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Snapshot
  • A 45-year-old man presents to see you complaining of shortness of breath and frequent headaches. His blood pressure was 160/85, 155/90, 162/90 mHg on three consecutive office visits despite having initiated a low-salt diet 6 months earlier, at your recommendation. He is not taking any medications, and does not have any other medical problems. You decide to initiate first-line medication to control his high blood pressure.
Introduction
  • Diagnosis is made after measuring BP > 140/90 mmHg three times 
    • from at least two separate clinical visits
    • and is more common in older individuals and African-Americans
  • 95% of all hypertension is idiopathic and called "essential" hypertension
  • Secondary hypertension can be divided into four major categories, as follows
    • cardiovascular
      • aortic regurgitation
        • wide pulse pressure
        • finger nail pulsations (Quincke pulses)
        • head bobbing (if severe)
        • waterhammer pulses (quick upstroke and downstroke of pulse)
      • coarctation of aorta
        • HTN in upper extremity
        • decreased BP in lower extremity
        • commonly seen in Turner's syndrome (XO)
    • renal
      • glomerular disease
        • proteinuria
      • renal artery stenosis
        • atherosclerosis
          • commonly seen in older dyslipidemic males
        • fibromuscular dysplasia
          • commonly seen in young females
      • polycystic disease
        • family history
        • autosomal dominant
          • chromosome 4 (PKD2) and 16 (PKDA1)
          • presents in adults
        • autosomal recessive
          • chromosome 6
          • seen in children/at birth
    • endocrine
      • Cushing's and Conn's 
        • HTN with hypokalemia and metabolic alkalosis
          • high levels of aldosterone increase Na+ reabsorption (HTN) and the kidney excretes excess K+ (hypokalemia) and H+ (alkalosis)
      • pheochromocytoma
        • episodic symptoms
        • tumor of the adrenal chromaffin cells
          • episodic release of catecholamines that act on alpha and beta receptors
      • hyperthyroidism
        • isolated systolic HTN
        • weight loss, irritability, tremor, fine hair and other signs of increased metabolic activity
    • drug-induced
      • oral contraceptives
      • glucocorticoids
        • HTN, fat redistribution, Cushing-like features
      • phenylephrine
        • α1 agonism increases vascular tone
      • NSAIDs
        • decrease renal prostaglandin release, decreasing GFR
Presentation
  • Symptoms
    • asymptomatic until complications develop
    • complications present with
      • shortness of breath
      • chest tightness
      • headache
      • vision changes
  • Physical exam
    • displaced PMI
    • retinal changes
      • A/V nicking and
      • copper wire changes to the arterioles
    • papilledema and retinal hemorrhages
    • systolic ejection click
    • loud S2
    • possible S4 heard on auscultation   
    • PVD might be found if bruits are appreciated distally
Evaluation
  • Diagnostic criteria
    • hypertension
      • elevation of systolic or diastolic BP >140/90 mmHg on two separate visits (3 or more BP readings)
    • "prehypertension" = systolic BP of 120-139 mmHg or diastolic BP of 80-89 mmHg
Treatment
  • Goals of treatment
    • want to get BP < 140/90 mmHg in most patients
    • consider treating patients with ACE inhibitors even sooner if they have an underlying condition that can lead to hyperfiltration damage (diabetes, scleroderma renal crisis)
  • Medical
    • lifestyle modifications 
      • indications
        • first line of treatment
      • modalities
        • including weight loss 
        • exercise
        • obstaining from alcohol
        • smoking cessation
        • salt restriction
        • decrease in fat intake
        • and cholesterol control 
          • to reduce risk of CAD
    • diuretic (HCTZ) and β-blockers (first line medications)
      • indications
        • lifestyle modification fail after 6 months to 1 year
      • medications include
        • diuretic (first-line HCTZ) and
        • β-blockers (no comorbid disease)
    • calcium channel blockers and ACEIs (second-line medications)
      • indications
        • lifestyle modification and first line medication fail
 
Drug
Indications
Contraindications
Side Effects
β-blockers
  • No comorbid disease
  • Previous MI
  • CAD
  • Pregnant
  • Young Caucasian
  • Low EF
  • Angina
  • CAD
  • Coexistent benign essential tremor 
  • Perioperative BP management
  • COPD
  • Hyperkalemia
  • Hypoglycemic events
  • Asthmatics
  • Bradycardia
  • Bronchospasm
  • Erectile dysfunction
Thiazide diuretics
  • 1st-line medication if no comorbid disease
  • 1st-line medication in isolated systolic hypertension 
  • African-Americans
  • CHF
  • Osteoporosis (thiazides)
  • Gout
  • Diabetes (thiazide)
  • Renal failure (K+ sparing)
  • Decrease excretion of calcium and uric acid; hypoNa
ACEIs
  • Diabetics
  • Previous MI
  • Chronic Kidney Disease
  • Low EF
  • Pregnancy
  • Renal artery stenosis
  • Renal failure
  • Cough (substitute ARB)
  • Angioedema
  • Hyperkalemia
Calcium channel blockers
  • Second-line agents
  • If other medication fails or if needed for controlling comorbidities
  • Lower extremity edema 
α-blockers
  • BPH
  • CHF: can increase risk of heart failure
  • Dizziness
  • Headache
  • Weakness
 
Complications
  • Hypertension left untreated can result in multiple chronic medical conditions including 
    • coronary artery disease
    • renal failure
    • stroke
      • best way to prevent stroke is to control hypertension
    • aneurysm
    • intracerebral hemorrhage 
    • congestive heart failure
      • systolic and diastolic
    • peripheral vascular disease
High Yield Medication Chart for Hypertension Treatment for Diseases
 
Disease
Blood Pressure Medication Indication
Coronary artery disease
  • β-Blocker
Hyperthyroidism
Grave's disease
Congestive heart failure
  • β-Blocker
  • ACE-I
  • ARB
Migraine
  • β-Blocker
  • Calcium channel blcoker
Osteoporosis
  • Thiazide diuretics
Hypocalcemia
Depression
  • Avoid β-blockers
Asthma
Pregnancy
  • α-Methyldopa
  • Labetalol
  • Nifedipine
Benign prostatic hypertrophy
  • α-Blocker
Diabetes
  • ACE-I
  • ARB
Scleroderma
  • ACE-I
Peri-operative blood pressure management
  • β-blockers (metoprolol)
 

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