Htn

Front 1

HTN and risk for cardiovascular disease

Back 1

1. doubles the risk
2. isolated systolic HTN increases the risk
3. ppl 40-70, each inc of 20mm systolic or 10 mm diastolic doubles the risk of VD disease!

Front 2

HTN and risk for stroke

Back 2

1. cerebrovascular dz 3rd leading cause of death
2. HTN most potent risk factor for all stroke types!
3. diastolic is not more impt than systolic!
4. >50yo, systolic may be more impt

Front 3

benefits of lowering BP

Back 3

1. 40% dec stroke incidence
2. 25% dec in MI
3. >50% dec in HF

Front 4

classification of BP

Back 4

1. nml = <120/80
2. preHTN = 129-139/80-89
3. Stage 1 HTN = 140-159/90-99
4/ Stage 2 HTN = >160/100

Front 5

diagnosis of HTN

Back 5

1. confirm high BP on 2 or 3 visits
2. define severity of HTN
3. determine presence or absence of risk factors
4. be alert for identifiable causes
-over 90% of all pts with HTN have ESSENTIAL HTN' <10% have IDENTIFIABLE CAUSES!

Front 6

identifiable causes of HTN

Back 6

1. drugs
2. chronic kidney dz (causes and effect)
3. sleep apnea
4. renovascular dz
5. primary hyperaldosteronism (K<3.5)
6. pheochromocytoma, thyroid crisis, cushings dz

Front 7

ssx: possivle indicatiors of identifiable causes of HTN

Back 7

1. truncal obesity
2. striae
3. hirsuitism
4. anxiety, tremor
5. inc HR
6. muscle weakness, cramps
7. absent or weak femoral pulses
8. periumbilical bruit

Front 8

drug/med-related HTN

Back 8

1. NSAIDs, Cox2 inhibitors
2. cocaine, amphetamines
3. sympathomimetics
4. OCs
5. sterids
6. erythropoietin

Front 9

Renovascular dz

Back 9

1. smoker
2. onset of HTN at age >60
3. abdominal bruits
4. "drug failure"
5. sudden increase in previously well-controlled BP

Front 10

Chronic kidney dz

Back 10

1. GFR <60, creatinine >1.5 men, >1.3 women (think cause of HTN)
2. need multiple drugs
3. ACEI and ARBs
4. if GFR <,30, need loop diuretics

Front 11

H&P of a person with HTN

Back 11

-subtle sx
-occipital HA
-flushing, palpitations
-drug history
-BMI
-fundoscopic exam
-cardio-vascular exam
1. rate and rhythm
2. S3 -> impaired LV funciton
3. S4 --> longstanding HTN
4. peripheral pulses, carotid bruits
5. abdomen: bruits, aneurysm

Front 12

lab eval

Back 12

1. UA
2. BUN and creatinine
3. potassium
4. glucose
5. Hct
6. fasting lipids
7. calcium
8. EKG

Front 13

goal of therapy

Back 13

1. nml BP is ideal
2. lifestyle change for preHTN
-aerobic exercise, sodium <2.4gdaily, wt loss, limit alcohol, adequate K intake
3. pts with the following disorders should be <130/80:
-DM
-cardiovascular dz
-target organ damage

Front 14

white coat HTN

Back 14

-may not be benign

Front 15

key reminders from JNC VII

Back 15

1. use thiazide-type diuretics in uncomplicated HTN
2. most pts with require 2 + meds to reach goal
3. if BP >/= 20/10 mm Hg above goal at outset, consider starting with 2 meds

Front 16

pharmacologic therapy factors to consider

Back 16

1. presence of "compelling indicators"
2. demographics: age and race
3. concomitant disease
4. quality of life
5. cost

Front 17

JNC III "compelling indicators"

Back 17

S/P MI: β-blocker, ACEI, aldo antagonist
Heart failure: β-blocker, ACEI, aldo antagonist
DM: ACEI/ARB
Chronic kidney disease: ACEI/ARB
LVH: all classes effective except hydralazine/minoxidil

Front 18

Thiazide diuretics

Back 18

-use low dosages
-not effective in renal insufficiency
-watch for dec K, Na and hypovolemia

Front 19

Beta blockera

Back 19

-Atenolol, metoprolol, bisprolol, propanolol
-blockade of B1 receptors--> dec CO
-blockade of renal B receptors --> dec renin
-blockade of CNS B receptors--> dec sympathetic
-C/I: severe asthma, COPD, high degree heart block, sick sinus syndrome

Front 20

ACE I

Back 20

-lisinopril, elanapril, ramipril
-dec angio II, dec sympathetic activity
-dec proteinuria in diabetics, inc survival in CHF, dec LVH
-less effective in black and elderly
-AE: cough, dec GFR, inc K, angioedema
-CI in preg!

Front 21

ARBs

Back 21

-losartan, candesartan
-most direct means of blocking Angio II
-fewer SE: less cough, rare angioedema
-no generic
-lack of dose-response

Front 22

Direct renin inhibitor: Aliskiren (Tekturna)

Back 22

-prevents formation of angio I
-can be combined with other drugs

Front 23

Ca channel blocker

Back 23

-dihydropyridine: nifedipine, amlodipine
-vasodilators: HA, flushing, swelling
-potential SE due ot vasodilation
-non-dihydropyrdines: verapamil, diltiazem; have no effects on cardiac conduction

Front 24

Alpha-adrenergic blockers

Back 24

-doxazocin, prazosin, terazocin
-dec NE --> dec vasoconstriction --> dec PVR
-do not use as monotherapy
-1st dose effect
-dizziness, lethargy, fatigue
-effect on BPH +; urge incontinence -

Front 25

Alpha 2 agonists

Back 25

-methyldopa, clonidine
-stimulate a2 receptors --> dec sympathetic outflow
-dec PVR, HR and BP
-AE: somnolence, dry mouth, rebound effect
-methyldopa --> preg
-clonidine --> hypertensive emergencies

Front 26

hypertensive urgency

Back 26

-severe inc in BP in asymptomatic person with no evidence of target-organ damage
-lower BP within 24hrs
-outpt
-avoid immediate release nifedepine
-Captopril
-Clonidine
-Labetolol
-Prazosin

Front 27

hypertensive emergency

Back 27

-elevated BP with acute target organ damage
-encephalopahy
-cerebrovascular: hemorrhage
-renal: failure
-cardiac: aortic dissection, LV failure with pul edema, acute MI, unstable angina
-severe HTN in preg!

Front 28

treatment of emergencies

Back 28

-hospitalize
-initially reduce BP by no more than 25%
-vasodilators: Sodium nitroprusside, Nicardipine, Hydralazine
-Adrenergic blockers: Labetolol, Esmolol, Methyldopa, Phentolamine
-IV!!!