Hypertension treatment and management

Question 1

To officially diagnosing hypertension

Answer 1

done by blood pressure, 2 measurements in office, separate days,

Cuff center at heart level,
Support arm horizontally at mid sternal level
Measure both arms.

Preferably measure in the sitting and standing position to check for postural hypotension

Confirm with 24 hr Ambulatory BP monitor or daily home tests for a week.

Question 2

Physical exam things that should always be checked in suspected hypertension

Answer 2

Retinas - grading of vessel damage 1-4

Heart size -
CXR or US for hypertrophy,
ECG for strain or IHD

All pulse points- symmetric

Auscultate renal arteries for bruits

Palpate kidneys

Question 3

Labs for hypertension

Answer 3

Blood hormones: 
Cortisol
Aldosterone
Renin
TSH
GH
Erythropoeitin

Blood Metabolic:
Glucose, fasting and random
Cholesterol, LDL, HDL, total, and TAGs

Blood electrolytes:
Sodium
Potassium
Calcium

Urine:
Proteinuria
Aluminuria
glucosuria
hematuria
ACR

Question 4

Imaging in hypertension

Answer 4

Renal ultrasound.

Question 5

Blood pressure values for hypertension and malignant hypertension

Answer 5

HTX > 140/90 in clinic, >135/85 for ABPM

Malignant >200 or >130

Question 6

What patient population is malignant htx most common in

Answer 6

Black, male, under 50 years

Question 7

Most common cause of secondary hypertension

Answer 7

Renal disease

75% intrarenal causes

25% renovascular disease, RA stenosis.

Question 8

Endocrine causes of secondary hypertension

Answer 8

Crushing's
Conn's
Pheochromocytoma
HyperPTHism
Acromegaly

Preggos

Question 9

Lifestyle treatment of hypertension

Answer 9

Limit Na intake <2.3 g/day sodium

Lose weight, BMI < 25kg/m2

Reduce cholesterol intake, eat veggies, etc.

Stop smoking

Limit alcohol

Regular exercise.

Question 10

When is drug treatment for HTX indicated?

Answer 10

For patients over age 80, above 150/90

For others, above 140/90

Diabetics above 130/80

Some studies indicate benefits for all patients above 120/80 once over age 50.

Question 11

What is main factor when deciding which drug to treat with

Answer 11

The effectiveness of lowering BP in your patient, and the tolerability for that patient.
bp drop is the most important part.

Question 12

1st line drug for black patients

Answer 12

Calcium channel blockers (verapamil), or thiazide

Question 13

1st line for non-black patients under 55 years

Answer 13

ACE-Is or ARBs.

Question 14

1st line for over 55 years

Answer 14

CCBs, or thiazide

Question 15

When are beta-blockers used for HTX

Answer 15

In younger patients, in women that will potentially become pregnant.
Or in intolerance to the other agents.

Question 16

Combination therapy for HTX

Answer 16

ACE-Is plus Calcium channel blocker OR diuretic.

Little evidence for benefit from triple combination, but all 3 can be used if 2 are not sufficient.

Or, add beta blockers
or, Spironolactone - K+ sparing diuretic.

Question 17

Which hypertensive drug is indicated for Diabetics?

Answer 17

ACEIs/ARBs

Question 18

Other alternative hypertensive drugs

Answer 18

Sympatholytics, clonidine

direct vasodilators, Hydralazine

Question 19

Treatment of malignant hypertension

Answer 19

If there are acute symptoms of encephalopathy: Urgent reduction is needed.
IV labetelol, or IV nitrates, to reduce diastolic BP to at least 110 mmHg over 4 hours.

If there are no seizures/mental changes/headache, the therapy is the same as other hypertensive therapy, and medications are orally given.

Goal to reduce bp to controlled range over time period of days. Rapid reduction can cause strokes, as cerebral regulation cannot rapidly compensate for very large drops in BP.

Question 20

Resistant hypertension types (4)

Answer 20

Resistant hypertension is high blood pressure in spite of triple drug treatment of HTN.

Pseudoresistant HTN: Poorly controlled HTN that appears resistant but is actually due to inaccurate bp measurement, poor lifestyle or drug compliance of the patient, or suboptimal prescribed drug therapy.

Apparent resistant HTN: accurate/appropriate drugs prescribed, but poor patient compliance.

True resistant: good scripts and good compliance, still HTN.

Refractory HTN: Resistant hypertension that remains even after maximal drug therapy with 5 drugs and high doses.