HTN Flashcards
What is refractory HTN
BP >140/90 despite max dosage of 2 drugs for 3-4 months
Main areas of target organ damage in HTN
Heart: Heart failure, LVH, Ischemic disease
Kidney: Renal insufficiency
Retina: Retinopathy
Blood vessels: Peripheral vascular disease, aortic dissection
Brain: Cerebrovascular disease
Risk Factors for CVD?
Levels of systolic and diastolic BP Men >55 Women >65 Smokers DM Dyslipidemia FHx premature CVD 102 in males, >88 in women C-reactive protein >1mg/dl
Also: Excessive alcohol intake Sedentary lifestyle High-risk socioeconomic groups High-risk ethnic groups
How can HTN be confirmed, based on BP readings?
Initial high BP readings must be confirmed with at least 2 more high readings over 3 months
Factors that can artificially raise BP
Apprehension - patient should be made to feel relaxed, and be seated for at least 5 minutes prior to taking BP
Caffeine - avoid caffeine for 4-6 hours before measurement
Smoking - avoid smoking for 2 hours before measurement
Eating - should not have eated for 30 mins before measurement
When is ambulatory BP monitoring indicated?
Not for everyone
For patients with fluctuating BP, borderline HTN, or refractory HTN
Causes of secondary HTN
Kidneys: Glomerulonephritis Reflux nephropathy Renal artery stenosis Other renovascular disease DM
Endocrine: Primary aldosteronism Cushing Syndrome Phaeochromocytoma (neuroendocrine cancer of medulla and adrenal glands) Oral contraceptives Other endocrine factors
Coarctation of aorta
Immune disorders - polarteriris nodosa
Drugs: NSAIDs, corticosteroids
Pregnancy
Abdominal systolic bruit suggestive of
Secondary cause: renal artery stenosis
Proteinuria, hematuria, casts are suggestive of
Glomerulonephritis
Bilateral kidney masses, with or without hematuria are suggestive of
Polycystic disease
Hx of claudication and delayed femoral pulse are suggestive of
Coarctation of the aorta
Progressive nocturia, weakness are suggestive of
Primary aldosteronism (check serum K+)
Paroxysmal HTN with headache, palor, sweating and palpitations are suggestive of
Phaeochromocytoma
Suggested follow up for normal BP reading
2 years
Suggested follow up for pre-HTN reading
120-139 / 80-89
1 year, with lifestyle advice
Suggested follow up for mild HTN (140-159 / 90-99)
Confirm diagnosis over the next 2 months with repeated readings. Give lifestyle advice
Suggested follow up for moderate HTN (160-179 / 100-109)
Evaluate or refer within 1 month - Give lifestyle advice
Suggested follow up for severe HTN >180 / >110
Further evaluate and refer within 1 week (or immediately, depending on clinical situation)
If BP is confirmed to be consistently this high, and ‘white coat’ HTN is excluded, drug treatment should be initiated as first-line
Findings on physical examination - HTN
ECG: May show LVH or old infarction
Echo: if suspecting HF (only if other CV risk factors)
Metabolic panel with estimated GFR: look for renal insufficiency. Unprovoked hypokalemia may suggest hyperaldosteronism.
Plasma renin measures - low renin suggests hyperaldosteronism
Lipid profile: Gain insight into CV risk
FBC with Hb: Anemia accompanies chronic renal failure. Polycythemia is seen in phaeochromocytoma
Urinalysis: Increased urine albumin indicates end-organ damage of kidneys
TFTs / TSH - for hypo or hyperthyroidism
Fundoscopy: Assess for retinopathy (in severe HTN)
Carotid and femoral US: may show abnormal intima media thickness
What are the features of the 4 grades of Hypertensive Retinopathy
Grade 1: Tortuous looking arterioles
Grade 2: Arteriovenous nipping (crossing over)
Grade 3: Arteriovenous nipping of tortuous looking vessels, PLUS Flame-shaped hemorrhages, and soft cotton-wool exudates
Grade 4: Papillodema
