Hypertension

Hypertension (HTN)

• an office blood pressure of 140/90 mmHg or above

  • taken at least twice on two separate days

• (though 2017 AHA considers 130/90 the cutoff value)

Hypertension Prevalence

• in the PH, shows a decreasing trend

• 32.9% (2013) → 19.2% (2018) for ages 20-59

• 41.2% (2015) → 35% (2018) for ages ≥ 60

Awareness:

• awareness is about 67.8%, of which 75% are treated, and 27% of treated have controlled HTN

• of 100% of people with it, only 47% are aware that they have it, 37% are treated, and only 14% have controlled BP

Sympathetic Nervous System Regulation

• baroreceptors in the carotid and aortic arch respond to changes in BP

• if elevated BP is sustained, the baroreceptors reset at higher levels

• this creates sustained elevated BP (the receptors are used to high BP)

Renin-Angiotensin-Aldosterone System (RAAS) Regulation

1. Renin is produced in the kidney

2. Angiotensinogen is produced in the liver

3. Produced Renin cleaves Angiotensinogen into Angiotensin I

4. ACE converts Angiotensin I to Angiotensin II

5. Angiotensin II acts on adrenal glands to produce Aldosterone

Primary Hypertension

Primary Hypertension

• also essential hypertension

• results from unknown pathophysiologic etiology

  • genetic factors may play a role

• cannot be cured, but can be managed

• more common

Secondary Hypertension

• results from specific cause

  • may be due to comorbid disease

  • may be due to drug

  • renal dysfunction due to CKD is most common cause

• can be mitigated and potentially cured

  • first step should be removal of offending agent

  • OR correction of underlying comorbid disease

• less common

Hypertensive Emergency

• type of hypertensive crisis

• severe elevations in BP (usually > 180/100)

• with presence of acute or ongoing target-organ damage

• requires immediate BP lowering

  • not necessarily to normal range, just to lower target range

  • goal is to lower BP to prevent or limit further target-organ damage

Hypertensive Urgency

• type of hypertensive crisis

• accelerated, malignant, or perioperative HTN without symptoms or new/progressive target-organ damage

• short-term risk is not as high; BP reduction occurs over several days

Modifiable Risk Factors

can be changed or altered

• smoking

• diabetes mellitus

• dyslipidemia/hypercholesterolemia

• obesity

• physical inactivity/low fitness

• unhealthy diet

Nonmodifiable Risk Factors

cannot or is difficult to change or alter

• CKD

• Family History

• Increased age

• Low socioeconomic status

• Low educational status

• Being male

• Obstructive Sleep Apnea

• Psychosocial Stress

Hypertension-Mediated Organ Damage

• structural or functional alteration of arterial vasculature or the organs it supplies that is caused by elevated BP

Brain:

• stroke

• dementia

Arteries:

• artery damage and narrowing

• aneurysm

• leg amputation

Heart:

• coronary heart disease

• heart attack

• congestive heart failure

Kidneys:

• kidney failure

• kidney artery aneurysm

Assessment for Hypertension-Mediated Organ Damage

• serum creatinine

• eGFR

• dipstick urine test

• 12-lead ECG

• MRI

• fundoscopy

• carotid ultrasound

• others

Hypertension Categories and Therapeutic Thresholds

for Filipino adults:

• Normal BP: < 120/80 mmHg

• Borderline BP: 120-139/80-89 mmHg

• Hypertension: ≥140/90 mmHg

Therapeutic Thresholds:

• Adults: treat at ≥140/90 mmHg

• Elderly (80 and up): ≥150/90 mmHg

  • elderly has higher threshold due to wear and tear of body and delayed onset of HTN problems

  • medication may cause more problems and may not be worth it if patient will not reasonably live for long enough for HTN to be a problem

(other guidelines’ categories in ppt)

(AHA has more stringent guidelines focusing on early prevention)

Risk Assessment

• no need to memorize table

Key Trends:

• higher # risk factors = higher risk of complications

• higher BP = higher risk of complications

• presence of organ damage (HMOD) = automatically high-risk for complications

Diagnosis

Diagnosis:

• based on elevated office BP readings taken at two separate occasions

• a single, markedly high BP reading is sufficient to establish hypertensive crisis

Assessment (Medical History)

Medical History:

• Blood Pressure

• Risk Factors

• Overall Cardiovascular Risk

• Signs and Symptoms of HTN or co-existent illness:

  • Chest Pain

  • Shortness of Breath (may indicate respiratory problem)

  • Palpitations

  • Claudication (extremity pain, may indicate peripheral complications)

  • Peripheral Edema

  • Headaches

  • Blurred Vision

  • Nocturia

  • Hematuria

  • Dizziness

• symptoms suggestive of secondary HTN

Assessment (Physical Exam)

Physical Examination:

• circulation and heart

  • pulse rate, rhythm, character

  • Jugular Vein Pressure (JVP)

    • may appear distended/bulging or visibly pulsate with heart or lung problem

  • extra heart sounds

  • basal crackles

    • popping sounds at base of lungs, suggesting fluid buildup/edema

• other organs/systems

Assessment (Laboratory Exams)

• blood tests

• urine tests

• 12-lead ECG (for heart function)

Algorithm for Evaluation of Patient with New-Onset/Uncontrolled Blood Pressure

• most of the time, patient seeks consultation due to uncontrolled blood pressure due to treatment

• screen for possible secondary causes

  • HTN may remain uncontrolled because underlying condition is not addressed

  • consider conditions such as malignant hypertension or marked hypokalemia

  • if these conditions, more serious and targeted investigation is necessary

Office BP Measurement

• blood pressure taken inside the clinic

  • controlled setting, ensures accurate results

• most common basis for HTN diagnosis and follow up

• diagnosis should be made based on 2 to 3 office visits

  • at 1 to 4 week intervals

• exception: if BP ≥ 180/110 mmHg, with evidence of CKD, diagnosis can be made in one visit (hypertensive crisis)

• must be confirmed with out-of-office BP measurement

Interpretation of Office BP Results

• < 130/85: remeasure within 3 years (1 year if with risk factors)

• 130-159/85-99: confirm with out-of-office measurement (if possible), or repeated visits

• >160/100: confirm within a few days or weeks

Out-of-Office BP Measurement

• BP measured at home, in community pharmacy, or with 24-hour ambulatory blood pressure monitoring (unless performed by a physician)

• more reproducible than office measurements

  • less affected by anxiety due to being observed by professional

  • better reflect patient’s actual day-to-day BP levels (representative of daily activity)

  • more closely correlated with HMOD and CV events

  • may identify white coat and masked hypertension

White Coat and Masked Hypertension

White Coat Hypertension:

• elevated BP in the office, normal BP in out of office

• seen in 10-30% of cases

• intermediate CV risk

Masked Hypertension:

• normal BP in office, elevated outside of office

• seen in 10-15% of cases

• similar CV risk to sustained HTN

• masked HTN is worse than white coat HTN

Cardiovascular Risk Comparison

Sustained/Actual HTN and Masked HTN > White Coat HTN > Normotensive Individuals

Medication History Screening

• screen patients w/ HTN or at risk for HTN for:

  • substances which may increase BP

  • substances that may interfere with BP lowering medications

• consider reducing or eliminating substances that raise BP

  • if substances are required or preferred, treat BP to goal anyway

Substances that Can Increase BP and Management Thereof (Summary)

NSAIDS:

• if analgesics are needed, consider alternatives

• utilize other routes (topical, local)

Recreational Drugs:

• discontinue

Steroids:

• can increase BP and induce/worsen other metabolic disorders (ex: DM)

• typically do not utilize oral/IV steroids

  • usually intranasal, topical, inhalation