questions 12

Hypertension

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Topic updated on 09/14/17 7:53pm

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)


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Qbank (5 Questions)

TAG
(M2.CV.8) A 45-year-old man with no known past medical history is presenting to your primary care office for the first time after discovering that he had a blood pressure of 150/85 at a screening event at his local community center two weeks ago. His only complaint is "heartburn" which occurs after large meals which is relieved by over the counter antacids. His physical exam is unremarkable except for a blood pressure of 160/90. Which of the following tests should be performed at this visit? Topic Review Topic

1. CBC
2. Urinalysis
3. Chest X-ray
4. Colonoscopy
5. Esophagogastroduodenoscopy

PREFERRED RESPONSE ▶
TAG
(M2.CV.146) An 81-year-old male presents to his primary care physician for an annual checkup. He generally feels well except being “old.” He has no significant past medical history except for hip replacement and cataract surgery. On physical exam, temperature is 98.8 deg F (37.1 deg C), pulse is 87/min, and blood pressure is 151/70 mmHg. At 1 month follow up, his blood pressure is 154/71 mmHg in the clinic. According to the patient, his blood pressure was 155/68 mmHg when he checked it recently at a local pharmacy. What of the following is the most appropriate management for this patient? Topic Review Topic

1. Defer treatment since isolated systolic hypertension is common in the elderly
2. Start a thiazide diuretic
3. Start a beta-blocker
4. Start a fast-acting calcium channel blocker
5. Start a centrally-acting alpha agonist

PREFERRED RESPONSE ▶
TAG
(M2.CV.163) A 44-year-old Caucasian man with a four-year history of diabetes mellitus presents to your office for a routine check-up. He has no complaints. His medications include metformin, aspirin, and a multivitamin. He works as an insurance salesman and has a sedentary lifestyle. He smokes one pack of cigarettes per day and drinks two cans of beer on weekends. He denies any illicit drug use. His diet includes mostly meat and large amounts of "junk food." On physical exam, his blood pressure is 157/96 mmHg, heart rate is 82 bpm. His BMI is 34.2 kg/m^2. The remainder of his physical exam is unremarkable. Laboratory studies reveal an HbA1c of 7.8%. At his last check-up one month ago, his blood pressure was 151/93 mmHg. Which of the following interventions would be most effective for lowering his blood pressure? Topic Review Topic

1. Smoking cessation
2. Regular aerobic exercise
3. Weight loss
4. Improved glycemic control
5. Dietary salt restriction

PREFERRED RESPONSE ▶
TAG
(M2.CV.182) A 42-year-old woman presents to her doctor complaining of poor sleep. She has also been feeling restless and agitated for several months. Upon further questioning, she reveals that she has also been suffering from headaches and has gained 18 pounds over the same time period. She denies any chest pain, palpitations, diaphoresis, or increased appetite. She has no significant past medical history other than two uncomplicated pregnancies resulting in normal spontaneous vaginal deliveries. She denies any tobacco, alcohol, or illicit drug use. Her vital signs show Temp 37 C (98.6 F), BP 164/112 mm Hg, HR 88/min, and RR 12/min. Physical exam shows an overweight woman with no palpable thyroid nodules or abnormalities on cardiopulmonary exam. Laboratory evaluation reveals the following:
Sodium 141 mEq/L, potassium 3.1 mEq/L, chloride 96 mEq/L, bicarbonate 25 mEq/L, BUN 10 mg/dL, creatinine 0.8 mg/dL, glucose 220 mg/dL, and calcium 9.5 mg/dL. Which of the following is the likely cause of her hypertension? Topic Review Topic

1. Hypothyroidism
2. Overactivity of the adrenal medulla
3. Hyperparathyroidism
4. Overactivity of the adrenal cortex
5. Atherosclerosis of the renal arteries

PREFERRED RESPONSE ▶
TAG
(M2.CV.199) A 61-year-old male visits a medical student clinic booth during a health and wellness fair at his workplace. A medical student listens to his heart and lungs and then immediately asks the man if he's ever been diagnosed with hypertension. Which of the following concerning findings might have led her to suspect this man's hypertension? Topic Review Topic

1. A crescendo-decrescendo murmur radiating to the carotids
2. A holosystolic murmur radiating to the axilla
3. A rough, scratching sound
4. A dull, low-pitched sound early in diastole best heard with the bell
5. An extra heart sound heard immediately before S1

PREFERRED RESPONSE ▶
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