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62 Cards in this Set

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What defines HTN?
systolic BP >140
or
diastolic BP >90
Which population has the highest BP risk for HTN?
african americans - 71%
Mexican americans - 61%
non-Hispanic whites - 60%

Prevalence increases with age over the age of 60
Which is more common primary or secondary HTN?
primary HTN = 90-95% of cases

secondary HTN = 5-10% of all adult HTN
What is primary htn?
complex process from a variety of physiological and environmental factors
what is 2ndary htn?
includes exogenous substances sicj as alcohol or NSAIDS, renal failure, dleep apnea, primary aldosteronism, pheochromocytoma, and cushing syndrome
How is insulin related to arterial BP?
Insulin resistance is ass/ with increased arterial BP

Hyperinsulinemia can increase vascular tone by 4 mechanisms:
1. Na retention
2. hypertrophy and hyperplasia of vascular smooth muscle
3. increases Calcium intracellularly
4. activates the SNS
How are CV risks correlated with BP?
risk of CV complications correlates with the degree of BP elevation
Why is htn referred to as the silent killer?
it is asymptomatic until it causes end stage organ disease
How do you Dx htn?
SBP >140
or
DBP > 90
at least 2 consecutive visits 2 weeks apart

exception is one time visit SBP > 210 or presence of sig end organ damage
These are the essential of blood pressure measurement
1. seated at rest for at least 5 minutes
2. no caffeine or cigs in last 30 min
3. bladder of cuff encircles 80% of arm
4. arm is supported at heart level
5. inflate cuff and listen for obliteration of radial arm pulse
6. auscultate over the brachial a. 10-20mmg past the palpable SBP
7. Systolic Pressure = onset of Korotkoff sounds
8. Diastolic = muffling or cessation of Korotkoff sounds
What are some eye pathologies you might see on fundoscopic examination?
retinal hemorrhages
AV nicking
Vascular tortuosity
Is primary htn genetic?
primary htn tends to run in fam hx
what is white coat htn?
pt does not truely have htn, but bp is elevated under the present conditons
what is pseudoHTN?
found in elderly
calcified, rigid blood vessels causes an increase in intra arterial BP
the actual BP is less then what the cuff is reading
what does a high fasting serum glucose mean?
indicates diabetes mellitus
what does unprovoked hypokalemia <3.5 meq/L mean?
hyperaldosteronism
what does an elevated creatine level mean?
renal insufficiency
what does proteinuria or microalbuminuria mean?
renal end-organ damage
what does hypercalcemia mean?
may preclude thiazide diuretics or hyperparathyroid disease
What are the different stages of HTN?
Optimal:
SBP < 120
DBO < 80

PreHTN:
SBP: 120-139
DBP: 80-89

Stage 1:
SBP: 140-159
DBP: 90-99

Stage 2:
SBP: >160
DBP: >100
what is the bp goal of a diabetic
BP <130/80
WHAT IS THE FIRST STEP IN TX OF PTS WITH NL RENAL FUNCTION AND NON-DIABETIC PTS WITH PRE-HTN
LIFESTYLE MODIFICATION
WHAT % OF PEOPLE ARE SALT SENSITIVE HTN
60%
RESTRICT SALT <2.4g/d
WHAT ARE SOME LIFESTYLE MODIFICATIONS ONE CAN MAKE?
AEROBIC EXERCISE 30-60 min 3-4x/wk
LIMIT ALCOHOL: <24oz/d BEER & <8oz/d WINE
WHAT % OF PEOPLE CAN BE HELPED BY LIFESTYLE MOD ALONE?
10%
WHEN SHOULD YOU START A PERSON ON MEDICATION?
AFTER 3-6 MO OF LIFESTYLE MOD AND NO RESULT
OR
PTS WITH STAGE 2 HTN AND DIABETIC PTS WITH SBP OVER 130 OR DBP OVER 80
WHAT IS THE THERAPEUTIC GOAL IN ALL PTS BP?
BP 120/80mmHg or less
what is isolated systolic HTN?
common in elderly
Systolic BP in elderly over age 60 can be managed with low-dose diuretics and beta blockers - these can significant reduce chance of strokes and MIs
What is the 1st line agent for htn?
diuretics
BB
CCB
ACEi
When should you consider giving a person 2 medications to manage htn?
if thier bp is more than 20/10 the inital goal
What is the 1st major drug used to manage htn?
thiazides
What is the MOA of thiazides?
inhibit Na reabs from renal tubules
reduces total blood vol
reduces PVR
What should the kidney function be for thiazide use?
DO NOT GIVE TO RENAL IMPAIRED PTS!!!!!!!!!!!!!!!!!!

GFR> 25
Creatinine levels <2 and <1.5 in elderly
what are some adverse side effects of thiazides?
hypokalemia
hyperurecimia
carbohydrae intolerance
hyperlipidemia
What dosage of thiazide daily should you give someone to avoid side effects?
keep below 25mg/d
What can you give someone who has renal impairement?
Cr > 2-2.5
Loops - furosemide*** are more effective

produce more diuresis and hypokalemia
What must you tell your pts to avoid with loops?
NSAIDS***
interferes with delivery of loops
How can calcium levels change with thiazides and loops?
thiazides - hyper-calemia

loops - hypO-calcemia
What is the MOA for Beta blockers?
decreases heart contractility
decrease release of renin for juxtaglomerular apparatus
What are NON-selective BB?
block both Beta 1 and beta 2 receptors

selective only block Beta 1
When would you use a beta 1 blocker?
Hx of reactive airway disease
if you want to reduce the risk of bronchospasm
What are beta blockers with intrinsic sympathomimetic activity (ISA)
Less likley to increase triglyceride levels or lower HDL levels
What are some side effects of BB?
bradycardia
fatigue
depression
insominia
sexual dysfunction
adverse effects on lipid profile
What pts should you avoid BB?
asthma
COPD
2nd or 3rd degree heart block
insulin dependent diabetes mellitus
What can happen if you suddenly take a person off a BB?
tachyarrhythmias
rebound htn
upregulation of beta receptors
What are ACEi?
inhibits the enzyme that converts angiotensin I into angiotensin II
What pts benefit most from ACEi?
CHF
Diabetics
great for renal protection
In what pts might ACEi not be effective?
Low renin states
elderly and african americans
what is a common side effect of ACEi?
cough from increased bradykinin
what can happen if you give ACEi to a person with renal a stenosis
may cause acute reversible renal failure
What are ARBs used for?
do not cause a cough nor skin rashes
great medication but not as effective in tx CHF and diabetic nephropathy
What are CCB?
diltiazem
verapamil
dihydropyridines

lower BP via peripheral vasodilatory action
how does diltiazem and verapamil work?
depress the AV node and myocardial contractility
how does duhydropyridine work?
more vasodilatory effect but less effect on cardiac contractility
What are some side effects of CCB?
dizziness
edema
constipation
headache
flushing
In what pts would NOT give diltiazem or verapamil?
anyone with a 2nd or 3rd degree heart block
CHF
anyone already taking a BB
What are centrally acting agents?
clonidine
methydopa
guanfacine
reserpine

lower bp by stimulating alpha-adrenergic receptors in the CNS, which in turn reduces peripheral sympathetic outflow

these are usually 2nd line tx since they have many side effects
what are alpha blockers?
alpha adrenergic receptor blockers
relax smooth muscle and decreases PVR

Prazosin
terazosin
doxazosin
what are some common side effects of the alpah blockers?
tachyphylaxis
headache
postural hypotension - to avoid give a small 1st dose and at bed time
What is a good drug to give men who are elderly with high BP and BPH?
alpha blockers

these relax smooth muscle in the prostate
What are some good diets for people with HTN?
DASH diet - The DASH diet is rich in fruits, vegetables, whole grains, and low-fat dairy foods; includes meat, fish, poultry, nuts and beans; and is limited in sugar-sweetened foods and beverages, red meat, and added fats

Sodium restriction
What should initial drug Tx be for htn?
Stage 1: 140-159/90-99
thiazide, may also consider and ACEi, ARB, BB, CCB, or combination

Stage 2: >160/100
2-drug combo, thiazide + ACEi, ARB, BB, or CCB