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70 Cards in this Set
- Front
- Back
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What are some diseases associated with hypertension?
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• diabetes mellitus
• hyperuricemia • obstructive sleep apnea • atherosclerosis • Lipoprotein (a) |
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What is a side effect of ACE inhibitors and beta blockers in regards to lipid levels?
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ACE inhibitors and beta blockers can make lipid levels worse (generally decrease HDL levels)
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What are some mechanisms that lead to hypertension?
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• arterial vasoconstriction and loss of elasticity of the vessels due to athersclerosis which can lead to increased resistance (or afterload)
• decreased blood flow to vital organs causes end-organ damage • decreased blood flow signals the body to create more pressure |
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Describe the renin-angiotensin system
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renin acts on angiotensiongen » creates angiotensin I »ACE works on angiotensin I to create angiotensin II
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Where is renin released from?
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the juxtaglomerular apparatus in the kidney
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What is the difference between an ACE inhibitor and an ARB?
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• ACE inhibitors prevent the conversion of angiotensin I into angiotensin II
• ARB (angiotensin II receptor blocker) prevents angiotensin II from binding to its receptor |
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Where is aldosterone produced?
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the adrenal cortex
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What is the function of aldosterone?
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retains sodium and water at the expense of potassium
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What are some of the effects of an excess release of aldosterone?
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can cause Cushing's Syndrome or primary hyperaldosteronism (which are causes of secondary hypertension)
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What category of hypertension accounts for 95% of hypertension?
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primary (or essential) hypertension
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What are some theorized causes of primary hypertension?
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• sympathetic nervous system hyperactivity - increased blood plasma catecholamines
• abnormal cardiovascular development - abnormal development of aortic elasticity or reduced development of the microvascular network • renin-angiotensin system activity • defect in natriuresis - hypertensive patient have a decreased ability to excrete excess sodium • intracellular sodium and calcium • exacerbating factors |
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What are some exacerbating factors that can elevate blood pressure?
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• obesity
• increased sodium intake • excessive use of alcohol • cigarette smoking • polycythemia • NSAIDs • low potassium intake |
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If the patient presents with hypertension and is less than 30 years-old or greater than 50 years-old without a family history of hypertension, what category of hypertension should the clinican consider?
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secondary hypertension
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What is the most common symptom of hypertension?
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Occiptal headache
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What are the different aspects of the physical exam that should be done when evaluating for hypertension?
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• check BP in both arms (and both legs if pulse differential is present)
• eye exam - check for "silver wiring," AV nicking, & flame-shaped hemorrhages • Cardiovascular evaluation - checking for LVH/CHF; loud A2 • abdominal evaluation for bruits - check for bruits in the renal arteries, abodminal aorta, illiac and femoral arteries • adequacy of pulses throughout |
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What are the basic studies done in evaluating for hypertension?
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• CBC
• Electrolytes • Serum Uric Acid • BUN/Creatinine • Urinalysis • Fasting Blood Glucose • EKG • Lipid Profile |
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What are some tests that should be done when secondary hypertension is suspected?
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• chest Xray
• echocardiogram for LVH/function • Catecholamine levels • aldosterone levels • urine electrolytes |
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What are 3 general categories of causes for secondary hypertension?
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• adrenal causes
• renal causes • other |
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List 3 adrenal causes of hypertension
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• primary hyperaldosteronism
• Cushing's syndrome • pheochromocytoma |
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List some renal causes of secondary hypertension
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• renal parenchymal disease
• renal vascular disease • renal artery stenosis |
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What are some other causes of secondary hypertension (11)?
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• oral contraceptives
• alcohol • NSAIDS • pregnancy • hypercalemia • hyperthyroidism • obstructive sleep apnea • obesity • coarctation of the aorta • acromegaly • increased intracranial pressure |
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What is the most common cause of secondary hypertension?
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renal parenchymal disease
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What is the target BP for patients with renal parenchymal disease?
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< 130/85
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Renal vascular disease is most common in what age group?
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less than 20 year-old or greater than 50 years-old with secondary hypertension
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What is the mechanism for hypertension in renal vascular disease?
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there is decrease blood flow to the kidney which stimulates excess renin release to compensate for the decreased perfusion
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What are some signs or symptoms that should make the clinician be suspicious for renal vascular disease?
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• claudications due to lower extremity atherosclerosis
• epigastric or renal artery abdominal bruit • severe, accelerated, or malignant hypertension |
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What can happen to the creatinine level of patient with renal vascular disease if given an ACE inhibitor?
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• ACE inhibitors can worsen renal function in a patient with renal vascular disease
• creatinine level would increase |
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What is the definitive diagnostic test for renal vascular disease?
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renal arteriogram
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What are the 2 most common causes of primary hyperaldosteronism?
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• Conn's syndrome (a unilateral adrenal adenoma)
• bilateral adrenal hyperplasia |
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What are some signs and symptoms for primary hyperaldosteronism?
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• muscle weakness and fatigue
• polyuria (excessive urination) and polydipsia (excessive thirst) |
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What is the best screening test for primary hyperaldosteronism?
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• determining the plasma aldosterone/renin ratio
• ratio > 25 require further evaluation for primary hyperaldosteronism |
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What are some causes of Cushing Syndrome?
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• long term corticosteroid therapy
• adrenl tumor |
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What is the difference between Cushing's Syndrome and Cushing's Disease?
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• Cushing's syndrome is caused by excess glucocorticoid from the adrenal gland
• Cushing's disease is caused by hypersecretion of ACTH of the pituitary gland |
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What is the most common cause of pheochromocytoma?
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adrenal tumor
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What are some signs or symptoms of pheochromocytoma?
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• sustained or paroxysmal HTN
• sudden onset HTN, headaches, sweating, palpitation • anxiety, tremor, wt loss, hear intolerance, abdominal pain, chest pain • marked orthostaic hypotenion associated with severe supine hypertension |
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What are the best diagnostic test or pheochromocytoma?
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urinary catecholamines & metanephrines and creatine during/after attack
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What is the treatment of choice for pheochromocytoma?
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removal of the tumor is treatment of choice
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What are some signs and symptoms of coarctation of the aorta?
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• diminished and delayed femoral pulses with differential BP between upper and lower extremities
• associated with bicuspid aortic value (normally is tricuspid) and berry aneurysm • ejection murmur along the left sternal border that radiates to the back (interscapular) |
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What is the diganostic test for coarctation of the aorta?
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echo/doppler test
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What can the EKG and Chest xray show on a patient with coarctation of the aorta?
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• EKG can show left ventricular hypertrophy
• chest xray can show rib notching and the aorta can have a "3 sign" |
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What is the target BP for patients with uncomplicated hypertension?
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< 140/90
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What is the target BP for patients when renal insufficiency is present?
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< 130/85
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What is the target BP for patients with diabetes?
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< 130/80
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What is the target BP for patients with renal insufficiency and proteinuria?
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< 125/75
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What is the goal for isolated systolic hypertension in the elderly?
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systolic < 150
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What is the treatment for prehypertension?
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• lifestyle modification
• no antihypertensive drug indicated without compelling indications (kidney diseae or diabetes must be treated to goal of < 130/80) |
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What is the treatment for stage 1 hypertension?
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• lifestyle modification
• thiazide-type diuretics for most with a goal < 140/90 • consider a second drug if necessary (ACE inhibitor, ARB, beta blocker, calcium channel blocker, or combo) • add therapy for compelling conditions (renal disease and diabetes) with target < 130/80 |
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What is the treatment for stage 2 hypertension?
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• lifestyle modification
• two drug combination for most (thiazide diuretic with either ACE inhibitor, ARB, beta blocker, or calcium channel blocker) • target BP is 140/90 • add therapy for compelling indications (renal disease or diabetes) with goal of < 130/80 |
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What is the drug of choice for treating isolated systolic hypertension?
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Calcium channel blocker are more specific of systolic hypertension
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What are some complications of hypertension (7)?
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• stroke (CVA/TIA)
• dementia • MI • CHF • retinal vasculopathy • aortic dissection • renal disease (proteinuria and nephrosclerosis) |
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Name 2 diseases assoicated with hypertension
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• preeclampsia/exclampsia
• metabolic syndrome |
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When would you use a loop diuretic over a thiazide diuretic?
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in a patient with renal dysfunction
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Diuretics are most effective with what groups?
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blacks, elderly, obese, and smokers
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What are some of the effects of beta blockers?
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• decreased heart rate and cardiac output
• decreased renin release |
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Beta blockers are more effective with what groups?
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young, white, post MI, stable CHF, migraine headaches, and anxiety
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What are some side effects of beta blockers?
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• bradycardia
• SA/AV blocks • nasal congestion • Raynaud's phenomenon • CNS symptoms (nightmares, depression, confusion) • fatigue • adverse lipid level effects • impotence (most common reason for men to stop this drug) |
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ACE inhibitors are most effective with what patients?
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young, white, DM (especially with renal insufficiency) and CHF (drug of choice)
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What are some side effects of ACE inhibitor?
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• chronic dry cough
• skin rash • angioedema • hyperkalemia • dizziness • taste alteration |
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In what type of condition does giving ACE inhibitors run the risk of causing renal failure?
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bilateral renal artery stenosis
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What are some of the effects of calcium channel blockers?
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• negative inotropic effects (may cause or worsen CHF)
• protective against stroke |
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Calcium channel blockers are most effective with:
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blacks, elderly, and isolated systolic hypertension
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What are some side effects of calcium channel blockers?
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• headaches, peripheral edema, bradycardia, and constipation
• dihydropyridine class has their own side effects, usually from vasodilation (headaches, flushing, palpitations, peripheral edema) |
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When are alpha-adrenoceptor antagonist preferred?
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in men with symptomatic prostatism
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What are some characteristics of alpha adrenergic agonist?
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reduces efferent peripheral sympathetic outflow
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What is the preferred drug for hypertension in pregnant woman?
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methyldopa
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What are some side effects of alpha-adrenergic agonists?
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• impotence, sedation, fatigue, dry mouth, postural hypotension
• rebound hypotension with withdrawl • methlydopa can cause hepatitis, and hemolytic anemia |
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Give some examples of arteriolar dilators
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hydralazine and minoxidil
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When should you refer a patient with hypertension?
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• if BP remains uncontrolled after three concurrent medications
• if patient has uncontrolled BP and signs/symptoms of end organ damage |
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What is the difference between hypertensive urgency and hypertensive emergency?
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• hypertensive urgency is marked hypertension (usually BP systolic > 220 or diastolic > 125) without end-organ damage
• hypertensive emergency is marked hypertension with end-organ damage (heart, kidney, brain, retina) |
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What is the treatment of hypertensive emergency?
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• decrease in mean arterial BP by 25% in 1-2 hours
• then reduce BP to 160/100 over next 6-12 hours • use of predictable meds that are dose dependant and transient (usually used IV) • drugs used are nitroprusside, labetalol, nitroglycerin |
