1
Q
Arterial blood pressure is represented in two numbers in the form of a fraction. a. What is the name of the blood pressure represented in the upper number, and what does it represents?
A
- Presión sistólica- presión del ❤️ cuando el corazón se contrae 2. Valor normal entre 90-110 mmHg
2
Q
Pre hypertension:
A
entre 120-139 mmHg
3
Q
HTN etapa 1 sistolica
A
HTN etapa 1 entre 140-159 mmHg (HTN benigna)
4
Q
What is the name of the blood pressure represented in the lower number, and what does it represents?
A
Presión diastólica- Cuando corazón se relaja Valor normal entre 60-79mm Hg Pre hypertension: entre 80-89 mmHg HTN etapa 1 entre 90-99 mmHg (HTN benigna) HTN etapa 2 entre 100-109mmHg (HTN Benigna) HTN etapa 3 mayor o igual 110mmHg (HTN maligna)
5
Q
HTN Etapa 2 sistolica
A
HTN etapa 2 entre 160-179mmHg(HTN benigna) 🙂👍🏻
6
Q
HTN Etapa 3 sístole ☠️☠️☠️
A
HTN etapa 3 entre mayor igual a 180mmHg (HTN maligna) ☠️☠️☠️☠️☠️
7
Q
What is the name of the blood pressure represented in the lower number, and what does it represents?
A
- Presión diastólica- Presión que tiene el ❤️Cuando corazón se relaja 2. Valor normal entre 60-79mm Hg
8
Q
Etapas HTN Diastolica
A
a. Etapa 1 está entre: 140 y 159 mmHg para la sistólica y entre 90 y 99 para la diastólica. b. Etapa 2 está entre: 160 y 179 mmHg para la sistólica y entre 100 y 109 para la diastólica. c. Etapa 3 está por encima de 180 mmHg para la sistólica 110 para la diastólica.
9
Q
What is benign hypertension?
A
HTN Benigna cuando el paciente está en etapa 1 o 2: Suelen no causar síntomas inmediatos.
10
Q
4-What is malignant hypertension?
A
- La HTN severa en etapa 3. Esta constituye una emergencia porque puede causar aumento de la presión intracranial y daño a los órganos. 2. Etapa 3 está por encima de 180 mmHg para la sistólica y 110 para la diastólica.
11
Q
Factores de riesgo NO modificables
A
- Edad- aumenta con el avance de la edad 2. Sexo - mujeres y mujeres negras 3. Raza y etnicidad - blacks are at increase risk for HTN 4. Family History : HPB runs in family & Risk is increased when combined with unhealthy lifestyle
12
Q
Modificable Risk factors
A
- Diet - high sodium diet 2. weight - obesity and physical inactivity 3. Tabaco use - smoking damages blood vessels causing atherosclerosis 4.Alcohol use - Excessive alcohol use leads to the development of chronic illness including HTN 5.disease condition - statitics have shown that 60% of those with DM also have HTN
13
Q
8-What is the JNC 7 BP classification.
A
a. La presión arterial sistólica normal debe estar entre 90 y 119 mmHg y b. la diastólica entre 60 y 79 mmHg.
14
Q
La prehipertensión, o presión arterial un poco más alta de lo normal
A
Es la presión entre 120 y 139 mmHg para la sistólica y entre 80 y 89 mmHg para la diastólica.
15
Q
Habitualmente cuando sube la sistólica la diastólica lo acompaña, de no ser así y una sola es la que aumenta recibe el nombre es:
A
Hipertensión sistólica aislada o hipertensión diastólica aislada.
16
Q
First line of prevention and the recommendations (question 11)
A
- Lifestyle changes, remain the first line of prevention and are continued throughout the treatment and management of HBP. 2. Recommendations: Lowering BP by lowering sodium intake combined with dietary approaches to stop hypertension (DASH) intake and increased consumption of fruit, vegetables, and whole grains. 3. Consuming no more than 2400 mg/d; however, further reduction to 1500 mg/d is desirable because this is associated with greater BP reduction. 4. In general, to lower BP, adults are advised to engage in an average of 40 min of moderate to vigorous intensity physical activity, 3 to 4 times per week.
17
Q
DASH DIET
A
The DASH diet (Dietary Approaches to Stop Hypertension) is a dietary pattern promoted by the U.S.-based National Heart, Lung, and Blood Institute (part of the National Institutes of Health, an agency of the United States Department of Health and Human Services) to prevent and control hypertension. DASH stands for Dietary Approaches to Stop Hypertension. The diet is simple: Eat more fruits, vegetables, and low-fat dairy foods. Cut back on foods that are high in saturated fat, cholesterol, and trans fats.
18
Q
sodium reduction to
A
The recommendations included consuming no more than 2400 mg/d; however, further reduction to 1500 mg/d is desirable because this is associated with greater BP reduction.
19
Q
Excersise
A
In general, to lower BP, average of 40 min of moderate to vigorous intensity physical activity, 3 to 4 times per week. 150 min por week
20
Q
Table 2. Proper In-office Procedure for BP Measurement
A
- Person is seated quietly for at least 5 minutes on a chair and not on the exam table with the feet on the floor and the arm supported at heart level. 2. Caffeine, exercise, and smoking should be avoided at least 30 minutes before the measurement. 3. Appropriately sized cuff should be used. Cuff bladder should circle at least 80% of the arm. 4. At least 2 measurements should be made and the average recorded. 5. BP measurement while standing is indicated periodically, especially among individuals at risk for postural hypotension before adjusting their drug regimen and those who report symptoms consistent with reduced BP upon standing 6. Manual BP determination and palpated radial pulse should be used to estimate SBP. Cuff should be inflated 20-30 mm Hg above the palpated level for auscultatory determination. Cuff should be deflated at a rate of 2 mm Hg per second. SBP is when the first Korotkoff sound is heard, and DBP is when the Korotkoff sound disappears. 7. Clinicians should provide the patient his or her BP numbers and BP goal verbally and in writing.
21
Q
JNC 7 BP Classification BP Classification SBP and DBP
A
Normal SBP < 120 and DBP < 80 Prehypertension SBP 120-139 or DBP 80-89 Stage 1 hypertension SBP 140-159 or DBP 90-99 Stage 2 hypertension SBP 160 or DBP 100
22
Q
Recommendations in the New Guidelines There are 9 recommendations in the JNC 8 guidelines.
A
Recommendations 1 through 5 address BP threshold and goals, recommendations 6 through 8 deal with the choice of antihypertensive drugs, and recommendation 9 is a summary of strategies based on expert opinion in starting and adding antihypertensive drugs
23
Q
Recommendation 1 General population JNC8 Grade A (strong recommendation)
A
Recommendation 1: In the general population, for those > or equal to 60 years old, a) pharmacologic therapy is initiated to lower SBP of 150 mm Hg or b) DBP of 90 mm Hg; and c) to treat to a goal of SBP 150 mm Hg or DBP 90 mm Hg A corollary recommendation: In the general population, for those > or equal to 60 years old, if drug therapy to treat high BP results in lower achieved SBP (eg, < 140 mm Hg) and treatment is well tolerated and without adverse effects on health or quality of life, treatment does not need to be adjusted.
24
Q
Recommendation 1 General population JNC8 Grade A (strong recommendation)
A
Recommendation 1: In the general population, for those equal or more than 60 years old, a) pharmacologic therapy is initiated to lower SBP ≥ 150 mm Hg or b) DBP of ≥ 90 mm Hg; and c) to treat to a goal of SBP < or equal 150 mm Hg or DBP equal or < 90 mm Hg A corollary recommendation: In the general population, for those > or equal to 60 years old, if drug therapy to treat high BP results in lower achieved SBP (eg, < 140 mm Hg) and treatment is well tolerated and without adverse effects on health or quality of life, treatment does not need to be adjusted.
25
Recommendation 2 General population JNC8 Grade A (strong recommendation) for those 30-59 years old
Recommendation 2: In the general population, for those \< less than 60 years old, initiate pharmacological therapy to lower DBP of \> equal to 90 mm Hg and treat to a goal of DBP \< 90 mm Hg.
26
JNC8 -Recommendation 3: Grade E (expert opinion)
Recommendation 3: In the general population, for those \< 60 years old, initiate pharmacologic therapy to lower SBP ≥ 140 mm Hg and treat to a goal of SBP \< 140 mm Hg
27
JNC8 -Recommendation 4 Grade E (expert opinion)
Recommendation 4: In the population of those more or equal to 18 years old with CKD, initiate drug therapy to lower SBP ≥ to 140 mm Hg or DBP ≥ to 90 mm Hg and treat to a goal of SBP \< 140 mm Hg or DBP \< 90 mm Hg.
28
JNC8 -Recommendation 5 Grade E (expert opinion)
Recommendation 5: In the population of those \> or equal of 18 years old with diabetes, initiate drug therapy to lower SBP ≥ to 140 mm Hg or DBP ≥90 mm Hg and to treat to a goal of SBP \< 140 mm Hg or DBP \< 90 mm Hg.
29
JNC8 -Recommendation 6 Grade B (moderate recommendation)
Recommendation 6: In the general non-black population, including those with diabetes, thiazide-type diuretic, CCBs, ACEIs, or ARBs are the initial drugs of choice.
30
JNC8 -Recommendation 7 Grade B (moderate recommendation) for general black population Grade C (weak recommendation) for black patients with DM
Recommendation 7: In the general black population, including those with diabetes, thiazide-type diuretic or CCBs should be the initial antihypertensive drug of choice
31
JNC8 -Recommendation 8 Grade B (moderate recommendation)
Recommendation 8: In the population of those \> or equal 18 years old with CKD, ACEIs or ARBs should be the initial drug of choice or added to their antihypertensive treatment to improve kidney outcomes. This applies to all CKD patients with hypertension regardless of race or diabetes status.
32
JNC8 -Recommendation 9 Grade E (expert opinion)
Recommendation 9: The main objective of HTN treatment is to attain and maintain the BP goal. If the BP goal is not reached within a month of treatment, increase the dose of the initial drug or add a second drug from 1 of the classes in recommendation 6 (thiazide-type diuretic, CCBs, ACEIs, or ARBs). The clinician should continue to assess BP and adjust the treatment regimen until goal BP is reached. If the BP goal cannot be reached with 2 drugs, add and titrate a third drug from the list provided. Do not use an ACEI and an ARB together in the same patient. If the BP goal cannot be reached using only the drugs in recommendation 6 because of a contraindication or the need to use more than 3 drugs to reach the BP goal, antihypertensive drugs from other classes can be used. Referral to a hypertension specialist may be indicated for patients in whom the BP goal cannot be attained using the previously described strategy or for the management of complicated patients for whom additional clinical consultation is needed.
33
Table 5. Four Classes of Drugs Recommended HTN Management: 1. Angiotensin-converting enzyme inhibitors
Captopril= Initial dose = 50 mg, target dose =150-200 mg BID Enalapril Initial dose= 5 mg, target dose = 20 mg daily to BID Lisinopril Initial dose= 10 mg, target dose = 40 mg daily
34
Table 5. Four Classes of Drugs Recommended HTN Management: 2. Angiotensin receptor blockers
Valsartan Initial dose =40-80 mg, target dose = 160-320 mg daily Losartan Initial dose = 50 mg, target dose = 100 mg daily to BID Candesartan Initial dose = 4 mg, target dose = 12-32 mg daily Irbesartan Initial dose = 75 mg, target dose = 300 mg daily Eprosartan Initial dose = 400 mg, target dose = 600-800 mg daily to BID
35
Table 5. Four Classes of Drugs Recommended HTN Management: 3. Thiazide-type diuretic
Hydrochlorothiazide Initial dose Table 5. Four Classes of Drugs Recommended HTN Management: 12.5-25 mg, target dose = 25-50 mg daily to BID Chlorthalidone Initial dose = 12.5 mg, target dose = 12.5-25 mg daily Indapamine Initial dose =1.25 mg, target dose =1.25-2.5 mg daily Bendroflumethiazide Initial dose = 5 mg, target dose = 10 mg daily
36
Table 5. Four Classes of Drugs Recommended HTN Management: 3. Thiazide-type diuretic
Hydrochlorothiazide Initial dose Table 5. Four Classes of Drugs Recommended HTN Management: 12.5-25 mg, target dose = 25-50 mg daily to BID Chlorthalidone Initial dose = 12.5 mg, target dose = 12.5-25 mg daily Indapamine Initial dose =1.25 mg, target dose =1.25-2.5 mg daily Bendroflumethiazide Initial dose = 5 mg, target dose = 10 mg daily
37
Table 5. Four Classes of Drugs Recommended HTN Management: 4.Calcium channel blockers
Calcium channel blockers Amlodipine Initial dose = 2.5 mg, target dose = 10 mg daily Diltiazem extended release Initial dose = 120-180 mg, target dose = 360 mg daily Nitrendipine Initial dose = 10 mg, target dose = 20 mg daily to BID
38
DX of HTN
A diagnosis of HTN is based on medical histories and a physical examination, including an accurate BP measurement with verification in the contralateral arm.
39
Recommendations for follow-up BP measurement after initial reading include the following:
Recommendations for follow-up BP measurement after initial reading include the following: (1) every 2 years for those individuals with normal BP, (2) every year for individuals with prehypertension, and (3) confirmation within 2 months or less, depending on other CV risk factors or end-organ damage, in individuals with stage 1 HTN.4
40
It is recommended that individuals with stage 2 HTN
It is recommended that individuals with stage 2 HTN (systolic blood pressure [SBP] of 160 and greater or diastolic blood pressure [DBP] of 100 and greater) are evaluated and referred within 1 month. In addition, those with BP of \> 180/110 are evaluated and treated immediately or within 1 week depending on their clinical situation and complications.
41
Self-monitoring of BP by individuals at home and at work is particularly useful in 2 situations:
those with out-of-office BP that is consistently \< 130/80 mm Hg despite elevated inoffice readings and those without target organ damage in order to avoid drug therapy and smokers
42
Strategies in managing HTN with therapy
Strategy A is to start with 1 drug and then titrate to the recommended maximum dose before adding a second drug. Strategy B is to start with 1 drug and then add a second drug before achieving the maximum dose of the first drug. This is followed by titration of both drugs to their maximum recommended dose. If the BP goal is not achieved with the 2-drug regimen, a third drug is added and titrated to its maximum dose. Strategy C is to begin with a 2-drug regimen at the same time, either 2 separate pills or as a single-pill combination.
43
Algoritmo 1.1 = Adult aged \> or equal 18 y/o with HTN
implement lifestyle interventions (continue throughout management. Set BP goals and initiate BP lowering medication based on age, DM, CKD
44
HTN - Renin angiontensine adolsterone system
This may be in response to low blood pressure and adverse changes in sodium activate to compensate, due to low sodium therefore low h2o , low BP Liver release- angiotensinogen, in response, kidney shoot renin, and produce angiontensine I, and the lungs will release ACE- convierte angiontensine, ACE and angiontensine I togheter will make antiontensine II, will get to adrenal glad and will create Aldosterone. When adolsterone increasing reabsorsion of sodium, increase the fluid and will increase the BP. Aldosterone decrease potasion poq se secreta en orina. Angiotensine 2 crea vasoconstriccion en los arteriolos, an enzyme reenen is secreted which cleaves angiotensinogen to form the inactive dekha peptide angiotensin one further transformation of angiotensin is carried out by angiontensine converting enzyme or ace
45
Isolated systolic hypertension or diastolic hypertension
only one is high
46
Consequences of HBP
Cause endothelial cell damage from the inside, causes wear and tears, lead to myocardial infarction, aneurysm or stroke tiny cracks and tears,
47
Primary hypertension or essential hypertension.
About 90% of the time, hypertension happens without a clearly identifiable underlying reason,
48
Risk factor for Primary HTN
obesity, salt heavy diets, sedentary lifestyles, old age,.
49
Secundary HTN
About 10% of the time, there is a specific underlying condition that can be found which is the cause of hypertension. For example, anything that limits the blood flow to the kidneys can cause hypertension, for example atherosclerosis, vasculitis, or aortic dissections affecting renal blood flow. This is because the kidneys play an important role in blood pressure regulation. When not enough blood is flowing to the kidneys, the kidney secretes the hormone renin which ultimately helps the kidneys retain more water. That water contributes to filling the arteries and making them more full which leads to higher pressures. Other diseases can cause secondary hypertension as well. Actually quite a few. Fibromuscular dysplasia which affects young women can cause the walls of the large- and medium-sized arteries to thicken. If it involves the renal artery, and limits blood flowing to the kidneys, it triggers more renin. Another one is a tumor that produces excess aldosterone, and like renin, excess aldosterone leads to fluid retention.
50
HTN emergency
Malignant hypertension is really severe stage 3 hypertension, and is an emergency because it can cause increased intracranial pressure and organ damage.
51
HTN - Algoritmo 1.2 : first, After implementing lifechanges then, Set BP goals and initiate BP lowering medication based on age, DM, CKD then :
For General population: \> or equal o 60 y. BP goal: - SBP \< 150 mmHg / DBP \< 90 mmHg For GP \< 60 y/o BP Goal: -SBP \<140 mmHg /DBP \<90 mmHg For DM : all ages DM no CKD: BP goal : - SBP \<140 mmHg /DBP \<90 mmHg non black : 1. Iniciate thiazide-type diuretic or ACE I or ARB or CCB alone or combination black : 2. Iniciate thiazide-type diuretic or CCB alone or combination
52
HTN - Algoritmo 1.3 : first, After implementing life changes then, Set BP goals and initiate BP lowering medication based on age, DM, CKD then : for patients with CKD present
All ages CKD present with or without DM BP goal: SBP \<140 mmHg /DBP \<90 mmHg All races: iniciate ACEI or ARB, alone or in comibnation with other class (never ACEI and ARB juntos).
53
HTN - Algoritmo 1.4 once you selected a drug - select a
Maximize first treatment titration strategy. a. maximize first drug before adding second b. add second medication before reaching maximum dose of first medication or c. start with 2 medication classes separately or as fixed -dose combination if goal is met continue current treatment and monitoring if not algoritms 1.5
54
HTN algoritms 1.5. after A-B-C titration strategy if goal is not bet
1. Reinforce adherence of medication and lifestyle 2. for strategies A and B, add and titrate thyazide -type diuretic or ACEI or ARB or CCB (use medication class not prev. selected and avoid combined ACEI with ARB. 3. for strategy C, titrate doses of initial medication to maximum. if goal met continue with current if not Algoritsm 1.6
55
HTN Algoritms 1. 6. titration ABC, if blood B goal not met,
1. Reinforce adherence of medication and lifestyle 2. Add titrate thyazide -type diuretic or ACEI or ARB or CCB (use medication class not prev. selected and avoid combined ACEI with ARB. if goal met continue with current if not Algoritsm 1.7
56
HTN algoritms 1.7, after 1.6 adding thiazide..or acei or arb
1. Reinforce adherence of medication and lifestyle 2. Add additional medication class Beta blockers, aldosterone antagonist, or others and or refer to physician with expertise in HTN management if not return to here, is yes continue with current med
57
HTN strategy A - Start one drug, titrate to maximum dose, and then add a second drug
If goal BP is not achieved with the initial drug, titrate the dose of the initial drug up to the maximum recommended dose to achieve goal BP If goal BP is not achieved with the use of one drug despite titration to the maximum recommended dose, add a second drug from the list (thiazide-type diuretic, CCB, ACEI, or ARB) and titrate up to the maximum recommended dose of the second drug to achieve goal BP If goal BP is not achieved with 2 drugs, select a third drug from the list (thiazide-type diuretic, CCB, ACEI, or ARB), avoiding the combined use of ACEI and ARB. Titrate the third drug up to the maximum recommended dose to achieve goal BP
58
B Start one drug and then add a second drug before achieving maximum dose of the initial drug
Start with one drug then add a second drug before achieving the maximum recommended dose of the initial drug, then titrate both drugs up to the maximum recommended doses of both to achieve goal BP If goal BP is not achieved with 2 drugs, select a third drug from the list (thiazide-type diuretic, CCB, ACEI, or ARB), avoiding the combined use of ACEI and ARB. Titrate the third drug up to the maximum recommended dose to achieve goal BP
59
C Begin with 2 drugs at the same time, either as 2 separate pills or as a single pill combination
Initiate therapy with 2 drugs simultaneously, either as 2 separate drugs or as a single pill combination. Some committee members recommend starting therapy with ≥2 drugs when SBP is \>160 mm Hg and/or DBP is \>100 mm Hg, or if SBP is \>20 mm Hg above goal and/or DBP is \>10 mm Hg above goal. If goal BP is not achieved with 2 drugs, select a third drug from the list (thiazide-type diuretic, CCB, ACEI, or ARB), avoiding the combined use of ACEI and ARB. Titrate the third drug up to the maximum recommended dose.
60
Important changes from the JNC 7 guidelines include the following:
In patients 60 years of age or older who do not have diabetes or chronic kidney disease, the goal blood pressure level is now \<150/90 mmHg In patients 18 to 59 years of age without major comorbidities, and in patients 60 years of age or older who have diabetes, chronic kidney disease, or both conditions, the new goal blood pressure level is \<140/90 mmHg
61
HTN First-line and later-line treatments
should now be limited to 4 classes of medications: thiazide-type diuretics, calcium channel blockers (CCBs), ACEIs, and ARBs
62
HTN Second- and third-line alternatives included
higher doses or combinations of ACEIs, ARBs, thiazide-type diuretics, and CCBs
63
HTN Several medications are now designated as later-line alternatives, including the following:
Beta-blockers, Alpha-blockers Alpha1/beta-blockers (eg, carvedilol) Vasodilating beta-blockers (eg, nebivolol) Central alpha2-adrenergic agonists (eg, clonidine) Direct vasodilators (eg, hydralazine) Loop diuretics (eg, furosemide) Aldosterone antagonists (eg, spironolactone) Peripherally acting adrenergic antagonists (eg, reserpine)
64
HTN When initiating therapy, patients of African descent without chronic kidney disease
CCBs and thiazides instead of ACEIs
65
HTN all patient first line
Use of ACEIs and ARBs is recommended in all patients with chronic kidney disease regardless of ethnic background, either as first-line therapy or in addition to first-line therapy ACEIs and ARBs should not be used in the same patient simultaneously
66
HTN in patients over the age of 75 with impaired kidney function
CCBs and thiazide-type diuretics should be used instead of ACEIs and ARBs in patients over the age of 75 with impaired kidney function due to the risk of hyperkalemia, increased creatinine, and further renal impairment
67
Stages of HTN
68
1. HTN First line of prevention and the recommendations
1. Lifestyle changes, remain the first line of prevention and are continued throughout the treatment and management of HBP
2. Recommendations: Lowering BP by lowering sodium intake combined with dietary approaches to stop hypertension (DASH) intake and
3. increased consumption of fruit, vegetables, and whole grains.
4. The recommendations included consuming no more than 2400 mg/d; however, further reduction to 1500 mg/d is desirable because this is associated with greater BP reduction. In general, to lower BP, adults are advised to engage in an average of 40 min of moderate to vigorous intensity physical activity, 3 to 4 times per week.
69
Causes of Secundary HTN
1. Fibromuscular displasia
2. Tumor producing aldosterone
3. causes that limit the blood flow to the kidneys : vaculitis, atereosclrosis and aortic disersion
Test 2 FNP Primary Care 2
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