Hypertension

Hypertension
Michael Ornes
Prevalence
 Adult population
 25-30% adults (higher in black, older, and female
individuals)
 >50% patients over 65 years old
 Only 10-60% of patients with known
hypertension have blood pressure < 140/90
 Asymptomatic
 Medications can have side effects
Definitions (JNC 7)
 Normal blood pressure <120/80
 Prehypertension 120-139/80-89
 Hypertension
 Stage 1: 140-159/90-99
 Stage 2: ≥160/100
 The higher value determines the
severity
 This assumes no medication usage
Essential or Primary
hypertension
 Risks
 Excessive salt intake
 Excess alcohol use
 Family history of hypertension
 Obesity
 African ancestry
 Age
Secondary hypertension
 Etiologies
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Renal artery stenosis
Oral contraceptives
Pheochromocytoma
Primary hyperaldosteronism
Cushing’ syndrome
Thyroid disorders and hyperparathyroidism
Sleep apnea
Aortic coarctation
Complications
 Cardiovascular disease
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ASCVD
Heart failure
LVF
Ventricular arrhythmia and sudden death
 Stroke and intracerebral hemorrhage
 Chronic renal failure and end-stage renal
disease
 Malignant hypertension
Diagnosis
 Screening blood pressure check at each office
visit in adults > 21 years old
 Every two years if normal blood pressure
 Every year if prehypertension exists
 Procedure
 Sitting quietly for 5 minutes with back supported
and arm supported at the level of the heart
 Adequate cuff size
 A minimum of three readings at least one week
apart for diagnosis
 Caffeine and smoking may affect blood pressure
White coat hypertension
 Elevation of blood pressure with visit to
physician office
 Worse with physician performing test
than technician or nurse
 Not as indicative of end organ risk
compared with ambulatory monitoring
Ambulatory monitoring
 More accurate if white coat effect
presumed
 Assesses effectiveness of medications if
apparent resistance
 If hypotensive symptoms (dizziness,
weakness) develop on medications
 Evaluation of episodic hypertension or
autonomic dysfunction
History
 Past blood pressure
 Prior treatment
 Medications (estrogen, adrenal steroids,
sympathomimetics, excessive sodium)
 Family history
Further history
 Symptoms of secondary causes
 Symptoms of end organ damage
 Presence of other vascular risk factors
 Dietary and psychosocial history
 Sexual function
 Sleep apnea symptoms
Examination
 Accurate blood pressure measurements
 General appearance (fat distribution, skin
lesions, muscle strength and alertness)
 Fundoscopy
 Palpation and auscultation of carotids and
thyroid
 Cardiovascular and lung exam
 Abdominal exam for bruits and masses
 Neurological exam
Evaluation
 Determine end organ damage
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Creatinine
Hemoglobin or hematocrit
Urinalysis
Fasting lipid profile
EKG
 Assess patient’s overall cardiovascular risk
 Evaluate for secondary treatable causes
Factors suggestive of
secondary hypertension
 Severe, refractory, or paroxysmal
hypertension
 Elevated creatinine or abnormal urinalysis
 Acute rise in blood pressure over baseline
 Proven age of onset before puberty or above
50 years
 Abdominal bruit
 No family history of hypertension
 History of flash pulmonary edema or
unexplained heart failure
Additional tests
 Microalbuminuria in diabetic patients
 Limited echocardiogram in patients with
borderline blood pressure
 CTA, MRA, renal artery duplex
ultrasound, or DSA of renal arteries in
patients with severe hypertension on
multiple medications
45 year old male
 Healthy and asymptomatic
 Smokes one pack per day
 Family history of hypertension
 BP 145/95 on repeated checks at the
clinic and the fire department
 Normal CV and neurological exam
Testing and treatment
 Testing
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Fasting lipid panel
Cr, Hgb, glucose, electrolytes
UA
EKG
 Treatment
 Smoking cessation
 Thiazide
 Limit salt intake
34 year old female
 PMH: Diabetes Mellitus type I
 microalbuminuria present
 blood pressure averages 135/85
 Normal heart exam
 Normal neurological exam
 Labs: Cr 1.3, K 4.5
Recommendation
 ACE I given DM and prehypertensive blood
pressure
 If patients develop cough on ACE I, an ARB
should be substituted
 After initiation of an ACE I or ARB the Cr and
K should be monitored especially in the first
1-2 weeks
 If patients fluid status changes their tolerance
of these medications may change
68 year old female
 PMH: PVD with mild claudication
 No personal or family history of
hypertension
 HPI: develops mild headache and on
evaluation BP 190/110
 Exam: soft bruit LUQ
 Cr 1.3
Renovascular Hypertension
 Most common correctable cause of
hypertension besides obesity and
alcohol abuse
 Usually more severe hypertension
 <1 % all hypertensive patients
 10-40% severe hypertensive patients
 More common in whites than blacks
Causes for suspicion of
renovascular hypertension
 Elevated creatinine (especially if after
ACE I started)
 Change in baseline blood pressure
 Evidence of other atherosclerosis
 Abdominal bruit or asymmetric kidney
size
 Negative family history of hypertension
Treatment of renovascular
hypertension
 Initially can be treated medically
 Follow Cr and BP closely especially if start
ACE I
 If difficult to control blood pressure, evaluate
with imaging test if would treat
 Initially angioplasty with stenting
 Rarely open bypass performed
 Main benefit is less antihypertensive medication
requirement
 May improve renal function and lessen risk of flash
pulmonary edema
34 year old male
 No medical problems and asymptomatic
 On screening, BP 185/105
 Normal exam including no edema
 Cr 1.2
 K 2.9
 Na 146
 CO2 34
Primary hyperaldosteronism
 Function adrenal adenoma or bilateral
hyperplasia (or rarely carcinoma)
 Screening: plasma aldosterone/renin level
 Also can test for urine potassium wasting
 Confirm with aldosterone level after
suppression maneuver
 Treatment is with adenoma resection or
aldosterone antagonist
32 year old female
 PMH: medullary thyroid cancer recently
diagnosed
 HPI: episodic headache, sweats and
tachycardia
 Exam: noted to have very labile BP
Pheochromocytoma
 Associated syndromes
 MEN-2 (MTC, Pheo, hyperparathyroidism
 Von Hippel-Lindau
 Rule of 10’s: 10% extraadrenal, 10%
bilateral or multiple, 10% malignant
 Variable presentation
 Diagnosed by urine catecholamines
 Treat with alpha antagonist and surgery
48 year old male
 PMH: Obesity, HTN
 SH/HPI:
 lives alone
 severe daytime fatigue
 chronic headaches
 Exam: BP 160/105, HR 90, O2 sat 90 % RA
 Mildly elevate JVP
 Mild pedal edema
Obstructive sleep apnea
 Common problem
 Complications
 Injury or social/job troubles
 Right heart failure
 HTN
 CPAP
 Can be cured by weight loss
20 year old male
 History
 Asymptomatic immigrant
 Exam
 BP 170/70 arms; BP 85/65 legs
 Delayed femoral pulse
 II/VI mid systolic murmur at the base
 EKG: LVH
 CXR: posterior rib notching
General treatment guidelines
 Diet modifications
 Sodium restriction (< 2.4 g sodium)
 DASH diet
 Weight loss if overweight
 Avoidance of excess alcohol intake
 Regular exercise
Medical therapy
 Should be initiated if BP >140/90 after
repeated checks and non-pharmacologic
recommendations not effective
 Initiate therapy in patients with DM and CRF
if BP >130/80 (ACE I or ARB recommended)
 Initiate therapy in patients with ASCVD if BP
>130/80-85 (beta antagonist and/or ACE I)
Medication Recommendations
(other indications)
 Thiazides
 ACE I/ARB (CHF, DM)
 Calcium channel antagonists (antianginal,
some with AVN rate control)
 Beta antagonist (CHF, ASCVD, AV node
rate control, ventricular arrhythmias,
antianginal, portal HTN)
Some trends in demographic
responses
 Younger patients may respond better to
beta antagonists and ACE I/ARB
 Older patients and black patients may
respond better to thiazides and calcium
channel antogonists
 Overall there is a variable response to
medications that is not especially
predictable
Other medications (other
indications)
 Spironolactone: CHF
 Loop diuretics: volume control in CHF
 Nitrates: antianginal, portal HTN
 Alpha antagonist: BPH, pheo
 Sympathetic antagonist (methly dopa,
clonodine)
 Vasodilators (hydralazine ,minoxidil)