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41 Cards in this Set

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Indications for ambulatory BP measurement?
1. Exclude white coat syndrome
2. Diagnose borderline HTN
3. Deciding Tx options in elderly
4. Identify nocturnal HTN
5. Assessing resistant HTN
6. Determine efficacy of a drug
7. Diagnose and treatment of HTN in pregnancy
8. Diagnosing HYPOtension
An increase in stroke volume (SV) can be due to?
1. Aortic regurgitation
2. Thyrotoxicosis
3. Hyperkinetic heart syndrome
4. Fever
5. Arteriovenous fistula
6. Patent ductus arteriosus
Essential hypertension has a strong genetic predisposition. Candidate genes include?
Those that regulate:
1. Sympathetic nervous system
2. RAA-system
3. Production of vasodilators (PGs, NO, etc.)
Individuals respond differently to sodium. Which groups are more sensitive to sodium?
1. Blacks
2. Elderly
3. Diabetics
Lifestyle factors that contribute to HTN
1. High dietary salt intake
2. Obesity
3. Excess alcohol consumption
4. Low dietary intake of K, Ca, Mg
5. Oral contraceptives
6. Stress
Endocrine causes of secondary HTN
1. Primary aldosteronism
2. Pheochromocytoma
3. Hypo-/hyperthyroidism
4. Cushing's syndrome
5. Acromegaly
6. Hyperparathyroidism
7. Carcinoid tumors
8. Congenital adrenal hyperplasia
Drugs inducing or exacerbating HTN
1. NSAIDs
2. Oral contraceptives
3. Sympathomimetics
4. Glucocorticoids
5. Mineralocorticoids
6. Cyclosporine, tacrolimus
7. EPO
8. VEGF inhibitors
9. Some herbal supplements
Diagnostic workup of HTN
1. Assess risk factors and comorbidities
2. Reveal identifiable causes of HTN
3. Assess presence of target organ damage
4. Conduct Hx and physical exam
5. Obtain lab tests
6. Obtain ECG
Routine lab tests for HTN
1. ECG
2. Urinalysis
3. CBC, including fasting Glc
4. Serum potassium, calcium
5. Serum creatinine, or GFR
6. BUN
7. Lipid profile, after 9-12 hrs fast
In adults, the best equation for estimating glomerular filtration rate (GFR) from serum creatinine is?
the isotope dilution mass spectrometry (IDMS)-traceable Modification of Diet in Renal Disease (MDRD) Study equation.

It does not require weight.
GFR and creatinine clearance are poorly interfered from serum creatinine alone. Why?
Because these are already inversely related to serum creatinine
When expressed as an excretion rate (i.e., urine albumin excretion rate [UAER]), this concentration averages?
1. 2.6-12.6 μg/min in males
2. 1.1-21.9 μg/min in females.
Definition of microalbuminuria?
1. 30-300 mg/d
2. 20-200 μg/min
RBC casts in the urine indicates?
1. Glomerulonephritis
2. Vasculitis
3. Tumors
Cellular or granular casts in the urine indicates?
Tubular necrosis
By how much must the lumen of the main renal arteries decrease by before it is significant?
70%
Most common causes of renaovascular stenosis?
1. Elderly: atherosclerosis
2. Young: fibrous dysplasia
Lab findings in renovascular HTN?
1. Hypokalemia
2. Proteinuria (nephrotic syndrome, progressive or otherwise unexplained renal failure)
3. Increased serum creatinine
4. Decreased GFR or sudden increase after ACEI or AT1 blockers
Investigative test for renal artery stenosis?
Captopril challenge test (more useful in adults than children)
To get an accurate interpretation of the peripheral renin activity or renin values, it is recommended that?
You measure 24-hr urinary sodium excretion
There are several ways to measure the plasma renin activity. What are some pros and cons of IRMA and ICMA?
1. Immunoradiometric Assay (IRMA). Uses antibodies. Measures the active form of renin, is unaffected by AT plasma levels. Advantageous when measuring renin in patients with heart or liver failure
2. Immunochemiluminometric Assay (ICMA). Also an immuno assay. Is very rapid.
Limitations of the captopril challenge test?
1. Bilateral RAS patients may be false negative 2. Sodium depletion may give a false positive in patients with primary HTN 3. Negative results do not rule out RVH
Lab findings in primary aldosteronism/Conn's syndrome?
1. Low plasma renin
2. Hypokalemia
Possible screening tests for PA?
1. Serum potassium, 24hr urinary potassium
2. Ratio of urinary potassium to serum potassium
Differential in hypokalemia?
1. PA
2. Pseudoaldosteronism
3. Secondary aldosteronism (malignant HTN)
4. Diuretics
5. Renal disease
6. Cushing's disease
7. RVH
Ideal screening test for primary aldosteronism?
Combination of increased Aldosterone/renin ratio (ARR) and plasma aldosterone levels >150 pg/mL
Tests that confirm primary aldosteronism?
1. Captopril challenge test (if ARR >30, is considered positive)
2. IV saline load
3. Oral soduim load
4. Fludrocortisone suppression test
What is the difference between Cushing's syndrome and Cushing's disease?
Cushing's syndrome refers to the clinical picture of cortisol excess, regardless of the cause. Cushing's disease refers to an excess of ACTH leading to increased adrenal cortex activity.
Biochemical features of Cushing's syndrome?
1. Excess endogenous cortisol
2. Loss of feedback on the HPA-axis
3. Abnormalities of the circadian rhythm of cortisol secretion
Screening tests for Cushing's syndrome?
1. Urinary free cortisol (most widely used)
2. Dexamethasone suppression test
3. Overnight test
4. 2-day low dose dexamethasone test
5. Circadian rhythm assessment
Tests to differentiate between ACTH dependent and independent forms?
1. Plasma ACTH levels
2. 2-day high dose dexamethasone suppression test
3. Metyrapone stimulation test
4. CRH stimulation test
Theory behind the dexamethasone test?
In normal individuals it will result in suppression of the HPA-axis, and consequently a fall in plasma and urinary free cortisol. The levels remain high in Cushing's syndrome
If plasma cortisol levels are high, and ACTH levels are low, this suggests?
ACTH-independent cortisol secretion, usually due to a cortisol secreting adrenocortical tumor
Which diagnoses should be considered in a patient whose ACTH and cortisol levels are high?
1. Cushing's disease
2. Ectopic coricotropin secreting tumor
3. CRH syndrome
Dexamethasone suppression test is useless in patients receiving
rifampicin
How would you differentiate between pituitary and ectopic ACTH secretion?
Metyrapone and CRH stimulation, either alone or in combination with dexamethasone. Patients with a pituitary dependent Cushing's disease will have a marked increase in plamsa 11-deoxycortisol.
Lab tests used to screen for Pheochromocytoma?
24-hr urine:
1. Fractionated metanephrine
2. Catecholamines
3. Vanillylmandelic acid (VMA)
Pharmacologic tests for Pheochromocytomas?
1. Stimulation test - glucagon
2. Suppression test - clonidine
When should T3 and T4 levels be measured?
If TSH value is abnormal.
Reason for HTN in acromegaly?
Occurs in 1/3 of patients with acromegaly, probably as a consequence of sodium retention and ECF expansion caused by excess GH.
Most widely used test for Glucocorticoid-Remediable Aldosteronism?
Low-dose dexamethasone suppression test