Hypertension Flashcards
What percentage of adults have hypertension defined as a systolic blood pressure greater than 130 mmHg or a diastolic blood pressure
greater than 80 mmHg or are taking medication for hypertension
About half, 48.1%
About half of adults (45%) with uncontrolled hypertension have a blood pressure of _____
140/90 mmHg or higher.
certain groups of people are more likely to have HTN than others:
- Men (50%) > than women (44%).3
- non-Hispanic black adults (56%) > than in non-Hispanic white adults (48%), non-Hispanic Asian adults (46%), or Hispanic adults (39%).3
- Among those recommended to take blood pressure medication, blood pressure control is higher among non-Hispanic white adults (32%) than in non-Hispanic black adults (25%), non-Hispanic Asian adults (19%), or Hispanic
adults (25%).
“Essential” primary hypertension
an older term based upon a
hypothesis that as we age, our vasculature
becomes stiffer, and that higher and higher
blood pressures are required to maintain
optimal cardiac output.
Primary hypertension
sustained blood pressures meeting
criteria (e.g., ACC/AHA 2017) for hypertension
related to multiple genetic and environmental
factors.
Primary Hypertension Risk Factors
- Increasing age
- Obesity/Overweight
- Family history
- Race
- Exposure to systemic racism
- Diabetes Mellitus
- High Na+ Diet
- Sedentary lifestyle
- Reduced nephron number (acquired or genetic)
Definition of Secondary Hypertension
HTN with an identifiable cause or contributor
Examples:
Rx or OTC meds (e.g., NSAIDs, certain
weight loss meds, etc.)
Primary renal disease
Obstructive or central sleep apnea
Cushing’s syndrome
Secondary Hypertension Causes:
ABCDE
A: Accuracy of diagnosis, obstructive
sleep Apnea, Aldosteronism
B: Bruits (renal artery stenosis), renal
parenchymal dz (Bad kidneys),
C: excess Catecholamines, Coarctation
of the aorta, Cushing’s
D: Drugs, Diet, excess Erythropoietin,
and
E: Endocrine disorders
High BP stage 1
Systolic: 130-139
or
Dyastolic: 80 - 89
Hypertension stage 2
S: 140 or higher
or
D: 90 or higher
Patient-related ERRORS in BP: What are practice quidelines?
Recent meal, caffeine,
nicotine use, a full bladder, or recent activity. BEST
PRACTICE: Need to be comfortable, quiet
environment, 5 minutes sitting.
Procedure-related ERRORS in BP: what are practice guidelines?
Arm lower than heart, legs crossed, patient talking, fast deflation. BEST
PRACTICE: Arm at chest level. Feet flat, back
straight. Sit still, remain quiet.
Equipment-related ERRORS in BP: what are practice guidelines?
Wrong cuff size. Device
is not calibrated. BEST PRACTICE: Size cuff per
directions. Calibrate device regularly.
Clinician-related ERRORS in BP: what are practice guidelines?
Not giving enough time (i.e., 5 minutes), letting patient talk, incorrect positioning of patient
Complications, Manifestations, & Sequelae of HTn
- Atherosclerosis à CAD àACS
- Myocardial hypertrophy à
Cardiomyopathy à Heart failure - Aneurysms à bleeds
- Hypertensive retinopathy à
loss/change of vision - Kidney disease
- Metabolic disorder
- TIA/CVA
- Dementia/MCI
- Sexual dysfunction
BP Diagnosis requires:
Two or more readings that meet criteria for HTN on two or more occasions
Diagnosis of HTN: In office readings
BP 130/80 (ACC) or 140/90 (AFP) or greater
* Reassess every 1-4 weeks to confirm
* a single BP reading of is 180/110 mm Hg or higher +CV disease requiring
immediate treatment
Diagnosis of HTN: Home readings
135/85 mm Hg or greater
* more consistent and better reflect hypertension-mediated organ damage risk.
* can differentiate white coat hypertension,
Diagnosis of HTN: 24-hour ambulatory monitoring
Must meet one of these three criteria
24-hour average BP of 130/80 mm Hg or greater, daytime average BP of 135/85
mm Hg or greater, or nighttime average BP of 120/70 mm Hg or greater.
Initial Visit recommendations:
Patient with an Elevated BP
Elevated (120-129/< 80) OR Suspected
High Blood Pressure (≥ 130/≥ 80 for first
time).
* Discuss/Encourage Lifestyle
Changes,
* Suggest 2-week follow-up
* keep home BP log (get a BP cuff), or
consider 24-hour ambulatory BP
monitor (ABPM)
* Consider: CMP or BMP, UA. (Why?)
Visit recommendations for Patient with Confirmed HTN: Stage I
- Calculate ASCVD Risk.
- If <10%, Lifestyle Changes
- If >10%, Lifestyle Changes + Anti-HTN
therapy
Visit recommendations for Patient with Confirmed HTN: Stage II
- Lifestyle Changes + Anti-HTN therapy
regardless of ASCVD score - Follow-up q4 wks (optimally q2wks by
phone/text/email) while titrating or switching
meds until BP goal met. - Follow-up in 3-6 months after initial
“stability”
Adult recommended sodium intake
1500 mg
1/2 tsp has 1200 mg
American Heart Association Physical Activity Recommendations
Reduce sodium
Exercise: 40 min of moderate intensity exercise 3-4 days a week
Reduce/eliminate alcohol
* Women - 1.5 standard drinks/day
* Men - 2 standard drinks/day
Hypertensive Emergency:
Relatively uncommon - reported as 1-2 cases
per million per year.
* Acute elevation of BP that results in
Target Organ Damage (TOD).
* Can be life-threatening,
* Requires quick work up and immediate
treatment
Target organ damage (TOD) examples
Intracerebral hemorrhage,
Acute MI, Acute LV failure with pulmonary
edema, dissecting aortic aneurysm,
pheochromocytoma, eclampsia, etc
Presentations of Hypertensive Emergency
Malignant hypertension:
Hypertensive encephalopathy:
Hypertensive thrombotic microangiopathy:
______ :Severe BP elevation
(commonly >200/120 mm Hg) associated with advanced bilateral retinopathy (hemorrhages, cotton wool spots, papilledema).
Malignant hypertension
_____ : Severe BP elevation
associated with lethargy, seizures, cortical blindness and
coma in the absence of other explanations.
Hypertensive encephalopathy
_____: Severe BP elevation associated with hemolysis and thrombocytopenia in the absence of other causes and improvement with BP-lowering therapy.
Hypertensive thrombotic microangiopathy
Other presentations of hypertensive
emergencies include:
- cerebral hemorrhage,
- acute stroke,
- acute coronary syndrome,
- cardiogenic pulmonary edema,
- aortic aneurysm/dissection, and
- severe preeclampsia and eclampsia
Symptoms of hypertensive emergency include:
headaches, visual disturbances, chest pain,
dyspnea, neurologic symptoms, dizziness, and
more unspecific presentations.
Medical history for hypertensive emergency:
preexisting hypertension, onset and duration
of symptoms, potential causes (nonadherence
with prescribed antihypertensive drugs,
lifestyle changes, concomitant use of BP
elevating drugs
Hypertensive Emergency
Management must be balanced against 2 ideas:
- Risk of TOD if BP is not reduced
enough in a rapid enough manner. - Risk of events with rapid lowering,
e.g., stroke, AKI, or MI. - vascular beds habituated to chronic
BP elevation.
Hypertensive Emergency workup
EKG, CXR, UA, CMP, Cardiac
biomarkers. CT or MRI of the brain as
indicated, Contrast CT or MRI or Echo
if aortic dissection suspected
Sympathetic hyperreactivity
amphetamines, sympathomimetics or cocaine
* consider benzodiazepines before antihypertensive
treatment.
* DON’T USE BB!!
* Phentolamine, a competitive alpha-receptor blocking agent and clonidine, a centrally sympatholytic agent with additional sedative properties are useful if
additional BP-lowering therapy is required.
Nicardipine and nitroprusside are suitable
alternatives.
Pheochromocytoma:
- responds well to phentolamine.
- Beta-blockers only after alpha-blockers have been introduced to avoid acceleration of hypertension.
- Urapidil and nitroprusside are additional suitable options
Hypertensive Urgency - NO Target Organ Damage workup
EKG, CXR, UA, CMP. Cardiac biomarkers;
CT or MRI of the brain as indicated; Contrast CT or MRI or Echo if aortic dissection suspected.
Hypertensive Urgency - NO Target Organ Damage Management
Reinstitute/intensify oral anti-HTN drug
therapy and arrange follow-up
Reduce over hours to days, to target to BP < 160/<
100.
Avoid reduction in MAP > 25-30% over 1st 2-4 hours.
Long-term target < 140/< 90
Hypertensive Urgency - NO Target Organ Damage PEARL
Laying in quiet room can reduce BP by 10-20
