I wasn't here for the talk but share some thoughts on hypertension.
https://www.hypertension.ca/en/chep, canadian guidelines are fantastic, especially the power point presentations are really easy to learn from. Two things to note, there has been a greater stress on home bp monitoring to rule out white coat hypertension (high with doctors, low at home), AND masked hypertension (low with doctor, but high at home).
Also, the individuals over 80 benefit from BP control (balancing the risk of lows and falls), we aim to keep there SBP <150. Renal patients goal is 140/90 (previously was 130/80)
HTN can be organized as primary (essential) or secondary (resulting from a specific cause).
Once you've confirmed hypertension, by 2 or more readings, patients has been still for 5 minutes, no caffeine hours before, proper cuff size, etc. You should start by looking for end organ damage and simple easy to fix causes of hypertension.
EXAM: S4 heart sound, anything to suggest coarctation, renal bruits (listening for systolic and diastolic bruits), other signs of peripheral vascular disease.
1. ECG (LVH)
2. BUN/creatinine - urinalysis/microscopy, as renal disease could be a cause
3. calcium
4. TSH
Screen for sleep apnea, http://www.sleepapnea.org/assets/files/pdf/STOP-BANG%20Questionnaire.pdf. STOP BANG is a mnemonic that does ok. Neck size greater than 18 inches has a strong association. We know this is underdiagnosed and multiple studies (with hundred of patients) have shown positive sleep studies in resistant hypertension, regardless of symptoms.
A few points about primary hypertension. Patient’s who are normotensive at age 55 have a 90% lifetime risk of developing hypertension. Across the BP range of 115/75 to 185/115 each increment of 20 mm Hg systolic BP or 10 mm Hg diastolic BP doubles the risk of cardiovacscular disease.
We generally do not look for secondary causes unless there is other compelling reasons (will discuss below). We do have three objectives of testing in patients with hypertension
1. Assess presence or absence of target organ damage
2. Assess presence or absence of other cardiovascular risk factors
a. smoking
b. obesity BMI >30
c. physical inactivity
d. dyslipidemia
e. diabetes
f. microabluminuira or eGFR <60
g. age >55 men, >65 women
h. family history of premature CVD, men <55, women <65
3. Identify secondary hyptertention
Initial screening should include ECG, electrolytes, BUN, creatinine, calcium, TSH, urine albumin/creatinine ratio, fasting glucose, fasting lipids
So everything comes back normal, firstly your goals are <130/80 if the patient has diabetes and <140/90 for everyone else
Patients with primary hypertension should try about 2-6 months of non-pharmocological approaches.
Weight reduction can decrease BP about 5-20mmHg/10Kg weight loss. DASH diet. Reduce sodium <2.4/day. Decrease alcohol drinks (<2/day for men). Aeorbic exercise.
Things that make you wonder about secondary causes of hypertension
1. Patient is less than 30, or greater than 55 with new onset hypertension.
2. BP is refractory to 3 drugs
3. Lack of family history
4. HTN emergency/urgency (really high bp)
5. Renal artery bruits, a systolic/diastolic component is 99% specific and a LR of about 40 for renal artery stensosi
6. Hypokalmia, alkylosis – could be due to cushings, RAS, reninoma, licorice, liddles syndrome
The best way to classify secondary hypertension is as follows
1. endocrine
a. primary aldosteronism
b. pheochromocytoma: rarely asymptomatic, best test is serum metanephrines, others say urine VMD. Be careful when palpating abdomen, could set off catecholamines.
c. thyroid disease
d. hyperparathyroidism – hypercalcemia causing vasoconstriction
e. cushings sydrome: need 2/3, 24 hours urine cortisol, low dose dx, salivary cortisol
2. Renal
a. Chronic kidney disease
b. Acute renal failure
c. Polycystic kidney disease
3. Vascular
a. Renovascular disease (RAS – due to fibromuscular dysplasia or atherosclerosis) – atherosclerosis assocated with CAD, PVD, AAA, strokes. Associated with flash pulm. Edema, progressive renal dysfunction, and if you give an ACE you get a >30% rise in creatinine
b. Coartation of the aorta, radio-femoral delay
c. Vasculitis: skin manifastations, rash, sinusitis, asthma
4. Pulmonary: sleep apnea
5. GI: obesity (kind of in the primary category)
6. Drug induced or drug related
a. prolonged corticosteroid therapy
b. NSAIDS
c. Cocaine
d. Alcohol
e. Decongestants (sympathomimetics)
f. COPS
g. Cyclosporine/tacrolimus
h. EPO
i. Stimulants – amphetamines/modafinil
7. Endocrine: pheo, cushings, cons
In quick summary:
common causes of secondary
Alcohol, meds, illicit drug use, obesity, CKD, OSA, thyroid disease
Less common
Renovascular HTN
Conn’s syndrome
Pheochromocytoma
Cushings syndrome
Finally, when patients are diagnosed with hypertension, we should also consider other vascular risk factors - diabetes, hyperlipidemia.
Non pharmacologic treatments - low salt diet (<2 grams/day), weight loss, decrease ETOH consumption.
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