Symptom To Diagnosis - Hypertension Flashcards
5 endocrine causes of HTN:
- Primary hyperaldosteronism.
- Pheochromocytoma.
- Thyroid.
- Hyperparathyroidism.
- Cushing.
2 renal causes of HTN:
- Chronic kidney disease.
2. Acute renal failure.
2 vascular causes of HTN:
- Renovascular disease.
2. COTA.
Pulmonary cause of HTN:
Sleep apnea.
GI cause of HTN:
Obesity.
10 drugs that cause HTN:
- Prolonged steroids.
- NSAIDS.
- Cox-2.
- Cocaine.
- Alcohol.
- Sympathomimetics (decongestants, anorectics).
- OCPs.
- Cyclosporine and Tacrolimus.
- EPO.
- Stimulants (modafinil, amphetamines).
Secondary causes of HTN are quite rare in unselected populations:
- 18%-4.4% –> Renovascular HTN.
- 04-0.2% –> Pheochromocytoma.
- 01-0.4% –> Primary hyperaldosteronism.
- 3% –> Cushing.
Patients who are normotensive at age 55 have a …% lifetime risk of developing HTN.
90%.
Across the BP range of 115/75mmHg to 185/115mmHg, each increment of 20mmHg systolic BP or 10 mmHg diastolic BP … the risk of cardiovascular disease.
Doubles.
There are 3 objectives of testing in patients with HTN:
Objective 1: Assess presence or absence of target organ damage (TOD).
Objective 2: Assess presence or absence of other cardiovascular risk factors.
Objective 3: Identify secondary HTN.
Initial testing in a patient with HTN and no clinical clues should include:
- ECG.
- Electrolytes.
- BUN/Cr.
- Calcium.
- TSH.
- Urine albumin-creatinine ratio.
- Fasting glucose.
- Fasting lipid panel (total cholesterol, HDL, TGs, LDL).
Assessing TOD - Heart:
- LV Hypertrophy - Physical exam, ECG, echocardiography in selected patients.
- CAD - History, ECG, stress test in selected patients.
- Heart failure - History, physical exam, echo.
Assess TOD - Brain:
- Stroke.
- TIA
- -> History, physical exam.
Assess TOD - Kidneys:
- Proteinuria.
- Chronic kidney disease.
- -> Albumin/creatinine ratio, serum creatinine.
Assess TOD - Eyes:
Retinopathy –> Fundoscopic or ophthalmologic exam.
Assess TOD –> Peripheral vasculature:
Peripheral vascular disease –> History and physical exam, ABI measurements in selected patients.
Non pharmacologic approaches to managing HTN:
Weight reduction –> 5-20mmHg/10kg weight loss.
DASH diet –> 8-14mmHg.
Reduced sodium diet ( 2-8mmHg.
Aerobic exercise 30 min/day, several days/week –> 4-9mmHg.
Limitation of alcohol 2-4mmHg.
Atherosclerotic renal artery stenosis - Textbook presentation:
- Patients generally have either very abrupt HTN.
- HTN that worsens over 6 months.
- HTN refractory to treatment with 3 drugs.
About …% of patients with renal artery stenosis have renovascular disease.
50%.
Predictive value of abdominal Bruits in renovascular HTN:
- Should listen to all 4 abdominal quadrants and also spine and flanks between T12 and L2.
- Should be systolic + diastolic.
- Prevalence 6.5-31% in a healthy population; prevalence of 28% in patients with HTN.
- Prevalence of 78-87% in patients with proven renal stenosis.
- Sens 39-63%, spec 90-99%.
Bilateral Renal artery stenosis - Response to ACEI:
A reversible increase in serum creatinine can develop in some patients with bilateral RAS when starting ACEI therapy.
- -> Peak creatinine somewhere between 4 days and 2 months.
- -> Cr returns to baseline within 1 week of stopping the ACEI.
Gold standard for renal artery stenosis imaging:
INTRA-arterial digital substraction angiography (DSA).
Primary hyperaldosteronism - How does it present?
A patient with HTN has unexplained hypokalemia.
Etiology of primary hyperaldosteronism:
- 30-60% –> Adenoma (Conn).
- Idiopathic bilateral adrenal hyperplasia in most other patients.
- Rarer causes include micro adenomas, unilateral adrenal hyperplasia, and adrenal carcinoma.
Prevalence of primary hyperaldosteronism:
True prevalence is UNKNOWN but could be as high as 12-15% in selected populations with resistant HTN.
Volume expansion in primary hyperaldosteronism suppresses?
Plasma RENIN levels.
Primary hyperaldosteronism - Most patients have … K levels.
Normal K levels (50-60%).
A normal potassium level does not rule out hyperaldosteronism.
What is commonly used as screening for primary hyperaldosteronism?
Plasma aldosterone concentration/plasma renin activity (ARR). Elevated in primary hyperaldosteronism.