Hypertension Flashcards
Diagnosis
Diagnosis is made after measuring BP > 140/90 mmHg three times from at least two separate clinical visits and is more common in older individuals and African-Americans
Types of hypertension
95% of all hypertension is idiopathic and called “essential” hypertension Secondary hypertension. Can be divided into four major categories.
Secondary Hypertension: Cardiovascular
Aortic regurgitation:
wide pulse pressure
Finger nail pulsations (Quincke pulses)
Head bobbing (if severe)
Waterhammer pulses (quick upstroke and downstroke of pulse)
Coarctation of aorta
HTN in upper extremity decreased BP in lower extremity
Commonly seen in Turner’s syndrome (XO)
Secondary Hypertension: Renal
Glomerular disease
proteinuria
Renal artery stenosis
Atherosclerosis; commonly seen in older dyslipidemic males
Fibromuscular dysplasia; commonly seen in young females
Polycystic disease
Family history
Autosomal dominant chromosome 4 (PKD2) and 16 (PKDA1) presents in adults Autosomal recessive chromosome 6 seen in children/at birth
Secondary Hypertension: Endocrine
Cushing’s and Conn’s
HTN with hypokalemia and metabolic alkalosis high levels of aldosterone increase Na+ reabsorption (HTN) and the kidney excretes excess K+ (hypokalemia) and H+ (alkalosis)
Pheochromocytoma
episodic symptoms
tumor of the adrenal chromaffin cells
episodic release of catecholamines that act on alpha and beta receptors
Hyperthyroidism
Isolated systolic HTN
Weight loss, irritability, tremor, fine hair and other signs of increased metabolic activity
Secondary Hypertension: Drug Induced
oral contraceptives
Glucocorticoids
HTN, fat redistribution, Cushing-like features
Phenylephrine
α1 agonism increases vascular tone
NSAIDs
decrease renal prostaglandin release, decreasing GFR
Symptoms
asymptomatic until complications develop
complications present with Dyspnea
Chest tightness
Headache
Vision changes
Physical Exam
Displaced PMI
Retinal changes
A/V nicking and copper wire changes to the arterioles
Papilledema and retinal hemorrhages
Systolic ejection click
Loud S2
Possible S4 heard on auscultation
PVD might be found if bruits are appreciated distally
Evaluation
Diagnostic criteria
Hypertension
elevation of systolic or diastolic BP >140/90 mmHg on two separate visits (3 or more BP readings)
“Prehypertension” = systolic BP of 120-139 mmHg or diastolic BP of 80-89 mmHg
Treatment Goals
Want to get BP < 140/90 mmHg in most patients
Consider treating patients with ACE inhibitors even sooner if they have an underlying condition that can lead to hyperfiltration damage (diabetes, scleroderma renal crisis)
Lifestyle Modifications
Indications
First line of treatment
Modalities
including weight loss
Exercise
Abstaining from alcohol
Smoking cessation
Salt restriction
Decrease in fat intake Cholesterol control to reduce risk of CAD
Medications
diuretic (HCTZ) and β-blockers (first line medications)
Indications
lifestyle modification fail after 6 months to 1 year
Medications include
diuretics (first-line HCTZ)
β-blockers (no comorbid disease)
Calcium channel blockers and ACEIs (second-line medications)
indications
Lifestyle modification and first line medication fail
Beta Blockers
Indications
No comorbid disease
Previous MI
CAD
Pregnant
Young Caucasian
Low EF
Angina
Coexistent benign essential tremor
Perioperative BP management
Beta Blockers
Contraindications
COPD
Hyperkalemia
Hypoglycemic events
Asthmatics
Beta Blockers
Side Effects
Bradycardia
Bronchospasm
Erectile Dysfunction
Thiazide Diuretics
Indications
First line if no comorbid disease
First line medication in isolated Systolic hypertension
African Americans
CHF
Osteoporosis
Thiazide Diuretics
Contraindications
Gout
Diabetes
Renal Failure (potassium sparing)
Thiazide Diuretics
Side Effects
Decrease excretion of calcium and uric acid (hyponatremia)
ACEIs
Indications
Diabetics
Previous MI
CKD
Low EF
ACEIs
Contraindications
Pregnancy
Renal Artery Stenosis
Renal Failure
ACEIs
Side Effects
Cough (substitute ARB)
Angioedema
Hyperkalemia
CCB
Indications
Second line agents
CCB
Contraindications
If other medication fails or if needed for controlling comorbidities
CCB
Side Effects
Lower extremity edema
Alpha Blockers
Indications
BPH
Alpha Blockers
Contraindications
CHF: can increase risk of HF
Alpha Blockers
Side Effects
Dizziness
Headache
Weakness
Complications
Hypertension left untreated can result in multiple chronic medical conditions including
Coronary artery disease
Renal failure
Stroke
Aneurysm
Intracerebral hemorrhage
Congestive heart failure: systolic and diastolic
Peripheral vascular disease
Hypertension Treatment for Diseases
β-Blocker
Coronary artery disease
Hyperthyroidism
Grave’s disease
Hypertension Treatment for Diseases
β-Blocker ACE-I ARB
Congestive heart failure
Hypertension Treatment for Diseases
β-Blocker Calcium channel blocker
Migraine
Hypertension Treatment for Diseases
Thiazide diuretics
Osteoporosis
Hypocalcemia
Hypertension Treatment for Diseases
Avoid β-blockers
Depression
Asthma
Hypertension Treatment for Diseases
α-Methyldopa Labetalol Nifedipine
Pregnancy
Hypertension Treatment for Diseases
α- Blocker
BPH
Hypertension Treatment for Diseases
ACE ARB
Diabetes
Hypertension Treatment for Diseases
ACE-I
Scleroderma
Hypertension Treatment for Diseases
β-blockers (metoprolol)
Peri-operative blood pressure management
