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PNS/Cardiology > Primary and Secondary Hypertension > Flashcards

Primary and Secondary Hypertension Flashcards

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1
Q

What is the difference between primary and secondary hypertension?

A

Primary - complex, multifactorial

Secondary - direct treatable cause

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2
Q

What is optimal blood pressure?

A

<80 diastolic

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3
Q

Why does diastolic pressure increase until age 50 and decline after age 50?

A

Vessels become stiffer and lose elasticity and cannot maintain the diastolic pressure

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4
Q

What is the best predictor of mortality due to hypertension?

A

Widened pulse pressure (systolic BP - diastolic BP)

Systolic increases, diastolic increases after age 50 because of stiffer vessels

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5
Q

What should normally happen to BP when asleep?

A

Nocturnal decline of BP (about 10%)

Loss of this decline is predictive of hypertensive events

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6
Q

Why is MAP not an accurate reflection of CV risk?

A

Can have a massive pulse pressure, but still a normal MAP

Hence, pulse pressure should be used instead

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7
Q

What is the definition of isolated systolic hypertension?

A

SBP >140 and DBP <90

Reflects widened pulse pressure due to stiffening of vessels with age

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8
Q

In early hypertensive, does CO or TPR contribute more to the elevated BP?

A

CO (better contraction of heart, less stiff vessels)

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9
Q

In late hypertensives, does CO or TPR contribute more to the elevated BP?

A

TPR (lesser contraction of heart, stiffer vessels)

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10
Q

What are the 3 major systems that regulate blood pressure?

A

Heart
Blood vessels
Kidney

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11
Q

Primary hypertension patients have at least one of 4 mechanisms involved, what are the 4 mechanisms?

A

Inability to handle sodium and water appropriately
Overactivity/overstimulation of sympathetic system
Defect in handling of intracellular calcium in vascular smooth muscle
Defect in RAAS

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12
Q

How does hypertension affect the eyes?

A

Retinal vein and artery thrombosis
AV nicking - enlarged artery crosses vein, indenting it
Copper wiring - can see enlarged artery on end

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13
Q

How does hypertension affect the heart?

A

Coronary artery disease
LV hypertrophy
Arrhythmias
Congestive heart failure

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14
Q

How does hypertension affect the kidney?

A

Renal failure

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15
Q

How does hypertension affect the vasculature?

A

Atherosclerosis

Peripheral vasculature disease

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16
Q

How does hypertension affect the CNS?

A

Strokes (ischemic or hemorrhagic)

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17
Q

What is the definition of malignant hypertension?

A

Severe increase in BP, especially DBP (know that DBP decreases after 50 so would see this in younger age groups)

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18
Q

What are the symptoms of hypertension?

A

NONE! Asymptomatic

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19
Q

What is the target BP in patients under age 60?

A

<140/90

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20
Q

What is the target BP in patients 60 and over?

A

<150/90

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21
Q

What are lifestyle modifications used to treat hypertension?

A

Weight reduction
Dietary sodium restriction
Increased physical activity
Moderation of alcohol/smoking

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22
Q

What categories of drugs are used to treat hypertension?

A

Diuretics
Sympatholytics
Vasodilators
RAS antagonists

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23
Q

How do diuretics help with hypertension?

A

Increased excretion of sodium and water

Decreased CO

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24
Q

How do sympatholytics (alpha and beta blockers) help with hypertension?

A

Prevent vasoconstriction

Decrease HR and sympathetic outflow

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25
How do vasodilators help with hypertension?
Calcium channel blockers - prevent vasoconstriction | Direct vasodilators - cause vasodilation
26
How do RAS antagonists help with hypertension?
ACE inhibitor - prevent conversion of AI to AII, prevent vasoconstriction and aldosterone release ARB - block AII receptor, prevent vasoconstriction and aldosterone release
27
Which drug should you use for first line therapy for uncomplicated hypertension?
ABCD - any of these are acceptable first line therapy ``` ACE inhibitors ARB Beta blockers Calcium channel blockers Diuretics - most commonly used ```
28
Which first line therapies do Caucasians normally respond better to?
AB ACE inhibitors ARB Beta blockers
29
Which first line therapies do African Americans normally respond better to?
CD Calcium channel blockers Diuretics
30
If a patient has hypertension in the setting of heart failure, what classes of drugs should be used?
Beta blockers ACE inhibitors ARB Mineralocorticoid receptor antagonist
31
If a patient has hypertension in the setting of post-MI, what classes of drugs should be used?
Beta blockers ACE inhibitors ARB
32
If a patient has hypertension in the setting of high risk-CAD, what classes of drugs should be used?
``` ACE inhibitor ARB Diuretics Beta blockers Calcium channel blockers ```
33
If a patient has hypertension in the setting of proteinuria, what classes of drugs should be used?
ACE inhibitor | ARB
34
What is the "Rule of Tens"?
For every additional 10 mm Hg reduction in systolic blood pressure that is necessary, 1 additional drug is needed
35
What are reasons for poor BP control during treatment?
Dietary indiscretion Patient discontinues drug Too few drugs - treatment not aggressive enough
36
What are major causes of secondary hypertension?
Chronic kidney disease Renovascular disease Adrenal disease Pheochroocytoma
37
What is the difference between chronic kidney disease and renovascular disease?
Chronic kidney disease - disease of parenchyma of kidney, within kidney itself Renovascular disease - refers to artery leading to the kidney
38
Describe the relationship between chronic kidney disease progression and hypertension
As disease progresses, % of patients that develop hypertension increases steadily
39
How does salt retention cause hypertension in chronic kidney disease?
Leads to increased blood volume and therefore BP
40
How does kidney injury cause hypertension in chronic kidney disease?
Activates RAAS Activates Sympathetic nervous system Impaired NO synthesis and endothelium-mediated vasodilation All of this causes vasoconstriction
41
How does renovascular disease cause hypertension?
Constricted renal artery = reduced blood flow to kidney = activation of RAAS Angiotensin II and aldosterone will cause systemic arteriolar constriction
42
How does the kidney maintain GFR in the setting of renovascular disease?
Constricted renal artery --> angiotensin II --> constricts efferent arteriole --> maintains normal GFR
43
Why should patients with renovascular disease never be given an ACE inhibitor or ARB?
Will prevent the compensatory constriction of the efferent arteriole, causing GFR to become compromised and leading to ischemia of kidney and damage
44
What are methods for screening for renal artery stenosis?
Captopril nuclear scan Duplex dopplers Magnetic resonance angiogram IV arteriography
45
What are the two types of renovascular disease?
Atheroma - atherosclerosis in renal artery (most common) | Fibromuscular displasia - increase in medial layer of renal artery
46
Which renovascular disease patients can be cured with renal angioplasty?
Patients with fibromuscular dysplasia
47
What are the two adrenal causes of hypertension?
Adenoma (tumor) | Hyperplasia (increase in size of adrenal cells)
48
How can you diagnose an adrenal cause of hypertension?
Check hormone levels - aldosterone and plasma renin Hypokalemia Aldosterone should be increased - adrenal gland is overproducing Plasma renin should be decreased - suppressed by the high aldo levels Increased retention of Na+ and water caused by aldosterone will also lead to excretion of K+
49
What drugs can be used to block the effects of aldosterone?
Spironolactone | Eplerenone
50
How does apparent mineralocorticoid excess cause hypertension?
Excess cortisol outcompetes aldosterone at the mineralocorticoid receptor in the kidneys Causes excess sodium and water retention and potassium excretion
51
What can cause apparent mineralocorticoid excess?
Licorice ingestion (also in chew tobacco) Cushing's disease Congenital adrenal hyperplasia Liddle's syndrome
52
What are the different types of congenital adrenal hyperplasia (CAH)?
21 hydroxylase deficiency 11 beta hydroxylase deficiency 17 hydroxylase deficiency - also will see sexual side effects
53
What is Liddle's syndrome?
Constitutive activation of sodium channels, results in hypertension and hypokalemia Aldosterone levels are undetectable
54
What is glucocorticoid remedial hypertension?
Autosomal dominant form of low renin hypertension Hyperaldosteronism Aldosterone secretion controlled by ACTH instead of Angiotensin II due to abnormal crossover of genes
55
What causes of secondary hypertension are suggested by HIGH ALDO and HIGH RENIN?
Renovascular disease Hypovolemia LVF
56
What causes of secondary hypertension are suggested by HIGH ALDO and LOW RENIN?
``` Adrenal causes (adenoma or hyperplasia) Glucocorticoid remedial hypertension (GRA) ```
57
What causes of secondary hypertension are suggested by LOW ALDO and LOW RENIN?
Apparent mineralocorticoid excess syndrome Cushing's disease Liddle's syndrome Congenital adrenal hyperplasia (21, 11, and 17 hydroxylase)
58
What is a pheochromocytoma?
Catecholamine secreting tumor of the medulla of the adrenal gland - originating in chromaffin cells
59
What are common signs and symptoms of pheochromocytoma?
Hypertension Headache Sweating Palpitations
60
How should pheochormocytoma be managed?
ABC's Alpha blocker - vasodilate to control blood pressure Beta blocker - control heart rate Catecholamine synthesis inhibitor - alpha methyl p-tyrosine
61
How does obstructive sleep apnea cause secondary hypertension?
Intermittent asphyxia Marked BP elevation Sleep fragmentation
62
What is the treatment for obstructive sleep apnea?
Weight reduction | Positive pressure breathing devices
63
What are clues to a patient having fibromuscular dysplasia?
Young female, smoker, abdominal bruit

PNS/Cardiology (33 decks)

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