Hypertension

Question 1

How often should you screen for hypertension?

Answer 1

screened every 2 years, starting at the age of 3 years

Question 2

Define hypertension

Answer 2

Persistent BP greater than 140/90 mmHg

In grading the severity of hypertension, use the worst number, whether diastolic or systolic

Question 3

What is the “two-measurement” rule in the diagnosis of hypertension?

Answer 3

BP should be measured two times on each of two separate office visits before the diagnosis and pharmacologic treatment of hypertension. However, after the first abnormal measurement, institute conservative measures and address associated comorbidities (e.g., obesity, diabetes)

Exceptions:

• markedly BP elevations (generally > 200/120 mm Hg) + acute target-organ damage (e.g., encephalopathy, MI, unstable angina, pulmonary edema, stroke) require hospitlization and parenteral drug therapy
• markedly BP elevations w/o target organ damage should be given immediate combination PO antihypertensive therapy (usually does not require hospitalization)

Question 4

What are the conservative (i.e., nonpharmacologic) treatments for HTN?

Answer 4

• Dietary changes (low Na, low fat, low calorie)
• reduced smoking and alcohol intake
• weight loss
• exercise

Stage I HTN - give a 1- to 2-month trial of lifestyle modifications before starting medication.

Stage II HTN or those with diabetes or renal disease - early pharmacologic treatment is often preferred.

Question 5

List the first-line medications for treatment of hypertension.

Answer 5

Thiazides (1st line therapy) +/- ACEi/ARB, ß blocker, or Ca channel blockers

Question 6

What are the 3 preferred treatments for women of reproductive age and pregnant women with hypertension?

Answer 6

Labetalol, hydralazine, and alpha-methyldopa are safe.

If preeclampsia is present, remember that magnesium sulfate lowers blood pressure.

Question 7

Define hypertensive urgency.

How is it different from hypertensive emergency?

Answer 7

Hypertensive urgency = BP > 200/120 mmHg without symptoms

Hypertensive emergency = BP > 200/120 mmHg with symptoms

Sx: LV failure, CP/angina, MI, encephalopathy (HA, confusion, retinal hemorrhages, papilledema, AMS, V, blurry vision, dizziness, and/or seizures), or acute renal failure (from necrotizing arteriolitis).

Both require immediate treatment

Hypertensive urgency: PO furosemide, clonidine, or captopril

Hypertensive emergency: IV nitroprusside, labetalol, or nicardipine

Question 8

What causes hypertension?

Answer 8

Roughly 90% to 95% of cases are idiopathic, multifactorial, or essential hypertension.

About 5% to 10% of cases are a result of secondary (known) causes.

Question 9

What are the common causes of secondary hypertension in younger men and women?

Answer 9

excessive alcohol intake (get the patient to quit)

In younger women: birth control pills, renal artery stenosis (RAS) from fibromuscular dysplasia (which may cause a bruit and should be treated with balloon angioplasty)

Question 10

List less common causes of secondary hypertension.

Answer 10

• Pheochromocytoma - wild swings in BP, diaphoresis, confusion. Get serum catecholamine products (metanephrines, vanillylmandelic acid, homovanillic acid).
• RAS - young patients (fibromuscular dysplasia), older patients (atherosclerosis); abdominal bruit is classically present; get magnetic resonance or conventional angiography.
  
  • ​Giving ACEi to patients with RAS may precipitate acute renal failure (sometimes the first diagnostic clue to its presence).
• Polycystic kidney disease - flank mass, (+) family history (AD inheritance), BUN/Cr elevations
• Cushing syndrome - stigmata of Cushing syndrome on exam. Get 24-urine collection to assess free cortisol or a dexamethasone suppression test.
• Conn syndrome (aldosterone-secreting adrenal neoplasm) - high aldo, low renin, hypernatremia, hypokalemia, metabolic alkalosis, and/or an adrenal mass on CT. Get plasma aldosterone to plasma renin ratio; a ratio > 30 is indicative of primary hyperaldosteronism
• Coarctation of the aorta - HTN in the upper extremities only, with unequal pulses, radiofemoral delay, and rib notching on CXR; associated with Turner syndrome. Get MRI or angiography
• Renal failure from any cause - In children, watch for poststreptococcal glomerulonephritis or hemolytic uremic syndrome.

Question 11

What does lowering blood pressure accomplish?

Answer 11

.Hypertension is the number-one modifiable risk factor for strokes. Lowering blood pressure decreases the risk for

• heart disease
• MI
• atherosclerosis
• stroke
• renal failure
• dissecting aortic aneurysm

Question 12

What is the most common cause of death among untreated patients with hypertension?

Answer 12

The same as for the general population—coronary artery disease.

Question 13

Which tests should be ordered for every patient with a diagnosis of HTN? Why?

Answer 13

1. ECG: determine whether the heart has been affected (LV hypertrophy).
2. BMP: look for secondary causes of HTN (electrolyte ∆s in Conn syndrome) and evaluation for diabetes.
3. UA: look for secondary causes of HTN (e.g., RBC casts in PIGN) and to kidney damage (proteinuria)
4. Hemoglobin and hematocrit: evaluate for anemia or polycythemia.
5. Lipid panel: evaluate for dyslipidemia as an additional risk factor for CAD