NUR 6111 Exam 3 Study Notes on Hypertension and Related Conditions

Epidemiology Risk Factors
• 30% of adults • family hx
• Men > Women • obesity, poor diet, stress
• ↑ w age: men- 50s; women- postmenopausal & >65 • ETOH, Smoking
• highest incidence: African Americans & Filipinos • physical inactivity
• RF for CAD, HF, Stroke, PAD, kidney disease, retinopathy • dyslipidemia
• 20mmHg ↑ SBP & 10mmHg ↑ DBP = associated w 2x risk of death • age
Etiology Secondary HTN
• Primary HTN: 90-95% of adults • younger: <30; severe & acute; resistant (at least 3 meds)
• Pregnancy induced HTN • malignant: organ damage, acute RF, retinal hemorrhages
• Secondary HTN: • Causes by Age:
-Renal- acute glomerulonephritis, CRF, PkD, pyelonephritis -Younger adults: renal artery stenosis
-Vascular- renal artery stenosis, coarctation of the aorta -Middle-aged: endocrine
-Endocrine- thyroid, pheochromocytoma, primary hyperaldosteronism, Cushing’s -Older adults: CkD
-Other-
‣ OSA, excessive caffeine, ETOH
‣ Pharm(stimulants, steroids, cocaine, NSAIDS, oral contraceptives, decongestants)
Clinical Presentation & Physical Exam
• most pts asymptomatic (HTN may be incidental finding)
• occipital HA, blurry vision
• PE: identify cause of HTN & assess for target organ disease
-ENT: optic fundi- AV nicking, arteriolar narrowing, silver/coppery wire, hemorrhage, papilledema
-Cardiac: S4, LVH
-Vascular: extremity changes dt peripheral circulatory impairment, bruit carotid/aortic/renal
-Thyroid: goiter, evidence of hyperthyroidism
-Neurologic: TIA, CVA symptoms
HTN Guidelines Dx
• 2 or more readings are required to dx HTN • Goal: identify if target organ damage or secondary cause
• JNC = pharm tx at stage 1 • CBC. CMP, Cr, fasting Lipids, TSH, UA, ECG, Echo
• ACC/AHA only drugs at stage 1 if 10yr CV risk >10% • CXR- if hx of smoking
• 24-hr urine cortisol- if Cushing’s suspected
• 24-hr Cr, Catecholamines, Metanephrines- pheochromocytoma suspected
• Uric acid, Urinary albumin to Cr Ratio




Goals of Tx
Clinical Conditions BP Threshold mmHg BP Goal mmHg
General
Clinical CVD or 10yr ASCVD risk ≥10% ≥130/80 <130/80
No clinical CVD & 10yr ASCVD risk <10% ≥140/90 <130/80
Older persons (≥65 yrs; noninstitUtionalized, ambUlatory, commUnity-living) ≥130 SBP <130 SBP
Specific Comorbidities
Diabetes Mellitus ≥130/80 <130/80
CKD ≥130/80 <130/80
CKD after Renal Transplant ≥130/80 <130/80
HF ≥130/80 <130/80
Stable Ischemic Heart Disease ≥130/80 <130/80
Secondary Stroke Prevention ≥140/80 <130/80
Secondary Stroke Prevention (lacunar) ≥130/80 <130/80
PAD ≥130/80 <130/80

, Hypertension contd… q w




Management
• ElevatedBPorStage1HTNwlowASCVDRisk- w
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-non-pharmtherapy,recheckin3-6m w
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• Stage 1 HTN & High ASCVD Risk (≥10% 10yr ASCVD risk)-
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-non-pharm&antihypertensivedrugtherapy,repeatBPin1m w
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• Stage2HTN- w
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-non-pharm&2antiHTNdrugsofdifferentclasseswrepeatBPin1m w
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• AdultswaveryhighaverageBP(≥160SBPor≥100DBP)- w
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-prompt eval, drug tx➜ carefulmonitoring & upward dose adjustment qw qw qw w
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Pharm Tx qw




• Note:
-↑or add after1 monthifnot atgoal q
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-NoACEorARBtogether w
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-3meds & notcontrolled➜ refertospecialist
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Non- Thiazides, CCB, ACEI, ARB Thiazides, qw qw qw qw qw




Black Blac qw CCB
ks CKDorD
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M MI
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Pregnancy Methyldopa, Labetalol, Hydralazine qw qw




Thiazides qw
Hydrochlorothiazide(Microzide),Chlorthalidone(Hygroton) ✓ for Blacks w
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CCB Dihydropyridine (DHP):“-pines”: ✓ for Blacks qw w
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Amlodipine(Norvasc), Nifedipine(Procardia), Nicardipine (Cardene) DPH (Amlodipine) ✓ for HF w
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Non-Dihydropyridine(NDPH):“non-pines”: NDPH(Diltiazem, Verapamil)X forHF w
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Diltiazem (Cardizem), Verapamil (Calan)
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X for systolicHF q w q w q w
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ACE “-pril”: ✓ for DM, CkD, HF qw qw qw




Enalapril (Vasotec), Lisinopril (Zestril), Ramipril (Altace) reducesmortalityinHF&renaldeclineinCkD SE: coug q w q w q w q w q w
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h,angioedema w
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ARB B qw
Losartan (Cozaar), Valsartan (Diovan), Olmesartan (Benicar) ✓ for DM, CkD, HF qw qw qw qw qw
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forptsintoleranttoACE(cough,angioedema) w
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B Selective (Beta-1 Specific): better for CAD, HFrEF, post- MI instead of HTN
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Atenolol (Tenormin), Nebivolol (Bystolic), Esmolol, Bisoprolol Metopr X forasthma(especiallynon- qw qw qw qw qw qw
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olol Succinate (Toprol XL), Metoprolol Tartrate (Lopressor) selective) avoid in younger pts dt SE- qw qw qw qw qw qw




fatigue
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Non-Selective(Beta-1 &2): qw w
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Propranolol, Carvedilol, Labetalol, Nadolol qw qw qw




LoopDiuretics Furosemide (Lasix)
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k- Sparing Spironolactone (Aldactone) qw




Alpha Agonists Methyldopa (Aldomet), Clonidine(Catapres)
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Renin-InhibitorAliskiren (Tekturna) qw
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Non-Pharm Tx q w




• DASH Diet qw • Exercise:
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• Weightloss:1kg=1mmHg w
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q -30min moderate-intensity aerobic at least 5days/wk for a total of 150min qw qw qw qw qw qw qw qw qw qw




• smoking & drug abuse cessation qw qw qw qw -25minvigorous aerobicactivityatleast3days/wk fortotal75min (orcombo ofmod& vigorous) w
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• ETOH-avoidorlimit w
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q -moderate-high intensity muscle-strengthening activity at least 2days/wk qw qw qw qw qw qw




• educateondisease(ptsmayfeelfine) w
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q -for lowering BP & cholesterol: 40min moderate-to-vigorous-intensity aerobic activity 3-4x/wk
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• PREVENTION
White Coat Syndrome qw qw


Other Considerations
• Office BP: ≥130/80 but <160/100 sp 3m lifestyle mod
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• Follow-up:labs,add-med?
• HBPM(homebpmonitoring)
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• Referral: elderly pts, dietitian, cardiologist, nephrology, endocrinology
• ABPM (ambulatory BP monitoring)
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• lifestyle changes
• if >130/80 – start antihypertensive med
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• Elderly:startlow-goslow,comorbidities,polypharm,schedule,orthostatic
ICD-10 Codes
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• Complications
• 110- Essential (primary) HTN qw qw qw




• 112.9- HTN CKD w stage 1-4 CKD or unspecific CKD qw qw qw qw qw qw qw qw qw




• 115.2- HTN secondary to endocrine disorders qw qw qw qw qw




• 111.0-HTNheartdiseasewHF Downloaded by Brian Njenga ()
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, Atrial Fibrillaiton q w




A-fib: ventricular arrhythmia
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Impact of A-fib qw q
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• ↑risk for stroke by 4-5x
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• causesabt25%ofischemicstrokes w
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• doublestheriskofheart-relateddeaths w
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• absent atria contraction ➜ loss of CO (15-30%) dt no "atrial kick", contributing to HF
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Risk Factors
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• advancing age qw • HTN qw • CAD qw • Cardiomyopathy
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• Obesity • athletesqw • DM qw •Europeanancestry
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• HF • Hyperthyroidism
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• rheumaticheartdisease w
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q • valvularheartdisease
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• enlargedLheartchambers w
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Valvular vs. Non-Valvular A-fib q w q w q w




• Valvular: AF w moderate-to-severe mitral stenosis (potentially requiring sx) orin the presence of anartificial (mechanical) heart valve
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• Non-Valvular:AFintheabsenceofmoderate-to-severemitralstenosisoramechanicalheartvalve w
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Clinical Presentation & Physical Exam
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• manyareasymptomatic&unawareoftheirdx-sometimesitisanincidentalfindinguponexam
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Symptomatic Presentation Physical Exam q w q w




• General Fatigue • Rapid/Irregular heartbeat
qw • Irregular Heart Rhythm: hallmark of AF qw qw qw qw qw qw qw




• Fluttering/"thumping"inchest • Dizziness • Tachycardia(typically110-140s),Hypotension w
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• SOB • Anxiety • Possiblefindings: qw qw




• Weakness • Faintness -JVD,Rales,EffusionfromHF,LEedema(HForDVT) qw w
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• Confusion • Fatigue wexercise -Murmurs (suggesting stenosisorregurgitation);Exophthalmia qw qw qw qw qw w
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• CPorPressure➜ Call911
qw qw -Stroke S&S (facial droop, arm weakness, slurred speech) qw q w w
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EKG
• Gold Standard: qw




-No visible P-waves (no measurable PR interval) q w q w q w q w q w q w




-Irregularly irregular QRS q w q w




-Ventricular rate is frequently fast q w q w q w q w




• IrregularR-Rintervals(irregularventricularresponse) w
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• NodistinctP-waves
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• F-waves(fibrillatory)replaceP-waves(varyingamplitude) w
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Classifying A-fib q w




Paroxysmal AF -AF that terminates spontaneously or w intervention within 7days of onset
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-episodesmay recurwvariable frequency w
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Persistent AF -continuous AF that is sustained >7days
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Long-standing Persistent AF -continuous AF >12m in duration qw qw qw qw qw qw




Permanent AF -termusedwhen pt &cliniciandecidetostopfurtherattemptstorestore&ormaintain NSR
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-acceptanceofAFrepresentsatherapeuticattitudeonthepartofthept&clinicianratherthanpathophysiologyofAF w
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-acceptance of AD may change as symptoms, efficacy of interventions, & pt or clinician preferences evolve qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw




Nonvalvular AF -absence of rheumatic mitral stenosis, mechanical or bioprosthetic heart valve, or mitral valve repair
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Dx
• Labs: CBC, CMP, TSH, BNP, PT, PTT, INR
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• Echocardiogram-
-evaluation of size & function of atria & ventricles, detect valvular heart disease, LV hypertrophy, & pericardial disease qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw




• Transesophageal Echocardiogram (TEE)- qw qw




-mostsensitive&specifictechniquetodetectLAthrombi w
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• Event Recorders (Implantable Loop Recorders or Holter monitors)-
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-identify arrhythmiaif intermittent, to correlate symptoms, or rate control strategies w
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• Stress Test qw




• EP Study
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GoalsofTx w
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CHADVASC– Determine Stroke Risk
• PreventionofThromboembolism-
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-useChadsscoretodetermine strokerisk
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• Rate Control (preferred over rhythm control)-
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-BB,NDPHCCB,DigitalisGlycosides
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• Rhythm Control- qw




-pts that don't tolerate loss of atrial kick (hemodynamic instability)
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-Synchronized Cardioversion; Pharm Cardioversion qw qw qw




Bleeding Assessment qw qw




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Pharm Tx qw




-VitKAntagonist: w
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Warfarin-serummonitoring:goal-INR2-3
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-Direct Thrombin Inhibitor: qw qw




qw Dabigatran (Pradaxa) 150mg PO BID -noserummonitoring qw qw qw qw qw w
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Anticoagtılation -FactorXaInhibitors: w
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(Thromboembolism Prevention) q w
Rivaroxaban, Edoxaban, Apixaban -no serum monitoring qw q w q w q w q w




Xarelto20mgPOQD -switchingWarfarintoXarelto➜dcWarfarin&startXareltowhenINR<3
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Eliquis5mgPOBID-2.5mgBIDif2ofthefollowing:>80yrs,<60kg,or>1.5Cr
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-Non-Vit K Antagonist Oral Anticoagulants (NOACs): qw qw qw qw qw




-contraindicated in pts wsignificant mitralstenosis or mechanical valves
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-BetaBlocker: w
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q w Atenolol, Metoprolol, Nadolol, Propranolol, Sotalol qw qw qw qw




-NDPH CCB:
RateControl
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q w Diltiazem, Verapamil qw




-Digitalis Glflcoside: qw




qw Digoxin
-Pharmacologic Cardioversion: qw




RhythmControl w
q q w Dofetilide, Flecainide, Propafenone, Ibutilide, Amiodarone q w q w q w q w




-Considerlonghalf-life,pulmonarytoxicity,thyroiddysfunction qw qw w
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Other Tx qw




• Watchman Device:leftatrialappendage(LAA)closuredevice permanentlyimplanted; closes offLAAso clots thatforminLAA cantentercirculation
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-indicated for pts w Non-VascularA-fibatrisk forstroke qw qw w
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-alternative for ptswho can’tbe on anticoagulation(hx bleedor highriskfor bleeding,drug interactions,etc.,)
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-Risks: LAA rupture during device implant, infection
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-ptwillprobablystillneedtotakeASA
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• Pacemaker:for flowHR w
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