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
