Download 1 Hypertension Shirley Paski Classifications Category Systolic

Hypertension
Shirley Paski
Classifications
Category
Normal
Prehypertension
Hypertension
Stage 1
Stage 2
Isolated systolic
Systolic mmHg
<120
120-139
Diastolic mmHg
<80
80-89
140-159
≥160
≥140
90-99
≥100
<90
History
 Signs and Symptoms
o Usually asymptomatic
o Headache, dizziness, palpitations, easy fatigue,
impotence
o Epistaxis, hematuria, blurred vision, focal neurologic
symptoms, angina, SOB
o Polyuria, polydipsia, muscle weakness (1° aldo)
o
o
Diagnosis
Recommendation: check blood pressure at each office visit for
patients over age 21
End-organ damage: only one measurement required
1. Neuro: ischemic stroke, ICH, TIA, aneurysmal SAH
2. Retinopathy
3. Cardiac: LVH, LVdysFx, MI, angina, CHF, PAD
4. Nephropathy: GFR<60, proteinuria >150mg/24h
No end-organ damage, mild hypertension: persistently
elevated blood pressure on 3-6 visits over weeks to months

Weight gain, emotional lability (Cushings)
Episodic headaches, palpitations, diaphoresis,
postural dizziness (pheo)
Past Medical History
o Family history of HTN including age of onset
o Smoking, alcohol, other drugs
o Medications: OCP, cold meds, sympathomimetics,
steroids
o Diabetes
o Dyslipidemia
o Diet, exercise
Physical Examination
Goals: 1. Measure and stage the blood pressure 2. assess overall CV risk (comorbidities – central obsesity, DM, CHOL, smoking;
target EOD) 3. identify secondary causes (<5%) – not cost-effective in most pts
 General
 H&N
o Obvious neurological signs of
o Thyroid
CVA/bleed/encephalopathy.
 Cardiovascular exam (signs of EOD)
o Signs of systemic associated diseases like
o JVP
Cushing’s syndrome, acromegaly, polycythemia,
o Carotid upstroke and bruits
chronic renal insufficiency, thyroid dz, OSA
o Precordial exam: rythym, LVH, S3, S4, acute
 Vitals/Blood Pressure
MR or AR
o Sitting in both arms (R/O dissection), average of
o Chest
3 measurements, standing @ 2mins. N: DBP
o Peripheral pulses (absent, diminished)
will on standing in essential hypertension
 Abdomen
o If coarctation suspected, palpate radiofemoral
o Waist circumference
delay and measure BP in legs. N: BP legs>arm
o Striae, central obesity
 Fundi
o Renal or adrenal masses (ex. Polycystic KD)
o Grade 1: silver wiring of arteries (“sclerosis of
o Renal or abdominal bruits *RCExam
vessel wall reduces transparency so central light
 Loud, systolic-diastolic, epigastrum
streak becomes broader and shinier”)
 Normal in 6-31%, less in older
o Grade 2: grade 1 + AV nicking
o Uterine fundus for pregnancy
o Grade 3: grade 2 + flame hemorrhages + cottonwool spots + hard exudates
o Grade 4: grade 3 + papilledema
Basic Investigations
 Always included:
o Urine for protein, blood, glucose, UA
o Hb
o K
o BUN, Creatinine
o Fasting glucose
o Total cholesterol
o EKG (LVH, old MI)

Usually included:
o TSH
o WBC
o HDL, LDL, trigs
o Ca, PO4
o CXR
o Limited echocardiogram (LVH)
1
Special Studies to Screen for Secondary Causes
 Renovascular disease: captopril renal scan, renal Doppler flows, MRI
angiography
 Pheochromocytoma: 24h urine creatinine, metanephrines,
catecholamines
 Cushing’s syndrome: overnight dexamethasone suppression test or
24h urine cortisol and creatinine
 Primary aldosteronism: plasma aldosterone:renin activity ratio
Suspect secondary causes if: ?
1. onset < 30y or >55
2. htn refractory to >/= 3 drugs
3. suspicious clinical situation (sx suggestive
of secondary cause)
Treatment
 When to start:
o SBP ≥ 180 or DBP ≥ 110  Start drug treatment and lifestyle modification
o SBP < 180 and DBP <110  Start lifestyle modification, stratify absolute risk
o High risk (3+ CV risk factors, diabetes)  Start drug treatment, stongly consider combination therapy as initial
treatment
o Moderate risk (1-2 CV risk factors) or low risk (0 CV risk factors)
 SBP 130-139 or DBP 85-89 on several occasions  No treatment, monitor BP and other RF’s
 SBP 140-179 or DBP 90-109 on several occasions  Start drug treatment
 Lifestyle modification:
o Diet (DASH), regular exercise, weight reduction, smoking cessation, stress management, control of other risk factors
contributing to the development of arteriosclerosis
 Drug management:
o Caveats
 Start with an agent that may also treat / not harm coexisting conditions
 Start with an agent that the patient is likely to tolerate best to optimize adherence
 For low or moderate risk pts, start with a low dose and increase gradually to achieve control
 Add an additional agent from a different, complementary class if bp not controlled on a moderate dose of the
first agent
 Use a diuretic when 2 agents are used, in nearly all cases
 Use thiazide diuretics only at low doses unless some pressing reason exists
 For medium to high risk patients, strongly consider low dose combination therapy as initial therapy:
 Diuretic + betablocker, ACEi, ARB
 CCB + ACEi, betablocker
o Guidelines for selecting initial drug therapy for hypertension:
Drug Class
Compelling indications
Possible
Compelling
Possible
indications
contraindications
contraindications
Diuretics
Heart failure
DM
Gout
Dyslipidemia
Elderly
Sexually active male
Systolic HTN
Beta blockers
Angina
Heart failure
Asthma
Dyslipidemia
Post-MI
Pregnancy
COPD
Athletes
Tachyarrhythmia
DM
Grade 2-3 AVB
PVD
ACE inhib
Heart failure
Pregnancy
LV dysfunction
Hyperkalemia
Post-MI
Bilat RAS
Diabetic nephropathy
CCB
Angina
PVD
Grade 2-3 AVB
CHF (verapamil or
Elderly
diltiazem)
Systolic HTN
ARB
ACE inhib cough
Heart failure
Pregnancy
Bilat RAS
Hyperkalemia
 Goals: <140/90 generally speaking; <130/80 for those with DM, CRI, CV disease. Careful not to drop DBP < 65 in those with
isolated systolic hypertension since this actually increases the risk of stroke.
References
Canadian Hypertension Guidelines, Harrison’s, UpToDate
2