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Hypertension

Terms in this set (119)

Essential or primary HTN means that we don't know the cause of it. What percent of all HTN cases are essential or primary?
95% of all cases! Multifactorial genetic disorder.
Some epidemiology facts of Essential HTN.
-Family Hx + environmental factors
-4x more prevalent among AA compared to Caucasians
-Male > famle
-Diabetics > Non-diabetis
-Risk factors include: stressful life style, high dietary intake of Na, obesity, and smoking.
Monitoring Therapy, when should patients follow up?
Re-evaluate q 2 wks-4wks until adequate control reached then f/u q 3-6 mos
What is the equation to calculate BP and Cardiac Output?
BP = Cardiac Output x Peripheral Vasculature Resistance

CO = HR x Stroke Volume
Assessing the Blood Pressure
Two readings at visit
Each arm
5 min rest
Appropriate sized cuff
No caffeine or smoking for 30 minutes prior
Repeat 1 week
What stage would you classify this BP?

BP 146/92
Stage 1: DBP 90 to 99 mm Hg, SBP 140 to 159 mm Hg
ACCOMPLISH trial
Directly compared different combination regimens
Combination tx with benazepril/amlopidine had fewer CV event than benazepril/hydrochlorothiazide
SNS hyperactivity can be a factor leading to the development of HTN, how does this occur?
What are the cardio-selective beta blockers used to treat HTN?
-Atenolol
-Metoprolol

*they are safer for pt's with Asthma, Diabetes, and COPD
What are some side effects of beta blockers?
-Bradycardia
-CHF
-AV conduction abnormalities
-Bronchial spasms
-Increased triglycerides and decrease HDL
-Impotence (erectile dysfunction)
Why is it so dangerous to abruptly stop taking beta blockers?
After taking something that blocks beta receptor activity for a while, the body gets smart and develops more B1 receptors on the heart. (a way to combat the loss of activity).

When you stop taking them abruptly or skip a dose, you can get angina, MI, or even death.
Review: How do Ca+ channel blockers treat HTN?
They block calcium from entering smooth vascular cells with prevents contraction and reduces peripheral vascular resistance.

*BP = CO x PVR
*Popular class of drugs esp. for pets w/asthma
*No change in venous capacitance - no change in pre-load, no-change in cardiac output, only affect is decrease in PVR
What are some advantages to using Ca channel blockers to treat HTN?
-No sedation or other CNS effects
-Not contraindicated in asthma
-Does not impair renal perfusion
-Does not affect male sexual function
-No effect on plasma lipid profiles
-May be used in pregnancy
Na Nitroprusside is a direct acting vasodilator used to treat Hypertension by decreasing what two things?
PVR and CO! (different from the others).
-It relaxes arerioles > decreasing PVR > decreasing after load.
-Relaxes venous vessels > decreases preload > Decreases CO

*Drug of choice in HTN emergence
What are the 4 categories of Diuretics?
1. Carbonic anhydrase inhibitors
2. Loop (high ceiling) Diuretics
3. Thiazides
4. K+ sparing diuretics
What are some examples of drugs that are Loop/High Ceiling diuretics?
-Ethacrynic acid
-Bumetanide
-Furosemide
-Torsemide
What are some adverse effects of loop/high ceiling diuretics?
-Ototoxicity - damage to the ear
-Hyperuricemia (excess uric acid in the blood), may exacerbate gout attacks
-Acute hypovolemia (too low of a decrease in blood volume)
-Hypokalemia (deficiency of potassium in the bloodstream)
What are some adverse effects of Thiazides?
-Hypokalemia (b/c increased Na in the lumen increases K+ secretion)
-Hyperuricemia (thiazides compete with uric acid for renal secretion, more uric acid in the blood, gout attacks)
- Hyperglycemia (Thiazides inhibit insulin secretion)
-Hyperlipidemic
All examples of AT1 receptor antagonists drugs
-Losartan
-Candesartan
-Valsartan
-Irbesartan
-Telmisartan
-Eprosartan
-Olmesartan
ACE inhibitors prevent the formation of angiotensin II.

What are examples of drugs in this category?
-Captopril
-Enalapril (prodrug Enalaprilat)
-Benazepril
-Fosinopril
-Lisinopril
-Moexipril
-Quinapril
-Ramipril
What are some adverse effects of ACE inhibitors?
-Dry cough, pruritic rashes, fever (due to increased bradykinin levels)
Known to cause neonatal morbidity and mortality when administered to pregnant women. Discontinue once pregnancy is detected; Not teratogenic in the first half
Not for pt's with renal problems > Ang II is critical in patients to maintain renal blood flow
-Dysguesia (abnormal taste sensation)
What class of anti-hypertensive drug would you use if the patient has diabetes (Type 1) with proteinuria?
ACE inhibitors
What class of anti-hypertensive drug would you use if the patient has heart failure?
-ACE inhibitors
-Diuretics
-Beta-blockers
What class of anti-hypertensive drug would you use if the patient recently had a Myocardial infarction?
-Beta blockers (non-ISAs)
-ACE inhibitors
What class of anti-hypertensive drug would you use if the patient has isolated systolic hypertension (elderly)?
-Diuretics
-Ca channel blockers
Patients over age 75 with impaired kidney function?
CCBs and thiazide-type diuretics
Favorable effects on co-morbid conditions.

What class of anti-hypertensive drugs have a favorable effect on angina?
-Beta-blockers
-Calcium antagonists
Favorable effects on co-morbid conditions.

What class of anti-hypertensive drugs have a favorable effect on Atherosclerosis?
ACE inhibitors
Favorable effects on co-morbid conditions.

What class of anti-hypertensive drugs have a favorable effect on Hyperthyroidism?
Beta blockers
Favorable effects on co-morbid conditions.

What class of anti-hypertensive drugs have a favorable effect on Diabetes Mellitus?
ACE inhibitors
Favorable effects on co-morbid conditions.

What class of anti-hypertensive drugs have a favorable effect on Osteoporosis?
Thiazide diuretics
Avoid using in co-morbid conditions.

What class of anti-hypertensive drugs have a negative effect on Bronchospastic Disease (asthma)?
Beta blockers

*Don't use Beta blockers in pt's with asthma.
Avoid using in co-morbid conditions.

What class of anti-hypertensive drugs have a negative effect on Dyslipidemia?
-Beta blockers (non-ISA)
-Diuretics
Avoid using in co-morbid conditions.

What class of anti-hypertensive drugs have a negative effect on Peripheral vascular disease?
-Beta blockers
Prehypertension
between 120/80 and 139/89 mmhg
Stage 1 hypertension
between 140/90 to 159/99
Stage 2 hypertension
greater than 160/100
Hypertension is a risk factor for the following
CVA, CAD, CHF, PVD, AD, CRF, Dementia
Indications for ambulatory BP monitoring
-white coat HTN
-masked HTN (normal bp but organ damage)
-pseudoresistant HTN (orthostatic HTN)
-Noctournal HTN
-HTN in children, elderly, pregnant women
Physical exam for HTN
2 blood pressure readings
Eye exam
Neck
Abdomin
Back
BRUITS
Cardiac, vascular, neurologic
Labs for HTN
Chemistry
CBC
Lipids
UA
EKG
TSH
Calcium
Uric Acid
What are examples of end organ damage due to HTN?
CNS - stroke, retina damage
Kidneys - renal failure, proteinuria
Heart - CHF, MI, death, angina
PVD
Exacerbating factors of HTN
Obesity
Salt
Cafein
Smoking
ETOH
Genetics
Lifestyle
NSAIDs
Low potassium
Polycythemia
What are some potential causes of primary HTN?
sypathetic nervous system hyperactivity
RAS
Defect in natriuresis
Intracellular Na and Ca
polycythemia
What are some identifiable causes of secondary HTN?
CKD
Primary aldosteronism
Renovascular disease
Sleep apnea
Cushing's syndrome
Pheochromocytoma
Coarctation of the aorta
Thyroid disease
Parathyroid disease
What are some drug induced causes of secondary HTN?
Cocaine, amphetamines
Sympathomimetics - Alpha/beta adrenergic agonists
OCPs
Corticosteriods
Cyclosporine and tacrolimus
Erythropoetin
OTC meds
What are some red flags in secondary HTN?
- compelling finding on initial evaluation
- hypertensiion so severe that it is refractory to intensive multiple drug therapy or requires hospitlization
What is aldosteronism?
cause of HTN
caused by adreanl adenoma or hyperplasia
What does aldosteronism present like?
Drug resistant HTN with hypokalemia
What is the best diagnostic study for aldosteronism?
Aldosterone/Renin Ratio >25
What are the diagnostic studies for CKD?
UA
BUN/Cr
Microalbumin
Renal US may show small kidney
What are the signs and symptoms for renal artery stenosis?
HTN > 50 with bruits, PAD, refractory HTN
or
HTN <30 female with renal artery bruits
- suspect fibromuscular dysplasia
What is the GOLD STANDARD for diagnosis Renal arterial stenosis?
Arteriography
What is a pheochromocytoma?
cause of HTN
adrenal adenoma
What is the presentation for pheochromocytoma?
Labile HTN
HA
Tachycardia
Diaphoresis
What are some studies to perform for Pheochromocytoma?
Plasma/24 hour urine
Metanephrines
Catecholamines
VMA

CT/MRI of adrenals
What is coarctation of the aorta?
cause of HTN
uncommon cause
narrowing of aortic arch, distal to left subclavian artery
What are some symptoms of C of A?
young, cold feet, decreased femoral pulses, high BP in arms, low in legs

labs -24 hr for catecholamines
What is presentation for cushings?
truncal obestiy
purple striae
muscle weakness

labs-24 hour free cortisol
What are the diagnostic studies for cushings?
1 mg dexamethasone suppression test
Adrenal CT
True or False: Steriods raise BP
True
What is a hypertensive urgency?
Severe elevations of BP WITHOUT symptoms, without signs of progressive target organ dysfunction
What medications are good for HTN urgency?
Labetalol
Clonidine
Captopril
What is hypertensive emergency?
BP >220/130 or higher
WITH organ damage
What are some symptoms of hypertensive emergency?
HA, confusion, blurred vision, vomiting, seizures
What are some medications for hypertensive emergency?
ALL MEDS SHOULD BE GIVEN IV !!!!
Nitroprusside- agent of choice

others Labetalol , Nitroglycerin
By how much should you reduce the BP in 1 hour?
no more than 10% in first hour
What is malignant HTN?
extremely high HTN causing rapid end organ damage such as encephalopathy or nephropathy with papilledema
When should you initiate treatment In pts >60 and what is the treatment goal? (1)
I
Goal: < 150 systolic, 90 diastolic
When should you initiate treatment in pts < 60 and what is the treatment goal? (2,3)
Goal: < 140 systolic, <90 diastolic
When should you initiate treatment in pts with CKD > 18 y/o and what is the treatment goal? (4)
Goal: < 140 systolic, <90 diastolic
Risk Stratification by JNC 8

(includes everyone, I'm in A)
A: no additional risk: no CV risk factors, no CV disease

B: moderate additional risk: at least one risk factor, NOT DM, CV disease or target organ disease

C: marked additional risk: clinical CV disease, target-organ disease, DM
What medications should be used to treat the non-black population (including DM)? (6)
Thiazide type diuretic
ACE inhibior
ARBS
CCB
What medications should be used to treat the black population (including DM) WITHOUT CKD
Thiazide type diuretic
CCB
What medications for htn in CKD (regards of other conditions) ?
ACE inhibitor or ARB
Side effects of thiazides include:
insulin resistance, T2DM, hypokalemia, hyponatremia, hypertriglyceridemia, hyperuriciemia, gout, erectile dysfunction, dermatitis, photosensitvity
Loop diuretics are contraindicated in ..
hepatic coma
What are some examples of potassium sparing diuretics?
Spironolactone, Triamterene
What are the actions of Beta blockers?
Decrease CO
Decrease HR
Decrease strength of contractions
Decrease sympathetic outflow - decreased renin
Examples of beta blockers:
Propranolol, Atenolol, Metoprolol,
beta/alpha blockers: Carvedilol and Labetalol
Contraindications for Beta Blockers
heart block, asthma, depression, cocaine, meth abuse
Side effects of beta blockers
DMII, heart block, acute decompensated heart failure, bronchospasm
Fatigue, depression, sexual dysfunction, mask hypoglycemic symptoms, rebound hypertension if abruptly discontinued , claudication
What are the compelling indications for beta blockers?
Heart failure, MI , Coronary artery disease
What is the mechanism of action for ACE inhibitors?
inhibits ACE to block production of angiotensinogen II
Inhibits breakdown of bradykinins (vasodilator)
Reduce Aldosterone
Affects vascular remodeling
improves vascular/endothelial structure and function
Examples of ACE-I.
Enalapril, captopril, lisinopril, ramipril
Contraindications for ACE-I.
pregnancy (teratogenic) , bilateral renal stenosis, hyperkalemia
Side effects of ACE-I
COUGH (switch to ARB), hyperkalemia, angioedema, leukopenia
What are some disadvantages of ACE-I?
dose reduction in Chronic renal failure
can cause hypotension with volume depletion
What are some compelling indications for ACE-I use?
Post MI
heart failure
CAD
DM
protects renal function in DM1
CKD
STROKE prevention, prior or TIA
Examples of ARBS?
Losartan, Valsartan, Candesartan
Side effects of ARBs?
similar to ACE but less severe
Teratogenic
Action of Calcium channel blockers?
inhibits calcium influx into cells to prevent muscle contraction
inhibits cardiac smooth muscle
decreases iomotropy ad chronotropy
vasodilates
Examples of CCBs?
Amlodipine (most common)
Felodipine
Nifedipine
Contraindications for CCBs?
monotherapy in CKD with proteinuria
Side effects of CCBs?
HA, flushing, ankle edema, gingival hyperplasia, GERD, hypotension, constipation, exacerbate CHF, bradycardia
Advantages of CCBs?
Angina, SVT, A.fib, migraine prophylaxis, ISOLATED SYSTOLIC HTN
Compelling indications for CCB use ?
African Americans
high coronary artery disease risk
DM
isolated systolic hypertension
Alpha blockers mechanism of action?
inhibits alpha 1 adrenergic receptor which results in vasodilation, decrease in PVR
Examples of alpha blockers?
Prazosin, Doxazosin, Terazosin
Advantages of alpha blockers?
also used to treat BPH
Disadvantages of alpha blockers?
Orthostatic hypertension with first dose
Orthostatis HTN
Fatigue
Dry mouth
vivid dreams
reflex tachycardia
Approved treatment for African Americans?
Thiazides and Calcium Channel Blockers
Treatment in Mexican Americans?
avoid diuretics, they can increase DM
Treatment for Elderly isolated systolic HTN?
CCB and diuretics only!
What is the BEST predictor of CV mortaility?
Widened Pulse Pressure
Why do you see low serum potassium in a hypertensive patient what should you think about?
Primary hyperaldosteronism
Will also see high urine potassium
What is considered low serum potassium?
below 3.5 mEq/L
When should you suspect Renal Artery Stenosis
Patient with renal artery stenosis and are dependent on angiotensin 2 to maintain blood flow. the angiotensin II constricts the EFFERENT arteriole.

If you put them on an agent that targets the angiotensin II and their BP drops, these are patients that you should suspect have a renal artery stenosis. Can cause kidney ischemia doing these
Papilledema is a hallmark for?
Malignant hypertension

Thickening of the optic nerve, no true borders
Cotton Wool Spots
Represent Ischemic infarcts
What is this?
Flame Hemorrhages
What is this?
Papilledema
What is this?
Important Blood Pressure Number Goals
<140/90 mmHg All patients
<150/90 mmHg Age >60
<120 mmHg High risk over 50
Which drugss should you choose for first line therapy for uncomplicated HTN?
Ace inhibitors
Angiotension Receptor Blockers
Beta blockers
calcium Channel Blockers
Diuretics
Rule of TENS
Each drug will reduce blood pressure by roughly 10 mmHg
Cliical caviat for Drug Treatments for first line therapy for uncomplicated HTN?
Caucasians generally respond beter to ACE/ARB/BB
African Americans have better response to CCB/diuretics
Initial Therapy & Comorbidity: Heart Failure
BBs, ACEIs, ARBs, and Aldosterone Antagonists
Initial Therapy & Comorbidity: High-Risk CAD (such as diabetes)
ACEI and ARBs, diuretics, BBs and CCBs
Initial Therapy & Comorbidity: Proteinuria
ACEI, ARBs
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