Tuesday HTN lecture

Question 1

When is initial combination therapy recommended?

Answer 1

Stage 2 if you’re 20/10mmHg above goal

Question 2

When should you ask a pt to RTC after Rx a HTN medication?

Answer 2

4-6 weeks (and perhaps do kidney panel to make sure you’re not causing damage)

Question 3

What 5 lifestyle changes should you recommend pts do?

Answer 3

1) Smoking cessation
2) Control blood glucose and lipids
3) Diet
4) Physical activity:150 minutes per week moderate to vigorous activity (3-4 session of 30-40 mins/week)
5) Weight loss for BMI > 25%

Question 4

What diet changes should you recommend pts make?

Answer 4

1) DASH diet
2) NaCl < 2400 mg per day (~ 1 teaspoon), K+ supplementation via diet
3) Avoid excessive ETOH (2 drinks men, 1 drink women)

Question 5

What lifestyle modifications have no significant evidence?

Answer 5

Calcium or magnesium supplements, relaxation therapy, yoga, or acupuncture

Question 6

Describe the DASH diet

Answer 6

-A flexible and balanced eating plan that helps create a heart-healthy eating style for life.
-The DASH eating plan requires no special foods and instead provides daily and weekly nutritional goals. This plan recommends:
a) Eating vegetables, fruits, and whole grains
b) Including fat-free or low-fat dairy products, fish, poultry, beans, nuts, and vegetable oils
c) Limiting foods that are high in saturated fat, such as fatty meats, full-fat dairy products, and tropical oils such as coconut, palm kernel, and palm oils
d) Limiting sugar-sweetened beverages and sweets.

Question 7

In the all-patient populations > 18 y/o with CKD, initial or add-on Rx should include what?

Answer 7

ACEi/ARB to improve renal outcomes

Question 8

General non-black population, including those with DM, but not CKD: initial treatment should incl. therapy with one of more of what types of drugs?

Answer 8

1) A thiazide type diuretic
2) CCB
3) ACEi or ARB

Question 9

General black population, including those with DM but not CKD: initial treatment should incl. therapy with one of more of what types of drugs?

Answer 9

1) A thiazide type diuretic
2) CCB

Question 10

1) Main objective of HTN treatment is to do what?
2) What should you do to meet these goals?
3) What is the goal in most ppl?

Answer 10

1) Obtain and maintain goal BP
2) Add and titrate Rx as necessary to meet these goals
3) < 130/80 mm Hg

Question 11

ACC/AHA guidelines: Hypertensive patients with an estimated 10-year ASCVD risk less than 10% should try _______ to _______ months of lifestyle modifications before initiation of pharmacotherapy

Answer 11

3 to 6

Question 12

AHA/ACC guidelines: patients with an initial BP of ___________ mm Hg or higher AND a high cardiovascular risk should be treated initially with lifestyle modifications and pharmacotherapy

Answer 12

130/80

Question 13

JNC-8 guidelines:
1) General population treatment threshold is _______ mm Hg
2) Elderly patient treatment threshold is ____________mmHg

Answer 13

1) 140/90
2) 150/90

Question 14

True or false: Any of the following 3 classes of medications may be used in most patients alone or in combination for initial therapy:
1) Thiazide diuretics
2) CCB
3) ACEi or ARB

Answer 14

True

Question 15

1) What are thiazide diuretics used for?
2) What are 2 main groups of effects?

Answer 15

1) HF and HTN
2) Decreased or increased excretion of substances

Question 16

What are the 2 things with decreased excretion with thiazide diuretics?

Answer 16

1) Uric acid (Contraindicated in gout)
2) Calcium (hypercalcemia)

Question 17

What are the 3 things with increased excretion with thiazide diuretics?

Answer 17

1) Na: hyponatremia
2) K: hypokalemia … especially if patient not salt restricted
3) Magnesium: hypomag can make it difficult to correct for hypo K

Question 18

Why should you avoid thiazide diuretics with lithium use?

Answer 18

Increasing risk of lithium toxicity

Question 19

1) What can happen with thiazide diuretics if the pt has hyperlipidemia?
2) When are thiazide diuretics not effective?
3) What is the exception to this lack of efficacy?

Answer 19

1) Elevate TG
2) If eGFR < 30-40 mL/min (CKD stage 3B)
3) Metolazone (Zaroxolyn); not useful for monotherapy but improves diuresis when used with loop diuretic (furosemide, torsemide, bumetanide, ethacrynic acid)

Question 20

List the initial and max doses for the following:
1) Hydrochlorothiazide
2) Chlorthalidone

Answer 20

1) 12.5-25mg/ day; 25mg
2) 12.5-25mg/ day; 50mg

Question 21

List 3 thiazide diuretics

Answer 21

1) Hydrochlorothiazide
2) Chlorthalidone
3) Indapamide

Question 22

What are the diuretics sites of action? (from proximal to distal)

Answer 22

MALTS
1) Mannitol (proximal convoluted)
2) Acetazolamide (proximal convoluted)
3) Loop diuretics (ascending loop)
4) Thiazide diuretics (distal convoluted)
5) Spironolactone (collecting duct)

Question 23

1) What are the 4 clinical indications for ACE inhibitors and ARBs?
2) Are ACEis and ARBs initial or add-on Txs?
3) In patients 18 and older with _____, treatment should include ACEi or ARB

Answer 23

1) HTN, HF, previous MI, CKD
2) Can be used for both
3) CKD

Question 24

ACEi and ARBs do what in diabetic patients?

Answer 24

Slows progression of microalbuminuria

(all DM patients should be screened for microalbumin and treated with ACEi or ARB if present)

Question 25

1) Why do ACEis cause a cough in 10-20% of patients? 2) What should you do if this happens?

Answer 25

1) Elevated bradykinin in lungs (site of action of ACEi) 2) Substitute ARB (works at receptors peripherally)

Question 26

ACEis and ARBs: 1) What can they increase? 2) What has an absolute contraindication? 3) What has a relative contraindication?

Answer 26

1) Lithium levels 2) Pregnancy 3) Pts with RAS and hyper K+

Question 27

ACEis and ARBs: 1) How do black patients respond? 2) What is 2-4x more common in black patients?

Answer 27

1) Relatively reduced BP response to monotherapy with ACEi or ARBs 2) ACEi induced angioedema

Question 28

Can ACEis and ARBs be used together in the same pt?

Answer 28

No; never ever

Question 29

What are the ACEis? What do they end in?

Answer 29

End in -pril 1) Fosinopril 2) Lisinopril 3) Qinapril 4) Ramipril

Question 30

What are the ARBs? What do they end in?

Answer 30

end in -sartan 1) Candesartan 2) Irbesartan 3) Losartan 4) Olmesartan 5) Valsartan

Question 31

1) What group of Ca+ channel blockers (CCBs) may cause some dependent edema and reflex tachycardia? 2) What group may exacerbate HF, bradycardia, or conduction blocks?

Answer 31

1) Dihydropyridine 2) Non-dihydropyridine

Question 32

Ca+ channel blockers (CCBs): 1) What may all of them cause 2) When are they generally avoided?

Answer 32

1) Postural hypotension, HA, fatigue, weakness 2) In HF in most patients

Question 33

Hypertension Geriatric (65+) considerations: 1) What is common? 2) What is the JNC-8 Threshold ? 3) What abt with either CKD or DM? 4) ACC threshold SBP is what?

Answer 33

1) Isolated systolic HTN common 2) SBP 150/90 mm Hg (without CKD or DM) 3) 140/90 mm Hg 4) ~ 130/80 mmHg Side effects to medications more frequent Any of the 3 classes appropriate CCB for isolated systolic HTN

Question 34

**HTN & Ischemic heart disease: Beta blockers** 1) When should you avoid? 2) What may they lead to?

Answer 34

1) In Asthma, COPD, heart block 2) Bronchospasm, bradycardia, HF, fatigue, decreased exercise tolerance, elevated TG

Question 35

1) What represent a spectrum of disease that affects women throughout pregnancy and the immediate postpartum period? 2) What 3 things are warranted in these cases?

Answer 35

1) Hypertensive disease of pregnancy 2) Close blood pressure (BP) monitoring, laboratory evaluation, and fetal assessment are warranted

Question 36

What does the spectrum of hypertensive disease of pregnancy include?

Answer 36

1) Gestational hypertension (HTN) 2) Preeclampsia, eclampsia, HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome 3) Chronic HTN, and chronic HTN with superimposed preeclampsia

Question 37

HTN of pregnancy: 1) What are first-line oral antihypertensives for outpatient BP management of chronic HTN? 2) What has long h/o use and appears safe alternative (monitor LFT’s)? 3) What should you do postpartum?

Answer 37

1) Labetalol and nifedipine extended release (Procardia XL) 2) Methyldopa (alpha-2 agonist) 3) Continued vigilance (6-8 wks)

Question 38

Resistant HTN refers to a BP that stays above the target in spite of the Tx with ___ drugs (among one of them is a diuretic)

Answer 38

3

Question 39

What are the two caveats to the general rule of "3 or more drugs and still high= resistant HTN"?

Answer 39

1) One must be a diuretic 2) Adequate dosing of all 3 classes of medications

Question 40

What are examples of exogenous substances?

Answer 40

1) Caffeine – energy drinks, supplements 2) Excessive alcohol, smoking, cocaine 3) NSAIDS, OCP, Steroids 4) EPO 5) Herbal agents

Question 41

How can you make sure resistant HTN is real?

Answer 41

Verify with clinic and out of office BP measurements

Question 42

How do you measure BP correctly in-office?

Answer 42

Quietly sitting 5 minutes, back supported, feet comfortably on the ground Cuff correct size – 80% of biceps Support arm at heart level Average minimum of 2 readings at least a minute apart Check BP in both arms Check BP standing for orthostasis

Question 43

Give examples of causes of secondary HTN

Answer 43

1) OSA 2) CKD – renal parenchymal disease and RAS

Question 44

Resistant HTN: How can you ensure a pt's regimen is appropriate? (3 things)

Answer 44

1) Appropriately dosed as tolerated 2) Typically, it's inadequate diuresis; consider longer acting diuretic 3) Change thiazide type diuretic to chlorthalidone

Question 45

Resistant HTN: Adjunctive therapy 1) What is a potential 4th drug? 2) Could you switch from ACEi to ARB or vice versa to help? 3) What other b-blockers could you consider? Why? Which increases nitric oxide levels? 4) What are 2 other meds to consider and their MOAs?

Answer 45

1) Spironolactone - potassium sparing & aldosterone antagonist 2) No benefit changing from ACEi to ARB or vice versa 3) Vasodilating B-blocker: Carvedilol, labetalol – both block alpha and beta receptors -Nebivolol increases nitric oxide levels 4) Clonidine: central alpha-2 receptor blocker Prazosin (Minipress): peripheral alpha -1 receptor blocker

Question 46

Stopping ___________ suddenly can cause rebound HTN

Answer 46

Clonidine

Question 47

1) What groups tend to be sensitive to diuretics? 2)

Answer 47

1) Obese, AA, or elderly patients 2)

Question 48

Tolerance to thiazides or “braking” effect: What are 3 things you should do?

Answer 48

1) Restrict salt intake 2) Increase dose 3) Add aldosterone inhibitor – spironolactone (Aldactone)

Question 49

Other Treatment considerations for HTN: 1) What are 2 reasons to consider aldosterone inhibitors? 2) What should you do for OSA?

Answer 49

1) PA, Cushing syndrome 2) CPAP (+ lifestyle modifications)

Question 50

Renal vascular disease causing HTN: 1) What did not improve outcomes over Rx alone in atherosclerotic RAS? 2) What is tx of choice for fibromuscular dysplasia ACEi and ARB relatively contraindicated?

Answer 50

1) Stenting 2) Angioplasty

Question 51

1) What is “the 4th BP medication”? 2) What is it the appropriate choice for? 3) At initiation eGFR should be what? What abt K+? 4) Resistant HTN is associated with higher levels of what? What does this lead to?

Answer 51

1) Aldosterone antagonist 2) Resistant HTN 3) eGFR should be > 30 mL/min (CKD 3 or better) and K+ < 4.5 mEq/dL 4) Higher levels of aldosterone, leading to secondary pharyngeal edema, increasing upper airway obstruction and making this a good choice for patients with OSA

Question 52

Give an example of a direct arterial vasodilator (i.e. combines with receptors in endothelium of arterioles and can cause palpation + tachy)

Answer 52

Hydralazine

Question 53

Give an example of a group of drugs that oppose effects of the sympathetic nervous system (decrease smooth muscle contraction)

Answer 53

Alpha-1 and alpha 2 adrenergic agonists

Question 54

Rx induced renal funct. decline: 1) What is the normal change? 2) What also dilate efferent arteriole, exaggerating decline in IG pressure? 3) What should you do if the change is abnormal?

Answer 54

1) Physiologic (normal) – up to 30% increase in creatinine, stabilizes Ex: 1.0 to 1.3 mg/dL 2) ACEi/ARB 3) If creatinine increases by more than 30%, agent should be reduced or discontinued

Question 55

True or false: Renal dysfunction may occur with any antihypertensive agent

Answer 55

True

Question 56

List the 5 steps you should take if BP is not controlled

Answer 56

1) Alter thiazide to chlorthalidone or indapamide 2) Add spironolactone or eplerenone 3) Add B-blocker. Alternative is alpha-blocker or diltiazem Qday. 4) Add hydralazine (3x/day). Add isosorbide if HFrEF 5) Substitute minoxidil. Involve specialist if not effective.

Question 57

Give examples of end-organ damage that may occur with a hypertensive emergency

Answer 57

1) CNS – dizziness, confusion, encephalopathy, TIA, ischemic or hemorrhagic stroke 2) Eyes – vision changes - papillary edema, retinal changes 3) Heart – angina, ACS, aortic dissection 4) Renal – ARF – hematuria and proteinuria

Question 58

A pt has a BP of 190/120 and no end organ damage. What do they have and what do you do?

Answer 58

Severe asymptomatic HTN; outpatient management

Question 59

1) Define severe asymptomatic HTN 2) What do these pts often have and what is the use of immediate diagnostic testing?

Answer 59

1) Defined as SBP > 180 or DBP > 110 (120) mmHg without symptoms of target organ injury 2) Often have pre-existing poorly controlled chronic HTN; immediate diagnostic testing rarely alters short term management

Question 60

Severe asymptomatic HTN: 1) >180/110 (120) mmHg is also the goal BP for what? 2) Describe when it most often occurs in patients previously Dx with HTN

Answer 60

1) rtPA in ischemic stroke) 2) In patients previously Dx with HTN: 60% chronically uncontrolled HTN 65% Medication noncompliance Rarely: unrecognized secondary HTN

Question 61

Severe HTN: 1) What is essential? 2) What parts of history definitely need to be asked? 3) What does ROS need to include? 4) Why is an exam needed?

Answer 61

1) Comprehensive history is essential 2) Medication history: New Rx and/or OTC Recreational drugs and alcohol excess Compliance with current prescriptions 3) For end organ damage 4) Look for end organ damage

Question 62

Describe how you should look for target organ injury (6 steps)

Answer 62

1) Neuro exam for focal deficits 2) Eye exam with fundoscopic exam 3) Retinal bleeding, papillary edema 4) Cardiovascular – bruits, pulses, JVD, abnormal heart sounds 5) Pulmonary - rales 6) Abdominal exam – pulsating abdominal bruits

Question 63

Recent study of outpatients of patients referred to ER for HTN urgency found that ~_____% of test were abnormal and ~____% had evidence of target organ injury

Answer 63

~5%; ~2%

Question 64

HTN urgency: 1) What can routine testing include? 2) How often is EKG done?

Answer 64

1) Routine? - CMP, UA, cardiac enzymes, CXR, CT head 2) EKG performed in < 1%

Question 65

True or false: No validated policies or nationally recognized clinical guidelines for HTN urgency

Answer 65

True

Question 66

List 4 questions to ponder in Severe Asymptomatic HTN

Answer 66

1) Does acute Rx management affect short term adverse outcomes? 2) How quickly should BP be lowered? 3) Who should be admitted? 4) How should admitted patients with HTN urgency be managed?

Question 67

1) Most outpatient clinicians hesitant to send patients home with severe hypertension. Why is this an issue? 2) Studies support a “conservative” approach; describe this

Answer 67

1) Lack of evidence of immediate increase in risk of major adverse outcomes -Common practice to acutely lower BP with short acting antihypertensives 2) Outpatient management PO antihypertensive Rx and follow up Acutely lowering BP may not be necessary or beneficial

Question 68

Asymptomatic severe HTN: 1) Gradually lower BP over ________to ________ to goal 2) Use GDMT, typically require at least ______ medications 3) If patient was stable on medications in the past, you should do what?

Answer 68

1) days; weeks 2) 2 3) Return to same medications

Question 69

Give the severe asymptomatic HTN BLUF

Answer 69

Patients with HTN urgency should have a history and exam to distinguish between severe asymptomatic hypertension and hypertensive emergency A 30-minute rest period is recommended when the initial BP is severely elevated. In more than 30% of patients, the BP will lower to an acceptable level without intervention after the rest period (<180/110 mmHg) An immediate diagnostic evaluation is not required in the initial management of severe asymptomatic hypertension Aggressive lowering of BP can be harmful and should be avoided in patients with severe asymptomatic hypertension. Gradual reduction over several days to weeks is recommended

Question 70

Describe HTN emergency Tx (covered in detail in emergency med)

Answer 70

1) Gradually lower BP by 10-20% in the 1st hour and a further 5-15% over the next 23 hours -Initial goal 1st hour is < 180/120 mm Hg -Goal for next 23 hours is < 160/110 mm Hg 2) Typically admitted and IV meds are used B-Blockers: Labetalol Nitrites: Nitroprusside CCB: Nicardipine

Question 71

True or false: syncope is generally not a brain issue

Answer 71

True

Question 72

1) Define syncope 2) What is the immediate cause? What are 2 potential causes of this?

Answer 72

1) Abrupt, transient complete loss consciousness associated with inability to maintain postural tone with rapid spontaneous recovery (not just MS changes such as intoxication or opioid OD) 2) Transient cerebral hypoperfusion -Systemic vasodilation, decreased cardiac output, or both

Question 73

What are 3 MOAs of syncope?

Answer 73

Usually a combination: 1) **Cardiac:** decreased cardiac output (CO), most often associated with sudden cardiac death 2) **Reflex (neurogenic):** most common type affecting systemic vascular tone and CO -Provoking factor: fear, pain, emotional distress, cough, micturition 3) **Orthostatic:** usually associated with positional changes -Dehydration, anemia, medication use

Question 74

1) Dehydration, anemia, medication use are examples of what types of syncope causes? 2) What is the most common type affecting systemic vascular tone and CO? 3) Fear, pain, emotional distress, cough, micturition can provoke what type?

Answer 74

1) Orthostatic 2) Reflex (neurogenic) 3) Reflex (neurogenic)

Question 75

What should you do for each of the following types of syncope? 1) Cardiac 2) Reflex 3) Orthostatic

Answer 75

1) Treat underlying issue 2) Pt education (trigger avoidance) and reassurance 3) Pt education and reassurance + anticipating triggers

Question 76

1) Define orthostatic hypotension 2) Define the criteria for Dx

Answer 76

1) Drop in BP after assuming a standing position from supine 2) Dx: drop of 20 mm Hg or more SBP or drop of 10 mm Hg or more DBP (Similar BP changes 60 degrees head up on tilt table)

Question 77

Symptoms (not required for Dx) of orthostatic hypotension are due to what?

Answer 77

Inadequate physiologic compensation and organ hypoperfusion

Question 78

List the following Sx for orthostatic hypotension: 1) Constitutional 2) CNS 3) Retina 4) CV 5) Pulmonary 6) GI 7) MSK

Answer 78

1) Fatigue 2) HA, lightheaded, presyncope/syncope 3) Visual disturbance 4) CP, palpitations, pallor, weakness 5) Dyspnea 6) Nausea 7) Shoulder and neck pain (coat hanger syndrome)

Question 79

1) How do you measure orthostatic hypotension BP? 2) What should you do if the pt can't safely stand?

Answer 79

1) Take BP and heart rate five minutes after supine and 3 minutes after standing + test = drop in 20 or more mm Hg SBP or 10 or more mm Hg DBP 2) Head up tilt table test

Question 80

List 3 risk factors for orthostatic hypotension

Answer 80

1) Prevalence increased in elderly – decreased baroreceptor sensitivity and increasd autonomic neurodegenerative disease 2) Peripheral neuropathy - T2DM 3) Postural symptoms that only occur when standing

Question 81

What is the significance of orthostatic hypotension?

Answer 81

Significant increase in CV risk, all cause mortality, and falls

Question 82

For neurogenic causes of orthostatic hypotension, list the following: 1) Change in HR/change in SBP (HR compensation ratio) 2) Symptoms of autonomic failure 3) Neurologic deficits

Answer 82

1) < 0.5 BPM/mm Hg 2) Dysfunction of urinary, GI Postprandial hypotension Symptoms worse in morning 3) Parkinsonism, cognitive dulling, cerebellar signs, peripheral sensory findings

Question 83

For non-neurogenic causes of orthostatic hypotension, list the following: 1) Change in HR/change in SBP (HR compensation ratio) 2) Symptoms of autonomic failure 3) Neurologic deficits

Answer 83

1) Marked increase in ratio 0.5 or more 2) None 3) None

Question 84

Orthostatic hypotension management: 1) What are the goals? 2) How is this done? 3) What is especially important in elderly? (per Beers Criteria 2024)

Answer 84

1) Reduce Sx, improve QOL 2) ID and Tx underlying conditions 3) Medication review

Question 85

Describe how to avoid aggravating activities with orthostatic hypotension (3 things)

Answer 85

1) Post prandial hypotension = smaller more frequent meals 2) Avoid hot humid conditions which leads to cooling via vasodilation 3) Proper hydration

Question 86

What 2 groups of medications can you use in orthostatic hypotension Tx? Give examples of each and their MOAs

Answer 86

1) Adrenergic receptor agonists a) Midodrine: short acting alpha-1 agonist b) Droxidopa: short acting prodrug of norepinephrine 2) Mineralocorticoids a) Fludrocortisone: increases salt reabsorption, IV volume, and vascular tone