1
Q
Define HTN
A
- systolic: over 140
- diastolic: over90
- must have more than 2 readings
2
Q
What are the three occasions to measure BP?
A
- clinic
- home monitoring
- ambulatory setting
3
Q
What are the BP classifications?
A
- normal
- preHTN
- stage I HTN
- stage II HTN
- isolated systolic HTN
4
Q
normal BP values
A
- systolic: less than 120
AND - diastolic less than 80
5
Q
preHTN values
A
- systolic: 120-139
OR - diastolic: 80-89
6
Q
stage I HTN values
A
- systolic: 140-159
OR - diastolic: 90-99
7
Q
stage II HTN values
A
- systolic: over 160
OR - diastolic: over 100
8
Q
isolated systolic HTN values
A
- systolic: over 140
AND - diastolic: under 90
9
Q
What can happen with preHTN?
A
develops into stage I HTN in 50% pts w/in 4 yrs
10
Q
T/F: HTN before 50y/o leads to majority having diastolic HTN.
A
- false, combo systolic and diastolic
11
Q
T/F: HTN after 50y/o leads to majority having diastolic HTN.
A
- false, systolic
12
Q
HTN epidemiology
A
- prevalence increases w/ age
- MC: blacks more than whites ==> appears earlier in life, more severe, and higher rates of M+M
13
Q
T/F: HTN doubles risk of all CV dz.
A
true
14
Q
Systolic BP tends to _____ w/ age. Diastolic BP _____ until age 55, then it ____.
A
- rise
- increases
- decreases
15
Q
Why is SBP higher in women over 60 in comparison to men over 60?
A
menopause –> estrogen is CV protective
16
Q
What is the consequence of the difference in changes of systolic v. diastolic BP?
A
widening of pulse pressures
17
Q
Which BP, systolic or diastolic, is a better predictor of morbid events in older patients?
A
systolic
18
Q
Which elevated BP, systolic or diastolic, is a more important CV risk factor in younger, healthy patients?
A
diastolic
19
Q
Why is there such a low rate of control of HTN?
A
- poor access to health care/Rx
- lack of adherence w/ long term tx
- silent dz therefore pt has no drive to tx
20
Q
HTN complications
A
- hypertensive cardiovascular dz
- hypertensive cerebrovascular dz + dementia
- hypertensive kidney dz
- atherosclerotic complications
21
Q
What is the MC cause of death in HTN pts?
A
hypertensive cardiovascular dz
22
Q
Describe the pathophys of hypertensive cardiovascular dz
A
LVH –> CHF –> ventricular arrhythmias –> MI –> death
23
Q
What part of the pathophys of hypertensive cardiovascular dz is preventable?
A
LVH
24
Q
HTN is the MC and most important risk factor for which dzs?
A
ischemic + hemorrhagic strokes
25
Which BP measurement does hypertensive cerebrovascular dz + dementia correlate to?
systolic
26
T/F: hypertensive cerebrovascular dz + dementia incidence will not decrease with tx.
false (preventable)
27
What is the MC etiology of secondary HTN?
primary renal dz
28
T/F: Liver is both a target and cause of HTN.
false, kidney
29
Which BP measurement does hypertensive kidney dz correlate to?
systolic
30
Who is hypertensive kidney disease more common in?
blacks > whites
31
What is a reliable marker for hypertensive kidney dz?
proteinuria
32
What is the BP goal for hypertensive kidney dz?
130/80
33
Which type of HTN complication do hypertensive therapies have a lesser impact on?
atherosclerotic complications i.e. aortic aneurysms/dissections
34
How are atherosclerotic HTN complications controlled?
multiple factors including but no limited to HTN control
35
Types of HTN
- primary/essential
- "White Coat Syndrome"
- secondary
36
primary/essential HTN etiology
- no single, reversible cause
- unknown
- secondary to genetic and environmental factors
37
% of blacks v. whites with primary/essential HTN
- 10-15% whites
| - 20-30% blacks
38
age of primary/essential HTN onset
- 25-55 y/o (prevalence increases w/age)
39
HTN risk factors
- race (blacks)
- age (m >55, w>65)
- 1st deg relative w/HTN
- obesity/wt gain
- high salt diet
- excess ETOH
- metabolic syndrome
- smoking
- inactivity/sedentary lifestyle
- dyslipidemia independent of obesity
- polycythemia
- Vit D def.
- low K intake
40
Patients with ____ have an increased risk of developing sustained primary HTN.
White Coat Syndrome
41
Causes of secondary HTN
- primary renal disease
- drug induced
- renovascular (renal a. stenosis)
- adrenal
- other endo d/o
- obstructive sleep apnea
- coarctation of aorta
- (pre)eclampsia
- rare genetic d/o
42
What is the MC cause of secondary HTN?
renal parenchymal disease (CKD)
43
What is the cause of renovascular causes of secondary HTN?
- arteriosclerosis
| - fibromuscular dysplaisa
44
What is the definitive diagnostic test for renovascular causes of secondary HTN?
renal arteriography
45
When should renovascular causes of secondary HTN be suspected?
- HTN onset before age 20 or after 50
- HTN resistant to 3+ drugs
- epigastric or renal a. bruits
- atherosclerotic dz in aorta or peripheral a.
- abrupt increase in serum creatinine after ACE-I admin
46
What are the causes of adrenal causes of secondary HTN?
- pheochromocytoma
- primary aldsteronism
- Cushing's Syndrome
47
Patient presents with triad of HTN, unexplained hypokalemia, and metabolic alkalosis. What do you suspect?
primary aldosteronism causing secondary HTN
48
75-80% of patients with what disease/syndrome have HTN?
Cushing's Syndrome
49
What other endocrine disorders are causes of secondary HTN?
- hypOthyroidism
- hypERthyroidism
- hypERparathyroidism (hypERcalcemia)
50
>50% of patients with what disease/syndrome have HTN?
obstructive sleep apnea (OSA)
51
What is the most common congenital CV cause of HTN?
coarctation (narrowing) of the aorta
52
What are the BP screening recommendations?
- 18+ y/o
| - q2yrs w/BP
53
What is the proper technique for measuring BP?
- sitting w/ arm at heart level for min 5 mins
| - after 20-30mi smoking/caffeine consumption
54
A discrepancy of ____ mmHg indicates ______ --> _____.
A discrepancy of over 15mmHg indicates subclavian stenosis --> peripheral arterial dx.
55
What do we do if we determine the patient has HTN?
- assess the presence/absence of target organ damage and CVD
- assess lifestyle + risk factors or current d/o
- r/o identifiable/secondary causes
56
HTN patient history
- if applicable: duration of HTN dx, previous tx with responses + SE
- FH
- dietary + psychosocial hx
- wt change
- dyslipidemia
- smoking
- diabetes
- physical inactivity
- evidence of secondary HTN
- evidence of target organ damage
57
HTN symptoms
- silent dz i.e. usually asx
- am occipital H/A in severe HTN
- nonspecific: dizziness, palpitations, fatigues, impotence
58
When a patient presents with HTN symptoms, what are the symptoms typically related to?
- complications of HTN
| - manifestations of secondary HTN
59
HTN physical exam
- body habitus/BMI/wt/ht
- BP, HR, palpate distal pulses
- fundoscopic exam
- thyroid/signs of thyroid dz
- displaced PMI
- auscultate the heart, a. for bruits
- palpate kidneys
- signs or CHF
- neuro exam
60
Given the following as S+S, what is a possible cause of secondary HTN?
- arm to leg SBP difference greater than 20mmHg
- delayed/absent femoral pulses
- murmur
coarctation of the aorta
61
Given the following as S+S, what is a possible cause of secondary HTN?
- increase serum creatinine s/p ACE or ARB initiated
- renal a. bruit
renal a. stenosis
62
Given the following as S+S, what is a possible cause of secondary HTN?
- brady/tachycardia
- heat/cold intolerance
- constipation/diarrhea
- heavy, irregular, or absent menstrual cycle
thyroid disorders
63
Given the following as S+S, what is a possible cause of secondary HTN?
- hypokalemia
aldosteronism
64
Given the following as S+S, what is a possible cause of secondary HTN?
- apneic during sleep
- daytime somnolence
- loud snoring
obstructive sleep apnea
65
Given the following as S+S, what is a possible cause of secondary HTN?
- flushing, H/A
- Labile BP
- ortho hypotension
- palpitations, sweating, syncope
pheochromocytoma
66
Given the following as S+S, what is a possible cause of secondary HTN?
- buffalo hump
- central obesity
- moon facies
- striae
Cushing's syndrome
67
What labs do you order for HTN?
- urinalysis
- CBC
- fasting BMP
- fasting lipids
- TSH
- EKG
- echo if ? LVH
68
nonpharm tx of HTN
LIFESTYLE MODIFICATIONS!
- dietary salt restriction
- wt loss
- DASH diet
- exercise (30mins x 5d/wk)
- decr ETOH
69
tx goals of HTN according to the JNC 8
- 60+ y/o = under 150/90
- under 60 y/o = under 140/90
- 18+ y/o with CKD or DM = under 140/90
70
primary goal of HTN tx
prevent end organ damage via decr BP
71
secondary goal of HTN tx
- minimize SE
- minimize pt cost
- tx comorbid conditions
72
What is the single most effective intervention for slowing the rate or progression of HTN-related CKD?
HTN control
73
pharm tx of HTN
- diuretics
- beta-blockers
- ACE
- ARB
- renin inhibitors
- aldosterone receptor blockers (not the same as ARBs)
- CCB
- alpha antagonist
- central alpha agonist
- direct vasodilators
74
SE of thiazides
- hypokalemia
- insulin resistance
- increased cholesterol
- increased uric acid
75
Loop diuretics are used in pts with what?
- renal failure
| - CHF
76
K+ retaining diuretics are rx'd how?
in combo w/ thiazide
77
MOA of diuretics
- decrease plasma volume initially
| - in long term, reduce peripheral vascular resistance
78
MOE of beta-blockers
decr. HR and CO
79
beta-blocker SE
- broncospasm
- bradycardia
- raynaud's
80
What is a huge risk of pts not taking their beta-blockers daily?
abrupt withdrawal can precipitate acute coronary events and severe increases in BP therefore if/when d/c, taper slowly
81
beta-blocker CI
- asthma/COPD
- 2nd or 3rd degree heart block
- sick sinus syndrome
82
MOA of ACE
- inhibit renin-angiotensin-aldosterone system
| - renoprotective
83
drug of choice in CHF and diabetes
ACE
84
When do you rx an ARB in relation to ACE?
a. always with
b. prior to starting
c. when pt fails ACE
d. idk, whats an ARB?
ARBs are second line treatment after ACE usually d/t cough
85
MOA of ARB
inhibits angoitensin receptor
86
SE of ARB
hyperkalemia
87
MOA of renin inhibitors
block renin-angiotensin system
88
T/F: Renin inhibitors are not first line tx of HTN.
true
89
aldosterone antagonist indications
- HTN
| - CHF
90
aldosterone antagonist CI
- renal failure
| - hyperkalemia
91
aldosterone SE
- hyperkalemia
| - gynecomastia/impotence/menstrual irregularities
92
CCB MOA
peripheral vasodilation
93
CCB SEs
- H/A
- peripheral edema
- bradycardia
- constipation
94
MOA of alpha blockers
decr peripheral vascular resistance
95
When are alpha blockers given as monotherapy?
in men w/ BPH
96
SE of alpha blocker
hypotension s/p 1st dose
97
MOA of centrally acting alpha agonist
decr. peripheral vascular resistance
98
MOA of vasodilators
decr. peripheral vascular resistance
99
SE of vasodilators
hirsutism
100
What is the first line therapy in:
- nonblack 18+y/o
- nonblack all ages with DM but not CKD
thiazide or ACE or ARB or CCB (alone or in combo)
101
What is the first line therapy in:
- blacks regardless of age
- blacks w/DM, and no CKD
thiazide or CCB (alone or in combo)
102
What is the first line therapy in all races with CKD w/ or w/o DM?
ACE or ARB alone or in combo w/other drug classes
103
When is mono therapy indicated?
BP over 20/10mmHg above goal BP
104
3 main classes used for initial monotherapy
- thiazide
- CCB
- ACE (or ARB)
105
When is the first line combo therapy indicated?
BP is over 20/10mmHg above goal
OR
SBP is over 160 and/or DBP is over 100
106
How do you add a second drug to monotherapy?
- select an agent from a different class
| - add ACE/ARB to thiazide or CCB
107
define resistant HTN
DMP over 90mmHg despite 3+ anti-HTN rx including a diuretic
108
What do you do a pt f/u's for HTN?
- reinforce lifestyle modifications at EVERY visit
- reassess risk factors at every visit
- screen for SE at every visit
109
What else do you do for txing HTN?
tx co-morbid/underlying conditions
110
When can you reccomend ASA for HTN tx?
- men 45-79 when the benefit is to reduce MIs
| - women 55-79 when the benefit is to reduce ischemic stroke
