What are the two most common causes of hypertension?
1) Essential HTN (95%) 2) OCPs are the most common secondary cause of HTN. Other secondary causes include renovascular disease, endocrine disorders, medications, coarctation and OSA.
Why are patients with HTN at increased risk of CAD, PVD and CVA?
HTN accelerates atherosclerosis
4 non-modifiable risk factors for HTN
1) Age > 60 2) Male 3) African-American 4) FHx
3 modifiable risk factors for HTN
1) Obesity 2) Sodium intake 3) Alcohol intake > 2 oz.
Complications of uncontrolled HTN
1) Cardiovascular: MI, CHF due to LVH, PVD, aortic dissection 2) Retinopathy: AV nicking, cotton wool spots, scotomata, hemorrhages, exudates and papilledema 3) CNS: hemorrhage, TIA, CVA and lacunar stroke 4) Renal: nephrosclerosis (atherosclerosis of afferent AND efferent arterioles), decreased GFR and ESRD
Diabetic & renal disease definition of HTN
A patient comes in for a BP check, how long should you wait if they just drank coffee or had a cigarette?
A patient comes to clinic and has blood pressure elevations on two separate visits over a span > 4 weeks. You diagnose him with HTN and assess for target organ damage. What labs do you want to order at this time?
1) UA (proteinuria) 2) BMP (K, BUN, Cr) 3) FBG (r/o DM) 4) Lipid panel (minimize atherosclerosis) 5) ECG (check for LVH)
When will most newly diagnosed patients with HTN get 2-drug tx from the start?
Stage II (> 160/100)
What lifestyle modifications have the most profound effect on dropping BP?
DASH diet (8-14), q10kg wt. loss (5-20), 30 min exercise q5-6x/week (4-9), Na
Best anti-HTN med for AAs? What if they have DM?
AAs = HCTZ. AA + DM = ACE-I is 1st line in all patients with DM due to its renal protective effect
Lifestyle modification necessary for HCTZ to work?
Na restriction, otherwise hypokalemia will be exacerbated
Best anti-HTN med for old men with BPH?
Meds usually tried in patients with HTN refractory to 1st and 2nd line therapy?
Vasodilators (hydralazine and minoxidil) in combination w/beta-blockers and diuretics
Anti-HTN medications contraindicated in pregnancy?
ACE-I, ARBs, CCBs and thiazides. Beta-blockers and hydralazine are safe.
Which anti-HTN is the best 1st line medication?
Unless there is a compelling reason HCTZ, dihydropyridine (CCB), ACE-I and ARBs are all commonly used as initial monotherapy.
ACCOMPLISH trial findings regarding effectiveness of combination therapy
Benazepril + amlodipine was more effective than and ACE-I or CCB alone.
A patient presents with HTN non-responsive to lifestyle modifications and 6 weeks of HCTZ. What is your next step?
Change to a different type of monotherapy before adding on a second medication.
Who gets screening lipid testing?
All adults > 20 yrs q5 years
What are the causes of primary dyslipidemia syndromes? How are they treated?
I) Exogenous HLD = chylomicrons, tx’d w/diet modification. IIa) Familial hypercholesterolemia = LDL, tx’d w/statins, niacin, cholestyramine. IIb) Combined hyperlipoproteinemia = LDL + VLDL, tx’d w/statins, niacin, gemfibrozil. III) Familial dysbetalipoproteinemia = IDL, tx’d w/gemfibrozil, niacin. IV) Endogenous HLD = VLDL, tx’d w/niacin, gemfibrozil, statins. V) Familial hypertriglyceridemia = VLDL + chylomicrons tx’d w/niacin, gemfibrozil
Causes of secondary dyslipidemia?
Endocrine (hypothyroidism, DM, Cushing’s), Renal (nephrotic syndrome), ESLD, Meds (propranolol, HCTZ, estrogen, prednisone) and Pregnancy.
Foods that will elevate LDL
Saturated fatty acids and cholesterol
Foods that will elevate triglycerides (VLDL)?
High calorie diets and alcohol
At what age do cholesterol levels stop increasing?
When do both genders have equal risk for HLD?
How is LDL measured?
Total cholesterol - HDL - TG/5
LDL levels associated with significant increase in CAD risk
Total cholesterol levels associated with significant increase in CAD risk?
160-200, > 240 is really bad
Why is HDL so good?
Every 10mg/dL increase = 50% decrease CAD risk. HDL 60 subtracts 1 point from risk.
Risk associated with total cholesterol to HDL ratio