HTN

HTN

HTN

A progressive cardiovascular syndrome with many causes that results in both functional and structural changes to the heart and vascular system

primary (essential)

What type of HTN is most common (95%) and has an idiopathic cause?

secondary

What type of HTN has a defined cause where we can treat the culprit and cure the patient?

accurate measurements and average of 2+ readings on 2+ occasions

HTN definition determined by ACC/AHA is based on

age, obesity, family hx, race, reduced nephron number, high sodium diet, excessive EtOH, physical inactivity, insufficient sleep, social determinants

What are some things associated with primary HTN - NOT the cause?

eye

What is one of the 1st places effected by HTN and the only place where you can see the damage?

HTN diagnosis (do not pass go, do not collect $200)

Any patient presenting with a hypertensive emergency

Ambulatory BP monitoring

basically a halter monitor for BP for episodic hypertension

ambulatory BP monitoring, patient self-check, home blood pressure

What are some strategies for diagnosing hypertension (how do you exclude white coat syndrome)?

improper cuff size, recent nicotine intake, recent caffeine, amount of rest prior to BP measurement, not checking same time of day, recent exercise, recent dietary intake, white coat

What things might cause change a BP’s accuracy?

2 years, yearly

When does USPSTF recommend screening for normal BP (120/80)? Prehypertension (120-139/80-89)?

We can’t control it, they are young

When do we do a work-up for secondary hypertension?

12 lead EKG, blood glucose, serum potassium, creatinine, UA, hematocrit, calcium, fasting lipid profile

What are some additional studies to consider for the diagnosis of HTN?

thiazide/ACEI/ARB/CCB alone or in combo

For non-black patients with HTN without CKD or DM what is our treatment plan?

thiazides/CCB alone or in combo

For black patients with HTN without CKD or DM what is our treatment plan?

thiazide/ACEI/ARB/CCB alone or in combo

For nonblack patients with HTN and DM without CKD what is our treatment plan?

thiazides/CCBs alone or in combo

For black patients with HTN and DM without CKD what is our treatment plan?

ACEI/ARB alone or in combo with another drug class

For all patients with HTN and CKD without DM, what is the treatment plan

thiazides, ACEI, ARBs, CCB

What are 1st line therapies for HTN - generally additive?

Chlorthalidone (thalitone), Indapamide (lozol), HCTZ

What are the thiazides used for HTN?

Benazepril (lotensin), lisonpril (prinivil, zestril), captopril

What are some of the ACEI are used for HTN?

telmisartan (Micardis), Losartan (Cozaar)

What are some of the ARBs used for HTN?

amplodipine (Norvasc - DHP), Verapamil (Calan, Isoptin - NDHP)

What are some of the CBBs used for HTN?

depression, gout

Beta blockers might worsen which conditions

Ease it in

If we are going to use beta-blockers like labetalol, atenolol, carvedilol, or metoprolol tartate what do we need to do for the patient?

beta blockers, K+ sparing diuretics, loop diuretics, central alpha 2 agonist, blood vessels dilator

2nd line treatments for HTN

labetolol, hydralazine, Nifedipine ER, methyldopa

What drugs are safe to use for HTN with pregnancy?

requires 3+ drugs

When should we refer our HTN peeps to a specialist like a nephrologist, cardiologist, endocrinologist, or IM?

losing weight, reducing salt intake, DASH diet, self-monitoring/appointment reminders, co-management with pharmacist, treating OSA, exercise, reducing EtOH intake, stop smoking

What are some lifestyle modifications HTN patients can make that kinda help?

age at onset, severity, abrupt nature of onset, family history

What are some red flags for secondary HTN?

chronic kidney disease

What is the most common cause of secondary hypertension?

primary aldosteronism

What is the second most common cause of secondary hypertension?

coarctation of the aorta, cushings, drug induced, obstructive uropathy, Pheo, renovascular HTN, sleep apnea, thyroid/parathyroid

What are some of the other causes for secondary HTN?

Do they have DM? estimate GFR, renal US, elevated serum creatinine/abnormal

How can we screen for Renovascular disease?

24 hr urine checking for VMAs, plasma fractionated metanephrines

How do you screen for pheos?

24 hr urinary aldosterone, unexplained hypokalemia, serum aldosterone:renin ratio

How do you screen for primary aldosteronism?

dexamethasone suppression test, 24 hour urine cortisol levels

How does one screen for Cushing’s syndrome?

sleep study

How does one screen for sleep apnea?

CT angiography, HTN in upper extremities, diminished/delayed femoral pulses, low/unobtainable arterial blood pressures

How are we screening for coartaction of the aorta?

TSH

How do we screen for thyroid issues?

Serum PTH, calcium

How do we screen for hyperparathyroidism?

They demanded the blood but get damaged by the increase in pressure

How are the kidneys both the victim and the culprit of secondary HTN due to renal parenchyma disease?

Diabetic nephropathy, glomerulonephritis, Hypertensive renal disease, drug induced renal disease, polycystic kidney disease

What are some of the possible causes for renal parenchyma disease that leads to secondary HTN?

narrowing of one or both renal arteries

On a U/S positive for renovascular disease (renal artery stenosis) what are you going to see?

atherosclerosis, fibromuscular dysplasia

What might cause renal artery stenosis?

rising creatinine after initiation of ACE inhibitor therapy

What is usually considers a sign of potential bilateral renal artery stenosis?

accelerates atherosclerosis and impairs baroreceptors, impaired blood flow leads to impaired renal perfusion

How might a coartation of the aorta increase BP?

systolic HTN UE vs. LE, rib notching on CXR, reduced femoral pulses

What are some of the classic findings for coarctation of the aorta?

episodic HA, sweating, tachycardia, paroxysmal HTN

What is the classic triad of a PHEO

Cushing syndrome

What is a rare cause of secondary hypertension due to too many glucocorticoids (ACTH)?

excessive metabolic activity leads to cardiac hyperactivity and increased blood volume (usually just increases systolic)

Why does hyperthyroidism lead to secondary hypertension?

Uncertain, maybe related to fluid retention (usually diastolic)

Why does hypothyroidism lead to secondary hypertension?

Usually due to hypercalcemia which is associated with an increased prevalence of hypertension, potential coexisting renal dysfunction

Why does hyperparathyroidism lead to secondary hypertension?

no clear cause-effect relationship

Why does sleep apnea lead to secondary hypertension?

estrogen, steroids, cyclosporines, EPO, sympathmimetics, alcohol, cocaine, meth

What are some medications that can lead to secondary hypertension?

treat the underlying disorder (start noninvasive)

How are we treating secondary hypertension?

hypertensive crisis

refers to a clinical situation when a patient’s bp is severely elevated (over 180/120 mmhg)

Hypertensive urgency

Hypertensive crisis with no obvious damage

hypertensive emergency

hypertensive crisis with obvious damage and evidence of impending/progressive target organ damage

uncontrolled essential hypertension, secondary hypertension

What is the main cause of hypertensive crisis?

asymmptomatic, HA, epistaxis, faintness

What are some of the symptoms associated with hypertensive emergencies

accelerated-malignant hypertension, hypertensive encephalopathy

Other names for hypertensive crisis

repeated BPs (consider an A line), fundoscopy, cardiopulmonary status, clinical volume status, neurologic status, vascular/pulse exam

What are some physical exam tools we can use in our diagnostic eval for hypertensive crisis

HA, vision changes, GI complaints, chest pain, dyspnea, neurologic deficit, stroke like symptoms, acute pulmonary edema, encephalopathy, cerebral hemorrhage

What are some S/S seen with hypertensive crisis that are evidence of impending organ damage?

electrolytes, renal function tests, UA, EKG

What labs are we ordering for a hypertensive crisis?

avoid rapid BP drops, do it at a rate the patient can tolerate

What are some basic rules of the road for hypertensive crisis?

ICU admit, parenteral meds, continuous cardiac monitoring, art line,

What will patients with true hypertensive emergencies will require

increase the dose, add another agent, start the meds again in non-adherent patients

How do you manage patients with true hypertensive urgencies and previously treated HTN

foresemide, clonidine, captopril

Oral Meds for HTN urgencies (goals is less than 160/100)

labetalol (most common), captopril, clonidine, nitroprusside, nicardipine

What medications are we using for ER level HTN crisis (I better see no oral meds in this house)?

nifedipine (drops too fast)

What med are we NOT going to use for HTN emergencies?

aortic dissection, acute hypertensive pulmonary edema, acute sympathetic crisis, MI, neurologic emergencies

What are some complications for hypertensive emergencies?

morphine, labetalol (#1), esmolol

What meds can be used for aortic dissection?

nitro (1st line), nicardipine

What meds are we using for acute hypertensive pulmonary edema?

lorazepam, diazepam (decrease sympathetic drive)

How are we treating acute sympathetic crisis (coke and meth abuse)?

Nitro (unless its RV - watch yo self), metoprolol

How are we treating MIs?

Get the head CT (HTN could be a protective measure)

How are we treating neurological emergencies with HTN emergencies?