Essential Hypertension Review - USMLE Step 2

Cardiology
HYPERTENSION
USMLE Step 2 Review
Marc Imhotep Cray, M.D.
BMS and CK Teacher

http://www.imhotepvirtualmedsch.com/
Cardiology| Hypertensive Vascular Disease
Topics Covered
2
Definition
Classification
BMS Concepts
RAAS
Causal Conditions
Target Organ Damage
Approach
Management
HTN in Elderly
DEFINITION of HTN
A BP of >140/90 mm Hg on two separate occasions

If there is end-organ damage, diagnosis is made on
the first visit

3
HY Points:
HTN is not diagnosed until two separate measurements on two separate
occasions are above 140/90 mm Hg (except in pregnancy, when
preeclampsia may be cause of hypertension)

Also, if hypertension is severe (>210 mm Hg systolic, >120 mm Hg diastolic,
or end-organ effects), immediate treatment with medication is warranted
JNC Classification of HTN
4
National High Blood Pressure Education Program. The Seventh Report of the Joint National
Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.
Bethesda (MD): National Heart, Lung, and Blood Institute (US); 2004 Aug. Classification of
Blood Pressure.
Available at http://www.ncbi.nlm.nih.gov/books/NBK9633/
BMS CONCEPTS OF HTN
Effect of CO and SVR on BP:
CO = HR SV
MAP = TPR CO
BP CO TPR
CO = MAP / TPR
MAP = dBP + 1 / 3 pulse pressure

AUTOREGULATION
CO MAP, detected by aortic and carotid baroreceptors
vasodilation TPR and hence CO (to balance the initial CO)

PRESSURE NATRIURESIS
MAP = renal perfusion, GFR, and aldosterone Na +
H2O excretion (natriuresis)
5
6
RAAS plays an important role in regulating blood volume and
systemic vascular resistance, which together influence cardiac
output and arterial pressure
Three important components to this system: 1) renin,
2) angiotensin, and 3) aldosterone
Renin, which is primarily released by kidneys, stimulates
formation of angiotensin in blood and tissues, which in turn
stimulates the release of aldosterone from the adrenal cortex
Renin-angiotensin-aldosterone
system (RAAS)
RAAS cont.
7
Renin is a proteolytic enzyme that is released into the
circulation primarily by the kidneys.
Its release is stimulated by:
i. sympathetic nerve activation (acting through 1-
adrenoceptors)
ii. renal artery hypotension (caused by systemic hypotension
or renal artery stenosis)
iii. decreased sodium delivery to distal tubules of kidney
RAAS schematic
8
http://en.wikipedia.org/wiki/File:Renin-angiotensin-aldosterone_system.png

CAUSAL CONDITIONS of HTN
1. 1 (essential HTN95% of cases)
2. 2 HTN
Renal/vascular ( CO)
RF, polycystic kidney disease, CoA, RAS
Endocrine ( SVR)
Hyperthyroidism, adrenal adenoma ( aldosterone, cortisone),
pheochromocytoma, Hyperparathyroidism

Reversible RF: obesity, poor dietary habits, high Na+ intake,
sedentary lifestyle, high EtOH and/or coffee consumption, high
stress, high normal BP, illicit drug use (e.g., cocaine),
herbal med (e.g., ma huang, ginseng, licorice, ginger)
9
Target Organ Damage in HTN
10
Cerebrovascular disease
TIA
Ischemic or hemorrhagic stroke
Vascular dementia
Hypertensive retinopathy
LV dysfunction
CAD
MI
Angina
CHF
CKD
Hypertensive nephropathy
Albuminuria
Peripheral artery disease
Intermittent claudication

APPROACH

Hx
Age of onset, duration, prior Rx and response, Hx of refractory
HTN? associated Sx (chest pain, palpitations, SOB, renal problems,
headaches, diaphoresis, polyuria, hematuria, edema), Hx, or
symptom of sleep apnea
Family Hx, meds, diet, coffee intake, and EtOH
End-organ damage
(stroke/TIA, MI, CHF, renal disease, retinal disease), CV risk
stratification

Elicit hypertensive emergency (hypertensive encephalopathy,
strokes, dissecting thoracic aortic aneurysm, malignant HTN, acute
LV failure, acute glomerulonephritis)
11
APPROACH
PE
BP measurement with calibrated instrument and appropriate
cuff size
Fundi (copper wire, cotton wool spots, AV nicking,
papilledema)
Complete CV exam (clubbing, cyanosis, peripheral pulses,
bruits, JVP, apex beat, parasternal heave, heart sounds and
murmurs, compare U/E and L/E BP),
Lungs auscultation,
Abdo exam for renal mass and bruits, edema, weight
12
APPROACH
Standard Workup
Electrolytes, BUN, CR, fasting gluc., U/A, lipid profile (fasting total
cholesterol, HDL, LDL, triglycerides), EKG (to evaluate LVH s)
13
APPROACH
2 Causes Workup
1. Renal and vascular
Renovascular (older pt, Hx of atherosclerosis, renal artery bruit)
Captopril renal scan/duplex U/S, MRI, angiography
Unilateral RAS: normal Cr
Bilateral RAS: hypervolemia, Cr
Renal parenchymal
BUN, Cr, Cr clearance
CoA
LE pulses, radiofemoral delay, systolic murmur, LVH, rib
notching on CXR
ECHO, aortogram
2. Endocrine
TSH, cortical, urinary VMA, PTH, aldosterone, renin, renin /
aldosterone ratio
14
MANAGEMENT
15
Annual F/U with high normal BP is recommended as 40% of pts
with sBP 130 to 39 mm Hg or dBP 85 to 89 mm Hg develop HTN
in 2 years

Home BP monitoring
Goal BP to <140/90 mm Hg; and if pt has diabetes or renal
disease, BP <130/80 mm Hg

Pharmacologic Rx
Select med with minimal or adverse effects on diabetes,
asthma, and that benefits CHF or myocardial ischemia
Initiate pharmacologic Rx for hypertensive pt refractory to
lifestyle s or pre-HTN + diabetes/renal disease
MANAGEMENT
16
HTN Alone
Thiazide diuretics, -blockers, ACEIs, ARBs, long-acting CCBs as
first-line Rx
If still response to Rx despite max tolerated dose or Rx-
related adverse effect, add CCB/ARB/-receptor blocker/centrally
acting agents (methyldopa)
HY Point:
For HTN that is nonresponsive to Rx, consider noncompliance, 2
HTN, drug interactions
ACEIs and ARBs are contraindicated in pregnancy
-Blockers are not recommended for pts older than 60 years without
indication
Avoid diuretic-induced hypokalemia by using K+ sparing agent
Antihypertensives in Pt with
Other Comorbidities
17
Whalen KL, Stewart RD. Pharmacologic management of hypertension in patients
with diabetes. Am Fam Physician. 2008 Dec 1;78(11):1277-82.
Available at http://www.aafp.org/afp/2008/1201/p1277.html#abstract

Which agent you choose is often based on comorbidities
Exogenous Aggravators of HTN

18
Prescription Drugs
NSAIDs, including coxibs
OCP and sex hormones
Corticosteroids and anabolic steroids
Vasoconstricting / sympathomimetics
Calcineurin inhibitors
(cyclosporin, tacrolimus)
EPO and analogs
MAOIs
Midodrine
Other
Salt
Excessive EtOH use
Sleep apnea
Licorice root
Stimulants including
cocaine
HY Point:
Urinary Albumin Secretion
Identify urinary albumin secretion for DM and CKD:
Rx differs without proteinuria
albumin/ creatinine ratio (ACR) >30 mg/mmol is AbN
Lifestyle Therapies in HTN
19
Refer to United States food guide
HYPERTENSION IN ELDERLY
20
DEFINITION
A BP of >140/90 mm Hg
Isolated systolic HTN (sBP >140; dBP <90) is more common in
elderly population
Prevalence may reach 60% to 80% in pts aged 60 years and older
BMS: Factors that contribute to prevalence of HTN in elderly:
Compliance of arterial wall
NO dependent arterial vasodilation
Numbers of functioning nephrons
Collagen, vascular thickening,
elasticity
CV physiological reservoir
Nikolaos Lionakis et. al. Hypertension in the elderly World J Cardiol. May 26,
2012; 4(5): 135147. Published online May 26, 2012.
Available at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3364500/
BMS of HTN in Elderly
21
Age-related s in aortic vascular property
Age progressive thickening of arterial wallspredominantly
in the intimal
layerintimal to medial thickness ratio
Fragmentation and depletion of arterial elastin coupled with
medial deposition of matrix metalloproteins and collagen
Collectively, this leads to thicker and stiffer arteries, predominantly
central elastic arteries
In elderly, sBP is characterized by widened arterial pulse
pressure or s in vascular morphology associated with age
small artery constriction that reflected component of the pulse
wave
Large artery stiffening that velocity of reflected wave, where it
moves from diastole to systole hence sBP
HTN in Elderly cont.
22
CAUSAL CONDITIONS
1 HTN
2 HTN
Med related (Na+ retaining agents e.g.,mineralocorticoids, anabolic
steroids, NSAIDs, antidepressants, sympathomimetics e.g.,
pseudoephedrine, herbal agents)
Endocrine: thyrotoxicosis, pheochromocytoma, Cushing disease,
1 aldosteronism, hyperparathyroidism, hyper/hypothyroidism
Renal: renovascular disease (RAS), renal parenchymal disease
Vascular: aortic coarctation
Sleep apnea
Other causes
White coat HTN
Pseudohypertension also prevalent in the elderly population due
to thickening and calcification of the arteries
23
APPROACH
Hx
In addition to usual Hx taking for HTN:
Meds: Prescribed, OTC and herbal drugs
Past medical history: DM, CRF, pre-HTN, hyperlipidemia, CAD
Social Hx: smoking, EtOH intake, dietary habits ( salt & fat diet)
PE
Vitals: BP (compare for both arms), weight, height, BMI, waist
circumference (assess for MS)
Head and Neck: funduscopy for retinal s, thyroid exam, JVP, carotid
bruit
Chest: signs of CHF, palpable murmur
CV exam: murmurs, Abdo aorta bruit, renal artery bruit,
Abdo. aorta aneurysm
24
MANAGEMENT
sBP and pulse pressure should be regarded as major
predictor of outcome
Rx should be initiated when sBP >160 mm Hg or >140 mm Hg
when pt has other RF like diabetes and smoking
Nonpharmacologic Rx: lifestyle modification, achieve target
BMI through diet and exercise, Na restriction, cessation of
smoking, judicious consumption of EtOH
Pharmacologic Rx: initiated if the above is inadequate
Benefit in treating systolic HTN in the elderly is two to four
times greater than in younger pt with 1 HTN
HTN in Elderly Mx cont.
25
Thiazide diuretic-First-line choice for elderly pt
Use lower doses (half of what is usually used in younger
population) to minimize side effects like postural
hypotension due to sluggish autoregulation in elderly
population
Periodically monitor lytes; hypokalemia may negate CV benefit
Dihydropyridines (nifedipine ) may also be used as an
alternative
William JE, Black HR Treatment of Hypertension in the Elderly
Am J Geriatr Cardiol. 2002;11(1)
Available at http://www.medscape.com/viewarticle/423503_1
Further Study
26

Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of the Joint
National Committee on Prevention, Detection, Evaluation, and Treatment of
High Blood Pressure: The JNC 7 Report. JAMA. 2003;289(19):2560-2571.
Available at http://jama.jamanetwork.com/article.aspx?articleid=196589
Kotchen TA Hypertensive Vascular Disease Ch. 247
In Kasper DL, Braunwald E, Fauci AS, et al. Harrison's Principles of Internal
Medicine (18th ed.). New York, NY: McGraw-Hill 2013. pp. 204058.
For more like this visit IVMSs latest Website/ Blog
http://drimhotepmd.wordpress.com/
Medscape Meena SM Hypertension
Available at http://emedicine.medscape.com/article/241381-overview

Nikolaos Lionakis et. al. Hypertension in the elderly World J Cardiol. May 26,
2012; 4(5): 135147. Published online May 26, 2012.
Available at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3364500/

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