Updated: 3/16/2021

Hypertension

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Snapshot
  • A 45-year-old man presents with complaint 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 a 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
  • Studies to evaluate for end-organ damage
    • electrocardiography
    • urinalysis
    • fasting blood glucose
    • hematocrit
    • electrolytes (including calcium)
    • creatinine
    • lipids profile
Blood Pressure
Category Systolic (mmHg)
And/Or Diastolic (mmHg)
Normal
  • < 120
  • And
  • < 80
Elevated
  • 120-129
  • And
  • < 80
Hypertension stage 1
  • 130-139
  • Or
  • 80-89
Hypertension stage 2
  • > 140
  • Or
  • > 90
Hypertensive crisis
  • > 180
  • And/Or
  • >120
 
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 (most effective)
        • 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
  • Pregnancy
    • use labetolol
    • avoid atenolol due to intrauterine growth restriction
  • 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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Questions (8)
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(M2.CV.17.4694) A 45-year-old male is presenting for routine health maintenance. He has no complaints. His pulse if 75/min, blood pressure is 155/90 mm Hg, and respiratory rate is 15/min. His body mass index is 25 kg/m2. The physical exam is within normal limits. He denies any shortness of breath, daytime sleepiness, headaches, sweating, or palpitations. He does not recall having an elevated blood pressure measurement before. Which of the following is the best next step?

QID: 107826
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Refer patient to cardiologist

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Treat with thiazide diuretic

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Repeat the blood pressure measurement

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4

Obtained computed tomagraphy scan

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5

Provide reassurance

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(M2.CV.16.4686) A 60-year-old male is admitted to the ICU for severe hypertension complicated by a headache. The patient has a past medical history of insulin-controlled diabetes, hypertension, and hyperlipidemia. He smokes 2 packs of cigarettes per day. He states that he forgot to take his medications yesterday and started getting a headache about one hour ago. His vitals on admission are the following: blood pressure of 160/110 mmHg, pulse 95/min, temperature 98.6 deg F (37.2 deg C), and respirations 20/min. On exam, the patient has an audible abdominal bruit. After administration of antihypertensive medications, the patient has a blood pressure of 178/120 mmHg. The patient reports his headache has increased to a 10/10 pain level, that he has trouble seeing, and he can't move his extremities and seems confused. After stabilizing the patient, what is the best next step to diagnose the patient's condition?

QID: 107387
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CT head with intravenous contrast

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CT head without intravenous contrast

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MRI head with intravenous constrast

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MRI head without intravenous constrast

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Doppler ultrasound of the carotids

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(M3.CV.16.10) A 45-year-old female with no significant past medical history present to her primary care physician for her annual check up. She missed her several appointments in the past as she says that she does not like coming to the doctor's office. When she last presented 1 year ago, she was found to have an elevated blood pressure reading. She states that she has been in her usual state of health and has no new complaints. Vital signs in the office are as follows: T 98.8 F, BP 153/95 mmHg, HR 80 bpm, RR 14 rpm, SaO2 99% on RA. She appears very anxious during the exam. The remainder of the exam is unremarkable. She reports that her blood pressure was normal when she checked it at the pharmacy 3 months ago. What test would you consider in order to further evaluate this patient?

QID: 103301
1

Measure TSH and free T4

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Repeat vital signs at her next visit

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Measure creatinine level

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4

Ambulatory blood pressure monitoring

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(1/1)

5

Obtain an EKG

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Evidence (15)
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