Hypertension I Pre-Class

Majority of patients have ______ HTN.

primary

_____ HTN: unclear etiology (could be lifestyle/environment, age, genetics)

primary

______ HTN: has an identifiable cause

secondary

What are identifiable causes of secondary HTN?

1. CKD

2. renal artery stenosis

3. primary aldosteronism

4. OSA

5. pheochromocytoma

6. drug-induced

7. thyroid disease

BP = _____ X _____

CO X TPR

Where do ACE-Inhibitors work in the RAAS?

converting enzyme from ATI to AT2

Where do ARB work in the RAAS?

block action of ATII at its receptor sites

Where do Beta blockers work in the RAAS?

decrease contractility

Where do CCB work in the RAAAS?

prevent muscle contraction that leads to vasoconstriction

Where does Thiazide work in the RAAS?

1. decrease total peripheral resistance

2. prevents sodium/water reabsorption

Main categories of target organ damage due to uncontrolled BP?

1. cardiac

2. neurologic

3. renal

4. ocular

Normal BP is defined as?

< 120 mmHg AND < 80 mmHg

Elevated BP is defined as?

120-129 mmHg AND < 80 mmHg

Stage I hypertension is defined as?

130-139 mmHg OR 80-89 mmHg

Stage II hypertension is defined as?

> 140 mmHg OR > 90 mmHg

BP Assessment includes?

1. minimum of two measurements at visit

2. utilize readings from > 2 visits

3. out-of-office readings

4. proper technique

____ HTN: No HTN in office/clinic, HTN at home/ABPM

masked

What would be recommended for a patient that had an office BP > 130/80 mmHg?

1. take BP at home

2. if still > 130/80, start antihypertensive drug (HTN)

3. if < 130/80, lifestyle modification & annual BP monitoring at home (white coat HTN)

What would be recommended for a patient that had an office BP 120-129/< 80 mmHg?

1. take BP at home

2. if > 130/80, start a antihypertensive drug (masked HTN)

3. If < 130/80, lifestyle modification & annual BP monitoring at home (elevated BP)

What history may suggest a patient has secondary HTN?

1. BP variability, episodic pallor & dizziness (pheochromocytoma)

2. snoring, daytime sleepiness (obstructive sleep apnea)

3. prostatism (CKD)

4. muscle cramps, weakness (aldosteronism)

5. weight loss, palpitations, heat intolerance (hyperthyroidism)

6. edema, fatigue, frequent urination (kidney disease)

7. central obesity, easy bruisability (Cushing's syndrome)

8. medication or substance use (alcohol, NSAIDs, cocaine, amphetamines)

9. no family history of HTN

What conditions suggest we need to screen for secondary HTN?

1. drug resistant/induced HTN

2. abrupt onset of HTN

3. onset of HTN at < 30 y

4. exacerbation of previous controlled HTN

5. disproportionate TOD for degree of HTN

6. accelerated/malignant HTN

7. onset of diastolic HTN in older adults (> 65 yo)

8. unprovoked or excessive hypokalemia

What secondary cause is heavily associated with resistant HTN?

obstructive sleep apnea

What is recommended for a patient with BP < 120/80?

1. promote optimal lifestyle habits

2. reassess in 1 year

What is recommended for a patient with elevated BP 120-129/

1. nonpharmacologic therapy

2. reassess in 3-6 months

What is recommended for a patient with Stage I HTN SBP 130-139 OR DBP 80-89?

1. asses if they have clinical ASCVD OR 10-year CVD risk > 10% OR diabetes OR CKD

2. if they do, BP lowering medication indicated with reassessment in 1 month

3. if they do not, non pharmacological therapy with reassessment in 3-6 months

If a patient with Stage I or II HTN is reassessed in 1 month on their new BP lowering medication and their goal is not met, what do you do?

1. assess & optimize adherence to therapy

2. consider intensification of therapy

What is recommended for a patient with Stage 2 HTN SBP > 140 OR DBP > 90 mmHg?

BP-lowering medication(s) with reassessment in 1 month

Which specific BP medication initiation would prompt the need to assess blood tests for electrolytes & renal function in 2-4 weeks?

1. ACE inhibitors

2. thiazide

What is the BP goal for all hypertensive patients on pharmacological therapy?

< 130/80 mmHg

How is resistance to HTN treatment confirmed?

1. office BP > 130/80 AND patient prescribed > 3 medications at optimal doses, including a diuretic

OR < 130/80 but requires > 4 antihypertensive meds

2. exclude pseudo resistance (accurate measurements, non adherence assessment, obtain home BP to exclude white coat effect)

3. identify & reverse contributing lifestyle factors

4. discontinue or minimize interfering substances (i.e. sympathomimetics, stimulants, oral contraceptives, NSAIDs)

5. screen for secondary causes of hypertension (aldosteronism, CKD, OSA, etc)

What medications/substances may cause elevated BP?

1. alcohol

2. amphetamines

3. antidepressants

4. atypical antipsychotics (i.e. clozapine)

5. caffeine

6. decongestants (i.e. phenylephrine, PSE)

7. herbal supplements

8. immunosupressants (i.e. cyclosporine)

9. oral contraceptics

10. NSAIDs

11. recreational drugs (cocaine, meth)

12. systemic corticosteroids (i.e. prednisone)

13. angiogenesis inhibitor (i.e. bevacizumab)

14. tyrosine kinase inhibitors (i.e. sunitinib)

What SBP/DBP is considered to be a hypertensive crises?

> 180/>120 mmHg

How do you determine if it's a hypertensive emergency or just markedly elevated BP?

presence of target organ damage that is new/progressive/worsening

What examples of target organ damage can lead to a hypertensive emergency?

1. encephalopathy

2. ICH

3. acute ischemic stroke

4. acute MI

5. LV failure with pulmonary edema

6. unstable angina

7. dissecting aortic aneurysm

8. acute renal failure

9. eclampsia

Lifestyle modifications recommended by the guidelines?

1. diet modification (DASH diet)

2. sodium restriction (< 1500 mg/day)

3. physical activity

4. additional: weight loss, reduce alcohol intake