Slide set 6 Flashcards by E *

HTN is

CV syndrome that may change function and structure of the heart and vascular system

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Primary HTN is

AKA Essential HTN and has unknown etiology

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Secondary HTN is

HTN that has a definable cause and can possibly be cured

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Classifications of HTN (5)

Pre-HTN HTN (Stage I and II) HTN Crisis (Urgency/Emergency)

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4 elements to HTN

Heart, BVs, Kidneys, and hormones

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DX of HTN is based on consistent elevation of

SBP >140 -OR- DBP>90

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Resistant HTN is based upon what

Consisttent BP elevation despite Rx adherence with 3 drugs

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What contributes to rises in BP

Heart - CO rises sue to SNS BVs - contrict due to SNS, Tone, Ion channels Kidney - Retaining H2O or NA+

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What is considered HTN end organ damage

Eyes, Kidneys, Strokes/TIAs, Heart, PAD/PVD

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Secondary has the same consequences as primary HTN?

Yes

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Factors suggesting secondary HTN (5)

Age of onset (20-50) Severity (Dramatic) Onset nature (usually abrupt)

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(MC’s) causing secondary HTN

1.CKD 2.Primary aldosteronism

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Screening for 2nd HTN with renovascular DZ - labs

GFR, U/S, Creatinine, UA

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Screening for 2nd HTN with Pheochromocytoma - labs

24hr UA Metanephrines/catecholamines

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Screening for 2nd HTN with aldosteronism - labs

24H urine aldosterone (>25:1 - serum:ua) Unprovoked hypokalemia May see a U-wave on EKG

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Screening for 2nd HTN with Cushings syndrome - labs

Dexamethasone suppression test 24H UA cortisol levels

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Screening for 2nd HTN with Sleep Apnea - labs

Sleep study

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Screening for 2nd HTN with Coarctation of the aorta - labs

CT angiography (Pulse in UE, delayed LE pulse)

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Screening for 2nd HTN with Thyroid - labs

TSH, FT4

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Screening for 2nd HTN with Parathyroidism - labs

Serum PTH and calcium

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The kidneys are

Selfish, they will kill the body to save themselves

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2nd HTN - renal artery stenosis is

Narrowing of one or both renal arteries

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What two mechanisms cause renal artery stenosis

Atherosclerosis 2/3 of pts Fibromuscular dysplasia 1/3 of pts

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MOA of renal stenosis and HTN

Decreased renal blood flow stimulates RAAS to increase retention,volume,BP

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What is an indicator of Bilateral renal artery stenosis

Creatinine rise after admin ACEI

MOA of ACEI

Stops ANG II and bradykinin synthesis

MOA of ARB

Blocks ANG II binding to AT1 receptors

Classic findings of Coarcation of the aorta

Systolic HTN in UE but not in LE CXR has rib notching Reduced femoral pulse

MOA coarctation of the aorta

Impaired blood flow distal to coarctation causes renal perfusion impairment

Pheochromocytoma classic triad

Episodic HA Sweating Tachycardia

Pheochromocytoma is a

Catecholamine secreting tumor found in the adrenal medulla usually

Pheochromocytoma is associated with what mutations

multiple endocrine neoplasia (MEN 2A/2B)

Hyperaldosteronism is

Excessive aldosterone secretion causing increased NA+ retention

What causes increased aldosteronism (3)

Adrenal adenoma (Conn Syndrome)(most pts) Bilateral hyperplasia (Primary) Renin-secreting tumors (Secondary)

Cushing syndrome is

Excess glucocorticoids (Cortisol) that leads to increased blood volume and renin production

Cushings disease refers to

Pituitary adenoma which secretes ACTH in excess

Hyperthyroidism causes HTN by

Excess metabolic activity causes increased cardiac activity (HR) and then (CO)

Hypothyroidism causes HTN by

Volume retention (>DBP usually)

Hyperparathyroidism due to

A parathyroid secreting adenoma secreting excess calcium effecting renal fx and causing HTN

Medications that can cause HTN (6)

Estrogens Corticosteroids EPO

Cocaine/Amphetamines can cause

Acute HTN - HTN crisis or emergency - AMI

BP measuring criteria

2 readings 5m apart with arm at heart level Confirm elevated BP in contralateral arm If BP is high in both arms and pt is <30yo -leg BP If pt is >65, DM, or antiHTN rx check orthostatics

BP documenting criteria

BP, patient position, which arm and cuff size

Ambulatory monitoring indications

White coat HTN & no end organ damage Episodic HTN HOTN symptoms on HTN meds

What association is there between BP, Sleep, CV risk

Absence of 10-20% drop of BP during sleep may indicate CV risk

When to check BP with pts that have NL BP

Every two years

When to check BP with pts that are pre-HTN

Yearly

What dx test can you consider with resist-HTN

CXR, 24H Ambulatory monitor, Echocardiography, microalbuminuria

TXT goals for >60yo - >150/90

Med to reduce BP to <150/90 (if <140 and tolerated - no change to med)

TXT goals for <60yo - >140/90

Med to reduce BP to <140/90

TXT goals for >18yo with CKD or DM - >140/90

Med to reduce BP to <140/90

HTN TXT for nonpharm

Weight loss – decrease in BP 5-20mmHg DASH Diet- decrease in BP 8-14 mmHg Na+ restriction – Decrease in BP 2-8 mmHg Exercise – decrease in BP 4-9 mmHg Mod ETOH Intake – decrease in BP 2-4 mmHg

Can you use ACEI or ARB in pregnancy

What does an ACEI do to K+

Increase K+ (adding loop diuretic helps)

Thiazide lab monitoring

Hypokalemia, hyponatremia

Loop diuretcs lab monitoring

Monitor lytes (k, Mg decrease)

ACEI/ARB lab monitoring

Kidney fx and hyperkalemia

Aldosterone lab monitoring

Hyperkalemia

Thiazides drugs (3)

Chlorthalidone Hydrochlorothiazide Indapamide

TXT of heart failure is based upon if

HF is systolic or diastolic in nature

Pharm TXT of Post MI is

B-BLK or ACEI

Pharm TXT of HTN urgency is

α agonist (Clonidine)

Pharm TXT of BPH is

α antagonist (-zosins)

Pharm TXT of cardiac issues with pregnancy is

1. Methyldopa or Labetolol 2. Nifedipine (can be added as 2nd line)

Pharm TXT of CHF is

Combo A/B-BLK (Labetalol or carvedilol)

α agonists (clonidine) SEs (2)

Dry mouth and Rebound HTN

Pharm TXT for pts who fail everything else

Hydralazine and minoxidil

Renin blocker example

Aliskiren

Pts requiring >3 drugs for HTN treatment should be

Referred to HTN specialist Nephrologist Cardiologist Endocrin

What are the two categories of HTN crisis

Urgency or Emergency

HTN crisis refers to

Severely elevated BP

HTN urgency refers to

Severely elevated BP in an asymptomatic pt without end organ damage

Timeline for TXT of HTN urgency is

PO Therapy within hours/days and F/U monitoring

End Organ damage is usually evident when BP is

>130 DBP

HTN emergency refers to

Severely elevated BP with end organ damage

Timeline for TXT of HTN emergency is

Therapy immediately and ADMIT

HTN crisis etiology

prolonged inadequate control of chronic HTN with a hemodynamic insult

HTN crisis pathophys

Severe elevate BP causes Arteriolar fibrinoid necrosis causing endothelial damage and PLT/Fibrin despostion leading to ischemia

HTN crisis labs

UA, CMP, CBC, CXR, EKG

In HTN crisis if BP is reduced too rapidly what can occur

End-Organ ischemia due to compensatory effects

Goal of TXT in HTN crisis is to reduce MAP by

20-25% and <100 DBP

HTN emergency requires (5)

ICU admit Parenteral Meds Continuous cardiac monitoring Invasive (radial

HTN urgnecy TXT in a pt already on anti-HTN (3)

Increase dose of current med or add another Check adherence Add diuretic and reinforce dietary Na+ restricts

HTN urgency management/pharm

Goal is to reduce BP <160/100 -F/U w/ long acting PO Furosemide PO Clonidine

HTN Emergency management/pharm

Parenteral Labetalol

Labetalol cannot be used in what two cardiac D/Os

Cocaine intoxication and Decomp Systolic HF

HTN Emergency (Aortic dissection) management/pharm

Goal in acute dissection is BP <140/110 Morphine for pain IV labetaolol or Esmolol

HTN Emergency (Pulmonary edema) management/pharm

Goal is by reduction by 20-30%, diuresis IV Nitroglycerin (1st line) IV Nicardipine (favors systolic dysfunction)

HTN Emergency (Cocaine/meth abuse) management/pharm

Initial TXT is benzodiazepine IV Lorazepam IV Diazepam

HTN Emergency (AMI) management/pharm

Goal 20-30% reduction of SBP >160 IV nitroglycerin (1st line) IV or PO Metoprolol

HTN Emergency (Neurologic ER) management/pharm

Get emergency CT scan to determine DX first