Hypertension

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  • Hypertension
    • Defined as an SBP > 140 or DBP > 90 on two separate occasions (MCQ)
    • 25 to 35% of adults have hypertension
    • Etiology
      • Essential hypertension (primary, idiopathic)
      • Secondary causes:
        • Renal parenchymal disease (chronic pyelonephritis)(MCQ)
        • Renal artery stenosis
        • Primary hyperaldosteronism (Cushing’s and Conn’s syndromes)
        • Pheochromocytoma(MCQ)
        • Eclampsia and preeclampsia
        • Coarctation of the aorta (congenital)(MCQ)
    • Pathophysiology
      • Usual mechanism is a normal cardiac output with increased peripheral vascular resistance.(MCQ)
    • Risk factors
      • Diabetes
      • High-sodium diet (MCQ)
      • Obesity
      • Tobacco use
      • Family history of hypertension
      • Black race
      • Malegender(MCQ)
    • Signs and symptoms
      • Most patients with hypertension have no symptoms.
      • Patients with severe hypertension may present with:
        • Light-headedness
        • Morning occipital headaches
        • Epistaxis
        • Hematuria
        • Blurred vision
        • Angina
        • Congestive heart failure
    • Diagnosis/evaluation
      • Blood pressure in both arms, repeated if abnormal
      • Funduscopic examination to look for AV nicking, hemorrhage, papilledema(MCQ)
      • Auscultation for renal artery bruits(MCQ)
      • ECG may show LVH or left ventricular strain.(MCQ)
      • Urinalysis to look for active sediment, hematuria
      • Blood urea nitrogen (BUN)/creatinine, serum potassium (evidence of renal insufficiency)
    • Treatment
      • For repeated elevated blood pressure measurements:
        • Dietary changes: (MCQ)
          • High fruits, vegetables
          • low-fat dairy products, lowtotal and saturated fats, low salt
        • Weight loss, physical exercise
        • Low-dose thiazide diuretics are first choice for stage 1 hypertension.(MCQ)
        • Low-dose ACE inhibitor, calcium channel blockers, or beta blockers arealso effective.(MCQ)
      • Two- or three-drug therapy for patients not initially controlled
    • Complications of hypertension(MCQ)
      • Stroke
      • MI
      • Atrial fibrillation
      • Heart failure
      • Peripheral vascular disease
      • Renal disease
    • Hypertensive emergency
      • Malignant hypertension is characterized by severely elevated blood pressure accompanied by end-organ damage.
      • Features that should alert the physician to the need for rapid blood pressure reduction.(MCQ)
        • New-onset neurologic signs, papilledema
        • chest pain
        • heart failure
        • renal failure
      • Diagnosis
        • Presence of end-organ damage (ECG changes, new-onset renal failure, active urinary sediment, intracranial bleed, etc.)
      • Treatment
      • Reduce the mean arterial pressure by no more than 20%.(MCQ)
      • Common intra- venous agents include:(MCQ)
        • Labetalol
        • Nitroprusside
        • Phentolamine for pheochromocytoma
        • Hydralazine or magnesium for preeclampsia-related hypertension

Clinical Pearls :

      • Over 90% of hypertension is essential, or idiopathic.
      • Hypertension due to pheochromocytoma is characterized by ectopic production of epinephrine and norepinephrine, causing wide swings in blood pressure.(MCQ)
      • A 29-year-old woman with preeclampsia treated with IV drip of magnesium complains of difficulty breathing and has diminished reflexes. What is next step?
        • Stop magnesium and give IV calcium.(MCQ)
      • An active urinary sediment contains blood, protein, and red and white cell casts.
      • Use parenteral blood pressure–lowering agents only if end-organ damage is found, due to the risk of rapid reduction in coronary and cerebral perfusion.
      • The mean arterial pressure is:(2DBPSBP)/3(MCQ)
      • Nitroprusside can cause cyanide toxicity.(MCQ)

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      • Low potassium intake is associated with higher blood pressure in some patients; an intake of 90 mmol/d is recommended(MCQ)
      • Polycythemia, whether primary or due to diminished plasma volume, increases blood viscosity and may raise blood pressure. (MCQ)
      • Nonsteroidal anti-inflammatory drugs (NSAIDs) produce increases in blood pressure averaging 5 mm Hg and are best avoided in patients with borderline or elevated blood pressures.
      • The metabolic syndrome (sometimes also called syndrome X or the “deadly quartet”) consists of (MCQ)
        • upper body obesity
        • hyperinsulinemia and insulin resistance
        • hypertriglyceridemia
        • hypertension
      • Liddle syndrome (MCQ)
        • anautosomal dominant condition
        • characterized by
          • early-onset hypertension
          • hypokalemic alkalosis
          • low renin and low aldosterone levels.
        • This is caused by a mutation that results in constitutive activation of the epithelial sodium channel of the distal nephron, with resultant unregulated sodium reabsorption and volume expansion.
      • Renal artery stenosis (MCQ)
        • present in 1–2% of hypertensive patients.
        • Its cause in most younger individuals is fibromuscular hyperplasia, particularly in women under 50 years of age.
        • The remainder of renal vascular disease is due to atherosclerotic stenoses of the proximal renal arteries
      • Renal vascular hypertension should be suspected in the following circumstances: if the documented onset is before age 20 or after age 50 years(MCQ)
        • hypertension is resistant to three or more drugs
        • if there are epigastric or renal artery bruits
        • if there is atherosclerotic disease of the aorta or peripheral arteries (15–25% of patients with symptomatic lower limb atherosclerotic vascular disease have renal artery stenosis
        • if there is abrupt deterioration in kidney function after administration of ACE inhibitors(MCQ)
        • ifepisodes of pulmonary edema are associated with abrupt surges in blood pressure
      • In young patients with fibromuscular disease, angioplasty is very effective, but there is controversy regarding the best approach to the treatment of atheromatous renal artery stenosis.
      • Although ACE inhibitors have improved the success rate of medical therapy of hypertension due to renal artery stenosis, they have been associated with marked hypotension and (usually reversible) kidney dysfunction in individuals with bilateral disease.(MCQ)

 

 

 

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