Hypertension
HTN
Primary
or Essenstial
Idioppathic

Most common type accordung for 90-95% of the cause
Secondary HTN
Due to Identifed Cause
Eg: Primary aldosreronisn chronic kidney disease renovascular disease oral contraceptive pills etc.
Definitions:
Hypertension is defined as sustained increase in resting systolic BP (≥ 140 mmHg), diastolic BP (≥90 mmHg), or both, when not on anti-hypertensive medications and not in acute illness.
Epidemiology:
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Accounts for~75 million deaths annually (12.8% of all deaths) (WHO).
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It is considered the leading risk factor for silent death in KSA.
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Hypertension is present in more than 25% of general population. 60% of those with HTN are on treatment and only half are adequately controlled.
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It is the most important modifiable risk factor for coronary heart disease and vascular diseases, stroke, and end stage renal disease.
Types:
Study guide:
Etiology:
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Essential Hypertension (Multifactorial):
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Environmental factors: Stress, sodium intake, obesity, and smoking.
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Genetics: 10 Genes, found mutated, were responsible for B.P regulation through Na/H2O reabsorption by the kidneys.
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Secondary Hypertension:
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Reno-Vascular Disease (most common cause).
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Renal parenchymal disease.
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Hypercortisolism.
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Pheochromocytoma.
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Cortication of the aorta.
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Hyperthyroidism.
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Medications: OCP, steroids, NSAIDS, EPO, cyclosporine, licorice.
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Risk factors:
Pathophysiology:
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Physiology: BP = Cardiac output (CO) x Total peripheral resistance (TPR)
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BP is product of cardiac out put (CO) and total peripheral vascular resistance (TPR), most of patient with long standing HTN have increase TPR with normal or diminish CO.
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Hypertension is the end result of ↑ C.O, ↑TPR, or ↑in both of them.
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Increase vascular stiffness contribute to systolic HTN in the elderly (thus isolated systolic hypertension is more common among elderlies).
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Clinical presentation:
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Usually Asymptomatic, until end organ damage develop (Silent Killer!).
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White coat Hypertension: Patient has hypertensive BP when measured in the clinic, normal outside, usually attributed to anxiety.
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Some times, initial presentation will be hypertensive crisis:
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Hypertensive Emergency: Severe Hypertension (diastolic >120mmHg) in patients with acute ongoing end organ failure.
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Hypertensive Urgency: Severe Hypertension (diastolic >120mmHg) in asymptomatic patients with no end organ failure.
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Signs and symptoms (indicating complicated Hypertension):
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Dizziness
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Headache
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Epistaxis
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Flushed face
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Fatigue
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Nervousness
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Diagnosis:
Table 1: Blood Pressure Classification adopted from JNC 7 Guideline & Step up to Medicine 3rd Edition, created by LtMed.
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Hypertension is diagnosed using a Sphygmomanometer.
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History, physical Examination and other tests ordered are to check if any underlying etiology and/or any organ damage are present.
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Methods of measuring B.P:
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Ambulatory blood pressure monitoring (ABPM):
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Indications:
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Suspected white coat HTN.
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Suspected episodic HTN.
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Resistant HTN (BP >140/90mmH Despite using 3 or more drug classes, one of which is Thiazide diuretic).
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Hypotensive symptoms while taking anti hypertension medication.
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Home Blood Pressure monitoring: (3A4 measures a day).
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Office-Based Blood Pressure Measurements:
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Still the primary method for diagnosis and management of hypertension.
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BP measured twice; patient seated and standing, separated by≥ 2min.
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Measured on 3 separate visits, each separated by at least 1 week.
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Preferably, measure both arms; ideally, the blood pressure difference should be no more than 15 mmHg.
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" If systolic and diastolic BP are in different stages the higher stage is used.
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Screening:
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According to USPSTF, all adults should check their BP:
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If normal BP → recheck every 2 years.
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If preAHypertensive → recheck every year.
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Management:
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Non-Pharmacological Treatment (life style modifications, LSM):
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↓Weight to reach the normal BMI.
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Follow DASH diet (high vegetables/fruits, low fat/ sweets and red meat).
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Restrict Sodium intake (<2.4g/day).
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Physical activity (Aerobic exercises for 30 min/day at least 4 days a week= 180min per week).
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Limit alcohol consumption (two standard drinks for males and one for females).
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Smoking cessation.
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Pharmacological Treatment:
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Should be initiated when blood pressure is 150/90 mm Hg or higher in adults 60 years and older, or 140/90 mm Hg or higher in adults younger than 60 years.
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In patients with DM, it should be initiated when blood pressure is 140/90 mm Hg or higher, regardless of age.
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If the target blood pressure is not reached within one month after initiating therapy -> increase the dose or add a second medication.
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Drug Classes Used in treatment of Hypertension:
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Thiazides
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Ca+ Channel Blockers (along with thiazide, the best initial therapy for black patients).
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Angiotensin converting enzyme inhibitors (ACEI) and angiotensin receptor blocker (ARB) -> best initial therapy for patients with DM or CKD.
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Others: beta-blockers and aldosterone antagonists -> if other medications failed.
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Management of Hypertensive Crises:
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Hypertensive urgency:
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Oral hypertensive drugs (beta blockers, clonidine, ACEIs).
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Lower the BP gradually over 24A48 hours.
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Hypertensive emergency:
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IV hypertensive drugs (labetalol, nitroprusside, nicardipine).
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Lower the mean arterial pressure by 25% over the first 2 hours to prevent cerebral hypoperfusion or coronary insufficiency.
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Blood pressure target: according to JNC8 recommendations:
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All patients at any age with CKD, DM or both -> BP<140/90mmHg.
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Patients < 60years of age with no CKD nor DM -> BP<140/90mmHg.
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Patients > 60 years of age with CKD nor DM -> BP<150/90mmHg.
Golden rules:
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White and < 65 -> ACEI or ARB.
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Black > 65 -> Ca channel blockers or thiazides, you can also add beta blockers if not contraindicated.
Complications:
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Stroke (HTN is the most common risk factor for strokes)
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Coronary artery Disease (Most common cause of death)
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Left ventricular Hypertrophy
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Congestive Heart Failure
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Peripheral Artery Disease
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Retinopathy
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Aortic Dissection
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Renal failure
Follow up:
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Assess adequacy of disease management.
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Assess overall cardiovascular disease risk.
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Assess the extent of endAorgan damage.
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Cardiopulmonary exam.
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Optic fundi.
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Abdominal exam (aneurysm, bruits, organomegaly).
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Neurologic exam.
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Rule out secondary causes of HTN.
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Check K and creatinine twice a year.
References:
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ARMSTRONG C. PRACTICE GUIDELINES: JNC8 GUIDELINES FOR THE MANAGEMENT OF HYPERTENSION IN ADULTS A AMERICAN FAMILY PHYSICIAN [INTERNET]. AAFP.ORG. 2016 [CITED 27 FEBRUARY 2016]. AVAILABLE FROM: http://www.aafp.org/afp/2014/1001/p503.html
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UPTODATE.COM. OVERVIEW OF HYPERTENSION IN ADULTS [INTERNET]. 2016 [CITED 27 FEBRUARY 2016]. AVAILABLE FROM: http://www.uptodate.com/contents/overviewAofAhypertensionAinAadults
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EMEDICINE.MEDSCAPE.COM. HYPERTENSION: PRACTICE ESSENTIALS, BACKGROUND, PATHOPHYSIOLOGY [INTERNET]. 2016 [CITED 27 FEBRUARY 2016]. AVAILABLE FROM: http://emedicine.medscape.com/article/241381A overview
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SAUDI HYPERTENSION MANAGEMENT GUIDELINES [INTERNET]. 2016 [CITED 27 FEBRUARY 2016]. AVAILABLE FROM: http://www.ssfcm.org/addon/files/hypertension.pdf
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MERCK MANUALS PROFESSIONAL EDITION. OVERVIEW OF HYPERTENSION [INTERNET]. 2016 [CITED 27 FEBRUARY 2016]. AVAILABLE FROM: http://www.merckmanuals.com/professional/cardiovascularA disorders/hypertension/overviewAofAhypertension
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BESTPRACTICE.BMJ.COM. BMJ BEST PRACTICE [INTERNET]. 2016 [CITED 27 FEBRUARY 2016]. AVAILABLE FROM: http://bestpractice.bmj.com/bestApractice/verifyAuserAnorthA americanAaccess.html
First author: Husam Tahan
Second author: Lama Al Luhidan
Reviewed by: Roaa Amer
Lujain AlKhalifa
Web Publisher: Bayan Alzomaili
Audio recording:
Read by: Assil Berkeit
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