NP 614 Module 1&2 - Sheet1 Flashcards
(232 cards)
1
Q
5 most common chronic illnesses
A
Pulmonary diseases, hypertension, stroke, diabetes, heart failure
2
Q
The primary goal of the Chronic Care Model is:
A
Improve outcomes for patients
3
Q
The single most critical component in any chronic treatment program is:
A
Interventions that target self-management
4
Q
Chronic problems have unique care issues. Those issues are:
A
Emotional drain on patient, family, and provider
5
Q
In the Health Belief Model examples of cues to action are:
A
Reminder letters, follow-up phone calls, and advertisements or pulic service announcements
6
Q
The Transtheoretical Model has been used extensively for smoking cessation. A patient who tells you that they are thinking of a change in the next 2 months is in what stage of change:
A
Contemplation
7
Q
If you are using Motivational Interviewing techniques with a COPD patient who states they are not interested in smoking cessation your best response is:
A
Tell them when they are ready to discuss smoking cessation you will be ready
8
Q
The Body Mass Index reflects:
A
Total body weight in relation to heigth
9
Q
When counseling patients about weight which statement is most accurate:
A
Belly fat is the most dangerous type of fat to your health because abdominal fat is metabolically active
10
Q
An adult BMI of ___ is considered obese.
A
30
11
Q
Medications used for weight loss have all of the following characteristics:
A
Used short time, are not used as monotherapy, and have significant adverse side effects.
12
Q
When to recommend weight loss therapy in relation to BMI
A
Weight loss therapy is linked to BMI of 30 of higher, or BMI between 25-29.9 with either high-risk waist circumference and/or other risk factors as stated in the NHLBI guidelines
13
Q
The purpose of the strict perioperative diet for bariatric surgery is considered contraversial. The documented evidence for its benefit is:
A
Reduces liver volume in patients with hepatomegaly
14
Q
Dumping syndrome post-bariatric surgery is a result from:
A
Hyperosmolar contents into the jejunum causing diarrhea
15
Q
Following bariatric surgery, which route of medication are appropriate
A
Rectal, transdermal, and liquid. Never delayed release!
16
Q
Question to ask patients regarding decisions or lifestyle changes:
A
How does this diagnosis affect your family and how does the family affect the diagnosis?
17
Q
Cord elements of the Chronic Care Model - based on self management
A
Partners, team, action-plan, organized, menaingful visits, electronic database, group visits, non-physician providers
18
Q
Motivational interviewing is all about:
A
The relationship
19
Q
A provider needs to avoid -
A
A “righting” reflex and trying to persuade patients to change
20
Q
A confrontational style of advice giving generally creates:
A
Resistance. Every time a provider hears the word “but”, listen to the reason the patient cannot make the change
21
Q
A patient-centered platform includes
A
Not just being nice; involves careful listening; provide structure to a discussion about change; explore feelings on readiness for change, importance of a change, and confidence to make a particular change
22
Q
Motivational interviewing is:
A
Patient driven; empowers patients to make changes, and less frustrating for providers
23
Q
Implementing a patient-driven approach includes:
A
Simple open questions; listening and encouraging with verbal and non-verbal prompts; clarifying and summarizing; reflective listening is higher-level counseling and involves making statements which aim at understanding the patient’s meaning.
24
Q
The ultimate goal of a patient-driven approach:
A
The patient devises their own plan. You only give the information based upon their desire for it.
25
No assuming with patient-driven approach:
Don't assume - the person ought to or wants to change, that the patient's health is their motivation, or that the consultation has failed is change does not occur.
26
Two phases of motivational interviewing
1) Assess and strengthen the person's desire to change and 2) then move toward actions
27
Pieces of phase 1 motivational interviewing
Opening strategies: Ask open questions. Listen reflectively. Summarize. Affirm. Elicit self-motivational statements - problem recognition, concern, intention to change, and optimism for change
28
Phase 2 of motivational interviewing
Looks forward - "What would you like to see your life like in 5 years".
29
If and only if the patient wants to explore change (regarding motivational interviewing)
Can you move to the next phase. If they say no, you simply bull back and tell them that you will be ready if they want to address the issue.
30
Pieces of phase 2 motivational interviewing
Moving toward action requires: making the transition; develop the end game; and handling resistance
31
Easy steps regarding motivational interviewing
Establish rapport, elicit information, reflect on your findings, and elicit their feelings
32
Ranking of obesity
4th of the 10 leading causes of death are related
33
Diseases associated with obesity
HTN, hyperlipidemia, CAD, gallbladder disease, sleep apnea, certain cancers, stroke, Type II diabetes
34
Benefits of weight loss based on evidence (category A)
Improves blood pressure, improves glycemic control, improes lipid profiles (lowers total cholesterol, lowers LDL, lowers triglycerides, and raises HDLs)
35
The goal for health regarding weight loss is:
A reduction of 10% in body weight over 6 months.
36
BMI measurements do not take into account:
Muscle mass or fat distribution
37
BMI 18-24.9
Normal
38
BMI 25-29.9
Overweight
39
BMI \>30
Obese
40
BMI \>40.0
Morbidly obese
41
Abdominal fat
Very active and metabolic and should be thought of as an endocrine organ. It produces hormones, enzymes, cytokines, and compliment factors, which play a role in the regulation of appetite, insulin resistance, and immune functions.
42
Barriers to weight loss
Media, lack of exercise
43
Resting Metabolic Rate (RMR)
Variable between individuals due to: the percentage of free fat mass (muscle requires more energy than fat), age, and sex. Familial effect can account for 41% of the variance in RMR.
44
Guideline recommendation for dieting
500-1000 less calories a day. Reducing fat and carbohydrates. Portion sizes matter.
45
Use of Orlistat for weight reduction
Inhibits fat absorption in the gut. Now over the counter at a reduced dose, but not at reduced cost. Can reduce calories by 150-200 a day. Average loss 4-5% of baseline weight within 1 year.
46
Use of Wellbutrin for weight reduction
Used for depression and smoking cessation. At 300 mg/day average weight loss was 4.6% of base weight.
47
Use of Glucophage for weight reduction
Average weight loss of 5% of baseline weight, but is this related to improved glucose tolerance or to the drug iteslf.
48
Use of Prozac for weight reduction
One of many SSRIs. Weight loss in clinical trials has been variable. Some gain and some lose.
49
Surgical interventions for weight loss
Favorable for morbid ovesity or BMI \>25 with 2 or more co-morbid conditions
50
Gastric by-pass and weight reduction
Has demonstrated loss in first 6 months to one year of 30-50 kgs
51
Complication of gastric bypass
40% of patients develop complications such as vitamin deficiencies, bacterial overgrowth, and hernias 14 years after procedure.
52
Recent study finding of positive of gastric by-pass
There was an associated reduction in the risk of death in the by-pass group of about 30% at 10 years when compared to control group.
53
Which diet works best for a patient?
The one the patient chooses and feels that they can stick with
54
Characteristics of patient and clinician partnerships
Good communication, shared purpose, and mutual trust and understanding
55
Population management activities
Integral to the implementation of the chronic care model and the patient'centered medical home, both paradigms for primary care transformation
56
The overall goal of primary care transformation
The creation of an environment that puts patients at the center of care while improving quality and efficiency
57
Why the chronic care model (CCM) was developed
In response to recognition that the traditional acute care model does not effectively meet the longitudinal health care needs of patients and populations with complicated chronic conditions
58
Aim of the chronic care model (CCM)
To change care from acute and reactive to proactive, planned, and population based
59
Four interventions that will lead to greatest improvements in health outcomes
Increased provider expertise and skill; educated and supported patients; planned, team-based care; and better use of registry-based information systems
60
6 components of the chronic care model (CCM)
Clinical information systems; delivery system design; decision support; self-management suppport; community resources; patient-centered medical home
61
Clinical information systems
Organize data to make efficient, safe, and effective care possible
62
Delivery system design
Refers to the role and tasks of each individual participating in patient care, the way these individuals work together, the structure of visits, and the management of ongoing follow-up
63
Self-management support
Crucial component of chronic care model and effectively implemented by use of the population approach. Goal is to engage patients in their own care and to empower them to reach their full potential.
64
7 Principles of the Patient-Centered Medical Home
personal physician: ongoing relationship, continuous, comprehensive care. Physician-directed medical practice. Whole person orientation. Care coordinated and integrated: prevention and chronic care. Quality and safety. Enhanced access. Payment reform.
65
Population health
Used to describe activities to promote healthyhabits and risk reduction in otherwise healthy, low-risk groups.
66
How to apply population management in primary care
risk stratifying the population on basis of criteria such as age, gender, habits, and personal and family history and by determining the most effective interventions to promote routine screenings and healthy habits
67
Population disease management
Describes activities targeted to patients with specific high-prevalence diseases, such as diabetes, HTN, asthma, and CHF
68
Key components of care management
Patient identification, risk and needs assessment, collaborative care planning, patient/family education, anticipatory coaching, tracking, and care plan revision
69
Pre-contemplation stage of transtheoretical model
No desire to change
70
Contemplation stage of transtheoretical model
Thinking about change
71
Preparation stage of transtheoretical model
Making plans
72
Action stage of transtheoretical model
Doing the change
73
Maintenance stage of transtheoreical model
Keeping the action going
74
Use of motivational interviewing in practice
Explores the patient's health behaviors, and listens for verbal hints that they may wish to make changes. Clinician uses reflective listening, affirmation, summarizing, and asking questions to guide patients to generate solutions that are feasible and workable given their personal situation.
75
Major goals of Healthy People 2020
Identify health improvement priorities; increase public awareness and understanding of health, disease, and disability; engage multiple sectors to take actions to strengthen evidence-based practices; identify critical research and data collection needs
76
3 maor focus areas for healthy lifestyle goals
Nutrition and weight management; physical activity and fitness; and increasing access to health facilities by increasing the number of people with insurance for prevention and promotion
77
Imbalances of lifestyle influences can lead to...
Type II diabetes, sleep apnea, gallbladder, HTN, musculoskeletal injuries, and psychiatric illnesses
78
Unmanaged stress is linked to...
HTN, heart disease, some forms of cancer, GI problems, and some emotional health disorders
79
High risk waist circumferences of men and women
Men - more than or equal to 40 inches. Women more than or equal to 35 inches
80
Cholesterol is essential for...
Production of bile acids, steroids, cell membranes, and sex hormones
81
Criteria of metabolic syndrome
Elevated waste circumference; elevated triglycerides or treatment; reduced HDL or treatment for this disorder; elevated BP or treatment for this disorder; and elevated fasting glucose or treatment for elevated glucose
82
5 elements of smoking cessation intervention
A strong message to quit smoking, self-help motivational quitting and relapse materials, brief conseling that includes a quit date, use of pharmacologic interventions when indicated, and follow-up support
83
Obesity
A chornic condition in which the body's homeostatic balance between energy intake and energy expenditure is dysfunctional, resulting in excess energy stored in adipose tissue
84
Adipose tissue
Composed of adipocytes (fat cells that store energy as triglycerides plus glycerol), preadipocytes, vascular structures, fibroblasts, endothelial cells, and macrophages
85
Functions of adipose tissue
Energy storage, body structure cushioning, and complex endocrine, exocrine, paracrine, and immune roles
86
Hedonic hunger
Occurs when there is no physiologic base for preceived energy needs
87
Common lab tests for obese individuals
Urinalysis; serum glucose, uric acid, BUN, creatining; CBC; thyroid levels; lipid profile; LFTs; alk phos; and 2-hr glucose tolerance test
88
Components of all weight loss and weight management efforts
An energy deficit from reduced kilocalories, physical activity, and behavioral change
89
Indications for bariatric surgery
BMI greater than 40 or greater than 35 if obesity-related comorbidity; fialure of previous weight loss attempts; commitment of post-op care, supplements, and testing; and exclusion of reversible endocrine or other causes of obesity
90
Contraindications for bariatric surgery
Current substance abuse; uncontrolled, severe psychiatric illness; lack of understanding regarding surgery adn expected outcomes and lifestyle changes required; and extremely high operative risk
91
Lifelong testing after bariatric surgery
Vitamin D, calcium, phosphorus, parathyroid hormone, and alk phos, and bone DEXA every 6 months until weight is stable. Annually - CBC, LFTs, glucose, creatinine, electrolytes, iron, vit B12, folate, calcium, vit A, xinc, and vit B1
92
Meds to avoid after bariatric surgery
NSAIDs, salicylates, corticosteroids, oral bisphosphonates, ethanol, and extended-release formulations
93
Elements of the Health Belief Model
There must be a preceived threat; preceived susceptibility; preceived severity; preceived benefits; preceived barriers; cues for action; self-efficacy
94
Health belief model - Preceived susceptibility - cultural considerations
Will I get this disease? Must understand the community's knowledge of the issue.. Assess literacy level of community. Assess English proficiency. Consider culturally based health beliefs and values.
95
Health belief model - Preceived severity - cultural considerations
How serious is the condition or consequence for me and my family? Consider previous experiences with trauma. Consider acceptance based on religious or spiritual beliefs - God's will.
96
Health belief model - Preceived benefits - cultural considerations
Will the change in behavior work to prevent this problem? Consider health belief systems. Consider the trust in health care systems. Trust in informaiton from government/official sources.
97
Health belief model - Preceived barriers - cultural considerations
How difficult will it be (psychologically or economically) for me & my family to make the behavior change? Consider economics of the change. Consider language barriers to understanding behavior change message. Consider going against traditions or advice of elders.
98
Health belief model - Cues to action - cultural considerations
What strategies will activate readiness to change behaviors? Media campaigns, brochures, word of mouth. Consider credibility of sources. Consider preferred ways of getting info. Consider literacy. Consider preferred language. Consider materials and training approaches respectful and reflect values of community.
99
Health belief model - Self-efficacy - cultural considerations
How confident am I that my family & I can make the behavior change? Consider racism & impace - distruct, learned helplessness, socioeconomic impact, bias, discrimination, stereotyping. Consider multiple competing demands/stresses.
100
Transtheoretical Model
Describes how people modify a problem behavior or acquire a positive behavior. This is a model of intentional change and focuses on the decision making of the individual. Involves emotion, cognitions, and behavior.
101
DASH diet
Dietary Approaches to Stop Hypertension
102
DASH diet high in...
Fruits, vegs, low fat or fat-free, whole grains, fish, nuts.
103
DASH diet rich - elements
Calcium, magnesium, potassium, protein, fiber and aims to decrease red meats, sweets, and added sugars
104
DASH diet food groups
Grains, vegetables, fruits, dairy, meets, nuts & seeds, & legumes, fat & oil, and sweets
105
What is the treatment for Stage 1 hypertension according to JNC7?
HCTZ 12.5 mg 1d and lifestyle changes
106
What is the best second agent for a patient suffering from Stage 1 HTN?
Calcium channel blocker
107
During the fundoscopic exam of a hypertensive patient you would check all....
Hemorrhages, pipilledema, and arteriolar narrowing
108
What would you assess in a patient recently started on Accupril, Lipitor, and Avanda?
If the patient is suffering from a new dry cough
109
A suggestion of renovascular hypertension
Renal arterial bruits in the abdomen, flanks, or back
110
Which class of hypertensive med is known for fatigue, depression, and must be tapered before discontinuing?
Beta blockers
111
What is a side effect of calcium channel blockers?
Lower extremity edema
112
What would you include in patient education regarding restricting dietary sodium
75% of sodium intake is derived from processed food
113
Disease
The explanation that the clinician brings to the symptoms. How the clinician organizes what he or she learns form the patient that leads to a clinical diagnosis
114
Illness
How the patient experiences all aspects of the disease, including its effects on relationships, function, and sense of well-being.
115
Excess dietary socium
Suppresses the renin-angiotensin-aldosterone system and promotes fibrosis in the heart, kidney, and arteries causing HTN and stroke
116
BMI calculation
Weight in kg divided by height in meters squared
117
Prehypertension readings
120-139 / 80-89
118
Stage 1 HTN readings
140-159/90-99
119
Stage 2 HTN readings
\> or equal to 160 / \> or equal to 100
120
Ideal BP readings for diabetic or renal disease patient
\<80
121
Vesicular breath sounds
Soft and low pitched. Heard through inspiration, continue without pause through expiration, and fade away about 1/3 through expiration. Heard over both lungs.
122
Bronchovesicular breath sounds
Inspiratory and expiratory sounds about equal in length and may be separated by a silent interval. Often heard in 1st and 2nd interspaces anteriorly and between the scapulae
123
Bronchial breath sounds
Louder, harsher, and higher in pitch, with a short silence between inspiration and expiration. Expiratory sounds last longer and heard over the manubrium
124
Where normal electrical impulses are initiated
The sinus node, is the cardiac pacemaker and the rate is 60-100
125
Factors that influence arterial pressure
Left ventricular stroke volume, distensibility of the aorta and the large arteries, peripheral vascular resistance, and volume of blood in the arterial system
126
Occurrance of sudden dyspnea
May indicate pulmonary embolism
127
Illnesses of cardiovascular disease
HTN, CAD, heart failure, stroke, and congenital heart disease
128
Health promotion to prevent cardiovascular disease
Screening for important risk factors and developing critical interviewing and counseling skills. Must understand demographics, identify cardiovascular risk factors, and form partnerships to help patients reduce risks.
129
Screening age for HTN
All people over 18
130
Screening age for diabetes
45 years and repeated every 3 years and for any patient with BMI greater than 25
131
Metabolic syndrome
A cluster of risk factors that create an increased risk of CVD and diabetes. Includes elevated waist circumference, fasting plasma glucose, HDL cholesterol, triglycerides, and HTN
132
Indication of elevated JVP
98% specific for an increased left ventricular end diastolic pressure and low left ventricular ejection fraction, and increases risk of death from heart failure
133
Using the diaphragm of stethoscope
Better for high-pitched sounds of S1 and S2, murmurs of aortic and mitral regurgitation, and pericardial friction rubs.
134
Using the bell of stephoscope
Sensitive to low-pitched sounds of S3 and S4 and murmur of mitral stenosis. Use at apex.
135
Follow up after bariatric surgery
1 wk, 1 month, 3 months, 6 months, 1 year, then annually
136
Why new guidelines regarding screening
Early testing gives the individual the opportunity to begin primary prevention. Identify early risk factors that are modifiable. Increase awareness of personal risks
137
Conditions under umbrella term ASCVD
ACS, history of MI, stable or unstable angina, coronary and other arteial revascularization, stroke, TIA, peripheral arterial disease presumed to be of atherosclerotic origin, diabetes
138
Prevention of ASCVD
Diet - DASH, physical activity, maintaining a healthy weight, and not smoking
139
Daily salt intake for a person with hypertension
1500 mgm
140
Daily salt intake for the general public
2300 mgm
141
Interventions for prehypertension
First - nonpharmacologic interventions (weight loss, DASH diet, exercise)
142
When to start treatment for HTN regardless of risks
130/80
143
Prehypertension classification
120-139/80-89. Encourage lifestyle modification
144
Stage 1 hypertension classification
140-159/90-99. Encourage lifestyle modification
145
Stage 2 hypertension classification
\>160/\>100. Encourage lifestyle modifications.
146
HTN white men versus black men
More prevalent in black men
147
HTN white women versus black women
More prevalent in black women
148
HTN white versus hispanics
Same
149
Kidney disease and failure secondary to HTN
HTN second most common cause of kidney failure (after diabetes). 1. Heart diease; 2. MI; 3. left ventricular hypertrophy; 4. cerebral hemorrhage; 5. eye complications - retinal microaneurysms
150
HTN and atherosclerosis
Well-established independent risk
151
Predictors or coronary, renal, cerebral, and peripheral vascular disease, and heart failure
HTN
152
Incidence of stroke
Rises in direct proportion to BP
153
Causes of peripheral arterial diseaes
Cigarette smoking, diabetes, and HTN
154
Systolic BP and prediction of arterial disease
For middle-aged and older adults, systolic BP may be even more predictive of arterial disease than diastolic BP
155
Primary hypertension
There is no underlying or immedite cause that can correct the blood pressure and is the majority of cases.
156
Secondary hypertensive types of patients
Small percentage of patients (5-10%) and is typically the young you should worry about OR someone who is on all three classes of meds and still cannot control BP.
157
Medications to avoid in someone with secondary hypertension
ACE and ARBs because you increase their risk for kidney failure
158
Individuals in which salt raises BP
Older, black, and diabetic hypertensive persons
159
Things that have a lowering effect on BP
Dietary calcium, potassium, and magnesium
160
Lifestyle choices that raise BP
Physical inactivity, stress, cigarette smoking
161
Region of US with higher BPs
southeastern US
162
Prevention of HTN
Prevention is best. Make visits motivating and stress follow-up
163
Doses of ASA in prevention
High does not work better than low-dose. Stick with 81 mg. Do not start preventitative ASA until BP is lower than 150/90
164
Target BP in diabetics
140/80
165
Why JNC7
Publiation of many new studies; need for a new, clear, and concise guideline useful for clinicians; need to simplify the classification of BP
166
Blood pressure and CVD risk
For people over 50, systolic is more important than diastolic
167
CVD risks and BP elevation
Starting at 115/75, CVD risk doubles with each increment of 20/10 throughout the BP rnage
168
Normotensive BP and lifetime risks of HTN
Persons who are normotensive at age 55 have a 90% lifetime risk for developing HTN
169
Initial therapy for most types of HTN
Thiazide-type either alone or combined with other drug classes
170
Drugs required by most patients to control BP
Most will require two or more to achieve goal BP
171
When to initiate dual drug therapy for BP
If BP is \>20/10 above goal, initiate two agents, one usually should be a thiazide-type diuretic
172
Most effective HTN therapy
One prescribed by the careful clinician will control HTN only if patients are motivated
173
How to improve motivation of BP patients
Improves when patients have a positive experience and trust their clinician
174
What is a potent motivator
Empathy
175
HTN prevalence
50 million people in the U.S.
176
BP relationship to risk of CVD
The risk is continuous, consistent, and independent of other risk factors
177
Signal of prehypertension
Signals the need for increased education to reduce BP in order to prevent HTN
178
Benefits of lowering BP
Stroke - 35-40%; MI - 20-25%; heart failure - 50%
179
In-office BP measurement techniques
Two readings, 5 minutes apart, sitting in chair. Confirm elevated reading in contralateral arm
180
Ambulatory BP measurement techniques
Indicated for evaluation of "white coat" HTN. Absence of 10-20% BP decrease during sleep may indicate increased CVD risk
181
Self-measurement BP technique
Provides information on response to therapy. May help improve adherence to therapy and evalaute "white-coat" HTN
182
BP drop at night and its indications
Usually drops 10-20% during night; if not, signals possible increased risk for CV events
183
What does self-measurement of BP provide
Response to antihypertensive therapy; improving adherence with therapy; and evaluating white-coat HTN
184
BP home measurements that indicate HTN
\>135/85
185
Evaluation objectives of documented HTN
1. Assess lifestyle and identify other CV risk factors or concomitant disorders that affects prognosis and guides treatment. 2. Reveal identifiable causes of higher BP. 3. Assess the presence or absence of target organ damage and CVD
186
CVD risk factors
HTN, cigarette smoking, obesity, physical inactivity, dyslipidemia, diabetes, GFR \<60 ml/min, older than 55 for men, older than 65 for women, family history of premature CVD
187
Identifiable causes of HTN
Sleep apnea, drug-induced or related causes, chronic kidney disease, primary aldosteronism, renovascular disease, chronic steroid therapy and Cushing's syndrome, pheochromocytoma, coarctation of the aortia, and thyroid or parathyroid disease
188
Target organ damage of HTN - heart
Left ventricular hypertrophy, angina or prior MI, prior coronary revascularization, and heart failure
189
Target organ damage - other organs
Brain - stroke or TIA; chronic kidney disease; peripheral arterial disease; retinopathy
190
Routine lab tests for HTN
ECG, UA, glucose, Hct, K+, creatining, calcium, lipid profile, HDL, LDL, triglycerices, and urinary albumin excretion
191
Goals of HTN therapy
Reduce CVD and renal morbidity and mortality; treat to BP 50
192
Systolic BP reduction with weight loss
5-20 mmHg per 10kg
193
Systolic BP reduction with DASH
8-14 mmHg
194
Systolic BP reduction with sodium reduction
2-8 mmHg
195
Treatment of prehypertension
No drugs - lifestyle modification
196
Treatment of Stage 1 HTN - without compelling indication
Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combinations.
197
Treatment of Stage 2 HTN - without compelling indication
Two-drug combos for most (usually thiazide and ACEI or ARB or BB or CCB.
198
Treatment of Stage 1 HTN - with compelling indication
Drugs for the compelling indications
199
Treatment of Stage 1 HTN - with compelling indications
other HTN drugs (such as ACEI, ARB, BB, CCB) as needed
200
Follow up and monitoring of HTN therapy
Pt should return until BP goal is reached. More frequent for stage 2 with complicating comorbid conditions. Serum potassium and creatinine monitored 1-2 times per year. When BP goal - visits 3-6 months. Co-morbidities influence frequency of visits
201
Special consideration of population regarding HTN
Minority, obesity, metabolic syndrome, left ventricular hypertrophy, PAD, HTN in older people, postural hypotension, dementia, HTN in women, HTN in children and adolescents, HTN urgencies and emergencies
202
BP treatment in patients with heart failure
Thiazide, BB, ACEI, ARB, aldostone antagonists
203
BP treatment in patients post MI
BB, ACEI, aldosterone antagonists
204
BP treatment in patients with high CAD risk
Thiazide, BB, ACE, CCB
205
BP treatment in patients with diabetes
Thiazide, BB, ACE, ARB, CCB
206
BP treatment in patients with chronic kidney disease
ACEI, ARB
207
BP treatment in patients with recurrent stroke prevention
Thiazide, ACEI
208
Important barriers to BP control
Socioeconomic factors and lifestyle
209
African Americans reduced response to what BP drugs
Monotherapy with BBs, ACEIs, or ARBs
210
African Americans respond better to what BP drugs
CCBs
211
Left ventricular hypertrophy
An independent risk factor that increases the risk of CVD
212
Regression of left ventricular hypertrophy
Occurs with aggressive BP management; weight loss, sodium restriction, and treatment with all classes except direct vasodilators hydralazine adn minoxidil
213
Peripheral arterial disease and BP
Equilalent in risk to ischemic heart disease. Any class of drugs can be used in most PAD pts. Other risk factors should be managed aggressively. Aspirin should be used.
214
HTN in older persons
More than 2/3 of people over 65 have HTN. This population has the lowest rates of BP control. Treatment should follow same principles outlined for general care of HTN. Lower initial drug doses may be indicated to avoid symptoms; standard doses and multiple drugs will be needed to reach BP targets.
215
Postural hypotension
Decrease in standing SBP \>20, when associated with dizziness/fainting, more frequent in older SBP patients with diabetes, taking diuretics, venodilators, and some psychotropic drugs. Drugs should be monitored in upright position. Avoid volume depletion and excessively rapid dose titration of drugs.
216
Dementia and HTN
Dementia and cognitive impairment occur more commonly in people with HTN. Reduced progression of cognitive impairment occurs with effective antihypertensive therapy.
217
HTN in women
Oral contraceptive may increase BP and it should be checked regularly. In contrast, HRT does not raise BP.
218
Pregnancy and HTN treatment
Should be followed carefully. Methyldopa, BBs, and vasodilators, perferred for the safety of the fetus.
219
Drugs contraindicated during pregnancy
ACEI and ARBs
220
HTN in children and adolescents
Defined as 95th percentile or greater, adjusted for age, height, and gender. Use lifestyle interventions first, then drug therapy for higher BP levels. Drug choices similiar to adults, but smaller doses. Uncomplicated HTN not a reason to restrict physical activity
221
Plus regarding thiazide-type diuretics
Slow demineralization in osteoporosis
222
BBs additional use
Atrial tachyarrhythmias/fibrillation, migraine, thyrotoxicosis (short-term), essential tremor, or perioperative HTN
223
Adjunct therapy of CCBs
Useful in Raynaud's syndrome and certain arrhythmias
224
Adjunct therapy of alpha-blockers
Useful in prostatism
225
Contraindications of thiazides
Used in caution with gout or history of significant hyponatremia
226
Contraindications of BBs
Generally avoided in patients with asthma, reactive airway disease, or second- or third-degree heart block
227
Contraindications of ACEIs adn ARBs
Contraindicated in pregnancy and those likely to become pregnant
228
Contraindications for ACEIs
Not used in individuals with history of angioedema
229
Adverse effects of aldosterone antagonists and postassium-sparing diuretics
Hyperkalemia
230
Ways to improve hypertension control
Adherence to regimens and resistant hypertension
231
Strategies for improving adherence to regimens
Clinician empathy increases patient trust, motivation, and adherence to therapy. Physicians should consider their patients' cultural beliefs and individual attitudes in formulating therapy
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Causes of resistant HTN
Improper BP measurement; excess sodium intake; inadequate diuretic therapy, medication - inadequate doses or drug interactions; excess ETOH
