When should screening for hypertension be done?
Start at 3 years old
Every 2 years thereafter
How is hypertension diagnosed?
>140 sys or >90 dia
x3 separate measurements
What is Stage 2 hypertension?
>160 sys or >100 dia
Add 2nd agent
What is severe hypertension?
>210 sys or >120 dia or end-organ effects
Immediate Rx
What is first line pharmaceutical treatment for hypertension?
Thiazides
What is prehypertension?
>120 sys or >80 dia
What are the compelling indications for treatment of prehypertension?
Diabetes
Chronic Kidney Disease
What is the goal BP in the treatment of prehypertension?
<130/80
What is the workup for hypertension?
Urinalysis
BMP
EKG
H&H
What is the first line treatment of hypertension?
Weight reduction
Exercise
Alcohol & Smoking cessation
- attempt for 3 to 4 months before medication
What are the five first-line agents in the treatment of hypertension?
Thiazides
ACE inhibitors
Beta-blockers
ARBs
Ca-Channel blockers
What are the three antihypertensive agents used during pregnancy?
Hydralazine
Labetolol
Alpha-methyldopa
What lowers the blood pressure in pre-eclampsia?
Magnesium-sulfate
What is hypertensive emergency vs. urgency?
Both >200/120
Emergency occurs with end-organ damage:
Acute left ventricular failure
Unstable angina / Myocardial Infarction
Encephalopathy
What are the signs and symptoms of encephalopathy?
Headache
Altered mental status
Vomiting
Blurred vision
Dizziness
Papilledema
What is the treatment of hypertensive emergency?
Nitroprusside
Nitroglycerin
Beta-blocker (Labatelol)
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)
What risks are lowered in lowering blood pressure?
Stroke (HTN most important risk factor)
Heart disease
Myocardial infarction
Renal Failure
Atherosclerosis
Dissecting Aortic Aneurysm
What is the most common cause of death in the untreated hypertensive patient?
Coronary disease
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
Contraindications for ACE inhibitors
Pregnancy (fetal cardiac defects)
Renovascular hypertension (renal failure)
Indications for use of Aldosterone receptor blockers (eg spironolactone, eplerenone)
Heart failure
Prior myocardial infarction
Contraindications for use of Aldosterone receptor blockers
Hypoerkalemia
Pregnancy
Indications for use of ARBs (eg losartan, irbesartan)
Heart failure
Diabetes
Chronic kidney disease
Contraindications for use of ARBs
Pregnancy
Renovascular Hypertension (renal failure)
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
Contraindications for use of Beta-blockers
Asthma
Chronic obstructive pulmonary disease
heart block
Sick sinus syndrome
*blocks signs of hypoglycemia
*causes hypercholesterolemia
Indications for use of Calcium channel blockers
Raynaud's syndrome
Atrial tachyarrhythmias
Contraindications for use of Calcium channel blockers
Heart block
Sick sinus syndrome
Congestive heart failure
Pregnancy
Indications for use of Thiazides
Heart failure
Diabetes
High risk of coronary artery disease or stroke
Osteoporosis
Contraindications for use of Thiazides
Gout
Electrolyte disturbances (eg hyponatremia)
Pregnancy
What are the clues to possibilty of secondary hypertension?
Onset before 30 yrs old or after age 55
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
What are the possible causes of secondary hypertension in a man?
Excessive alcohol intake
Pheochromocytoma
Cushing's syndrome
Conn's Syndrome
Polycystic Kidney Disease
What are the possible causes of secondary hypertension in the elderly?
Renovascular HTN due to atherosclerosis
(ACE inhibs precipitate renal failure)
Signs and symptoms of pheochromocytoma?
Urinary catecholamines
(vanillylmandelic acid, metanephrine)
Intermittent severe HTN
Dizziness
Diaphoresis
Signs and symptoms of Polycystic Kidney Disease?
Flank mass
Family history
Elevated BUN and creatinine
Signs and symptoms of Cushing's syndrome?
Dexamethasone suppression test
24-hr urine cortisol level
Signs and symptoms of renovascular hypertension?
MR/CT angiogram
Ultrasound
ACE inhib nuclear scan
Bruit on exam - angioplasty and stenting
Signs and symptoms of Conn's syndrome?
High aldosterone
Low renin
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
Diabetes screening
Generally not recommended, except
Obesity
Family History
Black, American indian, Latin American
Signs and symptoms of diabetes
Polyuria
Polydypsia
Polyphagia
Weight loss
Diagnosis of diabetes
Fasting (overnight) plasma glucose of 126 mg/dL
Random glucose of 200 mg/dL
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
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)
Treatment of DKA
Fluids
iv Insulin
Potassium
Phosphorous
Do not use bicarb unless pH <7
Find cause - often infection
Treatment of Nonketotic Hyperglycemic Hyperosmolar state
Fluids
iv Insulin
Electrolytes
mortality is high
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
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
Treatment of T2DM
Diet, exercise, wgt loss - cures 90%!!!
Sulfonylurea (glimepiride, glipizide, glyburide)
Metformin
Thiazolidinedione
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
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
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.
Monitoring of diabetes compliance
Hemoglobin A1c - 3 month avg, target 7%
C peptide is present with endogenous insulin
Insulin for patients undergoing surgery
1/3 to 1/2 usual dose because of NPO status
monitor intraoperatively - use D5 & regular insulin
Side effect of Chlorpropamide
SIADH
Treatment of diabetes and heart disease
Beta-blockers prevent physical manifestations of hypoglycemia (tachycardia, diaphoresis)
Benefits outweigh risks however
Cholesterol screening
Fasting lipid profile
Start at age 20 years
Every 5 years
More aggressive for family history and obesity
Lipoprotein analyis
Total - HDL - Trigly/5 = LDL
Secondary causes of hypercholesterolemia
Diabetes
Hypothyroid
Uremia
Obstructive liver disease
Alcohol (incrs trigly)
Medications that cause hypercholesterolemia
OCPs
Glucocorticoids
Thiazides
Beta-blockers
LDL levels and intervention
- no risk factors
<160 none, goal
160-190 diet, +/- medication
>190 medication, +diet
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
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
LDL levels and intervention
- known CAD or equivalent
<100 none, goal
>100 medication, +diet
DM, PAD, CAD, AAA
LDL levels and intervention
- very high risk
<70 none, goal
70-100 diet, +/- medication
>100 medication, +diet
CAD with MI or poorly controlled risks
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)
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
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.
Treatment of Hypercholesterolemia
Exercise and diet
- decrease calories,cholesterol,fats, alcohol and smoking
Modifying factors of HDL
Increased by exercise, estrogens, mod alcohol
Decreased by smoking, androgens, progesterone, hypertriglycerides
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)
What cancers have an increased risk in smokers?
Lung
Oral cavity, Esophagus, Larynx, Pharynx
Bladder, Kidney
Stomach, Pancreas
Cervix, vulva, penis, anus
Wernicke's Syndrome
Acute and reversible Thiamine (B1) Def
Opthalmoplegia
Nystagmus
Ataxia
Confusion
Korsakoff Syndrome
Chronic and irreversible Thiamine (B1) Def
Amnesia (anterograde)
Confabulation
Pathophysiology of Thiamine deficiency
Damage to mamillary bodies and thalamic nuclei
Specific dysmorphisms of Fetal Alcohol Syndrome
Epicanthal folds
Short palpebral fissures
Flattened filtrum
thin upper lip
"Railroadtrack" ears
Upturned nose
Flat nasal bridge
General recognition of Fetal Alcohol Syndrome
Mental retardation
Microcephaly
Micropthalmia
Short papebral fissure
Midfacial hypoplasia
Cardiac defects
Fetal Alcohol Syndrome
Most common preventable cause of mental retardation
Bacteria of aspiration pneumonia in alcoholics
Klebsiella (currant-jelly sputum)
Anaerobes
E. coli
Strep
Staph
Treatments for alcoholism
AA
Disulfiram
Naltrexone
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
Most common vitamin deficiencies in alcoholics
Folate
Magnesium
Thiamine
Important component in treatment of alcoholic
Alcohol precipitates hypoglycemia. But administer Thiamine before glucose othoerwise may precipitate Wernicke's
Treatment of esophageal varices
Bleeding - iv fluids, blood, endoscopy - sclerotherapy, cauterization, banding, vasopressin
TIPS (transjugular intrahepatic portosystemic shunt)
Portacaval shunting is now rare
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
Causes of respiratory acidosis
COPD, asthma, chest wall problems (paralysis, pain), sleep apnea, drugs (opioids, benzos, barbs, alcohol, resp depress)
Causes of respiratory alkalosis
Anxiety or hyperventilation, aspirin or salicylate od
Causes of metabolic alkalosis
diuretics (except CAI), vomiting, volume contraction, antacid abuse or milk-alkali syndrome, hyperaldosterone
Causes of metabolic acidosis
Ethanol, DKA, uremia, lactic acidosis (sepsis, shock) methanol or ethylene glycol, aspirin or salicylate, diarrhea, CAI
Signs and symptoms of Hyponatremia
Lethargy
Mental status changes
Anorexia
Seizures
Cramps
Causes of Hyponatremia in hypovolemia
Dehydration
Diuretics
DKA
Addison's disease
Hypoaldosteronism
Causes of Hyponatremia in euvolemia
SIADH
Psychogenic polydipsia
Oxytocin use
Causes of Hyponatremia in hypervolemia
CHF
Nephrotic syndrome
Cirrhosis
Toxemia
Renal failure
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
Classic finding with Addison's and Hypoaldosteronism in Hyponatremia
Elevated potassium
Na correction in hyperglycemia
Na decreases 1.6 per 100 glucose above 200
Signs and symptoms of Hypernatremia
Hyperreflexia
Altered mental status
Seizures
Coma
Causes of Hypernatremia
Dehydration
Diuretics
DI
Diarrhea
Renal disease (isothenuria from SC trait)
Iatragenic
Mimics DI by impairing renal concentrating mechanism
Hypokalemia and Hypercalcemia
Treatment of Hypernatremia
Normal saline - pts typically dehydrated
1/2 normal - once hemodynamically stable
D5W - should NOT be used
Pituitary vs. Nephrogenic DI
Pit - responds to Vassopressin
Nephrogenic - Thiazides (paradoxical)
Nephro - caused by lithium, demeclocycline, methoflurane, amphotericin
Signs and symptoms of Hypokalemia
Muscle weakness (smooth-ileus,hypotension)
EKG -
loss of T waves
presence of U waves
PVCs, PACs
tachyarrhythmias
Causes of Hypokalemia
Treatment
Changes in pH alter K distriution
Alkolosis causes hypokalemia
H leaves cells to correct H, K enters
Do not replace potassium too quickly, <20/h
Hypomagnesemia makes correction difficult, treat hypomag first
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
General cause of Hyperkalemia
Treatment
Changes in pH alter K distriution
Acidosis causes hyperkalemia
Give bicarbonate for severe Hyperkalemia
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
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
Signs and symptoms of Hypocalcemia
Neurologic
tetany (chvostek's-face, trousseau-carpopedal)
depression, encephalopathy, dementia
seizures
laryngospasm
EKG - QT prolongation
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
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
Signs and symptoms of Hypercalcemia
...