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Snap Shot
  • A 45-year-old man presents to see you complaining of shortness of breath and frequent headaches. His blood pressure was 160/85, 155/90, 162/90 on three consecutive office visits despite having initiated a low-salt diet 6 months earlier, at your recommendation. He is not taking any medications, and does not have any other medical problems. You decide to initiate a first-line medication to control his high blood pressure.
Introduction
  • Diagnosis 
    • made after measuring BP > 140 / 90 three times
      • from at least two separate clinical visits
      • if a patient has an elevated BP the best initial step is to repeat the blood pressure to ensure that the hypertension is real
    • more common in older individuals and African-Americans
    • prehypertension = systolic BP of 120 -139 or diastolic BP of 80 - 89
  • Pathophysiology
    • determinants of blood pressure
      • systolic depends on stroke volume (approximates preload)
        • stroke volume depends on blood volume, HR, contractility
      • diastolic depends on peripheral resistance (approximates afterload)
    • role of sodium
      • can ↑ blood volume → ↑ systolic
      • can ↑ vasoconstriction → ↑ diastolic
  • Types
    • essential hypertension
      • 95% of all hypertension
      • idiopathic vasoconstriction of arterioles
      • ↓ renal sodium excretion (commonly in African-Americans, elderly)
    • secondary hypertension 
      • causes
System
Disease process
Presentation
Cardiovasular Aortic regurgitation Wide pulse pressure, head bobbing, Quincke's pulses, waterhammer pulses
Coarctation of aorta

↑ BP in UE, ↓ BP in LE

Renal Glomerular Disease Proteinuria
Renal artery Stenosis Atherosclerosis, fibromuscular dysplasia, stenotic side has ↑ renin release, contralateral side has ↓ renin release, epigastric bruit
Polycystic Disease renal function
Endocrine Cushing's and Conn's HTN with metabolic alkalosis, hypokalemia and ↑ mineralocorticoids and aldosterone

 

Pheo chromocytoma Episodic symptoms due to ↑ catecholamine release
Pregnancy (eclampsia) ↑ synthesis of angiotensin II
Hypothyroidism diastolic HTN due to ↑ sodium retention
Hyperthyroidism Isolated systolic HTN
Hyper parathyroidism ↑ calcium results in ↑ arteriolar contraction
Drug induced

Oral contraceptives (↑ synthesis of angiotensinogen), Cocaine (vasospasm


Presentation
  • Symptoms
    • patients are asymptomatic until complications develop
    • often present with shortness of breath, chest tightness, headache, or vision changes
    • associated with obesity
Complications
  • Un/undertreated hypertension predisposes to
    • CAD/atherosclerosis
    • left ventricular hypertrophy followed by left ventricular dilation (late stage)
    • stroke
      • intracerebral bleed (rupture of Charcot-Bouchard aneurysms)
      • lacunar infarcts (sequelae of hyaline arteriolosclerosis)
    • CHF
      • systolic and diastolic
    • renal failure
      • benign nephrosclerosis (sequelae of hyaline arteriolosclerosis)
      • tubular atrophy
    • retinopathy
      • retinal hemorrhage, exudates
    • aneurysm/aortic dissection
Management
  • choose a blood pressure medications based on patient's comorbitidies
    • thiazide diuretics
      • typically first line
      • indicated in
        • hypocalcemia
        • osteoporosis
    • ACE inhibitor
      • indicated in
        • diabetes
        • scleroderma (renal crisis)
    • beta-blocker
      • indicated in
        • CHF
        • migraine headache
      • contraindicated in
        • depression
        • asthma (weak contraindication, many patient benefit more from beta-blockade as compared to symptoms of bronchoconstriction)
    • calcium channel blockers
      • migraine headache
      • Raynaud's phenomenon
    • ARB
      • same indications for ACE inhibitor in patient's who can't handle ACE inhibitor side effects
 

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