Term
| how recently has HTN been considered a disease? |
|
Definition
| since 1972, until that point it was assumed that HTN was needed in a compensatory fashion for problematic microvasculature |
|
|
Term
| what is the #1 cause of death in the US? |
|
Definition
|
|
Term
| what are the #1 and 2 causes of end stage renal disease? |
|
Definition
|
|
Term
| does prevalence of HTN increase w/age? |
|
Definition
|
|
Term
| what is considered normal BP? |
|
Definition
|
|
Term
| what is considered preHTN? |
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
| what are things to consider in preHTNsive pts? |
|
Definition
| a positive family hx, overweight, high risk ethnic group, and sedentary lifestyle |
|
|
Term
| since recognizine HTN in the 70s have awareness and control of the disease improved? |
|
Definition
|
|
Term
| what are the benefits of reducing BP? |
|
Definition
| stroke risk reduction (by 35-40%), MI risk reduction (by 20-25%), and heart failure risk reduction (by 50%) |
|
|
Term
| what % of total HTN pts have essential HTN? |
|
Definition
|
|
Term
| what causes essential HTN? |
|
Definition
|
|
Term
| what is the typical age of essential HTN onset? |
|
Definition
|
|
Term
| is there usually a postive fam hx w/pts w/essential HTN? |
|
Definition
|
|
Term
| does one gene controls essential HTN? |
|
Definition
| no, it is a polygenetic phenomenon |
|
|
Term
| what is the increase in essential HTN incidence for african americans? |
|
Definition
|
|
Term
| what are some secondary causes of HTN? |
|
Definition
| chronic kidney disease (impaired GFR can lead to HTN), renal vascular disease, (primarily atherosclerotic disease off the aorta), fibromuscular dysplasia (abnormality of the arteries themselves), sleep apnea, coarctation of the aorta, drug induced related causes (street drugs/NSAIDs/oral contraceptives), and primary aldosteronism/other endocrine problems (excess aldoesterone/mineralcorticoid/glucocorticoid, cushing's disease, thyroid/parathyroid disease, and pheochromocytoma) |
|
|
Term
| what are the 3 objectives for the pt evaluation? |
|
Definition
| 1) assess lifestyle/cardiovascular risk factors/concomitant disorders+comorbidities. 2) reveal identifiable (secondary) causes of high BP (perhaps rx). 3) evaluate for evidence of target organ/CV damage |
|
|
Term
| what are important questions when taking a hx related to HTN? |
|
Definition
| when did it start/how long? pertinent landmark life events (pregnancy/sx)? previously documented HBP? concomitant medical illnesses (renal disease/DM)? |
|
|
Term
| does lifestyle modification play an important role in managing HTN pts? |
|
Definition
|
|
Term
| what are risk factors for CVD? |
|
Definition
| *HTN, smoking, *obesity (calc BMI), physical activity level, *hyperlipidemia/dyslipidemia, *DM, microalbuminuria/est GFR <60 (renal impairments), age, fam hx of premature CVD. [metabolic syndrome starred] |
|
|
Term
| is the BP relationship risk of CVD dependent on other factors? |
|
Definition
| no, the relationship risk between BP and CVD is independent and continuous |
|
|
Term
| how much does a 20/10 mm Hg increment increase starting from 115/75 affect CVD risk? |
|
Definition
| each incremental increase of 20/10 mm Hg doubles CVD risk |
|
|
Term
|
Definition
| the need for increased education/awareness to ID risk |
|
|
Term
| what are examples of target organ damage (related to small vessel damage) associated with HTN? |
|
Definition
| retinopathy (fundoscopic), heart (LVH, angina or prior MI, prior coronary revascularization, heart failure), brain (stroke/transient ischemic attack), chronic kidney disease, and peripheral arterial disease (includes carotids) |
|
|
Term
| what are the waist size, triglyceride levels, HDL, BP, and fasting glucose measurements consistent with metabolic syndrome? |
|
Definition
| waist circumference: >102 cm in men and >88 in women, trigylcerides: ≥150 mg/dl, HDL: <40 for men and <50 for women, BP: >130/>85 mmHg or those who are already on medical therapy, and fasting glucose ≥110 |
|
|
Term
| what % of US adults have metabolic syndrome? do these pts have an increased risk of CVD/DM? |
|
Definition
|
|
Term
| what can prevent the majority of CVD events? |
|
Definition
| BP control, risk factor management |
|
|
Term
| what are important considerations for taking BP? |
|
Definition
| proper cuff size/both arms, take BP 5 min apart/pt seated comfortably/no recent smoking or caffeine |
|
|
Term
| what should be looked for in the fundoscopic exam? |
|
Definition
| arteriosclerotic or diabetic retinopic changes |
|
|
Term
| what needs to be considered on the CV exam? |
|
Definition
| rate, rhythm, PMI (if displaced, it could be LVH), murmurs, heaves, S3/S4, pulses and bruits |
|
|
Term
| what needs to be considered on the abdominal exam? |
|
Definition
| enlarged kidneys (usually not palpable if normal), masses, bruits (indicative of renal vascular disease) |
|
|
Term
| what needs to be considered on examination of the extremities? |
|
Definition
| distal pulses, hair loss, presence of ulcers, ask pts if they have intermittent claudication |
|
|
Term
| how can the state of hydration be assessed by taking BP? |
|
Definition
| the tilt test - take BP when pt sitting/standing. if there is a big difference in systolic, there could be an autonomic insufficiency or volume depletion |
|
|
Term
| how should BP be taken on first HTN appt? |
|
Definition
| 2 readings, both arms, 5 min apart, seated |
|
|
Term
| what is ambulatory BP monitoring? when is it used? |
|
Definition
| a cuff put on the arm and has the ability to check BP on patient every 15 mins for 24 hrs. this is indicated for "white coat HTN" and may help ID the lack of 10-20% BP decreases which should occur during sleep. if this is not happening = increased CVD risk |
|
|
Term
| is self BP measurement by pts at home useful? |
|
Definition
| yes, this can help address "white coat HTN", involve pts more with their care and increase compliance |
|
|
Term
| how long should a pt abstain from caffeine and smoking before getting their BP checked? |
|
Definition
| caffeine: 1 hr, smoking: 30 min |
|
|
Term
| what should the room be like when taking BP? |
|
Definition
|
|
Term
| how can you check to make sure the BP cuff is the correct size? |
|
Definition
| the bladder cuff length should be 80% and width 40% of circumference of the upper arm |
|
|
Term
| if you have a pt under 30 with a high difference between BPs, what should be checked? |
|
Definition
|
|
Term
| what % of pts are subject to "white coat HTN"? |
|
Definition
| 20-25% - this is why ambulatory or at-home measuring is useful |
|
|
Term
| what are signs of arteriosclerotic retinopathy? |
|
Definition
| AV nicking, cotton wool spots, retinal hemorrhage, papilledema |
|
|
Term
| what are useful laboratory tests when evaluating HTN? |
|
Definition
| EKG, urinalysis, blood glucose/hematocrit, serum K, creatinine/corresponding GFR and Ca, lipid profile. optional: urinary albumin excretion or albumin/creatinine ratio to see if there is significant damage causing leakage of protein into urine (nephrologist usually look at these) |
|
|
Term
| what can a renal ultrasound (US) or nuclear scan tell you about the kidney? |
|
Definition
| US:determination of renal blood flow/atery abnormalities and kidney shape/size/symmetry, nuclear scan: compare each kidney’s function, how well they clear the injection, take up the tracer, etc |
|
|
Term
| *what are the goals of therapy?* |
|
Definition
| 1) *treat BP <140/90 mm Hg or BP <130/80 mm Hg in pts w/DM or CKD and <125/75 if proteinuria (know this)* 2) achieve BP goal in pts, esp those >50 yrs 3) reduce CVD and renal morbidity and mortality |
|
|
Term
| what is the approx SBP (systolic BP) reduction from weight reduction? |
|
Definition
| 5-20 mm Hg per 10 kg (20-22 lbs) |
|
|
Term
| what is the approx SBP (systolic BP) reduction from the DASH (dietary approach to stop HTN) eating plan? what does DASH consist of? |
|
Definition
| 8-14 mm Hg. this includes minimization of meat, increasing fruit/veggie servings to 4-5/day, and low fat dairy products |
|
|
Term
| what is the approx SBP (systolic BP) reduction from dietary Na+ reduction? |
|
Definition
| 2-8 mm Hg, this can have big impact in patients with swelling |
|
|
Term
| what is the approx SBP (systolic BP) reduction from physical activity? |
|
Definition
|
|
Term
| what is the approx SBP (systolic BP) reduction from moderation of alcohol consumption? |
|
Definition
|
|
Term
| what is the most appropriate rx for stage I HTN pts w/o compelling indications? |
|
Definition
| thiazide diuretics, could also use ACEI, ARB, BB, CCB or combination - but stage I is rare to start multiple drugs |
|
|
Term
| what is the most appropriate rx for stage II HTN pts (BP > 160/100) w/o compelling indications? |
|
Definition
| these pts usually need 2 meds, many do ACEI (can get coughing) with thiazide or ARB with thiazide |
|
|
Term
| what is done with pts with stage I or II HTN and compelling indications? |
|
Definition
| determine underlying problem and treat accordingly. DM? a previous MI? peripheral vascular disease? optimize dosages, a specialist may be necessary |
|
|
Term
| what drugs are compellingly indicated for are pts w/DM and HTN? |
|
Definition
| ACE I and ARBs - which can decrease intraglomerular pressure b/c DM pts get hyperfiltering + leaking of proteins due to damage to BM, these drugs will aid in renal preservation and minimize proteinuria |
|
|
Term
| what drugs are compellingly indicated for are pts w/CKD and HTN? |
|
Definition
| ACE I and ARBs - which can decrease intraglomerular pressure b/c CKD pts get hyperfiltering + leaking of proteins due to damage to BM, these drugs will aid in renal preservation and minimize proteinuria |
|
|
Term
| what needs to be monitored in terms of GFR while pts are on drugs? |
|
Definition
| if the pt's GFR drops more than 20%, the drug needs to be stopped. the GFR should be checked once a week |
|
|
Term
| what drugs are compellingly indicated for are pts w/recurrent strokes and HTN? |
|
Definition
| thiazide diuretics and ACE I (also Ca++ channel blockers) |
|
|
Term
| what drugs are compellingly indicated for are pts w/heart failure and HTN? |
|
Definition
| diuretics, BB to help with CAD, ACI+ARB to help with afterload reduction, aldosterone antagonists can help with decreased ejection fraction -> attach HTN and manage heart on various levels |
|
|
Term
| what drugs are compellingly indicated for are pts post MI/CAD and HTN? |
|
Definition
| BB, ACEI, aldosterone antagonists - similar to heart failure pts |
|
|
Term
| what drugs are compellingly indicated for are pts @high CAD risk and HTN? |
|
Definition
| similar to heart failure, may use Ca++ channel blockers |
|
|
Term
| how can tx with a stage I HTN pt w/o risks be approached? |
|
Definition
| lifestyle changes for up to 6 mo before rx therapy |
|
|
Term
| how should tx with a stage II HTN pt w/o risks be approached? |
|
Definition
| initial drug therapy needs to be considered w/lifestyle modifications |
|
|
Term
| what needs to be done w/HTN pts until the BP goal is reached? |
|
Definition
| frequent f/u, and even more increased frequency w/stage II HTN or complicating co-morbid conditions |
|
|
Term
| one HTN pts are at BP goal, how often should f/u's be scheduled? |
|
Definition
| 3-6 intervals, w/reassessments of other comorbitiies each time |
|
|
Term
| what are special considerations for HTN? |
|
Definition
| ethnic background, LVH, tilt test (patients with normal pressure lying down but changes when standing – postural hypotension), metabolic syndrome, long term diabetes, amyloidosis, parkinsons, dementia pts, children/adolescents, emergency situations |
|
|
Term
| how does HTN affect the african american population? do they respond to drugs in a different manner? |
|
Definition
| HTN has a slightly higher prevalence and severity in the african american population. african americans also demonstrate a somewhat reduced response to monotherapy with BBs, ACEI or ARBs compared to diuretics or CCBs (these differences are usually eliminated by adding adequte doses of a diuretic) |
|
|
Term
| what are some important barriers to BP control on a global level? |
|
Definition
| socioeconomic factors and lifestyle |
|
|
Term
| what are some considerations in tx of HTN in women? |
|
Definition
| oral contraceptives can raise BP, ask what other rx's they're on. pregnant women w/HTN should be followed carefully and *ACEIs and ARBs are contraindicated in pregnancy* (know this, can cause RPM abnormalities in the fetus 2-3rd trimester). diuretics are usually not used, DOCs are methyldopa, BBs, and vasodilators. pregnancy can induce HTN as well, and these people should be consulted w/a specialist or OB |
|
|
Term
| what population has the lowest rate of BP control? |
|
Definition
| the elderly - more than 2/3 over 65 have HTN, can be due to not wanting to go on other meds/lack of understanding. |
|
|
Term
| what are some considerations in tx of HTN in the elderly? |
|
Definition
| lower initial doses to keep ADRs low, then necessary standard doses and potentially multiple drugs to keep BP down |
|
|
Term
| what is an independent risk factor that increases the risk of CVD? how can it be treated? |
|
Definition
| LVH - which can be treated via weight loss, Na+ restriction, and treatment with all classes of antiHTNsive drugs except hydralazine and minoxidil |
|
|
Term
| what is PAD equivalent to in risk? |
|
Definition
|
|
Term
| how do pts with PAD present? how is it treated? are there associated risk factors? |
|
Definition
| decreased peripheral pulses, hair loss, leg pain, ulcers. PAD can be treated with any class of drugs, those with vasodilating properties are preferred such as those of carbetalol (alpha/beta blocker) or Ca++ channel blockers and ASA to help with platelet aggregation. other risk factors such as *hyperlipidemia* should be managed aggressively to prevent atherosclerosis. |
|
|
Term
| what is postural hypotension? what rx can exacerbate it? how can it be tested for? |
|
Definition
| postural hypotension is a decrease of >10 mm Hg in systolic BP. diuretics (excessive volume depletion) can exacerbate this (need to make sure pts can tolerate medications under normal circumstances). it is tested for with the tilt test. |
|
|
Term
| does dementia occur more commonly in pts w/HTN? can antiHTNsive therapy improve dementia? |
|
Definition
| yes and antiHTNsive therapy can reduce the progression of dementia |
|
|
Term
| what is a HTN emergency? what characterizes a pt in one? |
|
Definition
| a pt with a marked BP elevation (can be as high as 220/110) and *acute target organ damage*. pts may have a change in mental status (encephalopathic), ischemia, unstable angina, pulm edema/SOB, eclampsia w/pregnancy, stroke, aortic dissection, hospitalization/IV drug therapy, and *symptomatic HTN* |
|
|
Term
| how is a HTN emergency treated? |
|
Definition
| hospitalization and IV drug therapy |
|
|
Term
| what is a HTN urgency? what characterizes a pt w/it? |
|
Definition
| pts with markedly elevated BP *without* acute target organ damage and *asymptomatic HTN* very high BP, (systolic around 180-200), usually these pts do not require hospitalization and generally are not compliant with medication b/c they don't feel sick. PO drugs are prescribed, often in office, with time to allow a re-check of BP. |
|
|
Term
| how can pts with HTN maintain normal perfusion and avoid excessive blood flows at high blood pressure levels? |
|
Definition
| autoregulation, which in pts with chronic BP elevations - structural and functional changes in arterial circulation shift the autoregulatory curve |
|
|
Term
| can sudden BP lowering in chronic HTN pts cause problems? |
|
Definition
| yes, due to autoregulation, often these pts have a different arterial capacity which may not be initially compatible with a sudden BP drop - which may cause ischemia-like symptoms and drop GFR too low |
|
|
Term
| why are pts in hypertensive emergencies put on IV drips in the hospital? when are drugs PO ok? |
|
Definition
| this allows monitored, aggressive tx that can be slowed down to keep BP from dropping too fast (or turned up). drugs can be given PO after 6-12 hrs. |
|
|
Term
| what is a potential favorable effect of thiazide diuretics? |
|
Definition
| slowing demineralization associated with osteoporosis |
|
|
Term
| what is a potential favorable effect of BBs? |
|
Definition
| simultaneous ts of A tach/fib, migranes, thyrotoxicosis, essential tremor or perioperative HTN |
|
|
Term
| what is a potential favorable effect of Ca channel blockers? |
|
Definition
| raynauds and certan arrhythmias |
|
|
Term
| what is a potential favorable effect of alpha blockers? |
|
Definition
|
|
Term
| what are a potential unfavorable effects of thiazide diuretics? |
|
Definition
| caution of gout exacerbation or w/hx of significant hypoanatremia |
|
|
Term
| what are a potential unfavorable effects of BBs? |
|
Definition
| BBs should be avoided in pts w/asthma, reactive airways disease or second/third degre heart blocks |
|
|
Term
| what are a potential unfavorable effects of ACEIs and ARBs? |
|
Definition
| contraindication in pregnancy, those likely to become pregnant |
|
|
Term
| what are a potential unfavorable effects of ACEIs? |
|
Definition
|
|
Term
| what are a potential unfavorable effects of aldosterone antagonists (spirinolactone) and K-sparing diuretics? |
|
Definition
|
|
Term
| what are strategies for improving tx adherence and control? |
|
Definition
| make the regiment as simple as possible, show empathy to increase trust/motivation/compliance, sensitivity to culture/socioeconomic situation, and pt education (=pt empowerment) |
|
|
Term
| when should secondary HTN as a designation be considered? |
|
Definition
| pts with no family hx of HTN, development of HTN at an odd time in life, and resistant HTN despite: compliance w/meds, diet, lifestyle, and no street drug use, or blood work indicative of secondary HTN |
|
|
Term
| how can the renovascular diseases atherosclerotic renal artery stenosis or fibromuscular dysplasia cause secondary HTN? |
|
Definition
| atherosclerotic renal artery stenosis can be perceived by the kidney as ischemia and thus generate more angiotensin II/aldosterone to increase BP. fibromuscular dysplasia causes a similar problem, but specifically affects young women |
|
|
Term
| can sleep apnea lead to secondary HTN? what are signs of a pt w/sleep apnea? what specialist should they see? |
|
Definition
| sleep apnea can lead to secondary HTN, these pts tend to have a large neck circumfrence, fall asleep easily during the day, and snore at night or stop breathing. these pts need to see a pulm dr |
|
|
Term
| what level of HTN do pts with renal artery disease (RAD) often have? |
|
Definition
| stage II HTN, often with TOD (target organ damage) - and are at risk of losing renal function |
|
|
Term
| when do pts with RAD typically develop HTN? |
|
Definition
| after age 50 or they suddenly become refractory to tx one day after a hx of good control |
|
|
Term
| what is also seen in pts with RAD? who is it more common in? |
|
Definition
| evidence of other vascular disease (carotids, coronaries, and peripheral circulation). RAD is more common in pts with a smoking hx and caucasians. |
|
|
Term
| is no family hx of HTN in RAD common? |
|
Definition
|
|
Term
| after initiation of ACEI or ARBs what might be seen in the blood work of a bilateral RAD pt? |
|
Definition
| elevated serum creatinine levels - b/c these drugs drop the GFR |
|
|
Term
| can RAD pts exhibit flash pulm edema w/SOB? |
|
Definition
|
|
Term
| how might abdominal bruits appear in a pt with RAD? |
|
Definition
|
|
Term
| what are 90% of the lesions in RAD? what makes up the other 10% |
|
Definition
| 90%: atherosclerosis 10%: fibromuscular dysplasia |
|
|
Term
| what is fibromuscular dysplasia? |
|
Definition
| a non-inflammatory, non-atherosclerotic disorder leading to arterial stenosis |
|
|
Term
| who does fibromuscular dysplasia more commonly affect? |
|
Definition
|
|
Term
| what arteries are most commonly affected by fibromuscular dysplasia? |
|
Definition
| the renal (most common) and internal carotid, vertebral and visceral arteries *may have an epigastric bruit" |
|
|
Term
| how does fibromuscular dysplasia present? |
|
Definition
| HTN, CVA, TIA, refractory HTN and onset of HTN before age 30 |
|
|
Term
| how do fibromuscular dysplasias appear on imaging? |
|
Definition
|
|
Term
| what do kidneys affected by advanced disease (atherosclerosis, fibromuscular dysplasia) |
|
Definition
| plaques, severe bilateral RAS, cortical thinning and a major decrease in GFR/kidney function |
|
|
Term
| how useful is revascularization (via stenting) in kidneys affected by HTN? |
|
Definition
| fibromuscular dysplasia is reduced by 60%, but atherosclerotic disease is only reduced <30% of the time (w/a high re-stenosis rate) b/c the damage is often farther down in the kidney (esp with CKD), past the point where you can stent |
|
|
Term
| can PTA/stenting help with preservation of kidney function? |
|
Definition
| not really, esp in those who have >60% loss of renal function - they already have a reduced GFR - no point in revascularizing them (damage already happened). therefore, PTA/stenting is really a last ditch effort |
|
|
Term
| is sleep apnea a common cause of secondary HTN? how many pts with this ar undiagnosed? |
|
Definition
| yes, 80-90% pts w/this are undiagnosed |
|
|
Term
| what are good sleep apnea diagnostic questions? |
|
Definition
| excessive daytime sleepiness? experienced apneic events during sleep? tired after a "good night's sleep?" |
|
|
Term
| what can be the result of treating sleep apnea? |
|
Definition
| a significant decrease in day & night BP levels after initiation of tx. likelihood of sudden cardiac death and other CVs are also dropped |
|
|
Term
| what is the most common endodrinopathic cause of HTN? |
|
Definition
|
|
Term
| how do pts with primary aldosteronism present? |
|
Definition
| pts have moderate to severe HTN, they are volume replete, non-edematous, have unprovoked/exaggerated hypokalemia, and mild metabolic alkalosis |
|
|
Term
| what is the most common cause of primary aldoesteronism? |
|
Definition
| adenoma of the adrenal glands |
|
|
Term
| how can primary aldosteronism be diagnosed? |
|
Definition
| low K levels, elevated bicarb, high aldoesterone levels, and abnormal adrenal glands on CT |
|
|
Term
| what is primary aldosteronism treated with? |
|
Definition
| aldosterone antagonists, aldactone and eplerenone |
|
|
Term
| what is a newer focus in pts with HTN? |
|
Definition
| defining "dippers" = pts, typically african american DM patients, elderly, or chronic kidney disease patients whose BP doesn't lower 10-20% at night. this is diagnosed though ambulatory BP testing and can be treated with ACEI administration at night |
|
|
Term
| what is the pathogenesis of HTN? |
|
Definition
| multiple factors, polygenetic, though some hereditary considerations such as salt sensitive phenotypes. liddle's syndrome and endocrine disorders also can cause HTN |
|
|
