Hypertension

Question 1

Which organ is essential in the maintenance of chronic hypertensive states?

Answer 1

Kidney

Question 2

Bp determined by

Answer 2

CO*SVR

Question 3

CO determined by

Answer 3

HR*SV

Question 4

Pressure natriuresis

Answer 4

Increasing BP causes excretion of Na and H2O due to baroreceptors at kidney. Then BP decreases

Question 5

Hypertension effect of pressure natriuresis

Answer 5

Respnse in blunted. Normal intake of sodium doesn’t increase output

Question 6

Where does pressure natriuresis occur?

Answer 6

In the proximal nephron

Question 7

How does hypertension affect the baroreceptors in the carotid sinus?

Answer 7

Stimulates them (this is acute regulation), to cause decreased cardiac output and vasodilation. These effects cause blood pressure reduction

Question 8

Essential hypertension

Answer 8

Essential hypertension is hypertension without an identifiable cause. Its the most common form of hypertension (90%) and is a diagnosis of exclusion. Multifactorial cause likely.

Question 9

Potential causes of essential hypertension

Answer 9

Genetics- hereditary component exists.

Systemic abnormalities – cardiac sympathetic overactivity, abnormal regulation of vascular tone

Renal abnormalities– excess sodium/water retention.

Question 10

What is more common at what stage in life?

Isolated diastolic hypertension or isolated systolic hypertension?

Answer 10

Isolated diastolic hypertension common earlier in life. Becomes less common because arteries harden due to increased pressure. Loss of elastic recoil. So isolated systolic hypertension becomes more common.

Question 11

Secondary hypertension

Answer 11

Presence of hypertension in the setting of clear structural/hormonal cause.

Question 12

Clues of secondary hypertension

Answer 12

Young age (<20 years)
New onset over 50.
More severe with rapid onset

Question 13

Causes of secondary hypertension

Answer 13

Chronic kidney disease (impaired ability of kidney to excrete sodium and water so rise in blood volume, elevation of CO.)

Renovascular (Renal artery stenosis due to atherosclerosis or fibromuscular dysplasia (young women)) Causes reduced renal blood flow and as a result, activation of the RAAS.

Aortic Coarctation – congenital narrowing of the aorta causes reduced blood flow to kidney

Question 14

Hypertension with high creatinine or abnormal urinalysis suggestive of

Answer 14

Secondary hypertension due to chronic kidney disease

Question 15

Hypertension with abdominal bruit, unexplained hypokalemia suggestive of

Answer 15

Renal artery stenosis. Treat with ace inhibitors

Question 16

Hypertension with higher BP in arms than legs, or higher BP in right arm than left arm, and rib notching suggestive of

Answer 16

Aortic coarctation

Question 17

Endocrine causes of secondary hypertension

Answer 17

Pheochromocytoma
Primary aldosteronism (Conn Syndrome, decreases renin from negative feedback)
Secondary aldosteronism (renin secreting tumor)
Excess glucocorticoids (expand blood volume and stimulate RAAS)

Question 18

How does pheochromocytoma present?

Answer 18

With paroxysms of palpitations/tachycardia/headaches

Question 19

How does thyroid dysfunction cause hypertension

Answer 19

Both hyper and hypothyroid patients can develop HT

Hyper: Cardiac hyperactivity, increase in blood volume
Hypo: Diastolic hypertension, increase in PVR.

Question 20

Some other causes of secondary hypertension

Answer 20

Cocaine, alcohol, cold remedies, EPO, oral contraceptives

Question 21

Consequences of hypertension

Answer 21

Arterial damage – smooth muscle hypertrophy, endothelial dysfunction, loss of elasticity.

Organ damage - brain, heart, aorta, kidney, retina.

Question 22

Consequences of increasing BP 20/10?

Answer 22

CV disease risk doubles with each increment

Question 23

Cardiac effects of hypertension

Answer 23

LV hypertrophy due to increased afterload. This leads to increased ventricular stiffness and diastolic dysfunction.

Systolic dysfunction due to hypertension and myocardial ischemia

Coronary artery disease- development of atherosclerosis which increases cardiac work and myocardial oxygen demand.

Question 24

Most common form of heart failure in elderly?

Answer 24

Diastolic

Question 25

Effect of hypertension on brain

Answer 25

Causes stroke! Both ischemic and hemorrhagic. Effective BP treatment has led to 50% reduction in stroke deaths

Question 26

Effect of HTN on aorta?

Answer 26

Aneurysm of the abdominal aorta (can burst causing death)
Aortic dissection (can occur at ascending and descending aorta) intima tears

Question 27

Hypertensive Urgency

Answer 27

SBP >180 or DBP >110 without evidence of end-organ damage. Requires immediate evaluation but not admission to ED

Question 28

Hypertensive Emergency

Answer 28

BP >180 or DBP > 100 with signs/symptoms of end organ damage including headache/blurred vision (encephalopathy), SOB (pulmonary edema due to LV hypertrophy), papilledema/retinal exudate.

Immediate hospitalization with rapid control of BP.

Question 29

Nonpharmacologic treatment for HTN

Answer 29

Weight reduction (each 10kg = 5-20 decrease in BP)
Exercise
Diet
Salt restriction
Decrease EtOH, stop smoking

Question 30

Pharmacologic treatment

Answer 30

Diuretics (best for mild-moderate HTN with normal renal function)

Beta Blockers – reduce CO, reduce renin secretion
REDUCE MORTALITY after MI/CHF

Alpha 2 agonists - decrease sympathetic outflow

Alpha 1 antagonists - relax smooth muscle

CCB- reduce influx of calcium necessary for cardiac/vascular smooth muscle contraction

Direct vasodilators - relax smooth muscle cells

ACE inhibitors– REDUCE MORTALITY

ARBs – REDUCE MORTALITY.

Question 31

First line for uncomplicated HTN

Answer 31

Thiazide diuretic