Arterial hypertention Flashcards
what is the aha/acc definition of arterial hypertention?
persistent systolic blood pressure of ≥ 130 mm Hg and/or diastolic blood pressure ≥ 80 mm Hg
what are the 2 types of hypertention?
- Primary( essential)- no underlying cause. with modifiable risks like diet, excercise etc and non modifiable like ethnicity, family history.
- secondary: causes
-Endocrine hypertension
Primary hyperaldosteronism (Conn syndrome): most common cause of secondary hypertension in adults. Hypercortisolism (Cushing syndrome)
Hyperthyroidism
Pheochromocytoma
Primary hyperparathyroidism
Acromegaly
Congenital adrenal hyperplasia
-Renal hypertension
Renovascular hypertension (e.g., due to renal artery stenosis)
Polycystic kidney disease (ADPKD)
Renal failure (renal parenchymal hypertension)
Glomerulonephritis
Systemic lupus erythematosus
Renal tumors
-Coarctation of the aorta
-Obstructive sleep apnea
-Medication: sympathomimetic drugs, corticosteroids, NSAIDs, oral contraceptives
Recreational drug use: amphetamines, cocaine, phencyclidine
what is the pneumonic RECENT stand for?
RECENT can help you remember the causes of secondary hypertension: R = Renal (e.g., renal artery stenosis, glomerulonephritis), E = Endocrine (e.g., Cushing syndrome, hyperthyroidism, Conn syndrome), C = Coarctation of aorta, E = Estrogen (oral contraceptives), N = Neurologic (raised intracranial pressure, psychostimulants use), T = Treatment (e.g., glucocorticoids, NSAIDs).
what are the clinical features of arterial hypertention?
Hypertension is usually asymptomatic until:
Complications of end-organ damage arise
Or an acute increase in blood pressure occurs
-Secondary hypertension usually manifests with symptoms of the underlying disease (e.g., abdominal bruit in renovascular disease, edema in CKD, daytime sleepiness in obstructive sleep apnea).
-Nonspecific symptoms of hypertension
Headaches, esp. early morning or waking headache
Dizziness, tinnitus, blurred vision
Flushed appearance
Epistaxis
Chest discomfort, palpitations; strong, bounding pulse on palpation
Nervousness
Fatigue, sleep disturbances
what are the subtypes or variant hypertention?
White coat hypertension (white coat effect): arterial hypertension detected only in clinical settings or during blood pressure measurement at a physician’s practice.
-Isolated systolic hypertension (ISH)
: increase in systolic blood pressure (≥ 140 mm Hg) with diastolic BP within normal limits (≤ 90 mm Hg)
Etiology
ISH in elderly: decreased arterial elasticity and increased stiffness → decreased arterial compliance
-ISH secondary to increased cardiac output:
Anemia
Hyperthyroidism
Chronic aortic regurgitation
AV fistula
-Clinical features:
Often asymptomatic
Signs of increased pulse pressure: e.g., head pounding, rhythmic nodding, or bobbing of the head in synchrony with heartbeats.
treatment: thiazide diuretics or CCB-dihydropyridines
what are the diagnostics of Hypertention?
epeated measurements on both arms : Hypertension is diagnosed if the average blood pressure on at least two readings obtained on at least two separate visits is elevated. Long-term measurement of blood pressure (24 hours) AHA: Normal:< 120 and < 80 Elevated:120–129 and < 80 Stage 1 hypertension: 130–139 or 80–89 Stage 2 hypertension: ≥ 140 or ≥ 90 JNC: Normal blood pressure < 120 and < 80 Prehypertension 120–139 or 80–89 Stage 1 hypertension 140–159 or 90–99 Stage 2 hypertension ≥ 160 or ≥ 100
- Initial evaluation of newly diagnosed hypertensive patients
-Stratification of cardiovascular risk: fasting blood glucose, lipid profile (HDL, LDL, and triglycerides levels)
-Evaluation of end-organ damage and underlying causes:
Complete blood count
Renal function tests: serum creatinine and eGFR
Serum Na+, K+, and Ca2+
Urinalysis
TSH
Electrocardiogram (ECG)
-screening: Individuals > 40 years of age or who are at increased risk for high blood pressure : Screen every year.
what is the non pharmacological treatment for arterial hypertention?
weight loss, DASH diet, low sodium intake: Daily sodium intake < 1500 mg/day, excercise. increases dietry potassium, decreased alcohol, quit smoking
what are the FIRST LINE pharmacological treatment for arterial hypertention?
- ACE inhibitors (e.g., lisinopril, captopril, enalapril)
Preferred as a first-line drug in patients with diabetes mellitus, renal disease (nephroprotective), ischemic heart disease, and heart failure
ACEi and ARBs should not be used in combination.
Dry cough, angioedema
↑ K+
Teratogenic - Angiotensin-receptor blockers (ARB) (e.g., losartan, valsartan)
↑ K+
Teratogenic - Thiazide diuretics (e.g., hydrochlorothiazide, chlorthalidone)
Preferred as a first-line drug in African Americans, salt-sensitive patients, and patients with isolated systolic hypertension
↓ K+, ↓ Na
↑ Glucose and cholesterol. - Calcium channel blockers Dihydropyridines (e.g., nifedipine, amlodipine)
Preferred as a first-line drug among African Americans and patients with isolated systolic hypertension
Nondihydropyridines are not commonly used.
Nondihydropyridines are contraindicated in patients with reduced ejection fraction.
Headache
Constipation
Gastroesophageal reflux
Pedal edema
Bradycardia (nondihydropyridines)
Nondihydropyridines (e.g., diltiazem, verapamil)
what is the indication of pharmacological therapy?
AHA/ACC: BP ≥ 140/90 mm Hg
BP ≥ 130/80 mm Hg with a 10-year-risk of cardiovascular death ≥ 10% (e.g., patients with age ≥ 65 years, diabetes mellitus, chronic kidney disease, heart failure, stable ischemic heart disease, peripheral artery disease, and/or previous stroke).
JNC 8:- Adults without diabetes mellitus or chronic kidney disease:
Age ≥ 60 years: BP ≥ 150/90 mm Hg
Age < 60 years: BP ≥ 140/90 mm Hg
-Adults with diabetes mellitus and/or chronic kidney disease: ≥ 140/90 mm Hg
what is the SECOND LINE pharmacological treatment for arterial hypertention?
1.Beta blockers (e.g., propranolol, metoprolol, labetalol)
Should be avoided in hypertension due to aortic regurgitation
Often used as a primary drug in patients with any of the following comorbidities:
Ischemic heart disease
Heart failure
Atrial fibrillation
Thoracic aortic disease (e.g., dissection, aneurysm)
Thyrotoxicosis
Migraine
Essential tremor
Bronchoconstriction with noncardioselective beta blockers
Increased triglycerides
2. Loop diuretics (e.g. furosemide, torsemide)
Used in symptomatic heart failure and CKD (if GFR < 30 mL/min)
↓ K+, ↓ Na
↑ Glucose
↑ Cholesterol
3. Alosterone antagonists (e.g., eplerenone, spironolactone)
Used in hypertension due to primary aldosteronism
Can be used as add-on therapy in resistant hypertension
↑ K+
Gynecomastia (spironolactone)
4. Direct renin inhibitors (e.g., aliskiren)
Should not be used in combination with ACEi or ARBs
↑ K+
5. Alpha-1 blockers (e.g., prazosin, doxazosin)
Used in hypertension due to pheochromocytoma
May be used as an adjunct in patients with benign prostatic hypertrophy
Postural hypotension
Headache
6. Alpha-2 agonists (e.g., clonidine)
Rarely used
CNS depression
Bradycardia
Rebound hypertension
7. Direct arteriolar vasodilators (e.g., hydralazine)
Hydralazine is a first-line treatment in pregnancy.
Sodium nitroprusside is used only in hypertensive emergencies.
Reflex tachycardia
Sodium and water retention
Cyanide toxicity with long-term use of sodium nitroprusside
what is the hypertensive treatment in pregnancy?
First-line treatment: methyldopa , labetalol, hydralazine (vasodilator), and nifedipine (CCB)
Second-line treatment: thiazides, clonidine (alpha-2 agonist)
Contraindicated: furosemide, ACE-I, ARB, renin inhibitors
what is the hypertensive treatment in children?
-Treat the underlying cause (e.g., surgical correction of coarctation of the aorta)
-Lifestyle changes in children with elevated BP (see nonpharmacologic measures in the treatment section below)
-Pharmacologic management is indicated for symptomatic hypertension, diabetes mellitus, CKD, and end-organ damage, as well as if there is an insufficient response or no response to lifestyle changes.
-Goal: BP < 90th percentile (BP < 50th percentile in children with DM or CKD)
Drugs: ACE inhibitor, ARB, or calcium channel blocker
In children with CKD or diabetes mellitus, ACE inhibitors or ARBs are preferable.
-Hypertensive emergency: labetalol, nicardipine, or sodium nitroprusside
-Beta blockers are not recommended for initial treatment of hypertension in children due to their metabolic side effects (e.g., impaired glucose tolerance) and the fact that they exacerbate asthma!
what are the complications of arterial hypertention:
- Cardiovascular system:
-Congestive heart failure, dilated cardiomyopathy, hypertrophic cardiomyopathy
-Coronary artery disease and myocardial infarction
-Atrial fibrillation
-Aortic aneurysm
-Aortic dissection
-Carotid artery stenosis
-Peripheral artery disease
-Atherosclerosis - Brain:
-Stroke , TIA
-Cognitive changes such as memory loss - Renal: Hypertensive nephrosclerosis
Pathophysiology: chronic hypertension → narrowing of afferent arterioles and efferent arterioles → reduction of glomerular blood flow → glomerular and tubular ischemia → arteriolonephrosclerosis and fibrosis (focal segmental glomerulosclerosis) → end-stage renal disease
Typical findings
Initially microalbuminuria and microhematuria
With disease progression, nephrosclerosis with macroalbuminuria (usually < 1 g/day) and progressive renal failure occur.
Biopsy: sclerosis in capillary tufts, arterial hyalinosis. - Eyes:
-Hypertensive retinopathy
Arteriosclerotic and hypertension-related changes of the retinal vessels
Fundoscopic examination:
Cotton-wool spots
Retinal hemorrhages (i.e., flame-shaped hemorrhages)
Microaneurysms
Macular star (results from exudation into the macula)
Arteriovenous nicking
Marked swelling and prominence of the optic disk with indistinct borders due to papilledema and optic atrophy (end-stage disease)
Presence of papilledema in a hypertensive patient may indicate a hypertensive crisis and warrants urgent lowering of the blood pressure (see hypertensive crises)
