JH IM Board Review - Hypertension I Flashcards
Hypertension is present in nearly …%?
30% of the general population.
HTN definition:
BP > 140/90mmHg or higher (SBP>140 OR DBP>90 OR BOTH).
Classification of BP:
Normal ==> <120 AND <80.
PreHTN ==> 120-139 OR 80-89.
STAGE 1 ==> 140-159 OR 90-99.
STAGE 2 ==> >160 OR >100.
The classification of BP applies to …?
Patients NOT taking antihypertensives + WITHOUT acute illness (which may raise or lower BP).
==> Patients taking antihypertensive medication are considered to have HTN.
If the SBP and DBP fall in different stages …?
The HIGHER stage is used.
==> A BP of 182/95 is categorized as stage 2.
Prehypertension is a …?
RISK CATEGORY (not a disease).
==> High risk of progressing to actual HTN and should be targeted for lifestyle modifications.
Hypertensive URGENCY:
Severe HTN WITHOUT ACUTE END-ORGAN DYSFUNCTION.
There is NO AGREED-UPON BP that defines hypertensive URGENCY, although …?
Some sources use 180/120.
What often contributes to elevated BP in patients with hypertensive urgency?
- Headache.
- Anxiety.
- Medication nonadherence.
Hypertensive emergency implies …?
Elevated BP WITH ACUTE END-ORGAN DYSFUNCTION.
Although hypertensive emergency is not defined by any specific level of BP, most patients have …?
BPs 180/120 of higher.
Epidemiology of HTN:
- Affects more than 60 million Americans.
- MC modifiable CV risk factor.
- More prevalent among AFRICAN AMERICANS, who also experience more end-organ damage.
There is a GRADED relationship between BP level and the incidence of …?
- Stroke.
- ESRD.
- HF.
- IHD.
Younger than 50, what is the most important predictor of adverse cardiovascular outcomes?
DIASTOLIC BP.
Older than 50, what is the most important predictor of adverse cardiovascular outcomes?
SYSTOLIC BP.
The prevalence of HTN rises with age:
SBP rises continuously.
DBP rises until approximately age 50 and then DECLINES.
ISOLATED SBP (SBP >140 and DBP <90) is …?
COMMON among the ELDERLY and is an IMPORTANT CV RISK FACTOR.
BP is the product of cardiac output and peripheral vascular resistance.
Increased CO can play a role in the INITIATION OF HTN.
==> However, most patients with long-standing HTN have increased peripheral resistance with normal or diminished CO.
In some “salt sensitive” patients, BP responds strongly to …?
Changes in sodium intake and extracellular fluid.
==> Salt sensitivity occurs more commonly among African Americans AND elderly.
End-organ damage from HTN can affect the …?
- Kidneys.
- Heart.
- Vasculature.
- Brain.
- Eyes.
HTN - CP:
Most patients are ASYMPTOMATIC.
==> Some have evidence of target organ damage at first presentation.
==> Occasionally, patients may present with hypertensive urgencies or emergencies.
7 Manifestations in ACUTE end-organ damage in hypertensive emergency:
- Hypertensive encephalopathy.
- Intracranial hemorrhage.
- Unstable angina.
- Acute myocardial infarction.
- LV failure with pulmonary edema.
- Acute aortic dissection.
- Eclampsia.
Hypertensive encephalopathy:
- Headache.
- Altered mental status.
- Seizures.
- Nausea, vomiting.
- Papilledema.
- Abnormalities on brain imaging.
Intracranial hemorrhage:
- Headache.
- Altered mental status.
- Focal neurologic abnormalities.
- Hemorrhage on brain imaging.
Unstable angina:
- Chest pain.
2. ECG abnormalities.
Acute myocardial infarction:
- Chest pain.
- ECG abnormalities.
- Cardiac enzyme elevation.
LV failure with pulmonary edema:
- Dyspnea.
- Hypoxia.
- Pulmonary congestion on chest imaging.
Acute aortic dissection:
- Chest pain.
- Syncope.
- End-organ ischemia.
Eclampsia:
- Proteinuria.
2. Seizures.
Clinical manifestation of CHRONIC target organ damage in HTN - 5 systems:
- Heart.
- Brain.
- Eyes.
- Vasculature.
- Kidneys.
Clinical manifestation of CHRONIC target organ damage in HTN - Heart:
A. LV HYPERTROPHY ==> Enlarged PMI (point of maximum impulse) or S4 gallop/ Evidence of LVH on ECG or ECHO.
B. LV DYSFUNCTION ==> Signs/symptoms of CHF / Enlarged PMI or S3 gallop/ Systolic or diastolic dysfunction on ECHO.
C. CAD ==> Angina/ History of MI, PCI, CABG.
Clinical manifestation of CHRONIC target organ damage in HTN - Brain:
Cerebrovascular disease ==> Hx of stroke/ Carotid bruit.
Clinical manifestation of CHRONIC target organ damage in HTN - Eyes:
Retinovascular disease:
- Arteriolar narrowing.
- AV nicking.
- Hemorrhage.
- Exudates.
Clinical manifestation of CHRONIC target organ damage in HTN - Vasculature:
Atherosclerosis.
- Claudication.
- Diminished or absent pulses.
- Renal or femoral bruits.
Clinical manifestation of CHRONIC target organ damage in HTN - Kidneys:
Hypertensive nephrosclerosis, ESRD.
- Proteinuria or microalbuminuria.
- Elevated serum Cr.
HTN - Dx and evaluation - Measurement of BP:
- Allow pt to relax and sit quietly for more than 5 min.
2. The patient should also refrain from smoking or consuming caffeine for more than 30 min before BP measurement.
HTN - Dx and evaluation - Use an appropriate sphygmomanometer cuff size:
The bladder cuff should encircle 80% or more of the arm without overlapping.
==> Using a smaller cuff may yield falsely elevated readings.
The arm in which BP is measured should be …?
Supported and relaxed at the level of the heart.
BP should be measured in both arms, and …?
The higher of the 2 readings used.
At each clinical visit, the BP preferably should be taken at least …?
TWICE in the arm with the HIGHER BP measurement.
==> The average BP should guide management.
2 methods to assess BP:
- Auscultatory method ==> SBP is defined as the 1st appearance of the Korotkoff sounds, and DBP is defined as the disappearance of Korotkoff sounds.
- Oscillometric method ==> Electronic BP measurement devices, which detect pressure fluctuations in the cuff.
==> This method is often preferred over the auscultatory method because it is not subject to human bias or error.
Elevated BP reading on 2 SEPARATE CLINICAL VISITS should be obtained before classifying a patient as hypertensive.
However, …?
If BP is very high (SBP >180) on MULTIPLE READINGS at the initial visit, it is reasonable to start antihypertensive medications at that time.
In elderly patients, or when orthostatic hypotension is suggested, …?
STANDING BP measurements should be taken.
Some pts may have marked discrepancy between BP measurements obtained at home and in the clinic:
- Elevated BP in clinic with normal out-of-office readings ==> White-coat hypertension.
- Elevated out-of-office BP with normal clinic readings is referred to as MASKED hypertension.
==> In EITHER CASE, home BP readings and/or 24h ambulatory BP monitoring should be obtained and used to guide management.
For DAYTIME home BP monitoring, HTN is defined as an average …?
Average BP greater than 135/85.
For 24h BP monitoring (which includes readings taken during sleep), …?
An AVERAGE BP greater than 130/80 is considered HYPERTENSIVE.
3 Goals in INITIAL evaluation of the hypertensive patient:
- Assess for target organ damage.
- Identify comorbidities.
- Identify other cardiovascular disease risk factors.
Assess for target organ damage - Requires:
Comprehensive physical examination:
- Vital signs.
- Body mass index.
- Cardiopulmonary systems.
- Auscultation of the major blood vessels to identify bruits in the eyes, neurologic system, and limbs.
Identify comorbidities:
- DM.
- CKD.
- Ischemic heart disease and cardiomyopathy.