Snapshot A 45-year-old man presents to see you complaining of shortness of breath and frequent headaches. His blood pressure was 160/85, 155/90, 162/90 mHg on three consecutive office visits despite having initiated a low-salt diet 6 months earlier, at your recommendation. He is not taking any medications, and does not have any other medical problems. You decide to initiate first-line medication to control his high blood pressure. Introduction Diagnosis is made after measuring BP > 140/90 mmHg three times from at least two separate clinical visits and is more common in older individuals and African-Americans 95% of all hypertension is idiopathic and called "essential" hypertension Secondary hypertension can be divided into four major categories, as follows cardiovascular aortic regurgitation wide pulse pressure finger nail pulsations (Quincke pulses) head bobbing (if severe) waterhammer pulses (quick upstroke and downstroke of pulse) coarctation of aorta HTN in upper extremity decreased BP in lower extremity commonly seen in Turner's syndrome (XO) renal glomerular disease proteinuria renal artery stenosis atherosclerosis commonly seen in older dyslipidemic males fibromuscular dysplasia commonly seen in young females polycystic disease family history autosomal dominant chromosome 4 (PKD2) and 16 (PKDA1) presents in adults autosomal recessive chromosome 6 seen in children/at birth endocrine Cushing's and Conn's HTN with hypokalemia and metabolic alkalosis high levels of aldosterone increase Na+ reabsorption (HTN) and the kidney excretes excess K+ (hypokalemia) and H+ (alkalosis) pheochromocytoma episodic symptoms tumor of the adrenal chromaffin cells episodic release of catecholamines that act on alpha and beta receptors hyperthyroidism isolated systolic HTN weight loss, irritability, tremor, fine hair and other signs of increased metabolic activity drug-induced oral contraceptives glucocorticoids HTN, fat redistribution, Cushing-like features phenylephrine α1 agonism increases vascular tone NSAIDs decrease renal prostaglandin release, decreasing GFR Presentation Symptoms asymptomatic until complications develop complications present with shortness of breath chest tightness headache vision changes Physical exam displaced PMI retinal changes A/V nicking and copper wire changes to the arterioles papilledema and retinal hemorrhages systolic ejection click loud S2 possible S4 heard on auscultation PVD might be found if bruits are appreciated distally Evaluation Diagnostic criteria hypertension elevation of systolic or diastolic BP >140/90 mmHg on two separate visits (3 or more BP readings) "prehypertension" = systolic BP of 120-139 mmHg or diastolic BP of 80-89 mmHg Treatment Goals of treatment want to get BP < 140/90 mmHg in most patients consider treating patients with ACE inhibitors even sooner if they have an underlying condition that can lead to hyperfiltration damage (diabetes, scleroderma renal crisis) Medical lifestyle modifications indications first line of treatment modalities including weight loss exercise obstaining from alcohol smoking cessation salt restriction decrease in fat intake and cholesterol control to reduce risk of CAD diuretic (HCTZ) and β-blockers (first line medications) indications lifestyle modification fail after 6 months to 1 year medications include diuretic (first-line HCTZ) and β-blockers (no comorbid disease) calcium channel blockers and ACEIs (second-line medications) indications lifestyle modification and first line medication fail Drug Indications Contraindications Side Effects β-blockers No comorbid disease Previous MI CAD Pregnant Young Caucasian Low EF Angina CAD Coexistent benign essential tremor Perioperative BP management COPD Hyperkalemia Hypoglycemic events Asthmatics Bradycardia Bronchospasm Erectile dysfunction Thiazide diuretics 1st-line medication if no comorbid disease 1st-line medication in isolated systolic hypertension African-Americans CHF Osteoporosis (thiazides) Gout Diabetes (thiazide) Renal failure (K+ sparing) Decrease excretion of calcium and uric acid; hypoNa ACEIs Diabetics Previous MI Chronic Kidney Disease Low EF Pregnancy Renal artery stenosis Renal failure Cough (substitute ARB) Angioedema Hyperkalemia Calcium channel blockers Second-line agents If other medication fails or if needed for controlling comorbidities Lower extremity edema α-blockers BPH CHF: can increase risk of heart failure Dizziness Headache Weakness Complications Hypertension left untreated can result in multiple chronic medical conditions including coronary artery disease renal failure stroke best way to prevent stroke is to control hypertension aneurysm intracerebral hemorrhage congestive heart failure systolic and diastolic peripheral vascular disease High Yield Medication Chart for Hypertension Treatment for Diseases Disease Blood Pressure Medication Indication Coronary artery disease β-Blocker Hyperthyroidism Grave's disease Congestive heart failure β-Blocker ACE-I ARB Migraine β-Blocker Calcium channel blcoker Osteoporosis Thiazide diuretics Hypocalcemia Depression Avoid β-blockers Asthma Pregnancy α-Methyldopa Labetalol Nifedipine Benign prostatic hypertrophy α-Blocker Diabetes ACE-I ARB Scleroderma ACE-I Peri-operative blood pressure management β-blockers (metoprolol)