Essential Hypertension:
Definitions:
- HTN: ≥ 140\90
- Isolated systolic HTN: SBP >140 and DBP <90
- Isolated diastolic HTN: SBP <140 and DBP > 90
- White coat HTN: office readings > 140\90 but out of office readings < 140\90
- Definition of HTN based on home\ambulatory reading:
- 24 hr average: > 135\85
- Day time average: > 140\90
- Night time average: > 125\75
Classification:
» If systolic and diastolic are in different stages -> use the higher stage
- Normal: < 120\80
- Pre-hypertensive: 120-139 \ 80-89
- Stage 1 HTN: 140-159 \ 90-99
- Stage 2 HTN: ≥160\100
Pathophysiology:
- Genetic + environmental
Diagnosis:
- 2 or more readings on 2 separate clinic visits
- Lab investigations:Â Cr, GFR, Na, K, fasting glucose, hematocrit (polycythemia -> polycystic kidney ds), UA, lipids, ECG
When to start anti-hypertensive medication?
- Younger than 60 yr: SBP > 140
- Older than 60 yr: SBP > 150
- Initial monotherapy: thiazide, long acting Ca channel blocker, ACEI\ARBs
- If inadequate response -> increase dose OR add another
- 2 drugs -> stage 2 HTN
Indications: | |
CKD, DM | ACEI\ARBs |
CHF | ACEI\ARBs, diuretics, aldosterone antagonist |
MI | B-blockers, ACEI, aldosterone antagonist |
BPH | a-adrenergic blockers |
Angina, migraine, essential tremor | B-blockers |
Contraindications: | |
Pregnancy | ACEI\ARBs |
Asthma, COPD, PAD | B-blockers |
Gout | Diuretics |
Heart block | B-blockers, verapamil, diltiazem |
Anti-hypertensive agents:
Secondary Hypertension:
Clues:
- Age of onset < 30 or > 50
- BP > 180\110 at dx
- Resistant HTN to 3 or more drugs including diuretics
Causes:
- Renal A stenosis: check table!
- Pheochromocytoma: check table!
- Hyperaldosteronism: check table!
- Hypercortisolism: check table!
- OSA
- Hypo\hyper thyroid, hypercalcemia
- Polycythemia
- Drugs: OCP, steroids, NSAIDs, EPO, cyclosporine, licorice
- Coarctation of aorta:
- In children \ adulthood
- HTN in upper extremities, no\delayed femoral pulses, low\no BP in lower extremities
- Machinery murmur over post chest
- CXR: rib notching + “3 sign”
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Hypertensive Crisis:
Definitions:
- Hypertensive urgency: severe HTN w\out acute target organ damage
- Hypertensive emergency: severe HTN w\ acute end organ damage
- Malignant HTN: check table for clinical features!
- Accelerated HTN: same as malignant HTN but w\out papilledema
Treatment:
- HTN urgency -> ↓ BP w\ oral agents (no need for hospitalizations)
- HTN emergency -> hospitalize + ↓ BP w\ parenteral therapy (↓MAP by 25% in mins-2hrs)
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Resistant Hypertension: Â
- Uncontrolled BP despite: 3 or more including diuretics OR 4 or more meds
- Mainly due to secondary causes of HTN
Treatment:
- For persistent volume expansion -> chlorthalidone (preferred to hydrochlorothiazide)
- If GFR < 30 -> loop diuretics
- Aldosterone antagonists
- If still uncontrolled -> labetalol, clonidine, hydralazine, minoxidil
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Hypertension in Pregnancy:
- Chronic HTN: HTN dx before pregnancy or before 20th week
- Gestational HTN: HTN developing after 20th week
- Preeclampsia: gestational HTN + proteinuria
- Eclampsia: preeclampsia + seizures
Treatment:
- When to start?
- SBP > 150 in 2nd trimester
- DBP > 100 in 2nd trimester
- SBP > 160 in 3rd trimester
- First line? Methyldopa
- For hypertensive crisis? Labetalol, IV hydralazine, oral nifedipine (avoid nitroprusside)
- For eclampsia \ preventing recurrent seizures? Magnesium sulfate
- What are the indications of delivery?
- After 34th week: preeclampsia
- Before 34th week: worsening maternal symptoms, end organ damage, deterioration of fetus
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Random notes:
- MCC of death among HTN pt -> CAD
- HTN is the second MCC of ESRD (1st is DM)
 Download the PDF version: here
References:
- The Johns Hopkins Internal Medicine Board Review
- Dr Alrasheed’s lecture