Cardiovascular [HYPERTENSION]

Introduction Hypertension
Hypertension is defined by a systolic BP > 140 or a diastolic > Cavitation
90. HTN is often an asymptomatic, chronic, age-related
condition that worsens and contributes to atherosclerotic Alarm Symptoms Urgent / PO / IV
180/120? Emergent BP Control
disease. In essential hypertension (primary hypertension) the
cause is idiopathic and independent of any one given risk
factor. This must be differentiated from secondary Aldo:Renin
HTN
hypertension - hypertension attributable to some hormonal, Renal Art U/S
CrCl
structural, or metabolic condition. Essential is by far the most Secondary
Age >20, Age <70 TSH
common but other causes must be investigated. HTN
Refractory, ↑↑HTN Ca
CXR
Diagnosis CBC
In order to diagnose hypertension there must be two blood
Essential
pressures taken at separate office visits that are greater than
140/90. Normal is 120/80. Pay attention to the severity/stage of Stage SYS DIA Initial Tx
hypertension. Remember the “20, 10, symptom rule”. Start at Normal 120 80 ?ARB?
120/80, then add 20 to the systolic and 10 to the diastolic to Pre-HTN 130 90 ARB
reach the next stage. Once at 180/120, the presence of end organ Stage I 140 100 Thiazide > ACE > CCB
Stage II 160 110 Comorbid Specific
damage pushes from urgency to emergency. It’s important at the
Urgency 180 120 PO Meds (Hydralazine)
time of diagnosis to evaluate for acute end organ damage, Emergency Alarm Sxs IV Meds (Labetalol)
which’d thrust the patient into the emergent category.
Alarm Sx = Stroke, MI, Papilledema, Proteinuria, ARF,
Management eclampsia, aortic dissection
Treatment is dependent on the stage of hypertension. For pre-
hypertension the renoprotective benefits of ACE/ARB doesn’t
decrease the number of events but does prevent progression of Condition Option
hypertension. For stage I, diuresis is the name of the game. If CAD (pre-MI) CCB + ACE > β-Blocker + Diuretic
drugs are to be added, diuretics > ACE/ARBs > CCB. When it Angina β-Blocker
comes to Stage II, many permutations exist with the expectation Post MI β-Blocker + ACE
that 2-4 medications will be required. If using β-Blockers CVA PPX ACE
DM ACE
combined vasodilators (Carvedilol) are better than non-
CKD ACE + Others
vasoactive (Propranolol). When using CCB be aware that
addition or increasing dose may take several days to see effect. CCB = Calcium Channel Blocker = Amlodipine
α-blockers (like clonidine) should be avoided until no other β-Blockers = Propranolol, Labetalol, Carvedilol
options exist. ACE/ARB = Lisinopril, Captopril, Losartan, Candesartan

Secondary Hypertension
This is refractory hypertension caused by something. If the Type History Workup
kidneys are nor perfused (renovascular, CHF, cirrhosis) then Renovascular DM or glomerulonephritis CrCl
the kidney responds with an increased RAS (which means ARF induced by ACE/ARB BMP
ANGII = HTN). A primary aldosterone secreting tumor Renal Bruit, Hypo K Aldo:Renin < 10
produces aldosterone without renin. Pheochromocytoma causes U/S Renal Artery
the release of catecholamines. Hyperthyroid causes an Pheochrom- Pallor, Palpitations, Pain, 24-Hr Urinary
ocytoma Perspiration, Pressure metanephrines, CT
increase in T3 metabolism. Even an isolated hypercalcemia can
Hyperaldo Refractory HTN or Aldo:Renin > 20
cause hypertension by accelerating plaque formation. Each are HTN and HypoK CT Pelvis
discussed in detail in other sections. Hyperthyroid Weight Loss, Sweating, TSH, Free T4
Heat intolerance,
Goals Palpitation,
In general, the minimum goal is <140/<90. Every 20 point Hypercalcemia Polyuria, AMS, “moans, Free Ca
groans, bones, kidney
systolic increase OR 10 point diastolic DOUBLES the risk of a
stones”
cardiovascular event. More stringent blood pressure control is
required for diabetics (<135/<85, some would even say
<130/<80).

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