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116 Cards in this Set
- Front
- Back
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what happens in the baroreceptor reflex when you have acute hemorrhage
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acute hemorrhage --> decrease MAP --> decrease stretch of carotid sinus baroreceptors --> decrease firing rate of carotid sinus nerve --> decreased PS stimulation and increased Sym outflow to heart and blood vessels --> increased HR, contractility, constriction of arterioles, venous return and also the decrease in PS innervation --> increase in HR
all of this will normalize MAP |
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what happens in RAA system with acute hemorrhage
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decrease blood flow/hypoperfusion --> stimulates renin release --> angiotensinogen --> ang 1 --> ang 2 --> aldosterone increases blood volume , arteries are also constricted to give increase in TPR --> increase in arterial pressure towrads normal
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what is the accurate way to take a blood pressure
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1. no tobacco, exercise, stress, eating x30 min before
2. quiet room, comfy temp 3. arm bare, at level of heart, 4. cuff bladder over brachial artery, 2 cm above elbow crease 5. radial artery palpation to est. SBP 6. at least a minute between BP 7. 2-3 elevated bp on diff days to dX HTN |
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if a pt had SBP 130 and 60 DBP, what do they have?
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preHTN
only need one elevated SBP or DBP for all the preHTN, HTN 1, HTN 2 |
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if a pt had 158 SBP what HTN are they?
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stage 1
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what are the categories of HTN
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prehtn = 120-139 or 80-89
HTN 1= 140-159 or 90-99 HTN 2= 160 + or 100+ |
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what is the cause of ~95% of HTN cases
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essential HTN
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characteristics of essential HTN
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onset 25-55 years of age
asymptomatic idiopathic |
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HTN is most prevalent among which age group and which race
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blacks and elderly
chances increase with age |
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what do you look for in the initial assessment
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stage the BP
assess cardiac risk (smoking, obesity, age, family hx, diabetes, cholesterol) detect clues of secondary HTN |
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what is considered overweight?
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overweight BMI = 25-29.9
obese = >30 |
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what do you examine upon PE for HTN
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check eyes, heart, kidneys (abd exam), brain (neuro) , palpate thyroid gland, lower ext (pulses and edema)
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what are the diagnostic tests you get for HTN
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CBC, CMP, lipid panel, TSH, UA, urine micoalbumin, EKG, echocardiography
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what 4 organs will have end organ damage with prolonged HTN?
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heart kidney eye brain
this is often dt thrombosis blood is going so fast, it can't make turn, stress causes damage to endothelium turning it into a prothrombotic state |
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what changes will you see in the heart with HTN
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LVH
S wave in V1 + R wave V5, V6 >35 mm PMI is displaced (ventricular hypertrophy) murmurs, bruits, CHF, arrhythmias, MI |
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what will you see in the kidneys with HTN
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HTN --> nephrosclerosis (thickening of lumen)
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what is the goal bp with chronic kidney dz
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130/80
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what drug do you use for kidney manifestations and what is the CI in using this drug
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ACE-inhibitors/ARBs
unless Cr >30% or k+ >5.6 mmol/L ace inh will decrease renal resistance and therefore make less work for the heart, increase CO, usu ang ii does vasoconstriction --> increase in BP --> increased HTN |
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why could ACE inhibitors exacerbate renal dz?
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it decreases ANG II, therefore vasodilates efferent arteriole --> hypoperfusion, decrease in GFR
bad for renal artery stenosis when there is already not enough blood going through |
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so once again, when do you NOT use ace inhibitors and you have kidney manifestations?
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cr <30% of baseline or k+ <5.6 mmol/L
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what are some eye manifestations of HTN
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copper wire
av nicking- narrowing of arterial diameter cotton wool exudates papilledema (optic disc swelling dt increase in ICP usu bilateral) |
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what are some brain manifestations
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ischemic stroke
hemorrhagic stroke multi-infarct dementia HTN encephalopathy |
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what is the MCC of secondary HTN
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chronic renal dz dt decreased renal perfusion by inflammatory or fibrotic changes in SMALL intra-renal vessels
this leads to activation of RAA and increase plasma volume |
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when should you think chronic renal dz?
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when you have renal insufficiency with HTN with proteinuria and creatinine >1.2 in women and >1.4 in men
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what is renovascular HTN and how is it different than chronic renal dz
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decreased perfusion of renal tissue dt stenosis of main or branch renal artery which will decrease renal blood flow and perfusion pressure --> renin release
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a 20 yo sexually active female pt comes in with HTN. what is at the top of your ddx
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fibromuscular dysplasia
2nd MCC of secondary HTN for young female on OCP |
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what is the other cause of renovascular HTN
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renal artery atherosclerosis (proximal renal arteries)
both renal artery atherosclerosis and FMD are dt increase renin release dt decrease in renal blood flwo |
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when should you suspect renovascular HTN
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early onset <20 yo or after 50
HTN resistant to 3+ drugs abrupt deterioration of renal fxn after ACE-I or ARB administration (increase in Cr) episodes of pulmonary edema a/w abrupt surges in BP recent worsening of HTN |
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what are some diagnostic tests to do for renovascular HTN
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duplex doppler US
CT ang MR ang ACE I renography |
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what are some reasons to be weary of using US?
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inadequate if obese, overlying bowel gas, dependent on skill of technician
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what do you have to be careful of when doing CT ang?
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be careful if pt has nephrotic dz because the IV contrast can icnrease risk of nephrotoxicity
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what do you have to be careful of when doing MR ang
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it uses IV gadolinium
evaluates main and accessory renal arteries |
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what does ACE-I renography use in its study?
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technitium 99 m
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what is the tx for renovascular HTN
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renal artery angioplasty
medical management of atherosclerotic factors consider revascularization if refractory HTN, progressive renal failure, bilateral stenosis |
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upon CT ang, what will fibromuscular dysplasia look like
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string of beads
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this secondary cause of HTN gives episodic palpitations, ha, pallor. what will be diagnostic in the tests done?
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pheochromocytoma has elevated urine or serum catecholamines
check for vanillylmandelic acid and metanephrines |
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how do you treat pheochromocytoma
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give alpha and beta blockade
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what are the different causes of primary hyperaldosteronism
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aldosterone producing adenoma
adrenal hyperplasia |
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how do you treat the diff causes of primary hyperaldosteronism
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adenoma= surgery
hyperplasia-= spironolactone |
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when would you think primary hyperaldosteronism is a ddx in a hypertensive pt?
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if they have HTN with HYPOkalemia
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what is diagnostic of primary hyperaldosteronism
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check aldosterone to renin ratio
<30 is normal >30 ratio , evaluate for primary hyperaldosteronism |
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if a pt snores a lot and falls asleep during the day time and has HTN, what do you think of
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sleep apnea
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what type of secondary cause of HTN is seen with failure to control BP in 3 dose regimen of medication
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resistant HTN
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what do you have to consider as causes for resistant HTN
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drugs- cocaine, etoh, ocp, nsaids
volume overload- too much salt intake, inadequate diuresis, volume retention dt kidney dz, renovascular HTN |
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what is white coat HTN
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when bp is elevated only when taken at the office, but lower under casual circumstances
do 24 hr bp monitoring if it is >130/80, rx should be increased |
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what is isolated systolic HTN
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htn in the elderly usu dt decreased elasticity and compliance of large arteries and accumulation of calcium and collagen with age
there is also degradation of arterial elastin. |
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is elevated SBP more important as a RF for cv and renal dz or is elevated DBP?
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SBP is more important
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what do you give for HTN and the elderly?
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ace inhibitors
beta blockers, ca2+ blockers, diuretics DACB |
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T or F it is common to have essential HTN in <10 yo
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false. look for secondary causes
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how do you dx HTN in kids?
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if the SBP or DBP is >95%
and the reading is taken on 3 separate occasions |
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what kind of kids are at an increased risk for HTN
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if they have a family hx of HTN or they are obese
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what are the causes of HTN in 1-6 and 6-12? what about 12-18
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renal parenchymal dz for 1-12
12-18 = essential HTN |
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with HTN in pregnancy, how do you differentaite between chronic HTN, gestational HTN, and pre eclampsia and eclampsia?
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chronic HTN = BP >140/90 before 20 weeks or prior to pregnancy
gestation = HTN after 20 weeks w/o proteinuria preeclampsia= HTN after 20 weeks w/ proteinuria Eclampsia = same but with seizures HELLP= hemolysis, elevated liver enzymes, low platelets |
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what are the tx for HTN in pregnancy
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methyldopa
calcium channel blockers, labetalol |
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what happens when you are diabetic with HTN
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HTN adds to the risk of macrovascular and microvascular complciations in diabetes
macro- CV, MI micro- nephro and retiniopathy |
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what is the first line treatment for HTN and diabetes
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ace inhibitor
delay progression of diabetic nephropathy |
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what do you have to be careful of when using ace inhibitors?
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must monitor increase in cr levels. if <30%increase, continue, if >30% increase and/or hyperkalemia, stop ace inhibitors
monitor urine microalbumin levels |
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what is HTN urgency
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when you have SBP >179 or DBP >109
and in the ABSENCE of acute target organ involvement |
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how do you treat hypertensive urgency
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oral anti HTN
lower BP within 24-48 hours often dt non compliance reduce BP slowly |
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what is the difference between HTN urgency and HTN emergency
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HTN emergency has an abrupt increase in systemic vascular resistance
there is end organ damage with TARGET ORGAN INVOVLEMENT heart kidney brain eye |
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what is the treatment for HTN emergency
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lower DBP 10-15% over 30-60 minutes
monitor in ICU IV anti HTN meds |
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what is DASH
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diet that is effective in lowering BP = DASH dietary approaches to stop hypertension
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what are some lifestyle modifications you can do?
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lose weight
reduce sodium intake stop drinking alcohol stop smoking increase exercise |
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what is part of the DASH eating plan
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fruits and vegetables, low fat, high fiber, mg, ca2+, k+ low saturated fat, low cholesterol, low salt
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this treatment of HTN is contraindicated in gout and have cross sensitivity to sulfonamides . it is also considered a first line treatment for HTN
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thiazide diuretic
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what would the labs look like for thiazide diuretic pts?
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increase in ca2+, lipids, uric acid
decrease in k+, mg+ |
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what demographic are diuretics more potent in?
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blacks and elderly
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what should you give along with thiazide diuretics so you don't become HYPOkalemic
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k+ sparing drugs like triamterene or spironolactone
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what is the other diuretic that may be more effective than thiazides but ci in renal insufficiency patients
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loops diuretics (lasix)
potential to cause hypokalemia |
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what is the SE for triamterene and when is it contraindicated?
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contraindicated in pts with HYPERkalemia
SE: kidney stones |
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what is the SE for spironolactone and when is it CI
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gynecomastia
CI in hyperkalemia k+>5.5 or GFR <30 aka chronic kidney disease |
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which beta blocker has alpha blocking activity
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carvedilol and labetalol
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when are B Blockers indicated?
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increase survivability post MI,
use for MI, angina, migraines |
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when are beta blockers contraindicated
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asthma , heart block, pheochromocytoma, caution in DM type 1
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what are the SE of beta blockers
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heart block
depression impotence raynaud's |
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what demographic is beta blockers better for
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young and white
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what are the SE of dihydropyridines
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amlodipine, nifedipine
se: ankle edema, HA, flushing |
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dihydropyridines are better for what demographic
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black and elderly
causes peripheral vasodilation |
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when can you NOT use amlodipine
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never used as monotherapy in kidney dz with proteinuria
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name the contraindication for non dihydropyridines
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diltiazem/verapamil
contraindicated in heart block |
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what are teh SE of non dihydropyridines (diltiazem /verapamil)
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constipation, av block, bradycardia, peripheral edema
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when do you use ACE inhibitors?
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most effective in young white pts
used for diabetes and CHF |
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what is the CI for ace inhib
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pregnancy and bilateral renal stenosis and hyperkalemia
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what is the major SE for aceinhibitors
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cough, rash, hyperkalemia, angioedema
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when do you use ARBS
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use for diabetes and CHF when you can't take the SE for ace inhibitors
this does not have coughing as a SE |
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when is it indicated to use alpha blockers
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prazosin, terazosin
used for BPH, urethral outflow obstruction |
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when are alpha blockers CI
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left ventricular dysfunction
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what are some SE for alpha blockers
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orthostatic hypertension, ankle edema, CHF
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these drugs reduce efferent peripheral sympathetic outflow, usually 2nd or 3rd line.
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central alpha adrenergic agonists
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when is clonidine used and when is methyldopa used?
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clonidine for drug or etoh withdrawal
methyldopa for HTN in pregnancy |
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what are some SE of methyldopa?
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hepatitis and hemolytic anemia
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what are some SE of alpha adrenergic agonists?
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orthostatic Hypotension, rebound HTN, sedation, fatigue, dry mouth, constipation
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what are some direct vasodilators?
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hydralazine, minoxidil, sodium nitroprusside
they relax the vascular smooth muscle give in combo with diuretic and beta blocker |
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which drug is indicated for HF? post MI? high CVD risk? diabetes? chronic kidney dz? recurrent stroke prevention
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HF: thiazide, ace inhibitor
post MI: beta blocker high CVD risk: thiazide diabetes: ace inhibitor chronic kidney: ace inhibitor recurrent stroke prevention: thiaze, ace inhibitor |
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which drugs do you give young whites?
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Aceinhibitors
beta blocker |
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which drugs do you give elderly and blacks
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ca2+ channel blockers and diuretics
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what do you give for resistant htn?
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a or b + c + d and add either alpha blocker or spironolactone or other diuretic
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what drugs raise BP?
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OCP
NSAIDS etoh cocaine, meth, diet pills, decongestants |
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what are the indicated tx for HTN
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ABCD and HEMAN
ace inhibitor betablockers ca2+ channel blockers diuretics hydralazine eplereonone and spironolactone minoxidil alpha 1 blockers and alpha 2 agonists nitrates |
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what are the indications for ACE-I
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CHF and diabetes, renal protection, post MI
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what do you have to be careful of when using ace inhibitor
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angioedema and dry cough
could possibly aggravate renal artery stenosis and worsen renal fxn |
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what are the indications for beta blockers
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increased survivability post MI and CHF
only carvedilol or metoprolol is used for CHF |
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what are the SE for beta blockers
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bradycardia, heart block, depression
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CI for beta blockers
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asthma, COPD
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ca2+ channel blockers are good for what?
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afib and peripheral vasodilation
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SE of ccb?
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ankle edema, HA, flushing
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which diuretic works on asecnding limb and is more potent in blacks and elderly?
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thiazides
increase in ca2+, uric acid, LDL decrease in k+, mg+ |
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this diuretic should be avoided in renal insufficiency or kidney stone patients
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lasix or loop diuretics
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which is the only diuretic that is not a sulfonamide and is indicated for edema
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ethacrynic acid
may cause HTN in elderly |
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this is a vasodilator that has a reversible lupus like rxn
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hydralazine
effective in AA |
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this is for resistant HTN w/ Renal artery stenosis
no gynecomastia |
eplerenone
also used in Post MI |
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this increases k+ by has SE of gynecomastia
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spironolactone
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thhis is a vasodilator that lowers BP, also increases hair growth but be careful with end stage renal dz
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minoxidil
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this is an effective tx for BPH but doesnt decrease mortality
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alpha 1 blocker "osins"
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this is going to decrease ca2+, inhibit NE so it lowers BP
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alpha 2 agonist
helps opioid withdrawal but gives rebound HTN |
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these are for vasodilation preload and afterload reduction, decrease of pressure but is CI in right sided MI or R ventricular failure
needs to take a drug holiday each day |
nitrates
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