Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content +++ 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 ... Your Access profile is currently affiliated with [InstitutionA] and is in the process of switching affiliations to [InstitutionB]. Please select how you would like to proceed. Keep the current affiliation with [InstitutionA] and continue with the Access profile sign in process Switch affiliation to [InstitutionB] and continue with the Access profile sign in process Get Free Access Through Your Institution Learn how to see if your library subscribes to McGraw Hill Medical products. Subscribe: Institutional or Individual Sign In Error: Incorrect UserName or Password Username Error: Please enter User Name Password Error: Please enter Password Sign in Forgot Password? Forgot Username? Download the Access App: iOS | Android Sign in via OpenAthens Sign in via Shibboleth You already have access! Please proceed to your institution's subscription. Create a free profile for additional features.