hypertension

Question 1

define HTN? and resistant HTN?

Answer 1

HTN: persistent SBP >= 140 and DBP >= 90

resistant HTN: BP that remains uncontrolled despite treatment with 3 or more antihypertensive drugs OR requires 4 or more drugs to be controlled

Question 2

etiology for primary and secondary HTN?

Answer 2

primary: old age, ethnicity, obesity, DM, smoking, alcohol use, substance use, high sodium diet

secondary:
-renal artery stenosis (fibromuscular dysplasia)
-endocrine (cushing, conn, hyperthyroid, pheochromocytoma)
-coarctation of aorta
-estrogen (OCP)
-steroid, NSAIDs

Question 3

clinical features?

Answer 3

-HTN is usually asymptomatic until end organ damage occurs
-secondary HTN will manifest through underlying cause

-non-specific symptoms of HTN:
headaches especially in the morning (typically occipital)
dizziness, blurry vision
chest discomfort, palpitations
-strong bounding pulse

screening is important to detect

Question 4

screening?

Answer 4

annually if pt is older than 40 or any age with risk factors for primary HTN

if pt is 18-39 with no risk factors, screen every 3-5 years

method of screening: in office BP measurement
if elevated, repeat on both arms
elevated BP on at least two readings obtained on at least two separate visits supports diagnosis of HTN.

confirmatory method: at home measurement, offer either:
-ambulatory BPM (device measures BP at fixed intervals)
-BPM manually

Question 5

evaluation for newly diagnosed HTN?

Answer 5

assess ASCVD risk
physical exam, hx

routine studies:
fasting glucose
serum Na, K, Ca (to establish baseline)
RFT
CBC
TSH (screening)
lipid profile
urinalysis and urinary albumin-Cr ratio (to detect microalbuminuria and hematuria)
ECG (for LVH, arrythmia, CAD)
fundoscopy
additional studies: HbA1c, LFT (NASH)

Question 6

lifestyle modifications?

Answer 6

-weight loss to target ideal BW (estimates 1mmHg reduction per Kg)
-diet: DASH (high fruit, vegetables, and whole grain, low trans fat)
-exercise: 90-150 min of aerobic exercise per week
-stop smoking and alcohol

Question 7

pharmacology?

Answer 7

step 1: start with ACEI or ARB (if patient is african american, start with CCB or thiazide diuretic)

step 2: combine ACEI/ARB with CCB

step 3: combine ACEI/ARB+CCB with thiazide diuretic

step 4 (resistant): if pt has preserved renal function and
K <4.5 add spironolactone
K >4.5 increase dose of thiazide diuretic
if ineffective, add alpha or BB

DO NOT GIVE ACEI WITH ARB TOGETHER it can lead to renal dysfunction and hyperkalemia and offers no benefit

Question 8

target BP in normal patients and diabetics?
complications of HTN?

Answer 8

target:
<140/90 in patients younger than 60
<130/80 in diabetics

heart: hypertrophic cardiomyopathy, CHF, MI
brain: stroke
kidneys: hypertensive nephrosclerosis
eyes: hypertensive retinopathy