When should screening for hypertension be done?

Start at 3 years old

Every 2 years thereafter
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How is hypertension diagnosed? >140 sys or >90 dia
x3 separate measurements
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What is Stage 2 hypertension? >160 sys or >100 dia
Add 2nd agent
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What is severe hypertension? >210 sys or >120 dia or end-organ effects
Immediate Rx
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What is first line pharmaceutical treatment for hypertension? Thiazides
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What is prehypertension? >120 sys or >80 dia
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What are the compelling indications for treatment of prehypertension? Diabetes
Chronic Kidney Disease
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What is the goal BP in the treatment of prehypertension? <130/80
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What is the workup for hypertension? Urinalysis
BMP
EKG
H&H
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What is the first line treatment of hypertension? Weight reduction
Exercise
Alcohol & Smoking cessation
- attempt for 3 to 4 months before medication
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What are the five first-line agents in the treatment of hypertension? Thiazides
ACE inhibitors
Beta-blockers
ARBs
Ca-Channel blockers
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What are the three antihypertensive agents used during pregnancy? Hydralazine
Labetolol
Alpha-methyldopa
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What lowers the blood pressure in pre-eclampsia? Magnesium-sulfate
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What is hypertensive emergency vs. urgency? Both >200/120
Emergency occurs with end-organ damage:
Acute left ventricular failure
Unstable angina / Myocardial Infarction
Encephalopathy
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What are the signs and symptoms of encephalopathy? Headache
Altered mental status
Vomiting
Blurred vision
Dizziness
Papilledema
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What is the treatment of hypertensive emergency? Nitroprusside
Nitroglycerin
Beta-blocker (Labatelol)
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What are the cariovascular effects of...
Nitroprusside
Nitroglycerin
Hydralazine, A1-antagonist, Ca-chnl blkrs Dilates arteries and veins (both)
Dilates veins (reduces preload)
Dilates arteries (reduces afterload)
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What risks are lowered in lowering blood pressure? Stroke (HTN most important risk factor)
Heart disease
Myocardial infarction
Renal Failure
Atherosclerosis
Dissecting Aortic Aneurysm
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What is the most common cause of death in the untreated hypertensive patient? Coronary disease
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Indications for use of ACE inhibitors Heart failure

Diabetes
Acute coronary syndrome or unstable angina
Acute or prior myocardial infarction
High risk of coronary artery disease or stroke
Chronic kidney disease
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Contraindications for ACE inhibitors Pregnancy (fetal cardiac defects)
Renovascular hypertension (renal failure)
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Indications for use of Aldosterone receptor blockers (eg spironolactone, eplerenone) Heart failure
Prior myocardial infarction
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Contraindications for use of Aldosterone receptor blockers Hypoerkalemia
Pregnancy
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Indications for use of ARBs (eg losartan, irbesartan) Heart failure
Diabetes
Chronic kidney disease
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Contraindications for use of ARBs Pregnancy
Renovascular Hypertension (renal failure)
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Indications for use of Beta-blockers Stable angina
Acute coronary syndrome or unsatble angina
Acute or prior myocardial infarction
High risk of coronary artery disease
Atrial tachycardia or fibrillation
Thyrotoxicosis, Essential tremor, Migraines
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Contraindications for use of Beta-blockers Asthma
Chronic obstructive pulmonary disease
heart block
Sick sinus syndrome
*blocks signs of hypoglycemia
*causes hypercholesterolemia
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Indications for use of Calcium channel blockers Raynaud's syndrome
Atrial tachyarrhythmias
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Contraindications for use of Calcium channel blockers Heart block
Sick sinus syndrome
Congestive heart failure
Pregnancy
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Indications for use of Thiazides Heart failure
Diabetes
High risk of coronary artery disease or stroke
Osteoporosis
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Contraindications for use of Thiazides Gout
Electrolyte disturbances (eg hyponatremia)
Pregnancy
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What are the clues to possibilty of secondary hypertension? Onset before 30 yrs old or after age
55
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What are the possible causes of secondary hypertension in a woman? In a young woman, most
common cause is OCP
Next, renovascular HTN from fibrous dysplasia
Look for renal bruit
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What are the possible causes of secondary hypertension in a man? Excessive alcohol intake
Pheochromocytoma
Cushing's syndrome
Conn's Syndrome
Polycystic Kidney Disease
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What are the possible causes of secondary hypertension in the elderly? Renovascular HTN due to
atherosclerosis
(ACE inhibs precipitate renal failure)
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Signs and symptoms of pheochromocytoma? Urinary catecholamines
(vanillylmandelic acid, metanephrine)
Intermittent severe HTN
Dizziness
Diaphoresis
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Signs and symptoms of Polycystic Kidney Disease? Flank mass
Family history
Elevated BUN and creatinine
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Signs and symptoms of Cushing's syndrome? Dexamethasone suppression test
24-hr urine cortisol level
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Signs and symptoms of renovascular hypertension? MR/CT angiogram
Ultrasound
ACE inhib nuclear scan
Bruit on exam - angioplasty and stenting
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Signs and symptoms of Conn's syndrome? High aldosterone
Low renin
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Signs and symptoms of coarctation of the aorta? Upper extremity HTN only
Unequal pulses
Radiofemoral delay
Associated with Turner's syndrome
Rib notching on xray
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Diabetes screening Generally not recommended, except
Obesity
Family History
Black, American indian, Latin American
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Signs and symptoms of diabetes Polyuria
Polydypsia
Polyphagia
Weight loss
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Diagnosis of diabetes Fasting (overnight) plasma glucose of 126 mg/dL
Random glucose of 200 mg/dL
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Differences between DM1 and DM2

-age at onset
-body habitus
-DKA
-hyperosmolar state
-endogenous insulin <30yo - >30yo
Thin - Obese
Yes - No
No - Yes
Low - High
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Differences between DM1 and DM2
-twin concurrence
-HLA association
-response to oral hypoglycemics
-antibodies to insulin
-Islet cell pathology <50% - >50%
Yes - No
No - Yes
Yes - No
Yes - No
Insulitis (loss of beta cells) - Normal # (+amyloid)
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Treatment of DKA Fluids
iv Insulin
Potassium
Phosphorous
Do not use bicarb unless pH <7
Find cause - often infection
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Treatment of Nonketotic Hyperglycemic Hyperosmolar state Fluids
iv Insulin
Electrolytes
mortality is high
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Complications of diabetes Atherosclerosis (CAD, PVD, MI, Stroke)
Retinopathy (Screen annually, rx-lasr photocoag)
Nephropathy - ACE inhibs prevent, 30% of ESRD
Neuropathy, Infections, Foot disease
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Sequellae of peripheral neuropathy in diabetes Gastroparesis (early satiety, nausea)
rx-metoclopromide
Charcot's joints
Impotence
Cranial nerve palsies (esp III, IV, VI - ocular)
Orthostatic hypotension
Silent myocardial infarctions
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Treatment of T2DM Diet, exercise, wgt loss - cures 90%!!!
Sulfonylurea (glimepiride, glipizide, glyburide)
Metformin
Thiazolidinedione
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Insulin preparations
- onset, peak, duration Aspart <.25 1-3 3-5 before meals
Lispro <.5 .5-2.5 3-5 before meals
Regular .5-1 2-4 5-8 inpatient
NPH 2-3 4-12 12-24 standard regimen
Lente 2-3 4-12 12-24 standard regimen
Ultralente 6-10 8-16 18-26 basal
Glargine 1.5-4 none 24+ basal
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Insulin dosing 0.5 to 1.0 U/kg per day
Initial requirements are less because of redisual endogenous insulin
Type 2 inpatients require more b/c of resistance
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Somogyi Effect vs Dawn Phenomenon High night-time insulin leads to low overnight glucose.
Then stress hormone release increases morning glucose. Decrease insulin.
High morning glucose from GH secretion without overnight hypoglycemia. Increase insulin.
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Monitoring of diabetes compliance Hemoglobin A1c - 3 month avg, target 7%
C peptide is present with endogenous insulin
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Insulin for patients undergoing surgery 1/3 to 1/2 usual dose because of NPO status
monitor intraoperatively - use D5 & regular insulin
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Side effect of Chlorpropamide SIADH
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Treatment of diabetes and heart disease Beta-blockers prevent physical manifestations of
hypoglycemia (tachycardia, diaphoresis)
Benefits outweigh risks however
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Cholesterol screening Fasting lipid profile
Start at age 20 years
Every 5 years
More aggressive for family history and obesity
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Lipoprotein analyis Total - HDL - Trigly/5 = LDL
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Secondary causes of hypercholesterolemia Diabetes
Hypothyroid
Uremia
Obstructive liver disease
Alcohol (incrs trigly)
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Medications that cause hypercholesterolemia OCPs
Glucocorticoids
Thiazides
Beta-blockers
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LDL levels and intervention
- no risk factors <160 none, goal
160-190 diet, +/- medication
>190 medication, +diet
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LDL levels and intervention
- 2 or more CHD risk factors <100 none, goal
100-129 diet, +/- medication
>130 medication, +diet

Age, FH, Smoking, HTN, Low HDL

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Coronary Heart Disease risk factors Age - men=45yrs, women=55yrs (premat menop)
FH - first degree premat CHD, men55/women65
Current smoker >10 per day
HTN - 140/90 or on anti-HTN meds
Low HDL - <40mg/dL
HDL > 60 is protective and negates one risk fac
DM is risk factor, not included b/c also CADequiv
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LDL levels and intervention
- known CAD or equivalent <100 none, goal
>100 medication, +diet

DM, PAD, CAD, AAA

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LDL levels and intervention
- very high risk <70 none, goal
70-100 diet, +/- medication
>100 medication, +diet

CAD with MI or poorly controlled risks

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LDL levels and medical intervention summary No risk factors >190 (160)
2 risk factors >130 (100)
CAD (DM,PAD,AAA) >100
High risk >100 (70)
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Epidemiology of Atherosclerosis Involved in...
Half of all deaths in U.S.
Third of all deaths ages 35-65
Most important cause of disability&hospitalization
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Other factors related to Coronary Heart disease NOT independent risk factors:
Obesity, stress, physical activity, type a personality
Hypertriglyceridemia alone is not a risk but when associated with hyperXOL causes more CHD
than hyperXOL alone.
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Treatment of Hypercholesterolemia Exercise and diet
- decrease calories,cholesterol,fats, alcohol and smoking
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Modifying factors of HDL Increased by exercise, estrogens, mod alcohol
Decreased by smoking, androgens, progesterone, hypertriglycerides
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First line medications fo Hypercholesterolemia Niacin - poorly tolerated but effective, raises
HDL
Bile acid-binding agents
(cholesteramine, colesevelam)
HMG CoA-reductase inhibitors - Statins
- effective, expensive, liver & muscle damage
Block cholesterol absorption (ezetimibe)
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What cancers have an increased risk in smokers? Lung
Oral cavity, Esophagus, Larynx, Pharynx
Bladder, Kidney
Stomach, Pancreas
Cervix, vulva, penis, anus
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Wernicke's Syndrome Acute and reversible Thiamine (B1) Def
Opthalmoplegia
Nystagmus
Ataxia
Confusion
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Korsakoff Syndrome Chronic and irreversible Thiamine (B1) Def
Amnesia (anterograde)
Confabulation
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Pathophysiology of Thiamine deficiency Damage to mamillary bodies and thalamic nuclei
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Specific dysmorphisms of Fetal Alcohol Syndrome Epicanthal folds
Short palpebral fissures
Flattened filtrum
thin upper lip
"Railroadtrack" ears
Upturned nose
Flat nasal bridge
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General recognition of Fetal Alcohol Syndrome Mental retardation
Microcephaly
Micropthalmia
Short papebral fissure
Midfacial hypoplasia
Cardiac defects
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Fetal Alcohol Syndrome Most common preventable cause of mental retardation
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Bacteria of aspiration pneumonia in alcoholics Klebsiella (currant-jelly sputum)
Anaerobes
E. coli
Strep
Staph
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Treatments for alcoholism AA
Disulfiram
Naltrexone
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Stigmata of chronic liver disease in alcoholics varices, hemorrhoids, caput medusae, jaundice,
ascites, palmar erythema, spider angiomas, gynecomastia, testicular atrophy, encephalopathy,
asterixis, prolonged PT, hyperbilirubinemia, spontaneous bacterial peritonitis, hypoalbuminemia,
anemia
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Most common vitamin deficiencies in alcoholics Folate
Magnesium
Thiamine
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Important component in treatment of alcoholic Alcohol precipitates hypoglycemia. But
administer Thiamine before glucose othoerwise may precipitate Wernicke's
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Treatment of esophageal varices Bleeding - iv fluids, blood, endoscopy - sclerotherapy,
cauterization, banding, vasopressin
TIPS (transjugular intrahepatic portosystemic shunt)
Portacaval shunting is now rare
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Acid-Base disorders on ABG pH CO2 HCO3
Met Acid low low low
Resp Acid low high high
Met Alk high high high
Met Acid high low low
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Causes of respiratory acidosis COPD, asthma, chest wall problems (paralysis, pain), sleep apnea,
drugs (opioids, benzos, barbs, alcohol, resp depress)
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Causes of respiratory alkalosis Anxiety or hyperventilation, aspirin or salicylate od
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Causes of metabolic alkalosis diuretics (except CAI), vomiting, volume contraction, antacid
abuse or milk-alkali syndrome, hyperaldosterone
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Causes of metabolic acidosis Ethanol, DKA, uremia, lactic acidosis (sepsis, shock) methanol or
ethylene glycol, aspirin or salicylate, diarrhea, CAI
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Signs and symptoms of Hyponatremia Lethargy
Mental status changes
Anorexia
Seizures
Cramps
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Causes of Hyponatremia in hypovolemia Dehydration
Diuretics
DKA
Addison's disease
Hypoaldosteronism
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Causes of Hyponatremia in euvolemia SIADH
Psychogenic polydipsia
Oxytocin use
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Causes of Hyponatremia in hypervolemia CHF
Nephrotic syndrome
Cirrhosis
Toxemia
Renal failure
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Causes and treatment of SIADH Head trauma, surgery, meningitis, small-cell cancer, painful
states, pulmonary infections, opioids, chlorpropramide
Water restriction
Demeclocycline (causes renal DI) if refractory
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Classic finding with Addison's and Hypoaldosteronism in Hyponatremia Elevated potassium
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Na correction in hyperglycemia Na decreases 1.6 per 100 glucose above 200
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Signs and symptoms of Hypernatremia Hyperreflexia
Altered mental status
Seizures
Coma
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Causes of Hypernatremia Dehydration
Diuretics
DI
Diarrhea
Renal disease (isothenuria from SC trait)
Iatragenic
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Mimics DI by impairing renal concentrating mechanism Hypokalemia and Hypercalcemia
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Treatment of Hypernatremia Normal saline - pts typically dehydrated
1/2 normal - once hemodynamically stable
D5W - should NOT be used
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Pituitary vs. Nephrogenic DI Pit - responds to Vassopressin
Nephrogenic - Thiazides (paradoxical)

Signs and symptoms of Hyperkalemia Weakness, paralysis

EKG - with increasing K
tall, peaked T waves
widened QRS
prolonged PR interval
loss of P waves
sine waves
Vfib, asystole
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General cause of Hyperkalemia
Treatment Changes in pH alter K distriution
Acidosis causes hyperkalemia
Give bicarbonate for severe Hyperkalemia
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Specific causes of hyperkalemia Renal failure
Severe tissue destruction
Hypoaldosteronism (hyporenin/aldoster in DM)
Adrenal Insufficiency
Medications - K-sparing diuretics, B-blockers, NSAIDS, ACE inhibs
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Treatment of Hyperkalemia Decreased intake
Kaxolate (Na-polysterene resin)
Calcium gluconate is cardioprotective
NaBicarb
Glucose with insulin (forces K inside cells)
Dialysis for renal failure
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Signs and symptoms of Hypocalcemia Neurologic
tetany (chvostek's-face, trousseau-carpopedal)
depression, encephalopathy, dementia
seizures
laryngospasm
EKG - QT prolongation
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Specific causes of Hypocalcemia DiGeorge's - tetany after birth, athymic
Renal failure - altered vitamin D metab
Hypoparathyroid - watch post thyroidectomy
Vitamin D deficiency
Psuedohypoparathyroid - short fingers and stature, MR, nml PTH, end-organ unresp to PTH
Acute pancreatitis
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General treatment of hypocalcemia Hypomagnesemia makes correction difficult, treat hypomag
first
Alkalosis can cause hypocalcemic symptoms. treat pH
Phosphorous and calcium levels change in opposite direction
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Signs and symptoms of Hypercalcemia