533-Exam-1-Comp-Notes

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535

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Medicine

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Oct 30, 2023

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533 Exam 1 Comp Notes Asynch w/ transcripts, live lecture, book HTN, HLD, Obesity, Metabolic Syndrome Hypertension ● Overview ○ Defined by determining the levels of BP that cause target organ damage, morbidity & mortality as arterial flow is delivered ○ Primary (essential) HTN→ no known cause ■ Genetics, environmental causes are theorized ■ *In ped pts usually occurs after 10 yo* ○ Secondary HTN → Due to structural, circulatory or chemical abnormalities ■ Pg 596 table 104.1 discusses endogenous & exogenous causes of 2ndary ■ Should be considered when it develops before 30 yo or after 65 yo ● ACC/AHA Guidelines HTN Dx Criteria: *MEMORIZE THIS* ○ Normal BP: SBp < 120, DBP < 80 ○ Elevated BP: SBP 120-129 & DBP < 80 ○ Stage 1 HTN: SBP 130-139 OR DBP 80-89 ○ Stage 2 HTN: SBP >140 OR DBP > 90 ○ Goal BP for oldies & adults w/ DM, CKD, CVD < 130/<80 ○ Resistant HTN: When BP reading are not at goal despite max dose of 3 drugs *including a diuretic* Pathophysiology of Hypertension ● Mechanism of HTN ○ Elevation of the systemic arterial BP as set forth by the guidelines of various accrediting bodies ex. AHA or American College of Cardiology ○ Primary HTN ■ Increase in cardiac output (CO) & peripheral vascular resistance (PVR) ■ Most cases classified as primary, 95% of cases have no known cause. ■ Could be related to genetics or environmental factors ○ Secondary HTN ■ Underlying dz process ● Ex. renal disorders, endocrine disorders ○ Acromegaly, hypercalcemia due to PHPT, primary aldosteronism & central SA ■ Make sure you exclude secondary causes first! ○ Risk factors ■ Modifiable ● Obesity, Smoking, stress, sleep apnea, high fat diet &/or excess sodium ingestion, socioeconomic status ● Metabolic syndrome, physical inactivity, excess alcohol intake &/or smoking ● Glucose intolerance, low intake of Mag & K ■ Non modifiable ● Age, ethnicity, family hx, genetics ○ Renin- Angiotensin-Aldosterone System (RAAS) ■ Maintains homeostasis w/in the body to maintain BP & ultimately tissue perfusion ■ In HTN overactivity of RAAS that can cause HTN bc of sodium and water retention→ increased vascular resistance ■ Uncontrolled RAAS→ arterial remodeling ● Structural changes in vessel walls → permanent increase in peripheral resistance ■ ACE and ARBs oppose the RAAS activity → decrease BP → decrease risk of end organ target damage ● HTN: End Organ Damage - What high BP can do to the organs ○ Basically affects everything given risk of vascular resistance & decreased tissue perfusion ○ Heart ■ Left ventricular hypertrophy → increased vascular resistance → heart failure → Myocardial infarction :O ■ Myocardium ■ Coronary arteries ● Atherosclerosis ● CAD, MI, Death ○ Aorta ■ Weakened vessel walls → dissecting aneurysm

○ Kidneys ■ Decreased blood flow→ sympathetic nervous system & RAAS activated → changes to GFR → End stage renal disease ○ Brain ■ Weak vessels, atherosclerosis, TIA, CVA, Aneurysms, hemorrhages, brain infarcts ○ Eyes (Retina) ■ Vessel changes that can be seen in the retina ● Ophthalmic exam → retinal exudates, hemorrhages, hypertensive retinopathy ● Increased pressure in the retinal artery (done by ophthalmologist) ■ Retinopathy grade 3-4 w/ exudates & hemorrhage is a significant physical finding ○ Arterial vessels of lower extremities ■ Changes due to decrease in blood flow & high pressure in arterials → atherosclerosis → intermittent claudication & gangrene ○ ● Clinical Presentation ○ Asymptomatic ■ Very important to screen ERYBODY ○ Symptoms usually occur only after end-organ damage occurs ■ Vascular ● Impotence, intermittent claudication ● Tearing or burning chest pain & interscapular pain w/ variation in bilateral arm or leg BP ■ Cardio ● Chest pain, syncope, stroke ← more common in long term withstanding undx HTN ● Dyspnea, ECG changes, S3, HF ■ Pulmonary ● Rales, Pulmonary Edema ■ Renal ● Oliguria, hematuria ■ Diabetic Nephropathy ■ Cushing’s syndrome ○ Focus of eliciting the presence of CV risk factors ■ Target organ dysfunction ■ Evidence of possible secondary cause of HTN ● Manifest earlier symptoms ex. Loud snoring (OSA) ○ Daytime somnolence ○ Hypokalemia ○ If left untreated ■ Stroke, CAD, Renal dysfunction, aortic dissection, retinopathy ● Exam ○ Comp H & P ■ Calculate ASCVD risk score on pts 40-75 yo ● Early CAD = men < 55 yo, women < 65 yo ■ Get an accurate BP!! ● Pt should be seated, feet flat on the floor, no legs crossed, leaning against something for the back, correct cuff size, arm at level of the heart. BP taken in both arms → average it out in the future take BP on the highest side. ● Have the patient sit for 5 minutes ■ Dx of HTN→ elevated BP 2 different times at 2 different visits 2 weeks apart ● Don’t take it during sick visits because the pt may be on BP elevating meds ex. Sudafed

○ Labs ■ UA, CBC, Uric Acid ■ CMP (K, Ca, BUN/Creatinine) ● Know what the panel represents where you’re at! ■ Glucose, Lipid panel ■ ECG to eval for Left ventricular hypertrophy (LVH) or ischemic Heart dz ○ Management is based on: ■ Patient’s age, ethnicity, comorbidities & BP guidelines ■ Individualized ■ Utilized shared decision making ■ If meds started F/U in 1-4 weeks to assess BP ● Chemistry profile 5-7 days after the med is started ● If pt has renal dysfunction GFR < 30 or HF start on loop diuretics & follow ● MOnitor Q3 months to determine tx efficacy & monitor electrolytes & renal status ○ Vascular effects of sustained HTN ■ Bruits in carotid, aorta & renal arteries ■ Cardiac ● Gallops, displaced apical impulse, Left ventricular enlargement which indicates complications of HTN & affects tx decision ■ Cerebral ● Deficits on neuro testing ■ Retinal ● Arteriolar narrowing, AV nicking, exudates, hemorrhages & papilledema ■ Renal ● Renal artery bruits or enlarged kidneys ● Oliguria, hematuria, proteinuria & RBC casts ■ Peripheral ● Diminished pulses, thin skin, loss of hair ● STriae, neurofibroma & pruritic areas JNC 8 Guidelines from 2014 *NOT using these guidelines anymore* do NOT need to know the algorithm! ● All adults > 18 yo w/ HTN ○ Implement lifestyle modifications ○ Set BP goal, initiate BP lowering med based on algorithm ● Lifestyle changes: based on pts age, ethnicity, comorbidities & BP guidelines ○ Smoking Cessation ○ Stress management ○ Control Blood sugar & lipids ○ Diet ■ Healthy diet ex DASH ■ Mod alcohol consumption (1 drink a wk for gals, 2/wk for boys) ■ Reduce sodium intake to no more than 2300mg/day ○ Physical activity ■ Mod to vigorous activity 3-4 days a week approx 40 min a day. 150 min/wk ■ Wt loss ● Drugs of Choice ○ ACE Inhibitor (ACEI) ■ Renal protective ● Lookin at you DM and CKD pts ■ Monitor K & renal function ○ Angiotensin receptor blocker (ARB) ■ Renal protective ● Also Dm & CKD pts ■ Monitor K & renal function ■ Better for Asian patients ○ Thiazide diuretic ■ AA pts ■ Increase Uric acid levels ● Do not give to gout patients ○ Calcium Channel Blocker (CCB) ■ Per JNC 8 works better on Asian & AA

■ SE: proteinuria, bradycardia, fluid retention ○ Beta Blocker (BB) ■ For Heart Failure patients ■ If coming off beta blocker, remember to taper! ■ Labetalol for preggo people ○ Loop Diuretic or Spironolactone ■ HF patients to help w/ volume management ■ Spironolactone SE gynecomastia ■ Monitor K ○ Vasodilators ■ Watch out for reflex tachycardia & fluid retention! ○ Centrally-acting Agents ○ Isolated SBP - common in pts > 60 yo result of aging → vascular stiffening ■ Responds best to diuretics & CCB ● Med algorithm ○ Diabetes or CKD w/ HTN? Goal: < 140/90 ■ CKD w/ow/o DM? ● Initiate ACEI or ARB alone or in combo w/ another class ○ Over > 60 yo w/ no DM or CKD ? Goal : < 150/90. < 60 yo? Goal: < 140/90 ■ Not black? → Thiazide, ACEI, ARB or CCB alone or in combo ■ Black? → Thiazide or CCB alone or combo ■ Not at BP goal after initiation: 1. Reinforce lifestyle and adherence ○ Titrate meds to max dose or consider adding another med (ACEI, ARB, CCB, Thiazide) 2. Still not BP goal? - Continue to reinforce lifestyle & adherence - Add med class not already selected ex. Beta blocker, aldosterone antagonist etc, titrate above meds to max 3. Still not at BP goal? - Reinforce lifestyle & adherence - Titrate meds to max dose, add another med and/or refer to HTN specialist ACC/AHA 2017 Guidelines - Based on BP severity & Estimated 10 yr Atherosclerotic CVD Risk **Know the Live lecture chart slide 7!! ** ● ****GOAL BP < 130/80** ● Elevated BP or Stage 1 w/ estimated 10 yr ASCVD risk < 10% ○ Non Pharm intervention w/ repeat BP eval in 3-6 mo ● Stage 1 & ASCVD risk >/= 10% ○ Combo of lifestyle mods & 1 drug tx w/ f/u BP eval in 1 mo ● Stage 2 ○ Lifestyle mod + 2 drugs from different classes w/ recheck BP in 1 mo ● Very high average BP (>180 SBP or > 110 DBP) ○ Evaluate ASAP followed by prompt antiHTN drug tx ● BP 180/120 & evidence of target organ dysfunction → Hospitalize!!! ○ Ex. BP 184/130 & has a HA, bruits, AV nicking, retinopathy etc. ○ 180/120 but no S/S? Can manage outpatient ● Well controlled HTN? Follow annually Orthostatic Hypotension ● Decrease in SBP of 20+ milligrams of mercury or decrease in DBP of 10+ w/in 3 min of moving to a standing position ● Body is supposed to compensate for positional changes through sympathetic activity & baroreceptors in the carotid sinus & aortic arch ○ As we age, postural reflexes may not be as effective and we can see a drop in BP that could ultimately lead to falls or injury ● Secondary causes ○ Drug actions such as antihypertensives or antidepressants ○ Role of NP is to ID and manage ● Management ○ Increase sodium intake in the diet ○ Raise HOB ○ Slowly change positions

○ Wear thigh-high stockings ○ Possibly medications ex. Corticosteroids or vasoconstrictors Pathophysiology of Obesity ● An increase in body adipose tissue due to a caloric intake that exceeds our caloric expenditure ○ Changes in the brain and the hypothalamus that regulate intake ○ Genetic factors ■ Age, gender, ethnicity ○ If you eat more and don’t expend the calories → obesity ■ Basal Metabolic Rate - Sedentary person’s essential energy output ● 50-70% of sedentary energy output, makes up basal metabolic rate ● Remaining energy is in physical activity 25% ● Non exercise activity 7% ● Thermal effects of food ○ High protein takes more energy to burn the meal ■ Increased Energy intake, decreased energy expenditure ● We use 300+ calories more a day due to sugary things ■ Physical activity ● Should have 30 min a day of mod intensity or 20 min of vigorous activity ● Weight Influences ○ Smoking, Environmental factors ■ Food quality, nutrients, availability ■ Breast fed babies vs bottle fed ● Breast fed babies generally have better self regulation ○ Sleep, Gut Microbiota, Stress & Cortisol ○ Meds ■ DM meds, antidepressants, neuroleptic & seizure meds ■ Antihistamines, cardiac meds ■ Hormonal meds ○ Screen for depression & eating disorders ● Why is some extra cushion bad ○ Excess body fat is assoc w/ increased dz risk ■ BMI - Measures body fat ● Does not take in many factors, ex. body fat %, hip to waist ratio ● Normal: 18.5-24.9 ● Obese: >30 ○ Assoc w/ central obesity & higher morbidity & mortality ■ Waist Circumference ● Greater the circumference the higher the morbidity/mortality ● Strongest predictor of cancer & CVD ○ Waist to hip ratio related to increased cardiometabolic dz risk ■ > 40 in M, > 35 in F ● Common Complications of Obesity ○ GI ■ Increase in ghrelin hormones, decrease in GLP ■ GERD, gallstones, fatty liver ○ Liver becomes insulin resistant ■ Can change to cirrhosis, liver failure ○ Pancreas increase insulin secretion ■ Ultimately decrease in beta cell function which will thereby limit the amount of insulin available as those tissues become insulin resistant ○ Muscles become more insulin resistant and take less glucose into the tissue ■ Leads to inflammation & other changes ■ Excess wt leads to OA ● Require possible joint replacement ■ Low back pain ■ Plantar fasciitis ○ Vascular system ■ Endothelial dysfunction of the blood vessels as well as changes like plt aggregation ■ Inflammation of blood vessels

■ Atherosclerosis ● More risk of cholesterol deposits w/in the walls of the blood vessels leading to hardening ● Can result in HTN, CAD, HF ● Increased risk for stroke, renal disease ○ Hormonal changes ■ Insulin resistance ■ Lead to DM2, metabolic syndrome ■ Infertility ○ Pulmonary changes ■ Sleep apnea ● Increases cardiovascular risk ■ Increased risk of asthma ■ Exercise intolerance ○ Increased risk of cancer ■ Breast, colon, renal, endometrial, esophageal, stomach, pancreas, liver, ovarian cancer ● Differential Dx ○ PCOS ■ Acne, male pattern baldness, hirsutism ■ Linea nigrans ○ Hypothyroidism ■ Absent eyebrows, karetinemia on hands ○ Cushing Syndrome ■ Upper back fat pad, moon face, thin skin, easily bruising ■ Screen! ● 24 hour free cortisol level, dex suppression test etc ○ Sleep Apnea ■ Men w/ neck circumference of ■ Women w/ neck circumference of ○ Heart failure ○ Drug induced Obesity ■ Prader-Willi Syndrome ■ Bardet-Biedl Syndrome ■ Alstrom ○ Secondary Neurological Obesity ● Interprofessional Collaborative management ○ Motivational interviewing - The 5 As ■ Ask ● Ask if it’s okay to discuss weight ■ Assess ● BMI ■ Advise ● Health Risks ■ Agree ● Agree w/ pt on realistic Goals ■ Assist ● Assist pt in finding resources ○ Lifestyle Interventions ■ Energy deficit ● Reduce calories ■ Physical activity ■ Behavioral changes ○ Eating for Wt Loss ○ Pharm Wt Loss ■ CNS stimulation, insomnia, nervousness, tremors, dry mouth ○ Surgery ■ Bariatric surgery does not cure obesity! ■ These pts have nutrient deficits ex. B12, Vit A ○ SE of Wt Loss ■ Usually due to meds from chronic conditions ● Hypoglycemia, hypotension

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