Updated: 9/27/2020

Hypertension

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Snapshot
  • A 45-year-old African American man presents to his primary care physician for an annual wellness exam. He reports to feeling well and has no acute concerns. Medical history is unremarkable. He occasionally drinks a glass of wine every few days and does not smoke cigarettes. He exercises regularly and tries to maintain a healthy diet by incorporating more fruits, vegetables, and lean proteins. Physical examination is significant for a blood pressure of 155/105 mmHg. In his next two consecutive office visits, his blood pressures are 150/100 mmHg and 146/96 mmHg. He is started on hydrochlorothiazide.
Introduction
  • Clinical definition
    • a sustained increased systemic arterial pressure
      • typically defined as a
        • systolic blood pressure ≥ 140 mmHg OR 
        • diastolic blood pressure ≥ 90 mmHg
  • Epidemiology
    • risk
      • age
      • race
      • family history
      • physical inactivity
      • obesity
      • excessive alcohol use
      • high-sodium diet
  • Etiology
    • primary (essential) hypertension (accounts for ~95% of cases)  
      • idiopathic
    • secondary hypertension 
      • renal disease (e.g., fibromuscular dysplasia and renal artery stenosis)
      • pregnancy (e.g., eclampsia)
      • obstructive sleep apnea
      • hyperaldosteronism
      • thyroid disease
  • Pathogenesis
    • background
      • blood pressure is the product of cardiac output and peripheral vascular resistance (BP = CO X SVR)
        • cardiac output
          • a function of stroke volume and heart rate
            • sodium homeostasis affects stroke volume (e.g., high sodium diet increases the amount of water retained and thus increasing filling pressure, which determines stroke volume)
        • systemic vascular resistance
          • determined by the neural and hormonal inputs to the arteriole
      • the kidneys, heart, and adrenal glands work together to regulate vascular tone and blood volume
        • kidneys
          • e.g., renin-angiotensin-aldosterone system
        • heart
          • e.g., myocardial natriuretic peptides
        • adrenal glands
          • e.g., aldosterone
    • pathology
      • essential hypertension
        • a multifactorial processed influenced by genetics, the environment, reduced sodium excretion, and vasoconstrictive influences
      • secondary hypertension
        • depends on the underlying etiology
          • e.g., renal artery stenosis decreases the amount of glomerular flow and pressure sensed by the kidneys
            • this upregulates the renin-angiotensin-aldosterone system to increase blood pressure
  • Prognosis
    • ↑ risk of stroke and cardiovascular disease
Presentation
  • Symptoms
    • asymptomatic
      • most patients are not aware they have hypertension
Studies
  • Blood pressure measurements
    • the diagnosis should be based on ≥ 2 blood pressure readings in ≥ 2 visits
  • Pathophysiological changes 
    • decreased diastolic filling
    • normal ejection fraction
    • increased renin production
Treatment
  • Managment approach
    • in secondary hypertension, it is important to address the underlying problem
    • certain antihypertensive medications are indicated if it addresses a comorbid condition 
  • Conservative
    • weight loss
      • indication
        • for all patients
    • exercise
      • indication
        • for all patients
    • dietary modifications
      • indication
        • for all patients
  • Medical
    • first-line treatment options in patients without a specific indication for a particular agent that would address a comorbid condition
      • thiazide diuretics
      • angiotensin-converting enzyme inhibitors
        • cough is an important side effect
      • angiotensin receptor blockers
      • long-acting calcium channel blocker 
        • lower extremity edema is an important side effect
Complications
  • Ischemic or hemorrhagic stroke and transient ischemic attacks
  • Left ventricular hypertrophy 
  • Heart failure 
  • Chronic kidney disease
  • Visual disturbances (e.g., retinal hemorrhages and exudates)
  • Peripheral vascular disease
  • Aortic dissection
  • Aortic aneurysm
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(M1.CV.13.83) A 75-year-old man with hypercholesterolemia, coronary artery disease, and history of a transient ischemic attack (TIA) comes to your office for evaluation of his worsening hypertension. Two weeks ago, his blood pressure was 160/100 mmHg and his creatinine was 0.54 mg/dL. He was started on an ACE inhibitor. Today, he presents for a followup, his blood pressure is 180/115 mm Hg, and his creatinine is 1.2 mg/dL. The patient reports that he has been compliant with his blood pressure medication. What is the most likely cause of his hypertension? Tested Concept

QID: 100599
1

Progression of his essential hypertension

10%

(6/63)

2

Renal artery stenosis

78%

(49/63)

3

Coarctation of the aorta

0%

(0/63)

4

Pheochromocytoma

10%

(6/63)

5

Hypothyroidism

2%

(1/63)

M 1 E

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(M1.CV.13.124) A 75-year-old over-weight gentleman with a long history of uncontrolled hypertension, diabetes, smoking and obesity is presenting to his primary care physician with a chief complaint of increased difficulty climbing stairs and the need to sleep propped up by an increasing number of pillows at night. On physical examination the patient has an extra heart sound just before S1 heard best over the cardiac apex and clear lung fields. The EKG and chest x-ray are attached (Figures A and B respectively). What is the largest contributor to this patient's symptoms? Tested Concept

QID: 100640
FIGURES:
1

Long-term smoking

18%

(11/61)

2

Uncontrolled Hypertension

80%

(49/61)

3

Obesity

0%

(0/61)

4

Sleep Apnea

0%

(0/61)

5

Acute Myocardial Infarction

2%

(1/61)

M 1 E

Select Answer to see Preferred Response

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Evidence (6)
Topic COMMENTS (13)
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