Chapter 10-03: Diseases & Pathophysiology in General Medicine

HYPERTENSION

• Goals Per Joint National Committee 8 (JNC8): See Figure 10.2

  • - Patients without diabetes or CKD:

    • Age <60 yr: Goal <140/90 mmHg

    • Age ≥60 yr: Goal <150/90 mmHg

  • - Patients with diabetes (no CKD): Goal <140/90 mmHg

  • - Patients with CKD (+/– diabetes): Goal <140/90 mmHg (although some nephrologists recommend SBP <130 mmHg, especially if proteinuria)

• Emerging evidence: There is some evidence that targeting a goal SBP <120 mmHg reduces mortality and decreases nonfatal cardiac events, but controversial (SPRINT trial, New Eng J Med 2016)

• Etiology:

  • - Essential hypertension (estimated 95% of hypertension cases):

    • Risk factors: Older age (M >55 yr, F >65 yr), male gender, black or African American race, obesity, family history, salt intake, alcohol use

  • - Secondary hypertension (estimated 5% of hypertension cases):

    • Renal/renovascular: Renal artery stenosis, chronic renal failure, polycystic kidney disease

    • Endocrine: Hyperaldosteronism, Cushing’s, pheochromocytoma, hypo/hyperthyroidism, acromegaly

    • Medications/drugs: Oral contraceptive pills, decongestants, estrogen, chronic steroids, TCAs, NSAIDs, cocaine

    • Coarctation of the aorta (differential hypertension in each arm with brachial-femoral pulse delay)

    • Sleep apnea

• Complications:

  • - Cardiac: CAD can result in angina/MI; left ventricular hypertrophy, which can lead to CHF

  • - Neurologic: Intracerebral hemorrhage or other stroke subtypes: TIAs, ischemic strokes, lacunar stroke; posterior reversible encephalopathy syndrome (PRES)

  • - Kidneys: Arteriosclerosis called nephrosclerosis; decreased GFR with eventual renal failure

  • - Eyes: AV nicking (discontinuity in retinal vein due to thick artery wall), scotomata, copper wiring, cottonwood, papilledema

• Diagnosis:

  • - Two elevated blood pressure measurements at least 1 week apart

    • Accurate blood pressure measurement is dependent upon technique. The patient should be seated, resting (ideally for >5 minutes prior), the arm should be at heart level, and the blood pressure cuff should be the correct size.

  • - Physical exam: May be normal, but should evaluate for the following:

    • Eyes: Copper wiring, AV nicks, cottonwood spots

    • Neck: Elevated jugular venous pressure (JVP), carotid bruits

    • Heart: S4 (LVH), S3 (dilated), displaced point of maximal impulse (PMI)

    • Abdominal: Abdominal aortic aneurysm (pulsatile epigastric mass), abdominal bruit, renal bruit

  • - At time of initial diagnosis, check the following studies:

    • Urinalysis for occult hematuria, proteinuria

    • Chemistry panel (evalute for renal dysfunction)

    • Lipid profile, hemoglobin A1c

    • Women (age <50 yr): Discuss fertility goals and consider checking a pregnancy test if indicated (important because thiazides diuretics, ACEi/ARBs, and CCBs are contraindicated in pregnancy/teratogenic)

    • Consider baseline EKG, TTE

    • If severe hypertension, resistant hypertension (hypertension despite three anti-hypertensive agents at adequate doses), or age of onset <30 yr (especially if the patient is not obese and does not have a family history of hypertension) consider further workup for etiologies of secondary hypertension (e.g., consider checking plasma aldosterone to renin ratio, TSH, sleep study)

• Treatment:

  • - Lifestyle modifications: Weight loss (most effective), DASH diet (2–4 g salt/day), exercise, smoking and alcohol cessation

  • - Anti-hypertensive medications: See Figure 10.2 and medication classes on the next page. There is an increasing preference to counsel patients to take anti-hypertensive medications at night.

• Monitoring:

  • - Check blood pressure at every ...