Value: Complete/Incomplete (100 points is Complete and 0 is Incomplete)

Due: Day 7

Grading Category: Other Assignments

Overview

In this assignment, you will complete the following Annotated Study Guide. The study guide is based on the content from this module and is to be completed as you go through your learning material for this module.

It is strongly suggested that you complete this assignment to better prepare for upcoming assignments and exams. This tool will make a handy reference as you go forward in your practice and career.

Instructions

Download the Hypertension Management Annotated Study Guide (Word) before you begin your week’s assigned geriatric assessment assigned readings.

Review the study guide for topics that will be of particular importance during your reading, and type notes from your reading into the guide to annotate it.

Save your final file with your name and assignment title, then follow the instructions to submit your study guide file.

Use this study guide for yourself to study for the course exams and to review for your boards.

Please refer to the Grading Rubric for details on how this activity will be graded.To Submit Your Assignment:

Select the Add Submissions button.

Drag or upload your files to the File Picker.

Select Save Changes.

Submission status

Submission statusSubmitted for gradingGrading statusGradedTime remainingAssignment was submitted 3 days 10 hours earlyLast modifiedThursday, 2 February 2023, 12:59 PMFile submissionsNU664E_Hypertension_Annotated_Study_Guide OKS.docxTurnitin ID: 200491202071%2 February 2023, 12:59 PMSubmission commentsComments (0)

Annotated Study Guide for Hypertension Management

Instructions

Complete/Incomplete

Due Day 7

Each of the hypertension management topics you are responsible for knowing have been collected in this study guide. To help recall and master this material, you will annotate each topic in this study guide with notes, thoughts, and/or images as you perform the required readings at the start of this week. There will be prompts for each topic, but do not consider yourself constrained by these, as long as each topic is annotated in some way.

This assignment will be marked complete and receive full credit if most or all of the topics have been annotated. Your assignment will most likely not receive feedback since the value of this assignment is in its creation (taking notes while reading facilitates active learning which, in turn, promotes better recall) and as a study aid for class exams.

Hypertension Management Topics

Hypertension is

the most common risk factor for MI and stroke

Strong contributor to heart disease, CHF, Kidney disease

Modifiable risk factor for premature cardiac disease

Smoking

Dyslipidemia

DM

Notes:

Blood pressure is

the major determinant in the reduction of CV risk

Notes:

Complications associated with hypertension are

LVH

HF

Stroke- ischemic and hemorrhagic

Ischemic heart disease

MI

CKD

Notes:

HTN Stats (CDC, 2016)

Approximately 1 of 3 adults in America (70 million people) have hypertension.

54% of those have their blood pressure under control.

High blood pressure costs the nation $48.6 billion each year.

29.5% of adults are affected by high blood pressure, half of them have it under control

Notes:

Hypertension prevalence

SOURCE: https://www.healthypeople.gov/2020/topics-objectives/topic/heart-disease-and-stroke

Notes: (How has this map changed since 2011?)

Healthy People 2020

Visit the HP 2020 progress review

Present your key thoughts after reviewing slides 6, 7, and 24 – 31.

Key thoughts:

AHA 2017 guidelines for hypertension

Look at the US Preventative Task force for who, when, and how often you should be screening for HTN.

USPSTF

Annual screening: Adults over the age of 40

High risk

130-139/80-8

Obese

African American

Notes:

Risk factors for primary HTN

Age

Obesity

Family Hx (2x as common with hypertensive parent)

Race – African American

High sodium diet

Excessive ETOH

DM

Dyslipidemia

Notes:

Contributing factors for secondary HTN

(Annotate table to reinforce understanding and recall)

Prescription/ OTC medications:Oral contraceptivesChronic NSAID useTCA, SSRIGlucocorticoidsDecongestants –  pseudoephedrine Weight loss medicationsStimulants or illicit drugsRenal DiseaseRenal artery stenosisCKDHyperaldosteronismHypertension Unexplained hypokalemiaMetabolic alkalosisObstructive sleep apnea Pheochromocytoma – paroxysmal HTN Cushing’s syndromeThyroid disordersPregnancyCoarctation of the aorta

Be familiar with the complications of HTN

(Annotate table)

LVHCHFCADMISudden DeathAortic DissectionCVDProteinuriaRenal InsufficiencyAtherosclerosisRetinopathyDecline in function- Vascular Dementia, Alzheimer’s Dx

Think about the clinical presentation of HTN

Often initially not noticed- Preventative Screening imperative

Symptoms usually occur as consequences of end organ damage – stroke, renal dx, retinopathy, aortic dissection, sequelae of LVF

2nd HTN – usually present with s/s consistent with the underlying cause

Notes:

Understand the following HTN information

Identify target organ damage

Identify signs of secondary HTN

Identify reversible exacerbating factors

Develop baseline to document progression

Notes:

Your assessment should include at a minimum

(Annotate table)

Aggravating factors:MedicationsETOHDietDuration: Last known normal blood pressurePrevious attempts at treatmentMedicationsPresence of risk factors for CV diseaseSmokingDMDyslipidemia Physical inactivity Family HistorySleep ApneaSnoringDaytime somnolencePsychosocial Factors

Look for signs / Sx of target organ damage

Heart: Chest pain, palpitations, activity intolerance, etc.

Brain: dizziness, confusion, transient loss of function

Kidneys: history of renal disease

Peripheral arterial disease: intermittent claudication

Retinopathy: visual disturbances

Notes:

Review Metabolic Syndrome

3or more of the following:Abdominal obesity: Waist circumference >40” men >35” womenGlucose intolerance: Fasting glucose >110High Triglycerides:  >150HTN : >130/85

Low HDL: <40

Notes:

Important aspects of the PE

Accurate BP – 2 readings

Height/Weight/BMI

Vascular Effects: Retinal exam: Arterial narrowing, AV nicking, exudate, hemorrhage,  papilledema

Auscultate for carotid, femoral, renal artery, abd bruits

Thyromegaly, nodules

Notes:

Target organ damage & secondary causes of HTN

Derm: Signs of Cushing’s –

              Cause of secondary HTN (striae and hirsutism)

Notes:

Cardio-Resp: Signs of Heart Failure, Aortic insufficiencyRales, murmurs, tachycardia, S3, S4, lifts, heaves, displaced PMI, edema

Abd: masses, bruits, pulsation

Notes:

Neuro:  focal deficits, h/o TIA or past stroke, cognitive impairment, visual field cuts

Peripheral VascularFemoral bruitsFemoral pulses (Delayed or absent in aortic coarctation)Symmetrical pulsesLower extremity shin hair loss (shiny)

LE edema 

Notes:

HEENTRetinal Exam – Arteriole narrowing, AV nicking, exudate, hemorrhage, papilledemaOral Exam – Sleep ApneaPalpate ThyroidCarotid Bruits

Neck vein distension

Notes:

Reference images

Go to Uptodate and search on ocular effects of hypertension to find an article with the following images:

Cotton wool spots ocular effects of hypertension–view images

Hypertensive retinopathy

Notes:

Diagnostics to understand when treating hypertension

Electrolytes

Creatinine

Fasting glucose

Urinalysis

Lipid profile

Abnormal EKG (LVH)

Echocardiogram (ejection fraction)

Notes:

Pregnant Women

ACE-I/ARB are contraindicated

Treatment of HTN                           

Methyldopa

Beta blockers

Vasodilators

Notes:

African Americans

Prevalence and severity of HTN is elevated

Generally respond best to Thiazide and CCB rather than ACE-I, monotherapy recommended for improved response to treatment

Angioedema with ACE-I occurs 2-4x more frequently

Notes:

Lifestyle Modifications

Review Dash diet

Weight Loss: ca 1 mm Hg for every 1 pound

Decrease ETOHWomen – 1 drink/day women

Men – 2 drinks/day

Aerobic Exercise-30 min most days

Smoking Cessation

Stress ReductionYoga or meditation

Muscle relaxation

Notes:

Treatment goals

Review when you should initiate treatment and what your goals are.

Non-black population (including diabetics):

Thiazide, CCB, ACE or ARB

Black population (including diabetics)

Thiazide or CCB

Age >18 years w/CKD

ACE or ARB

Notes:

Thiazide diuretics

Act by decreasing blood volume/cardiac output

Decrease peripheral resistance during chronic therapy

No added benefit of increasing HCTZ higher than 25mg daily – add 2nd agent

Drug of choice for pts with no comorbidities, African Americans,  obese individuals and elderly

Notes:

Side Effects/Precautions

Hypokalemia

Hyponatremia

Hyperglycemia

Hyperuricemia

Hyperlipidemia

Not safe in renal and hepatic insuff

Favorable – Osteoporosis

Notes:

Angiotensin Converting Enzyme Inhibitors (ACE-I)

“-pril”

Block conversion from Angiotensin I to angiotensin II

First line therapy:HF or LV dysfunction (Reverse remodeling)DM

Proteinuric kidney disease (renal protective)

Absolutely Contraindicated in Pregnancy/Breast feeding

African Americans are more prone to angioedemaCan occur months to years after startingACE angioedema not a normal allergic reaction

Treatment is removal of drug and supportive care (airway management)

Cough (dry and irritating) – 5 to 20%More common in women and black patients

Should stop within 4 days when medication stopped

Hyperkalemia (5% of patients)

Renal Insufficiency (Baseline Serum Creatinine <3.0 mg/dl is safe)

Hypotension (Restart at half dose)

Notes:

Angiotensin II Receptor Blockers

Patients who do not tolerate an ACE-I

“- sartan”

Relative contraindication:Previous angioedema with ACE

2% will have reaction with ARB as well

In general do not co administer with ACE

Only benefit with late stage CHF

Peak effect 4-6 weeks

Proteinuria control is equal to ACE-I

Notes:

Calcium Channel Blockers (CCB)

Myocardial (non-dihydropiridine) and vascular smooth muscle relaxation

Dihydropyridines – Amlodipine (Norvasc)Peripheral vasculature

Adverse Effects: Peripheral EdemaWomenDoses >5 mg

Adding Ace decreases edema

Non-Dihydropyridines – Diltiazem, VerapamilNegative inotropePeripheral vasculature and cardiac tissueSlow AV node conductionRate control

Reynaud’s Favorable

Notes:

CCB adverse effects

Peripheral edema

Hypotension

Flushing

Nasal congestion

Tachycardia

Dizziness

Nausea

Nervousness

Bowel Changes/constipation

Notes:

Management for older adults

Thiazide diuretic decrease morbidity and mortality in CVA, CHF, MI

Observe closely for:DehydrationOrthostatic hypotension

Hypokalemia

Start low and go slow – prevent falls

Notes:

General management

Return one month after starting agent

Improves compliance

Maximize compliance

Work with patients to reduce adverse effectsPt education on what to look for

Switch to another agent if necessary

Notes:

General treatment contraindications

Make notes for each contraindication to reinforce your recall:

AHA, ACC and CDC 2013 Suggested HTN Drug choice by medical conditionDrugNotesSystolic HFACE or ARB, BB, Diuretic Post MIACE or ARB, BB Proteinuric CKDACE or ARB AnginaBB, CCB Afib/flutter rate controlBB, nondihydropyridine CCB 

General treatment contraindications

Make notes for each contraindication to reinforce your recall

ContraindicationDrugNotesAngioedemaACE Inhibitor BronchospasmBeta Blocker PregnancyACE or ARB Heart BlockBB or nonhydropyridine CCB