3 - Hypertension (Shapiro)

Question 1

Objectives: Explain operational nature of term hypertension

Answer 1

• Hydrodynamic Approach
• Altered renal set point necessary to maintain hypertension
• Level of blood pressure with benefits of treatment outweigh the risks

Question 2

Objectives: Discuss the differential diagnosis of hypertension and express the approximate incidences of the various diseases

Answer 2

• Primary (Essential, 90-95%)
• Secondary: ~ 5%
  
  • Renal Failure (2-5%)
  • Renovascular (1-3%)
  • Aldosteronism (<1%)
  • Pheochromocytoma (<1%)
  • Other
    
    • Sleep Apnea (may be 50% of secondary)

Question 3

Objectives: When would it be appropriate to work up a patient for secondary causes of hypertension

Answer 3

• Hypertension without a family history
• “Early” presenting hypertension
• Severe, difficult to control hypertension

Question 4

Objectives: Describe pathogenesis of hypertension in renovascular disease, primary aldosteronism, pheochromocytoma, chronic renal failure

Renovascular disease

Answer 4

• Presentation
  
  • Old - Atheromatous
    
    • PVD
  • Young - Fibromuscular Dysplasia
    
    • ​Female > Male
    • Unusual in Afr. descent
    • Responds well to RX
• Test: Captopril Renogram, Arteriogram
• Low Pressure Kidney influences Renin-A2-Aldosterone System, decreaing Na Excretion; leading to hypertension

Question 5

Objectives: Describe pathogenesis of hypertension in renovascular disease, primary aldosteronism, pheochromocytoma, chronic renal failure

Primary Aldosteronism

Answer 5

• Hyperaldosteronism (see Hypokalemia, w/ACE inhibitor)
• Autonomous aldosterone production leads to ECF expansion and increased BP
• BP very high; renin levels usually supressed with low serum potassium
  
  • Diagnosis made on basis of nonstimulatable renin levels and nonsupressable aldosterone levels
• Cause: Adrenal Tumor (Conn’s Syndrome)
  
  • _​_Adrenal Hyperplasia
    
    • Glucocorticoid Sens (rare)
    • Glucorcorticoid Insens (mroe common)
  • Pseudohyperalsosteronism
    
    • Black Licorice/Tobacco
    • Liddle’s Syndrome

Question 6

Objectives: Describe pathogenesis of hypertension in renovascular disease, primary aldosteronism, pheochromocytoma, chronic renal failure

Pheochromocytoma

Answer 6

• Adrenal Medullary Tumors
• Epinephrine/Norepinephrine autonomous production (vasocostrictors)
  
  • ​Catecholamine Level tests may help
• Measure: Urinary catecholamines and/or metabolic products
• Decreased Sodium Excretion
  *

Question 7

Objectives: Describe pathogenesis of hypertension in renovascular disease, primary aldosteronism, pheochromocytoma, chronic renal failure

Chronic Renal Failure

Answer 7

• Some patients with sig. renin stimulation
• Possible expanded Plasma Volume playing primary role in hypertension
  
  • Ciculating inhibitor of sodium pump
  • Activation of SNS
• Decreased Sodium Excretion

Question 8

JNC 7 Categories of BP Table

Question 9

What are benefits of lowering BP relative to stroke and MI?

What are Compelling Indications for HBP?

Answer 9

Decreased Stroke risk the most

Decreases MI too, but not as much :(

Heart Failure, Diabetes with proteinuria, CAD (prior MI, high risk), Chronic Renal Insufficiency, CVA

Question 10

***Objectives: According to the Guyton Model, what is necessary to maintain hypertension?

Answer 10

Altered set point necessary to maintain hypertension

e.g. Renal involvement necessary to produce sustained hypertension

Question 11

Explain Malignant Hypertension and how it’s identified initially

Answer 11

• Medical Emergency
• Evidence for acute vascular injury; found during retinal exam

Question 12

Grading of Fundoscope Changes

Answer 12

• Narrowing - 1
• Nicking - 2
• Hemorrhages and/or exudates - 3
• Papilledema - 4

Question 13

Risk Factors for Atherosclerosis

Answer 13

Smoking

Dyslipidemia (high LDL, or low HDL)

Age > 60

Male or Post-menopausal Female

Family History