Hypertension/High Blood Pressure

Hypertension Chronic

Essentials Of Diagnosis

  • Usually asymptomatic
  • Severe Hypertension : Occipital headache at awakening,blurry vision
General Consideration
  • Mild to moderate hypertension nearly always asymptomatic.
  • Severe hypertension usually due to parenchymal renal disease,endocrine abnormalities.renal artery stenosis,drug use,or abrupt cessation anti hypertensive medications.
  • Table 42 provides classification based on blood pressure (BP) measurements.
  • Table 43 summarizes potential identificable causes of hypertension.
  • Resistant hypertension is defined as failure to reach BP control in patients.
  • Adherent to full doses of a 3 drug regimen (including a diuretic).
  • Table 44 summarizes reason for failure to reach BP control. 
Demographics
  • 70 % of aware of their condition.
  • 50 % of those aware are receiving treatment.
  • 25 % of all hypertensive patients have BP under control.
  • Incidence of hypertension increases with age.
  • More men than women in early life.
  • More Women than men later life.
Symptoms & Signs
  • Usually asymptomatic.
  • Occipital headaches characteristic but uncommon.
  • Elevated BP
  • Loud A2 on cardiac examination.
  • Retinal arteriolar narrowingwith "Silver wiring" arteriovenous nicking.
  • Plame-Shaped Hemorrhages.
  • Laboratory findings usually normal.
  • In severe hypertension,renal dysfunction and hemolysis. 
Hypertension Chronic

Differential Diagnosis
Primary (Essential)Hypertension
  • White Coat Hypertension.
  • BP cuff too small.
Secondary Hypertension

  • Adrenal

-Primary hyperaldosteronism.
-Cushing`s Syndrome.
-Pheochromocytoma.

  • Renal
-Chronic renal disease

-Renal artery stenosis(Atherosclerotic or fibromuscular dysplasia)

  • Other
-Oral Contraceptives
-Alcohol
-Non-Steroidal Anti-Inflammatory drugs.
-Pregnancy associated.
-Hypercalcemia
-Hyperthyroidism
-Obstructive Sleep apnea
-Obesity
-Coarctation of the aorta.
-Acromegaly
-Increased Intracranial Pressure.

Diagnosis 
Laboratory Test.
  • Heamoglobin
  • Urinalysis
  • Serum Creatinine,Blood Urea Nitrogen.
  • Serum Pottasium.
  • Fasting Blood glucose
  • Serum Uric acid 
  • ECG.
  • When a secondary cause is suspected,consider.
-Chest X-Ray.
-ECG
-Plasma metanephrine levels.
-Plasma aldosterone Concentration,Plasma renin activity
- Urine electrolytes.

Treatment
Medication
  • Initiation of drug therapy based on level of BP,Presence of target end-organ damage,and overall cardiovascular risk profile.
  • Mejor risk Factors include.
-Smoking
-Dyslipidemia
-Diabetes mellitus
-Age > 60 years.
-Family history of cardiovascular disease.
  • Specific choice of pharmacotherapeutic agent should be based on other risk factors,Compliance and cost.
  • Diuretics.
  • β-Adrenergic blocking agents.
  • Angiotensin-converting enzyme(ACE)inhinitors and angiotensin receptor blockers.
  • Calcium channel-blocking agents.
  • α-Adrenergic blockers,vasodilators,centrallyacting agents.
Hypertension Chronic



Therapeutic Procedure
  • Dietary changes(DASH diet):high in fruits and vegetables,low fat,low salt.
  • Weight reduction
  • Alcohol restriction 
  • Salt reduction
  • Adequate potassium intake.
  • Increase physical activity
  • Smoking cessation
  • Aggressive risk factor management should be consideredin all patient with hypertension
  • Anti Hypertensive medications should be indivisualized.
  • Diabetes and hypertension should be treated aggressively,aiming for target BP < 140/80 mm Hg,given hish risk of cardiovascular events and ACE inhibitors or angiotensin receptor blockers should be part of regiemen.
Follow Up
  • frequent visits until BP is controlled 
  • Once Controlled,Visits can be infrequent,Limited laboratory tests.
  • Lipid monitoring every year
  • ECG every 1-2 year,depending on initial ECG
Complication
  • Stoke 
  • Dementia
  • Myocardial Infarction
  • Congestive heart failure
  • Retinal Vasculopathy
  • Aortic dissection
  • Renal Disease.Including Proteinuria and nephrosclerosis
When to Refer
  • Refer if BP remains uncontrolled after three concurrent medications.
  • Refer if patient has uncontrolled BP and symptoms and signs of end organ damage 
When to Admit
Consider Hospitalization if symptoms and signs of of a hypertensive emergency(see Urgencies & emergencies)including,in the setting of very high BP ,Severe Headache ,Neurologic symptoms,Chest pain altered mental status,or acutely worsening renal failure.

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