Treatment of HTN

Question 1

Types of HTN

Answer 1

Primary HTN
Secondary HTN
White-coat HTN
PseudoHTN
Isolated systolic HTN
Resistant HTN
Hypertensive crises

Question 2

Define Primary HTN

Answer 2

Unknown cause; due to body’s compensation

90%

Question 3

Define Secondary HTN

Answer 3

Identifiable cause - disease (CKD), drug (NSAIDs), birth control, etc

Question 4

Define White-Coat HTN

Answer 4

BP increases in a clinical setting

Question 5

Define PseudoHTN

Answer 5

BP falsly elevated due to rigid calcified brachial artery

Question 6

Define Osler’s maneuver

Answer 6

BP cuff inflated above peak SBP, if radial artery remains palpable + Osler’s = PseudoHTN

Question 7

Define Isolated systolic HTN

Answer 7

Only systolic BP increase

Question 8

Define resistant HTN

Answer 8

Not at goal BP on max dose of at least 3 drugs, one of which is a diuretic

Question 9

Define Hypertensive crisis

Answer 9

> 180/120

Emergency or urgency

Question 10

Define Hypertensive Emergency

Answer 10

Extreme elevation in BP accompanied with acute or progressing target-organ damage

Question 11

Treatment goals for Hypertensive Emergency

Answer 11

Immediate but gradual decrease in BP with IV agents over minutes to hours (DBP <110)

Question 12

Define Hypertensive Urgency

Answer 12

High BP without acute or progressing target-organ damage

Question 13

Hypertensive Urgency treatment

Answer 13

Decrease BP with PO agent to stage 1 values over several hours to days

Question 14

Automated BP measurment arm cuff

Answer 14

Preferred over manual bc they decrease user error

Arm cuff because finger and wrist are as accurate

Question 15

Diagnosis from automated BP cuffs

Answer 15

Average of 2 reading taken on separate occasions

Question 16

Self Monitoring of BP

Answer 16

Should be routine
Useful to guide in diagnosis, response to therapy and improve adherence
- Evaluate white-coat HTN

Question 17

Diagnosis based on self monitoring

Answer 17

Average readings over 5-7 days

>130/85 is abnormal

Question 18

Ambulatory BP Monitoring

Answer 18

24 hour monitoring records BP at frequent intervals throughout the day
- Evaluate white-coat HTN
>130/85 is abnormal

Question 19

BP during sleep

Answer 19

should dip 10-20%, if not may indicated increased risk of CVD

Question 20

Normal Classification

Answer 20

less than 120/80

Question 21

Pre-HTN Classification

Answer 21

Systolic: 120-139
AND
Diastolic: 80-89

Question 22

Stage 1 Classification

Answer 22

Systolic: 140-159
AND
Diastolic: 90-99

Question 23

Stage 2 Classification

Answer 23

Systolic: >160
AND
Diastolic: >100

Question 24

Major CV Risk Factors

Answer 24

HTN
Obesity >30
Dyslipidemia
DM
Smoking
Physically inactive
Albuminuria GFR 55, F: >65)
Family history of premature CVD

Question 25

Identifiable causes of HTN?

Answer 25

``` Sleep apnea Primary aldosteronism Cushing's syndrome or steroids Drug induced Renovascular disease Pheochromocytoma CKD!!! Thyroid ```

Question 26

Baseline Lab test to look at?

Answer 26

Urinalysis (albumin, RBC, WBC), microalbumin:creatinine, hematocrit, fasting lipid panel, Chem 7, calcium, ECG, LFTs

Question 27

5 Steps of Diagnostic Workup

Answer 27

``` Assess RF and co-morbidities Reveal identifiable causes Assess presence of target organ damage History and PE Baseline labs ```

Question 28

Goals of therapy

Answer 28

Decrease CV and renal morbidity/mortality Prevent target organ damage Lifestyle modifications

Question 29

Who needs lifestyle modifications?

Answer 29

All patients | For stage 1 pts with CV abnormalities (6-12 months)

Question 30

What kind of lifestyle modifications?

Answer 30

``` Weight reduction Dash diet Dietary Na restrictions Physical activity Moderate alcohol (<2 per day) ```

Question 31

Define DASH diet

Answer 31

Fruits and veggies, low-fat dairy, reduced saturated fat

Question 32

Define Na restrictions

Answer 32

<1500mg

Question 33

How much exercise?

Answer 33

30-40 minutes x 3-4 per week

Question 34

BP Goals for CKD or DM or most patients

Answer 34

<140/90

Question 35

BP Goal for >80 or 60-80 and frail

Answer 35

Unless CKD or DM | <150/90

Question 36

Stage 1 HTN Therapy?

Answer 36

MONOtherapy: ACEI, ARB, CCB, or Thiazide

Question 37

Stage 1 HTN & Black Therapy ?

Answer 37

CCB or Thiazide

Question 38

Stage 2 HTN Therapy?

Answer 38

Two drugs: Thiazide or CCB + ACEI or ARB

Question 39

Specifically two drug combo is recommended when?

Answer 39

>20 mmHg SBP above goal or >10 mmHg DBP

Question 40

Left Ventricular Dysfunction Treatment

Answer 40

Diuretic + ACEI or ARB then add beta blocker | Add on: aldosterone antagonist

Question 41

Post-MI treatment

Answer 41

Beta-blocker then add ACEI or ARB

Question 42

Coronary Artery Disease Treatment

Answer 42

Beta blocker then add ACEI or ARB | Add on: CCB then thiazide diuretic

Question 43

DM Treatment

Answer 43

ACEI or ARB; ARB, CCB or Thiazide | Add on: CCB or thiazide

Question 44

CKD Treatment

Answer 44

ACEI or ARB

Question 45

Recurrent Stroke Prevention Treatment

Answer 45

Thiazide diuretic or thiazide diuretic + ACEI

Question 46

ALLHAT Conclusions

Answer 46

No difference in primary outcomes or all-cause mortality ACEI less effective in black pts to decrease BP and CV outcomes Chlorthalidone was the drug of choice, decreases secondary outcome and least expensive More than one agent was required to control BP

Question 47

First Line agents

Answer 47

Thiazide diuretics, ACEI, ARBs, and CCBs

Question 48

4 Classes of Diuretics

Answer 48

Thiazides Loop Potassium-sparing Aldosterone antagonists

Question 49

Diuretics MOA

Answer 49

Early BP decrease due to diuresis Chronic BP decrase due to decreased PVR Syngergistic on BP with ACEI, ARBs or beta-blockers

Question 50

1st Gen Thiazides

Answer 50

Chlorathalidone and HCTZ

Question 51

2nd Gen Thiazide Like

Answer 51

Indapamide (Lozol) | Metolazone (Zaroxoyln)

Question 52

Thiazide + Renal Dysfunction

Answer 52

1st gens don't work as well

Question 53

Thiazide place in treatment?

Answer 53

1st line | Esp in black and elderly

Question 54

Thiazide side effects

Answer 54

``` HYPOkalemia HYPOmagnesemia HYPERuricemia Increase Ca reabsorption HYPOtension and dizziness ```

Question 55

Thiazide clinical pearls?

Answer 55

Effect decrease with time Takes 2-3 wks to see max benefit Chlorthalidone is 1.5X as potent as HCTZ with longer half life Increase the dose = increase electrolyte problems

Question 56

Loop diuretics

Answer 56

Furosemide (Lasix) Torsemide (Demadex) Bumetanide (Bumex)

Question 57

Loop diuretics place in treatment

Answer 57

Considered in uncomplicated HTN in patients with significant renal dysfunction not responsive to thiazides

Question 58

Loop diuretics Clinical pearls

Answer 58

Limited routine use Biggest roles is in resistant HTN with renal dysfunction Significant diuresis and electrolyte issues (K and Mg)

Question 59

Potassium Sparing DIuretics

Answer 59

Amiloride (Midamor) Amiloride/HCTZ (Moduretic) Triamterene (Dyrenium) Triamterene/HCTZ (Dyazide/Maxide)

Question 60

Potassium Sparing Diuretics Clinical pearls

Answer 60

Weak diuretics Primarily with thiazides to decrease HYPOkalemia May cause HYPERkalemia with ACEI/ARBs

Question 61

Aldosterone Antagonists

Answer 61

Eplerenone (Inspra) Spironolactone (Aldactone) Spironolactone/HCTZ (Aldactazide)

Question 62

Spironolactone is contraindicated in?

Answer 62

When CrCl <30

Question 63

Eplerenone is contraindicated in?

Answer 63

CrCl less than 50 Elevated SCr greater than 1.8 in F or >2 in M Type 2DM

Question 64

Aldosterone Antagonists Clinical Pearls

Answer 64

Potassium sparing | Significant HYPERkalemia esp with ACEI, ARB, or K supplement

Question 65

What do you monitor with diuretics?

Answer 65

Chem 7 | Baseline then 1-2 wks then every 6-12 months or after initiating other agents which may affect electrolytes