) Older persons (>/=65 years; noninstitutionalized, ambulatory, community-living adults)

Answer 27

1) >/= 140/90 to Tx, goal of <130/80 2) >/= 130/80 to Tx, goal of <130 (SBP)

Question 28

Diagnostic evaluation of HTN should focus on several major areas, including what? (4 things)

Answer 28

1) Possible secondary HTN 2) S/Sx of coexistent illness 3) HTN mediated organ damage – brain (and retina), heart, PVD, kidneys -Acute or chronic 4) Assessment of overall cardiovascular risk

Question 29

Describe primary HTN

Answer 29

Common Onset is gradual Usually over 40 y/o Symptoms remote from onset + Family history Idiopathic Life long

Question 30

Describe secondary HTN (important)

Answer 30

Less common Onset acute Younger/elderly onset Symptomatic at onset Family Hx +/- May resolve with treating underlying etiology

Question 31

List the ACC BP thresholds (4 categories)

Answer 31

1) Normal: <120 and <80 2) Elevated: 120-129 and <80 3) HTN stage 1: 130-130 or 80-89 4) HTN stage 2: >/= 140 or >/= 90

Question 32

List 2 common causes of secondary HTN not emphasized on the slides (but that he mentioned)

Answer 32

Thyroid issues (esp. hyper), hyperaldosteronism (Addison’s disease)

Question 33

Secondary HTN causes: 1) How common is OSA? 2) Main Sx? 3) How is it screened for? 4) How is it diagnosed? 5) How is that scored? How is it treated?

Answer 33

1) Very common condition 2) Snoring 3) STOP-BANG 4) Sleep study 5) AHI 5-15 is mild 15 – 30 is moderate > 30 is severe -CPAP device

Question 34

Secondary HTN causes: 1) What is chronic kidney disease? 2) What are 2 types of renovascular disease?

Answer 34

1) Renal parenchymal diseases 2) Atherosclerosis Fibromuscular dysplasia

Question 35

Secondary HTN causes: 1) What are 2 types of renal parenchymal disease? 2) What are a couple clues? 3) The first-line imaging test is what? 4) Do you need to refer these pts?

Answer 35

1) Glomerulonephritis and polycystic kidney disease 2) Early-onset and resistant HTN -Frequent urinary tract infections, hematuria, nocturia, family history of polycystic kidney disease, and/or elevated serum creatinine level 3) Renal ultrasonography, to assess for the presence of underlying disease 4) Referred to a nephrologist for further evaluation, including possible kidney biopsy

Question 36

1) Renovascular disease has a prevalence of up to _______ of patients with secondary HTN. 2) Who is it suspected in? 3) Renal artery stenosis also should be considered if there is more than a _____% decrease in eGFR after management with an angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB)

Answer 36

1) 1/3 2) Patients with resistant/difficult-to-control HTN 3) 30%

Question 37

1) What are some clues for renal artery stenosis? 2) What may it present with?

Answer 37

1) Younger than < 30 y/o, most common due to fibromuscular disease Older than 30 y/o, most common atherosclerotic disease 2) Accelerated or resistant HTN, renal disfunction, flash pulmonary edema -ACEi/ARBs may worsen renal function and/or hyperkalemia

Question 38

Clinical findings suggestive of renovascular disease in a hypertensive patient include what 2 things?

Answer 38

1) Bruits (abdominal/renal): systemic effects of atherosclerotic vascular disease 2) Significant increase in serum creatinine after starting Rx for HTN

Question 39

Renovascular disease in HTN pts: 1) What is the initial diagnostic imaging? 2) What is as effective as renal artery revascularization (angioplasty or stenting) in managing atherosclerotic RAS?

Answer 39

1) Renal magnetic resonance angiography (MRA) 2) Medical therapy

Question 40

Recommended medical approach to renal artery stenosis includes what? (4 things)

Answer 40

1) Improved glycemic control for patients with diabetes, 2) Rx: initiation of a renin-angiotensin system (RAS) antagonist – e.g., spironolactone 3) Rx: antiplatelet and statin therapy (for atherosclerosis – a systemic process) 4) Lifestyle - smoking cessation

Question 41

Secondary causes of HTN: Renovascular disease: Who should you Tx with revascularization?

Answer 41

Patients who do not benefit from medical management and for those with Takayasu arteritis (large vessel arteritis/fibrosis) or fibromuscular dysplasia

Question 42

Describe primary hyperaldosteronism (incl. who it's found in, what supports Dx, what is on BMP, etc)

Answer 42

1) Present in 5-10% of HTN patients and 7-20% of those with resistant HTN 2) Unprovoked hypokalemia further supports this diagnosis although is not present on the majority of cases 3) Low K+ noted in BMP 4) Diagnosis is based on aldosterone:renin ratio

Question 43

What are some other secondary causes of HTN? Incl. in children.

Answer 43

1) Pheochromocytoma 2) Hypercortisolism 3) Hyperthyroidism 4) Excessive alcohol 5) Meds: NSAIDS, corticosteroids, some antidepressants, sympathomimetics 6) In children: coarctation of aorta, renal parenchymal disease

Question 44

Give the OLDCARTS for HTN

Answer 44

CC: none – found with screening BP or may have CC consistent with end organ damage Onset, duration, timing – chronic, insidious (may be acute if secondary) Location: cardiovascular (may be more widespread if secondary) Character: asymptomatic (may have end organ damage if secondary) Alleviating: none (treat underlying cause is secondary) Aggravating: OTC and Rx medications, anxiety, lifestyle Risk factors: Modifiable – smoking, obesity, excessive salt intake and alcohol consumption, physical inactivity Non-modifiable – family history, age, sex, ethnicity Associated Symptoms: primary HTN – none, secondary HTN varies

Question 45

When looking for signs of end organ damage on PE: 1) What should you look for regarding general appearance? 2) What abt in VS?

Answer 45

1) Distribution of body fat, skin lesions, muscle strength, alertness/orientation (brain, aldosterone, Cushing's) 2) BMI, BP both arms (Subclavian Steele syndrome) and one leg (aortic coarctation)

Question 46

When looking for signs of end organ damage on PE, what may fundoscopy show for hypertensive retinopathy?

Answer 46

-Ischemia causes optic nerve edema, cotton wool spots -While leakage causes hemorrhage and disc edema -Elevated retinal artery BP causes A-V nicking, copper wire arterioles

Question 47

When looking for signs of end organ damage on PE, what should you look for for each of the following?: 1) Neck 2) Lungs 3) Abdomen 4) Extremities

Answer 47

1) Palpation and auscultation of carotids and thyroid gland 2) CTA 3) Renal masses, bruits over abdominal aorta and renal arteries, femoral pulses 4) Peripheral pulses, edema

Question 48

When looking for signs of end organ damage on PE, what should you look for for each of the following?: 1) Skin 2) Neurologic

Answer 48

1) Stigmata of Cushing's 2) MS changes (confusion), visual disturbance, focal weakness

Question 49

When looking for signs of end organ damage on PE, what should you look for on a cardiovascular exam?

Answer 49

1) Cardiac PMI displacement (enlarged LV), S4 gallop (stiff LV) 2) Palpate peripheral pulses and listen for bruits; especially renal

Question 50

Subclavian Steel Syndrome: 1) What is it? 2) What does it cause?

Answer 50

1) Right subclavian stenosis 2) Blood flows from left vertebral artery to basilar to right subclavian artery to right arm resulting in potential posterior CNS ischemia

Question 51

Coarctation of the aorta: 1) What is it? 2) What does it result in?

Answer 51

1) Stenosis of the aortic arch 2) Blockage of blood flow to the descending aorta and distribution -Overload and elevated BP of head and UE

Question 52

Hard exudates, inflamed macula, flame hemorrhage, and cotton wool spots may indicate what?

Answer 52

HTN damage

Question 53

What lab testing should you do for HTN?

Answer 53

1) CBC (CKD with microcytic anemia) 2) Renal panel – electrolytes (K+) and serum creatinine to calculate eGFR (CKD) -look for hyperaldosteronism 3) Urinalysis – proteinuria + …. Prompt urinary albumin to creatinine ratio 4) Fasting glucose or A1C 5) TSH 6) Lipid profile (additional) CV risk

Question 54

1) Why should you do an ECG for HTN? 2) What should you calculate if appropriate?

Answer 54

1) ECG for LVH, LAE Echo if LVH seen on ECG 2) 10-year ASCVD risk

Question 55

What additional testing should be done & for who with HTN?

Answer 55

1) Urinary microalbumin to creatinine ratio in all patients with CKD or DM 2) Microalbumin : creatinine ratio is recommended annually in all DM

Question 56

Describe Targeted approach of evaluation for secondary HTN in patients with unusual presentation

Answer 56

1) New onset in young or old age 2) Presentation with severe HTN 3) Abrupt onset in previous normotensive patient 4) Significant recent elevation in BP in a patient with previously well controlled HTN (compliant patient)

Question 57

1) What is drug resistant HTN a sign of? 2) Give examples of clinical clues for a specific cause of HTN

Answer 57

1) Drug resistant HTN (3 or more drugs and still not well controlled BP) concerning for secondary HTN 2) Abdominal bruit (RAS), low serum K+ (primary aldosteronism)