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How should follow up be conducted after starting a patient on antihypertensives?
- Initially see every 1-2 weeks until BP is stabilized.
- Then Q 3 months for 1 year
- Then Q 6-12 months
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What is the first line drug for uncomplicated HTN?
thiazide diuretics (low doses are sufficient-no more than 25mg HCTZ qd)
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How does alcohol effect HTN?
- it is a vasopressor!
- Men: <1oz ethanol qday (<24oz beer, 10 oz wine, 3 oz 80 proof wiskey)
- Women: <0.5 oz ethanol q day (half the amount of men)
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What is the DASH diet?
- "Dietary Approaches to Stop Hypertension"
- It is an eating plan rich in potassium, magnesium, and calcium obtained from fruits, veggies, and low fat dairy.
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What steps should be taken to implement a weight loss plan to control HTN?
- 1. Specify a target weight
- 2. coordinate a dietary intervention (such as 1500 calorie diet)
- 3. give an exercise prescription program
- 4. Use frequent follow-up visits such as every 4-6 weeks.
- 5. Local community groups (Weight Watchers)
- Pts do not need to attain ideal body weight to benefit.
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Mnemonic for secondary causes of HTN: ABCDE
- A: accuracy, alcohol, apnea(OSA), aldosteronism(hyokalemia, hyperaldosteronism)
- B: bruits(renovascular HTN), bad kidneys(renal parenchymal dz)
- C: Catecholamines(pheo), coarctation(rib notching on CXR), cushings(wt gain, hirsutism, amenorrhea, striae, moon facies)
- D: Drugs(sympathomimetics, corticosteroids, NSAIDS, OCPs, MAOIs), diet(excess sodium or obesity)
- E: endocrine (thyroid or hyperparathyroidism), erythropoietin (COPD can increase EPO)
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Criteria for LVH on EKG
Deepest S wave in lead V1 or V2 plus tallest R wave in lead V5 or V6 > 35mm and/or R wave in lead aVL > 12mm
Age > 35
Left ventricular strain pattern(assymetric ST segment depression and T-wave inversion, usually in leads I, aVL, V4-V6
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What are target BP goals with treatment?
- Most patients: <140/90
- Diabetics, renal dz or known CV disease: <130/80
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How can one screen for hyperaldosteronism in a HTN workup?
Get a CMP: check potassium and sodium levels!
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Labs in HTN workup
- UA: proteinuria and hematuria. If no protein, consider urine microalbumin to screen for early nephropathy.
- Kidneys: BUN and Cr
- ECG: LVH, arrhythmia, and baseline ST segment changes or signs of previous MI
- An echo may be indicated if LVH is supsected on ECG.
- Full Cholesterol panel
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Physical exam in HTN
- BMI
- CV exam: cardiac size, rhythm, third heart sound (S3), peripheral edema, decreased pulses, carotid bruits.
- Neuro: focal weakness, abnormal gait or other neuro abnormalities suggest prior CVA.
- Opthalmoscopic exam for hypertensive retinopathy
- Cushingoid features: moon face
- Renal: diastolic abdominal bruit, suggestive of renovascular HTN
- Coarctation: diminished femoral pulses with HTN in arms
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What symptoms suggest end-organ damage in a patient with HTN?
Chest pain, orthopnea, PND, lower extremity edema, claudication.
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What are the most common secondary causes of HTN in primary care?
- 1. Alcohol use
- 2. chronic renal dz
- 3. drugs (OTC such as decongestants and illicit drugs)
- Also consider: renovascular HTN, hyperaldosteronism, pheochromocytoma, OSA.
- Specific symptoms that suggest secondary causes: sweating, palpitations, flusing.
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Stages of HTN?
- Stage 1:
- SBP 140-149
- DBP 90-99
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What is the criteria for diagnosing HTN in most cases?
SBP>140 and/or DBP>90, an average of 3 readings over at least 6 weeks.
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How high must BP be to make the diagnosis of HTN in a single office visit?
- SBP>200
- DBP>120
- -In the absence of a recognized cause of sencondary elevation.
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How can an auscultatory gap be avoided when measuring BP?
- Palpate the ipsilateral radial pulse while inflating the cuff, the pulse will disappear when the cuff is adequately pressurized.
- *Take BP in both arms on first BP measurement!!
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What is the USPSTF recommendation on screening for HTN
Screen adults 18 years and older, but no mention of an interval for screening.
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Reducing systolic BP below 150 mm Hg decreases what?
- Decreased incidence of all types of strokes
- Lowering DBP by 10mm reduces number of strokes by up to 56% and incidence of CAD by 37%.
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