Hypertension

Question 1

Etiology of hypertension

Answer 1

95% are Essential Hypertension, aka Idiopathic, Primary Hypertension.
Involves Sodium retention, Increased blood volume
Increased Vascular constriction and resistance.

The rest are Secondary hypertension, following a definable cause.

Question 2

Risk factors for essential hypertension

Answer 2

Genetics, highly heritable/familial correlation

Obesity, Smoking,

Sedentary life

High salt intake

Stress

Question 3

Secondary hypertension causes

Answer 3

Renal disease
Diabetes,
Polycystic kidney disease,
Glomerulonephritis, Vasculitides, Atherosclerosis Renal artery stenosis

Endocrine diseases
Hypercortisolism,
Pheochromocytoma,
Hyperthyroidism

Aortic Coarctation

Pregnancy, Preeclampsia

Obesity

Excessive salt intake

Question 4

Malignant hypertension

Answer 4

Systolic above 200, or diastolic above 130.
Presents with Headache and Visual Disturbances
Often with Proteinuria and Hematuria

Clinical emergency, rapid progression to RENAL failure and STROKE.

associated with hyperplastic arteriolosclerosis, onion skinning, and vessel necrosis/fibrinoid necrosis in the vessels small vessels of the kidney.

Question 5

Complications of hypertension

Answer 5

ACCELERATED ATHEROSCLEROSIS

heart –> MI
brain –> Strokes
Kidney 00> Renal failure

Question 6

Symptoms of severe HTX

Answer 6

Headache, dizziness, fatigue, visual distrubances.

4th heart sound

Question 7

HTX treatment indications

Answer 7

Patients with malignant HTX

Patients with evidence of CAD, cerebrovascular, or peripheral vascular disease, and BP > 140/90

Patients with evidence of LV hypertrophy, proteinuria, or retinopathy, and BP >140/90

Patients with no other comorbidities, but BP >160/100 persisting after lifestyle management.

Target is BP< 140/85
In DM patients, target should be more aggressive, <130/80

Question 8

Non-medical treatment

Answer 8

Indicated for all HTX patients.
Salt intake <2.4g/day

Limit alcohol, Stop smoking

Regular exercise

Maintain BMI below 25

DASH diet:
5 portions per day of fresh fruit or veggies
Miminize dietary fat and cholesterol
Whole grains, fish, chicken
Minimize sweetss and sugars

Question 9

HTX drug therapy:

Answer 9

5 major classes used:
ACE-Is
ARBs
Beta Blockers
Calcium channel blockers
Thiazide Diuretics. 

Similar efficacy at HTX management,
choice mainly based on side effects and other patient risk factors, limitations, drug interactions, and cost (coverage).

Monotherapies:
ACE-Is or ARBs - in young
Beta blockers - Esp if pregnant
Ca channel blockers

Combination therapies: Combined treatment is usually better, and more effective than increasing doses of individual agents.

Question 10

Specific indication for alpha blockers

Answer 10

Benign prostatic hyperplasia

Question 11

Specific indication for ACE-Is or ARBs

Answer 11

Heart failure
Established CAD
T1DM nephropathy
Clear LV hypertrophy

Question 12

Specific indication for Beta Blockers

Answer 12

Post MI
Angina
Heart failure

Question 13

Specific indication for Calcium Channel blockers

Answer 13

Isolated Systolic hypertension
Elder patients
Angina

Question 14

Specific indication for Thiazide diuretics

Answer 14

Elderly
Heart failure
Systolic hypertension.

Question 15

A+B combination

Answer 15

First line for young individuals, who typically have high RAAS activity

A ACEIs ARBs
B BBs

Question 16

C + D

Answer 16

first line for black patients and elderly
typically have lower Renin levels and are less responsive to the RAAS acting agents.

C Calcium antagonists
D Diuretic

Question 17

Risk for B + D combination

Answer 17

Slightly increases risk for T2DM

Question 18

Typical 2nd line

3rd line

4th line

Answer 18

A + C or D

A + C + D

Add Beta blocker, Aldosterone receptor blocker, 2nd diuretic,

Question 19

Urgent Malignant hypertension drugs to lower BP rapidly

Answer 19

First, oral BBs and/or CCBs

Refractory or deteriorating patients, or evidence of pulm edema:

IV Labetalol
IV Nitroprusside