Hypertension

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: Cr, GFR, Na, K, fasting glucose, hematocrit (polycythemia -> polycystic kidney ds), UA, lipids, ECG

HTN 2

 

When to start anti-hypertensive medication?

  1. Younger than 60 yr: SBP > 140
  2. 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


HTN 1

 

Anti-hypertensive agents:

HTN 10htn-11.jpg

 


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”

 

HTN 7 


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

HTN 9

Treatment:

  • HTN urgency -> ↓ BP w\ oral agents (no need for hospitalizations)
  • HTN emergency -> hospitalize + ↓ BP w\ parenteral therapy (↓MAP by 25% in mins-2hrs)

HTN 8

 


Resistant Hypertension:  

  • 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

 


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

 


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

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