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 click ‘Continue’ to continue the affiliation switch, otherwise click ‘Cancel’ to cancel signing in. 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 Username Error: Please enter User Name Password Error: Please enter Password Forgot Username? Forgot Password? Sign in via OpenAthens Sign in via Shibboleth