HTN Flashcards
HTN doubles the risk of CV diseases
CHD, CHF, ischemic and hemorrhagic strokes, renal failure and peripheral artery disease.
Mortality rate for stroke and coronary heart diseases have decreased by 50-60% over the past decade
The number of patients w/ end stage kidney disease and heart failure continues to rise
Why is there such a low rate of control of HTN?
Poor access to health care and medications
Lack of adherence w/ long term therapy
“Silent Disease”
HTN- Systolic BP
Systolic BP tends to rise as we age
After age 60, SBP of women>males
Systolic BP is a better predictor of morbid events than diastolic BP in older patients
HTN- Diastolic BP
Diastolic blood pressure increases progressively with age until age 55, then it tends to decrease.
Consequence is a widening of pulse pressure beyond age 55
Diastolic BP is a more important cardiovascular risk factor than is elevated SBP in younger patients w/o major comorbidities
Major Complications of HTN (4)
Hypertensive Cardiovascular Disease
Hypertensive Cerebrovascular Disease and Dementia
Hypertensive Kidney Disease
Atherosclerotic Complications
Hypertensive Cardiovascular Disease (4)
Most common cause of death in HTN patients
Major cause of morbidity and mortality in primary HTN
Result of LVHCHFVentricular arrhythmiasmyocardial ischemiasudden death
Occurrence of heart failure can be reduced by 50% w/ antihypertensive therapy
LVH regresses w/ therapy
Hypertensive Cerebrovascular Disease and Dementia (5)
Stroke is the 2nd most frequent cause of death in the world
HTN is the most common and most important risk factor for ischemic stroke
More closely correlates to systolic vs diastolic BP
Incidence of both ischemic and hemorrhagic strokes decreases w/ therapy
HTN is the most important risk factor for the development of a hemorrhagic stroke
HTN is associated w/ a higher incidence of both vascular and Alzheimer types dementia
Hypertensive Kidney disease (6)
- The kidney is both a target and a cause of HTN
- Primary renal disease is the most common etiology of secondary HTN
- Related to systolic BP as opposed to diastolic.
- HTN is a risk factor for renal injury and end stage renal disease.
- More common in blacks than whites
- Proteinuria is a reliable marker of the severity of chronic kidney disease and is a predictor of it’s progression.
Atherosclerotic Complications (4)
Blood vessels may be a target organ for atherosclerotic disease secondary to long standing elevated BP
Most Americans w/ HTN die of complications of atherosclerosis
Hypertensive therapy has a lesser impact on these complications
Reduction of atherosclerosis requires control of multiple risk factors including but not limited to HTN alone
Definition of HTN (2)
A systolic blood pressure of 140mmHg or higher, or a diastolic blood pressure of 90mmHg or higher
*Need 2 or more readings on 2 separate occasions over one to several weeks to diagnose HTN
Home monitoring is better correlated w/ target organ damage than clinic-based values
Ambulatory BP recordings provide a more comprehensive assessment of HTN than office readings
3 Types of HTN
Primary or Essential Hypertension
“White Coat Syndrome”
Secondary Hypertension
Essential HTN (8)
80-95% of patients w/ hypertension
No single, reversible cause
Specific etiology is unknown
Secondary to multiple genetic and environmental factors
Occurs in 10-15% of white adults in the US
Occurs in 20-30% of black adults in the US
Onset is usually b/w ages 25-55 years of age
Prevalence increases w/ age
Risk Factors for HTN (12)
Race (more common in blacks) Age (> 55 for men, >65 for women) First degree relative w/ HTN Obesity/Weight gain Diet high in sodium/salt Excess ETOH intake Metabolic Syndrome Cigarette smoking Inactivity/sedentary lifestyle Dyslipidemia, independent of obesity Polycythemia Vitamin D deficiency Low potassium intake
White Coat HTN (3)
20-25% of patients w/ stage 1 office HTN have “white-coat” or isolated office HTN
repeatedly normal when measured at home, work or by ambulatory BP monitoring)
Patients have increased risk of developing sustained primary HTN
Ambulatory BP Monitoring (ABPM) which records the BP at preset intervals during the day and night can be used to confirm or exclude the presence of white coat HTN in pts w/ persistent office HTN but normal BP readings out of the office
Secondary Causes of HTN (9)
Primary Renal Disease Drug induced Renovascular Adrenal Rare genetic D/O HTN with pregnancy Obstructive Sleep Apnea (OSA) Other endocrine D/O Coarctation of the aorta
Primary Renal Disease
Renal parenchymal disease (CKD) is the most common cause of secondary HTN
Others: renal cysts, renal tumors, obstructive uropathy
Drug Induced Secondary HTN (6)
Oral Contraceptives NSAIDS Antidepressants (MAO-I, and TCA) Decongestants Cocaine Glucocorticosteroids
Renovascular (renal artery stenosis) (5)
1-2% of hypertensive patients and secondary to:
Arteriosclerosis- older patients w/ obstructing plaque
Fibromuscular dysplasia- strong predilection for young white women, may be unilateral or bilateral
Renal arteriography is the definitive diagnostic test
Treated either medically or surgically
Renovascular should be suspected if… (6)
Onset of HTN before age 20 or after age 50
HTN is resistant to 3 or more drugs
If there are epigastric or renal artery bruits
If there is atherosclerotic dz of the aorta or peripheral arteries
If there is an abrupt increase in the level of serum creatinine after administration of ACE inhibitors
If episodes of pulmonary edema are associated w/ abrupt surges in BP
Adrenal Cause of HTN (Secondary) (3)
Pheochromocytoma:
D/t catecholamine-secreting tumors in the adrenal medulla
Primary aldosteronism:
Increased aldosterone production resulting in sodium retention, HTN, hypokalemia and low PRA (plasma renin activity)
Should be suspected in any patient w/ a triad of HTN, unexplained hypokalemia and metabolic alkalosis
Cushing’s Syndrome:
Related to excess cortisol production d/t either excess ACTH secretion (pituitary tumor) or to ACTH-independent adrenal production of cortisol
- HTN occurs in 75-80% of patients
Other endocrine disorders (Secondary Cause of HTN)
Hypothyroidism, hyperthyroidism, and hyperparathyroidism (hypercalcemia)
Obstructive Sleep Apnea (OSA) (2nd cause of HTN)
Independent of obesity
HTN occurs in >50% of patients w/ OSA
HTN Associated with Pregnancy
Preeclampsia and Eclampsia: one of the most common causes of maternal and fetal morbidity and mortality
Coarctation of the aorta (2nd cause of HTN)
Most common congenital cardiovascular cause of HTN
Screening: 2007 USPSTF
The USPSTF recommends blood pressure screening in adults 18 years and older because there is good evidence that it can identify adults at increased risk of cardiovascular disease from high blood pressure.
every 2 years for persons w/ systolic and diastolic pressures below 120mmHg and 80mmHg respectively and
yearly for persons w/ a systolic pressure of 120-139 or a diastolic pressure of 80-89.
Measurement of HTN (3)
Proper measurement and interpretation of the BP is essential in the dx and mgmt of HTN
Proper way: Preferably in a sitting position w/ arm at the level of heart after 5+ minutes of rest and 20-30 minutes after smoking/caffeine consumption
Systolic BP in the left and right arms should be roughly equivalent. A discrepancy of >15mmHg indicates subclavian stenosis peripheral arterial dx
What do we do if we determine our patient has HTN? (3)
Assess the presence or absence of target organ damage and CVD
Assess lifestyle (diet, exercise, habits) and identify other CV risk factors or current disorders that may affect prognosis and guide treatment
Rule out identifiable/secondary causes of high BP (often curable)
PT History for HTN (6)
Duration of HTN (if ongoing)
Previous therapies (if any), responses and side effects (if any)
FH of HTN or CVD
Dietary and psychosocial Hx
Other risk factors: weight change, dyslipidemia, smoking, diabetes, physical inactivity
Evidence of Secondary HTN:
Hx of renal dz, change in appearance, muscle weakness, spells of sweating, palpitations, tremor, snoring, erratic sleep, symptoms of thyroid disease, medication use (Rx and OTC), etc
Evidence of Target organ damage:
Hx of TIA, stroke, angina, MI, CHF, kidney disease
