Updated: 9/29/2018

Hypertension

Topic
Review Topic
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Questions
4
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Evidence
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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
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
      • angiotensin receptor blockers
      • long-acting calcium channel blocker
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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Questions (4)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M1.CV.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 hypertension. Previously, his blood pressure was controlled with diet and an ACE inhibitor. Today, his blood pressure is 180/115 mm Hg, and his creatinine is increased from 0.54 to 1.2 mg/dL. The patient reports that he has been compliant with his diet and blood pressure medications. What is the most likely cause of his hypertension? Review Topic

QID: 100599
1

Progression of his essential hypertension

0%

(0/10)

2

Renal artery stenosis

80%

(8/10)

3

Coarctation of the aorta

0%

(0/10)

4

Pheochromocytoma

20%

(2/10)

5

Hypothyroidism

0%

(0/10)

M1

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PREFERRED RESPONSE 2

(M1.CV.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? Review Topic

QID: 100640
FIGURES:
1

Long-term smoking

12%

(1/8)

2

Uncontrolled Hypertension

88%

(7/8)

3

Obesity

0%

(0/8)

4

Sleep Apnea

0%

(0/8)

5

Acute Myocardial Infarction

0%

(0/8)

M1

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PREFERRED RESPONSE 2
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