questions 4

Hypertension

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Topic updated on 09/03/17 3:04pm

Snap Shot
  • 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 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 a first-line medication to control his high blood pressure.
Introduction
  • Diagnosis 
    • made after measuring BP > 140 / 90 three times
      • from at least two separate clinical visits
      • if a patient has an elevated BP the best initial step is to repeat the blood pressure to ensure that the hypertension is real
    • more common in older individuals and African-Americans
    • prehypertension = systolic BP of 120 -139 or diastolic BP of 80 - 89
  • Pathophysiology
    • determinants of blood pressure
      • systolic depends on stroke volume (approximates preload)
        • stroke volume depends on blood volume, HR, contractility
      • diastolic depends on peripheral resistance (approximates afterload)
    • role of sodium
      • can ↑ blood volume → ↑ systolic
      • can ↑ vasoconstriction → ↑ diastolic
  • Types
    • essential hypertension
      • 95% of all hypertension
      • idiopathic vasoconstriction of arterioles
      • ↓ renal sodium excretion (commonly in African-Americans, elderly)
    • secondary hypertension 
      • causes
        System
        Disease process
        Presentation
        Cardiovasular Aortic regurgitation Wide pulse pressure, head bobbing, Quincke's pulses, waterhammer pulses
        Coarctation of aorta

        ↑ BP in UE, ↓ BP in LE

        Renal Glomerular Disease Proteinuria
        Renal artery Stenosis Atherosclerosis, fibromuscular dysplasia, stenotic side has ↑ renin release, contralateral side has ↓ renin release, epigastric bruit
        Polycystic Disease renal function
        Endocrine Cushing's and Conn's HTN with metabolic alkalosis, hypokalemia and ↑ mineralocorticoids and aldosterone

         

        Pheochromocytoma Episodic symptoms due to ↑ catecholamine release
        Pregnancy (eclampsia) ↑ synthesis of angiotensin II
        Hypothyroidism diastolic HTN due to ↑ sodium retention
        Hyperthyroidism Isolated systolic HTN
        Hyperparathyroidism ↑ calcium results in ↑ arteriolar contraction
        Drug induced

        Oral contraceptives (↑ synthesis of angiotensinogen), Cocaine (vasospasm)

 

Presentation
  • Symptoms
    • patients are asymptomatic until complications develop
    • often present with shortness of breath, chest tightness, headache, or vision changes
    • associated with obesity
Complications
  • Un/undertreated hypertension predisposes to
    • CAD/atherosclerosis
    • left ventricular hypertrophy followed by left ventricular dilation (late stage)
    • stroke
      • intracerebral bleed (rupture of Charcot-Bouchard aneurysms)
      • lacunar infarcts (sequelae of hyaline arteriolosclerosis)
    • CHF
      • systolic and diastolic
    • renal failure
      • benign nephrosclerosis (sequelae of hyaline arteriolosclerosis)
      • tubular atrophy
    • retinopathy
      • retinal hemorrhage, exudates
    • aneurysm/aortic dissection
Management
  • choose a blood pressure medications based on patient's comorbitidies
    • thiazide diuretics
      • typically first line
      • indicated in
        • hypocalcemia
        • osteoporosis
    • ACE inhibitor
      • indicated in
        • diabetes
        • scleroderma (renal crisis)
    • beta-blocker
      • indicated in
        • CHF
        • migraine headache
      • contraindicated in
        • depression
        • asthma (weak contraindication, many patient benefit more from beta-blockade as compared to symptoms of bronchoconstriction)
    • calcium channel blockers
      • migraine headache
      • Raynaud's phenomenon
    • ARB
      • same indications for ACE inhibitor in patient's who can't handle ACE inhibitor side effects


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Qbank (2 Questions)

TAG
(M1.CV.83) A 75-year-old man with hypercholesterolemia, coronary artery disease, and history of a transient ischemic attack (TIA) comes to your office for evaluation of hypertension. Previously, his blood pressure was controlled with diet and an ACE inhibitor. Today, his blood pressure is 180/115 mm Hg, and his creatinine is increased from 0.54 to 1.2 mg/dL. The patient reports that he has been compliant with his diet and blood pressure medications. What is the most likely cause of his hypertension? Topic Review Topic

1. Progression of his essential hypertension
2. Renal artery stenosis
3. Coarctation of the aorta
4. Pheochromocytoma
5. Hypothyroidism

PREFERRED RESPONSE ▶
TAG
(M1.CV.124) A 75-year-old over-weight gentleman with a long history of uncontrolled hypertension, diabetes, smoking and obesity is presenting to his primary care physician with a chief complaint of increased difficulty climbing stairs and the need to sleep propped up by an increasing number of pillows at night. On physical examination the patient has an extra heart sound just before S1 heard best over the cardiac apex and clear lung fields. The EKG and chest x-ray are attached (Figures A and B respectively). What is the largest contributor to this patient's symptoms? Topic Review Topic
FIGURES: A   B        

1. Long-term smoking
2. Uncontrolled Hypertension
3. Obesity
4. Sleep Apnea
5. Acute Myocardial Infarction

PREFERRED RESPONSE ▶
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