Hypertension

Accurate BP measurement

  • Questions may involve how to accurately measure

    • After the pt empties their bladder and at least 30mins after coffee/exercise

    • Pt seated, feet flat, relaxed for 5 mins

    • Use correct size cuff (27-34cm for adults, 35-44cm for larger adults) directly on skin

    • Cuff at level of atrium with arm supported

    • Use higher reading when getting bilateral BPs

    • Consider out-of-office readings to R/O "white-coat HTN"

  • NEVER REPORT MANUAL BP IN ODD NUMBERS

BP cuff is a sphygmomanometer (ask someone to hand you a sphygmomanometer)

Everyone is hypertensive πŸ€·β€β™‚οΈ

Normal BP: 119/79

120/79 is elevated

120/80 is stage 1 HTN

Primary (Essential) hypertension (MC)

  • Pathogenesis is poorly understood but strongly associated with RF

    • ↑ age, ↑ BMI/↓PA , ↑ salt intake, ↑ etOH, family hx, race

Secondary hypertension

  • HTN attributed to a cause that you can identify and probably tx

    • Renovascular HTN (↓ blood flow to kidneys βž” rebound HTN)

      • Renal artery stenosis (usually associated with atherosclerosis)

    • Endocrine

      • Hypo/hyper-thyroid, Cushing's, pheochromocytoma

  • 2Β° SSX:

    • Resistant to meds

    • < 30yo with out family hx or risk factors

    • HTN with electrolyte disorder (hypoK/ ↑ pH)

  • 2Β° DX:

    • Primary hyperaldosteronism βž” ↑ aldosterone:renin ratio (ARR)

      • ↑ aldosterone (PAC) levels βž” ↓ renin activity (PRA)

  • SSX

    • Headache/dizzy/blurred vision/tinnitus/epistaxis

    • Usually ASX until end organ damage manifests

  • COMPLICATIONS of end organ damage)

  • Cardiac

    • LVH, HF, ischemic heart disease

  • Nephro

    • Chronic & end stage kidney disease

  • Neuro

    • CVA - ischemic stroke/intracerebral hemorrhage

  • Optic

    • Hypertensive retinopathy

  • What you should order:

    • Electrolytes

    • SrCr βž” eGFR

    • Fasting glucose

    • Urinalysis

    • CBC

    • TSH

    • Lipid profile

    • EKG

    • 10 Year ACVD risk

Flame hemorrhage - damaged vessels

Papilledema - ↑↑ pressure βž” optic disc swelling

Cotton wool spots - microinfarcts βž” damaged axons

Arteriovenous nicking - stiff and thick arteries displace and indent veins where they cross

HTN TX

  • Anyone with BP > 180 systolic or > 120 diastolic needs to come in (hypertensive crisis)

  • Elevated BP and stage 1 HTN without ASCVD or 10-year risk > 10%

    • Tries lifestyle modification first (weight loss, exercise, ↓ etOH) reassess 3-6 mo

      • DASH diet (Dietary Approaches to Stop Hypertension)

        • ↑ vegetables, fruits, low-fat dairy products, whole grains, poultry, fish, nuts; ↓ sugar and red meats

  • Stage 1 HTN with ASCVD or 10-year risk > 10%

    • Gets medication plus lifestyle modification, reassess in 1 mo

  • Goal BP 140/90 (150/90 when > 60yo)

    • If a pt is unresponsive to 1st drug, it is better to switch drugs rather than add

      • If pt responds but still > 140/90, then add a medication

      • Over time... pt will likely need multiple med classes

HTN MEDICATIONS

  • Thiazide/Thiazide-like diuretics

    • Indapamide, chlorthalidone > HCTZ

    • ADR: Hypokalemia, hyponatremia, metabolic alkolosis, hypercalcemia, hyperuricemia, hyperglycemia

  • Long-acting calcium channel blockers

    • Dihydropyridine βž” vasodilation

      • Amlodipine

    • Non-dihydropyridine βž” ↓ HR/contractility (with some vasodilation)

      • Verapamil, diltiazem

  • Angiotensin-converting enzyme (ACE) inhibitors

    • Capto, enala, rami, benaze-pril

    • ADR: hypotension and hyper-kalemia, cough, angioedema, CI in preg

  • Angiotensin II receptor blockers (ARBs)

    • Lo, val, irbe-sartan

    • ADR: hypotension and hyper-kalemia, CI in preg

Who gets what?

  • Consider age, race, and coexisting conditions

    • AGE

      • < 50yo monotherapy with ACEi/ARB

    • RACE

      • Black pts

        • Initial monotherapy: amlodipine (dihydropyridine CCB) or chlorthalidone (thiazide-like)

        • Combo therapy: ACEi/ARB and CCB (or ACEi/ARB and thiazide if ssx of hypervolemia)

    • Coexisting conditions

      • ACEi first line in HF, MI, DM, CKD

      • Ξ²-blockers: Added to ACEi in A-fib, post-MI, angina

      • Amlodipine for renal failure (↑ SrCr)

      • Osteoporosis: thiazides (↑ Ca reabsorption)

      • Preg: Labetalol, methyldopa, nifedipine

    • Avoid:

      • Avoid Thiazides in gout

      • Avoid Ξ²-blockers in COPD/bronchospasm and DM

        • COPD - can use cardioselective: atenolol, metoprolol

      • Avoid CCB in HF