• Is defined as BP >140/90 mmHg over 3 visits

1. Nearly 6 million Canadians aged 20 years and older  – more than 20% of adults – were living with diagnosed hypertension in 2006/07
   1. 24.0% of women
   2. 21.3% of men
2. The age-standardized prevalence of diagnosed hypertension is increasing, because people live longer:
   1. 12.9% in 1998/99
   2. 19.6% in 2006/07

DRUGS

1. Oral Contraceptives (occurs in 5% of users)
2. Estrogen Replacement Therapy
3. Licorice
4. Mineralocorticoids
5. Steroids
6. NSAIDs
7. COX-2 Inhibitors
8. Levothyroxine
9. Growth Hormone
10. Cocaine
11. Amphetamines
12. Steroids
13. Benzodiazepine withdrawal
14. Methylphenidate
15. MAOi can cause acute HTN crisis when taken with high Tyramine foods such as wine or aged cheese
16. Venlafaxine (1%), dose related

INFECTIONS/INFLAMMATIONS:

1. SLE

METABOLIC:

1. Primary Aldosteronism
2. Hyperparathyroidism
3. Pheochromocytom
4. Hyperthyroidism: systolic Hypertension
5. Hypothyroidism: diastolic Hypertension
6. Cushing’s Disease

STRUCTURAL:

1. Renovascular or renal parenchymal disease
2. Aortic Coarctation
3. Sleep Apnea

Organ system history:

1. Hyperparathyroidism (Hypercalcemia)
   1. Confusion
   2. Major Depression
   3. Abdominal Pain
   4. Constipation
   5. Nephrolithiasis
2. Cushing’s Disease
   1. Acne Vulgaris
   2. Osteoporosis
   3. Bone Fractures
   4. Glucose Intolerance
3. Aldosteronism
   1. Hypokalemia
   2. Muscle Weakness
   3. Paresthesias
   4. Tetany
4. 11-Hydroxylase deficiency
   1. Premature virilization in males
   2. Masculinization in females
5. 17-Hydroxylase deficiency
   1. Failed sex maturation
6. Pheochromocytoma
   1. Sweating
   2. Tremor
   3. Panic
   4. Facial pallor
   5. Headache
   6. Weight loss
7. Sleep Disorder
   1. Sleep Apnea
   2. Exaggerated snoring

Past Medical History:

1. Onset and severity of Hypertension
2. Average Blood Pressure
3. Recurrent UTI
4. Diabetes Mellitus
5. Hyperthyroidism
6. Hypothyroidism
7. Hyperparathyroidism (Hypercalcemia)
8. Cushing’s Disease
9. Aldosteronism
10. Premature virilization in males
11. Masculinization in females
12. Failed sex maturation
13. Pheochromocytoma

Family History

1. Hypertension
2. Kidney disease
3. Pheochromocytoma
4. Cushing’s disease

SOCIAL HISTORY:

1. Alcohol
2. Smoking
3. Salt intake
4. Fat intake
5. High caloric intake contributing
6. Obesity
7. Physical activity

1. Vitals
   1. BP Examination in both arms
   2. Pulse both radials and femoral
2. Assess for Obesity
   1. Weight, height
   2. BMI
   3. Waist circumference
3. Retinal Exam
   1. Retinal Hemorrhage
4. Neck Exam
   1. Thyroid exam
   2. Carotid Bruits
   3. Neck vein exam
   4. JVP
5. Chest exam:
   1. Congestive Heart Failure signs
   2. Palpable intercostal pulses
6. Cardiovascular Exam:
   1. S4 Gallop rhythm (decreased LV compliance)
   2. Tachycardia
   3. Accentuated S2 Heart Sound
   4. Aortic Insufficiency murmur
7. Abdominal Exam:
   1. Abdominal bruit
   2. Abdominal Aortic Aneurysm
   3. Abdominal mass (flank)
   4. Striae
   5. Hirsutism
8. Genitourinary exam in youth for abnormal sexual development
9. Peripheral Vascular Disease
   1. Femoral bruits
   2. Symmetrical pulses
   3. Lower extremity shin Hair Loss
10. Neurologic
    1. Peripheral Neuropathy
11. Skin examination
    1. Stigmata of Cirrhosis
    2. Neurofibromata
    3. Hair atrophy
    4. Akin atrophy
12. Cushing’s Disease
    1. Striae
    2. Acne Vulgaris
    3. Hirsutism
    4. Moon face
    5. Central obesity
    6. Pigmentation

1. Urinalysis
2. Urine protein (microalbuminuria)
3. Complete Blood Count
4. Fasting lipid profile
5. FBS
6. Electrolytes, BUN, Cr
7. TG, Cholesterol, LDL, HDL
8. eGFR or abnormal urinalysis:
   1. renal ultrasound of kidney assessment
   2. phosphate
   3. electrolytes
   4. urinalysis
9. Serum Calcium
10. Uric Acid
11. 24 hour Urine Creatinine
12. 24 Hour Urine Protein
13. Sleep apnea:
    1. Overnight pulse oximetry
14. Cushing’s Disease
    1. 24 hour Urine Cortisol or Salivary cortisol
    2. Overnight 1 mg dexamethasone suppression test
15. Pheochromocytoma
    1. 24h Urine Metanephrine
    2. Vanillylmandelic Acid (VMA)
16. Renal parenchymal disease
    1. Renal Ultrasound
17. Renal Artery Stenosis
    1. MR Angiography
18. Primary Aldosteronism
    1. K (Hypokalemia)
    2. Aldosterone to plasma renin ratio

1. Chest X-Ray (evaluate for coarctation, heart size)
2. ECG
3. Echocardiogram
4. Kidney ultrasound
5. Renal artery MR Angiography

1. General Guidelines
2. Smoking cessation
3. Avoid alcohol and stimulant drugs such as cocaine
4. Weight reduction
5. Salt intake reduction
6. Physical activity 30-45 min daily 4 to 7 days a week
7. Dietary advice
8. Ensure compliance

ACEi:

1. The best medications in hypertensive patients with any type of background illness (DM, CHF, Post-MI, prevention of recurrent CVA, Chronic Kidney Disease)
2. Agents:
   1. Captopril
   2. Enalapril
   3. Lisinopril
   4. Ramipril
   5. Losartan
   6. Valsartan
3. Side effects:
   1. Mania
   2. Anxiety

Hallucinations

1. Beta-Blockers:
   1. Avoid in Asthmatics/COPD
   2. Avoid in 2 and 3 heart block
   3. Avoid in depression
   4. Side effects:
      1. Fatigue
      2. Depression
      3. Anxiety
      4. sexual dysfunction
      5. nightmares
      6. hallucinations

Furosemide

1. HTN:                                        40 mg po BID (max 6 mg/kg)
2. CHF:                                        up to 2-2.5 gr/day po or IV
3. Chronic renal Failure:                up to 2-2.5 gr/day po or IV
4. Acute pulmonary edema:           40 mg IV in 1 hr up to 80 mg
5. Edema:                                     20-80 mg OD PO; 20-40 mg BID IV/IM
6. Side effects:
7. Sexual dysfunction
8. Depression

Thiazides:

1. Avoid in Gout

Calcium Channel Blockers:

1. Warning:
   1. Avoid in 2 and 3 heart block
   2. Avoid in heart failure
2. Agents:
   1. Nifedipine
   2. Verapamil
   3. Diltiazem
3. Side effects:
   1. Dizziness
   2. Headache
   3. Flushing
   4. Tachycardia
   5. Depression

Alpha-adrenergic blockers

1. Agents:
   1. Prazosin
   2. Terazosin
   3. Doxazosin
2. Side effects:
   1. Syncope
   2. Dizziness and vertigo
   3. Palpitations
   4. Drowsiness
   5. Weakness
   6. Confusion

Central alpha-adrenergic agonists

1. Agents:
   1. Clonidine
   2. Methyldopa
2. Side effects:
   1. Drowsiness
   2. Sedation
   3. Fatigue
   4. Depression
   5. Impotence
   6. Delirium
   7. Psychosis
   8. Nightmares
   9. Amnesia

Direct vasodilators

1. Agents:
   1. Hydralazine, minoxidil
2. Side effects:
   1. Tachycardia
   2. Headache
   3. Dizziness

Peripheral adrenergic neuron antagonists

1. Agents:
   1. Reserpine,
   2. Guanadrel
2. Side effects:
   1. Drowsiness
   2. Depression
   3. Nightmares
   4. Tardive dyskines