Cardiology HTN

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What are some diseases associated with hypertension?: ⬢ diabetes mellitus
⬢ hyperuricemia
⬢ obstructive sleep apnea
⬢ atherosclerosis
⬢ Lipoprotein (a)
What is a side effect of ACE inhibitors and beta blockers in regards to lipid levels?: ACE inhibitors and beta blockers can make lipid levels worse (generally decrease HDL levels)
What are some mechanisms that lead to hypertension?: ⬢ arterial vasoconstriction and loss of elasticity of the vessels due to athersclerosis which can lead to increased resistance (or afterload)
⬢ decreased blood flow to vital organs causes end-organ damage
⬢ decreased blood flow signals the body to create more pressure
Describe the renin-angiotensin system: renin acts on angiotensiongen » creates angiotensin I »ACE works on angiotensin I to create angiotensin II
Where is renin released from?: the juxtaglomerular apparatus in the kidney
What is the difference between an ACE inhibitor and an ARB?: ⬢ ACE inhibitors prevent the conversion of angiotensin I into angiotensin II
⬢ ARB (angiotensin II receptor blocker) prevents angiotensin II from binding to its receptor
Where is aldosterone produced?: the adrenal cortex
What is the function of aldosterone?: retains sodium and water at the expense of potassium
What are some of the effects of an excess release of aldosterone?: can cause Cushing's Syndrome or primary hyperaldosteronism (which are causes of secondary hypertension)
What category of hypertension accounts for 95% of hypertension?: primary (or essential) hypertension
What are some theorized causes of primary hypertension?: ⬢ sympathetic nervous system hyperactivity - increased blood plasma catecholamines
⬢ abnormal cardiovascular development - abnormal development of aortic elasticity or reduced development of the microvascular network
⬢ renin-angiotensin system activity
⬢ defect in natriuresis - hypertensive patient have a decreased ability to excrete excess sodium
⬢ intracellular sodium and calcium
⬢ exacerbating factors
What are some exacerbating factors that can elevate blood pressure?: ⬢ obesity
⬢ increased sodium intake
⬢ excessive use of alcohol
⬢ cigarette smoking
⬢ polycythemia
⬢ NSAIDs
⬢ low potassium intake
If the patient presents with hypertension and is less than 30 years-old or greater than 50 years-old without a family history of hypertension, what category of hypertension should the clinican consider?: secondary hypertension
What is the most common symptom of hypertension?: Occiptal headache
What are the different aspects of the physical exam that should be done when evaluating for hypertension?: ⬢ check BP in both arms (and both legs if pulse differential is present)
⬢ eye exam - check for "silver wiring," AV nicking, & flame-shaped hemorrhages
⬢ Cardiovascular evaluation - checking for LVH/CHF; loud A2
⬢ abdominal evaluation for bruits - check for bruits in the renal arteries, abodminal aorta, illiac and femoral arteries
⬢ adequacy of pulses throughout
What are the basic studies done in evaluating for hypertension?: ⬢ CBC
⬢ Electrolytes
⬢ Serum Uric Acid
⬢ BUN/Creatinine
⬢ Urinalysis
⬢ Fasting Blood Glucose
⬢ EKG
⬢ Lipid Profile
What are some tests that should be done when secondary hypertension is suspected?: ⬢ chest Xray
⬢ echocardiogram for LVH/function
⬢ Catecholamine levels
⬢ aldosterone levels
⬢ urine electrolytes
What are 3 general categories of causes for secondary hypertension?: ⬢ adrenal causes
⬢ renal causes
⬢ other
List 3 adrenal causes of hypertension: ⬢ primary hyperaldosteronism
⬢ Cushing's syndrome
⬢ pheochromocytoma
List some renal causes of secondary hypertension: ⬢ renal parenchymal disease
⬢ renal vascular disease
⬢ renal artery stenosis
What are some other causes of secondary hypertension (11)?: ⬢ oral contraceptives
⬢ alcohol
⬢ NSAIDS
⬢ pregnancy
⬢ hypercalemia
⬢ hyperthyroidism
⬢ obstructive sleep apnea
⬢ obesity
⬢ coarctation of the aorta
⬢ acromegaly
⬢ increased intracranial pressure
What is the most common cause of secondary hypertension?: renal parenchymal disease
What is the target BP for patients with renal parenchymal disease?: < 130/85
Renal vascular disease is most common in what age group?: less than 20 year-old or greater than 50 years-old with secondary hypertension
What is the mechanism for hypertension in renal vascular disease?: there is decrease blood flow to the kidney which stimulates excess renin release to compensate for the decreased perfusion
What are some signs or symptoms that should make the clinician be suspicious for renal vascular disease?: ⬢ claudications due to lower extremity atherosclerosis
⬢ epigastric or renal artery abdominal bruit
⬢ severe, accelerated, or malignant hypertension
What can happen to the creatinine level of patient with renal vascular disease if given an ACE inhibitor?: ⬢ ACE inhibitors can worsen renal function in a patient with renal vascular disease
⬢ creatinine level would increase
What is the definitive diagnostic test for renal vascular disease?: renal arteriogram
What are the 2 most common causes of primary hyperaldosteronism?: ⬢ Conn's syndrome (a unilateral adrenal adenoma)
⬢ bilateral adrenal hyperplasia
What are some signs and symptoms for primary hyperaldosteronism?: ⬢ muscle weakness and fatigue
⬢ polyuria (excessive urination) and polydipsia (excessive thirst)
What is the best screening test for primary hyperaldosteronism?: ⬢ determining the plasma aldosterone/renin ratio
⬢ ratio > 25 require further evaluation for primary hyperaldosteronism
What are some causes of Cushing Syndrome?: ⬢ long term corticosteroid therapy
⬢ adrenl tumor
What is the difference between Cushing's Syndrome and Cushing's Disease?: ⬢ Cushing's syndrome is caused by excess glucocorticoid from the adrenal gland
⬢ Cushing's disease is caused by hypersecretion of ACTH of the pituitary gland
What is the most common cause of pheochromocytoma?: adrenal tumor
What are some signs or symptoms of pheochromocytoma?: ⬢ sustained or paroxysmal HTN
⬢ sudden onset HTN, headaches, sweating, palpitation
⬢ anxiety, tremor, wt loss, hear intolerance, abdominal pain, chest pain
⬢ marked orthostaic hypotenion associated with severe supine hypertension
What are the best diagnostic test or pheochromocytoma?: urinary catecholamines & metanephrines and creatine during/after attack
What is the treatment of choice for pheochromocytoma?: removal of the tumor is treatment of choice
What are some signs and symptoms of coarctation of the aorta?: ⬢ diminished and delayed femoral pulses with differential BP between upper and lower extremities
⬢ associated with bicuspid aortic value (normally is tricuspid) and berry aneurysm
⬢ ejection murmur along the left sternal border that radiates to the back (interscapular)
What is the diganostic test for coarctation of the aorta?: echo/doppler test
What can the EKG and Chest xray show on a patient with coarctation of the aorta?: ⬢ EKG can show left ventricular hypertrophy
⬢ chest xray can show rib notching and the aorta can have a "3 sign"
What is the target BP for patients with uncomplicated hypertension?: < 140/90
What is the target BP for patients when renal insufficiency is present?: < 130/85
What is the target BP for patients with diabetes?: < 130/80
What is the target BP for patients with renal insufficiency and proteinuria?: < 125/75
What is the goal for isolated systolic hypertension in the elderly?: systolic < 150
What is the treatment for prehypertension?: ⬢ lifestyle modification
⬢ no antihypertensive drug indicated without compelling indications (kidney diseae or diabetes must be treated to goal of < 130/80)
What is the treatment for stage 1 hypertension?: ⬢ lifestyle modification
⬢ thiazide-type diuretics for most with a goal < 140/90
⬢ consider a second drug if necessary (ACE inhibitor, ARB, beta blocker, calcium channel blocker, or combo)
⬢ add therapy for compelling conditions (renal disease and diabetes) with target < 130/80
What is the treatment for stage 2 hypertension?: ⬢ lifestyle modification
⬢ two drug combination for most (thiazide diuretic with either ACE inhibitor, ARB, beta blocker, or calcium channel blocker)
⬢ target BP is 140/90
⬢ add therapy for compelling indications (renal disease or diabetes) with goal of < 130/80
What is the drug of choice for treating isolated systolic hypertension?: Calcium channel blocker are more specific of systolic hypertension
What are some complications of hypertension (7)?: ⬢ stroke (CVA/TIA)
⬢ dementia
⬢ MI
⬢ CHF
⬢ retinal vasculopathy
⬢ aortic dissection
⬢ renal disease (proteinuria and nephrosclerosis)
Name 2 diseases assoicated with hypertension: ⬢ preeclampsia/exclampsia
⬢ metabolic syndrome
When would you use a loop diuretic over a thiazide diuretic?: in a patient with renal dysfunction
Diuretics are most effective with what groups?: blacks, elderly, obese, and smokers
What are some of the effects of beta blockers?: ⬢ decreased heart rate and cardiac output
⬢ decreased renin release
Beta blockers are more effective with what groups?: young, white, post MI, stable CHF, migraine headaches, and anxiety
What are some side effects of beta blockers?: ⬢ bradycardia
⬢ SA/AV blocks
⬢ nasal congestion
⬢ Raynaud's phenomenon
⬢ CNS symptoms (nightmares, depression, confusion)
⬢ fatigue
⬢ adverse lipid level effects
⬢ impotence (most common reason for men to stop this drug)
ACE inhibitors are most effective with what patients?: young, white, DM (especially with renal insufficiency) and CHF (drug of choice)
What are some side effects of ACE inhibitor?: ⬢ chronic dry cough
⬢ skin rash
⬢ angioedema
⬢ hyperkalemia
⬢ dizziness
⬢ taste alteration
In what type of condition does giving ACE inhibitors run the risk of causing renal failure?: bilateral renal artery stenosis
What are some of the effects of calcium channel blockers?: ⬢ negative inotropic effects (may cause or worsen CHF)
⬢ protective against stroke
Calcium channel blockers are most effective with:: blacks, elderly, and isolated systolic hypertension
What are some side effects of calcium channel blockers?: ⬢ headaches, peripheral edema, bradycardia, and constipation
⬢ dihydropyridine class has their own side effects, usually from vasodilation (headaches, flushing, palpitations, peripheral edema)
When are alpha-adrenoceptor antagonist preferred?: in men with symptomatic prostatism
What are some characteristics of alpha adrenergic agonist?: reduces efferent peripheral sympathetic outflow
What is the preferred drug for hypertension in pregnant woman?: methyldopa
What are some side effects of alpha-adrenergic agonists?: ⬢ impotence, sedation, fatigue, dry mouth, postural hypotension
⬢ rebound hypotension with withdrawl
⬢ methlydopa can cause hepatitis, and hemolytic anemia
Give some examples of arteriolar dilators: hydralazine and minoxidil
When should you refer a patient with hypertension?: ⬢ if BP remains uncontrolled after three concurrent medications
⬢ if patient has uncontrolled BP and signs/symptoms of end organ damage
What is the difference between hypertensive urgency and hypertensive emergency?: ⬢ hypertensive urgency is marked hypertension (usually BP systolic > 220 or diastolic > 125) without end-organ damage
⬢ hypertensive emergency is marked hypertension with end-organ damage (heart, kidney, brain, retina)
What is the treatment of hypertensive emergency?: ⬢ decrease in mean arterial BP by 25% in 1-2 hours
⬢ then reduce BP to 160/100 over next 6-12 hours
⬢ use of predictable meds that are dose dependant and transient (usually used IV)
⬢ drugs used are nitroprusside, labetalol, nitroglycerin

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