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53 Cards in this Set
- Front
- Back
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Define hypertension
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Systolic blood pressure (SBP) > 140mmHg, diastolic BP (DBP)>90mmHg, or taking antihypertensive medication
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What is the objective of identifying and treating high BP?
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To reduce the risk of cardiovascular disease and assocaited morbidity and mortality
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Describe the different techniques of BP measurement
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-In-office: Two readings, 5 minutes apart, sitting in chair
-Ambulatory BP monitoring: Indicated for evaluation of "white-coat" HTN. Absence of 10-20% BP decrease during sleep may indicate CVD risk -Self-measurement: Provides information on response to therapy. May help improve adherence to therapy and evaluate "white-coat" HTN |
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Describe the different classifications of BP
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Normal <120 and <80
Prehypertension 120-139 or 80-89 Stage 1 HTN 140-159 or 90-99 Stage 2 HTN >160 or >100 |
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Describe the relationship between blood pressure and cardiovascular risk
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-Well established
-Strong, continuous, graded, consistent, predictive and etiologically signficant for those with and without coronary artery disease |
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Why treat hypertension?
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To decrease:
-Cerebrovascular accidents 35-40% -Coronary events 20-25% -Heart failure 50% -Progression of renal disease -Progression to severe hypertension -All cause mortality |
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What is the goal of prevention and management of hypertension?
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To reduce morbidity and mortality by the least intrustive means possible
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What factors should be considered in treating hypertension?
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-Repeat readings, rule out secondary causes
-Estimate risk status -Lifestyle changes -Co-morbid conditions -Drugs |
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Describe secondary hypertension
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-Difficult to control
-Sudden onset of HTN -Well controlled can becoem difficult to contol -Severe hypertension |
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Describe the initial workup for secondary hypertension
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-Renal disease
-UA, spot urine protein/creatinine, serum creatinine, USG -Renovascular -Captopril scan -Coarctation -Lower extremity BP -Primary aldosteronism -Serum and urinary K -Plasma renin and aldosterone ratio -Pheochromocytoma -Spot urine for metanephrine/creatinine |
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Describe the laboratory tests for uncomplicated HTN
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-ECG
-Urine analysis -Blood glucose -Hematocrit -Basic metabolic panel -Lipid profile after 9-12 hour fast -Urine microalbumin |
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Describe estimation of risk status in hypertension
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-Hypertension
-Smoking -Obesity -Dyslipidemia -Diabetes -Microalbuminia or GFR <60ml/min -Age >55 (men), 65 (women) -Family history of CVD (Men <55, Women<65) -Presence of target organ damage |
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Describe target organ damage in risk assessment of hypertension
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-Heart disease
-CAD (Angina, MI, coronary revascularization) -Left Ventricular Hypertrophy -Heart failure -Stroke/TIA -Chronic kidney disease -Peripheral arterial disease -Retinopathy |
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Describe the goal of hypertension therapy
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-BP<140/90mmHg
-BP<130/80mmHg in patients with diabetes or chronic kidney disease -Achieve SBP goal especially in persons >50 years of age |
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Describe high risk patients
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-If BP systolic>200 or diastolic>120, therapy should begin immediately and if symptomatic organ damage is present, the patient should be hospitalized
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Describe initial drug therapy in normotensive patients
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None
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Describe initial drug therapy in prehypertensive patients
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Without compelling indication: No antihypertensive drug indicated
With compelling indications: Drug(s) |
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Describe initial drug therapy in stage 1 hypertensive patients
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Without complelling indication: Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination
With compelling indications: Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed |
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Describe initial drug therapy in stage 2 hypertensive patients
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Without complelling indication: Two-drug combination (usually thiazide and ACEI or ARB or BB or CCB)
With compelling indications: Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed |
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Describe the lifestyle modifications that have been shown to lower BP and reduce other risk factors at minimal cost and risk
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1. Weight - BM of >25 is correlated with hypertension. Weight reduction of even 10lbs produces a significant lowering of the BP
2. Moderation of ethanol - Limit to 1oz of ethanol 3. Physical activity - Regular aerobic activity 4. Moderation of dietary Na - Overwheling support for loweing daily Na to 100 mmol/day or less. Elderly, renal failure, DM, African Americans especially benefit. 5. DASH eating plan - Diet rich in fruits, vegetables, reduced saturated and total fat. 6. Stop smoking 7. High K, Ca, Mg intake, avoidance of caffeine, and low protein diets, relaxation, and biofeedback are controversial |
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Describe the considerations for drug therapy in a hypertensive patient
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-Start with a low dose, titrate upwards
-Once-daily dosing with 24hr efficacy -Consider low dose combinations -Demographics -Drug interactions -Side effects |
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Why are long acting drugs preferred?
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-Compliance is better
-They may cost less -Hypertension control is persistent and smooth -Protection against sudden death/heart attack/CVA |
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Describe the drugs that are not well-suited for initial monotherapy due to side effects
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1. Reserpine (depression), direct acting smooth muscle vasodilators-hydralazine and minoxidil (sympathetic activation and fluid retention)
2. Short-acting nifedipine has precipitated ischemic events and has been reported to increase mortality in patients who have had an MI 3. Demographic factors may be important. Blacks and eledery patients in general are more responsive to calcium-blockers and diuretics than ACEI or beta blockers 4. Drug interactions; some are helpful (diltiazem reduces dose of cyclosporin), others are deleterious (NSAIDs may blunt the action of diuretics) |
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List the independent systes that contribute to elevated blood pressure
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1. Renin-angiotensin system
2. Sympathetic nervous system 3. Na intake -In Blacks and the elderly, Na intake dominates -In young White patients, sympathic system dominates |
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What are the initial drugs used for hypertension?
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-Diuretic
-Beta blocker |
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What should be done if the initial drug choice in treating hypertension is inadequate?
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1) Add a second agent if there are no significant adverse effects
2) Substitute another agent if there are significant adverse effects |
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Describe resistant hypertension
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-If BP is >140/90 on triple therapy that includes a diuretic
-If BP is >160 if isolated systolic hypertention |
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Describe the drugs used to treat hypertension in a patients with heart failure
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-Diuretics, Beta blockers, ACEI, Angiotensin receptor blockers, Aldosterone analog
-Do not use Calcium channel blockers |
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Describe the drugs used to treat hypertension post MI
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-Beta blocekrs, ACEI, Aldosterone antagonists
-Do not use diuretics, angiotensin receptor blocker, or calcium channel blockers |
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Describe the drugs used to treat hypertension in a patient with high coronary disease risk
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-Diuretic, beta blocker, ACEI, calcium channel blocker
-Do not use Angiotensin receptor blocker, aldosterone analog |
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Describe the drugs used to treat hypertension in a patient with diabetes
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-Diuretic, beta blocker, ACEI, aldosterone receptor blocker, calcium channel blocker
-Do not used aldosterone analog |
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Describe the drugs used to treat hypertension in a patient with chronic kidney disease
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-ACEI, angiotensin receptor blocker
-Do not use diuretics, beta blocker, calcium channel blocker, or aldosterone analog |
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Describe the drugs used to treat hypertensionin a patient needing recurrent stroke prevention
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-Diuretic, ACEI
-Do not used beta blocker, angiotensin receptor blocker, calcium channel blocker, or aldosterone analog |
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What are the compelling indications for using a diuretic?
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-Heart failure
-High coronary disease risk -Diabetes -Recurrent stroke prevention |
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What are the compelling indications for using a beta blocker?
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-Heart failure
-Post-MI -High coronary disease risk -Diabetes |
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What are the compelling indications for using a ACEI?
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(Everything)
-Heart failure -Post-MI -High coronary disease risk -Diabetes -Chronic kidney disease -Recurrent stroke prvention |
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What are the compelling indications for using a angiotensin receptor blocker?
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-Heart failure
-Diabetes -Chronic kidney disease |
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What are the compelling indications for using a calcium channel blocker?
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-High coronary disease risk
-Diabetes |
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What are the compelling indications for using a aldosterone analog?
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-Heart failure
-Post MI |
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Describe beta blockers
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-Cardioprotective against reinfarction, arrhythmias and sudden death
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Describe ACEI
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-In MI with systolic dysfunction, heart failure and mortality improved
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Describe the treatment of hypertension in a patient with renal insufficiency
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-Goal: BP<130/85 with whatever antihypertensive
-Most patients have volume overload: diuretics should be included in the regimen. Thiazides ineffective if Screat>2.5 -ACEI should be used if no contraindications. Initial, transient drop in GFR expected. If persistently elevated, bilateral renal artery stenosis should be suspected |
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Describe hypertensive emergencies
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-Those rare situations that require immediate blood pressure reduction to prevent or limit target organ damage
-Most emergencies are treated with parenteral drugs initially -The goal is to reduce the BP by 25% within minutes to 2 hours then to 160/100 within 2-6 hours (avoiding excessive falls in BP) |
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Describe hypertensive urgencies
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-Require blood pressure to be reduced within a few hours
-Drugs with fast onset of action: loop diuretics, beta-blockers, ACEI, alpha2 agonists or calcium blockers -NOT nifedipine |
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What are the parenteral vasodilators for treatment of hypertensive emergencies?
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-Nitroprusside
-Fenoldopam -Nitroglycerine -Enalaprilat -Nicardipine -Hydralazine |
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What are the parenteral adrenergic inhibitors for treatment of hypertensive emergencies?
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-Lavetalol
-Esmolol -Phentolamine |
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Describe hypertension in women
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-No significant gender differences
-Hypertension 2-3x more common with oral contraceptives, esp age>35 -Usually reversible |
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Describe patients with pregnancy and hypertension
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Either have:
-Chronic hypertension -Pregnancy induced hypertension (preeclampsia) |
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Describe the drugs used for pregnant women with chronic hypertension
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-Continue using drugs that were being used pre-pregnancy
-Avoid ACEI or AII blockers |
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Describe the drugs used for pregnant women with preeclampsia
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-Methyldopa
-Beta blockers (not earliy in pregnancy) -Hydralazine is the parenteral drug of choice |
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What is systolic BP a predictor of in the elderly?
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-CAD
-CHF -CVA -ESRD -Mortality |
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Describe treatment of hypertension in older patients
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-Primary HTN more common than secondary
-Older patients respond to salt reduction and weight loss -Starting doses of medications should be 1/2 of younger patients -Diuretics are recommended for initial therapy -Calcium blockers are good, beta blockers are adequate -Drugs that exacerbate postural hypotension should be avoided -Target BP should be 140/90 although with isolated systolic hypertension, goal of 160 may be neccessary |
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Describe the causes of resistant hypertension
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-Improper BP measurment
-Excess Na intake -Inadequate diuretic therapy -Medication -Inadequate doses -Drug actions and interactions (e.g., nonsteroidal antiinflammatory drugs (NSAIDs), illicit drugs, sympathomimetics, oral contraceptives) -OTC drugs and herbal supplements -Excess alcohol intake -Identifiable causes of HTN |
