Dfinition
- Is defined as BP >140/90 mmHg over 3 visits
Epidemiology
- Nearly 6 million Canadians aged 20 years and older – more than 20% of adults – were living with diagnosed hypertension in 2006/07
- 24.0% of women
- 21.3% of men
- The age-standardized prevalence of diagnosed hypertension is increasing, because people live longer:
- 12.9% in 1998/99
- 19.6% in 2006/07
Differential diagnosis
DRUGS
- Oral Contraceptives (occurs in 5% of users)
- Estrogen Replacement Therapy
- Licorice
- Mineralocorticoids
- Steroids
- NSAIDs
- COX-2 Inhibitors
- Levothyroxine
- Growth Hormone
- Cocaine
- Amphetamines
- Steroids
- Benzodiazepine withdrawal
- Methylphenidate
- MAOi can cause acute HTN crisis when taken with high Tyramine foods such as wine or aged cheese
- Venlafaxine (1%), dose related
INFECTIONS/INFLAMMATIONS:
- SLE
METABOLIC:
- Primary Aldosteronism
- Hyperparathyroidism
- Pheochromocytom
- Hyperthyroidism: systolic Hypertension
- Hypothyroidism: diastolic Hypertension
- Cushing’s Disease
STRUCTURAL:
- Renovascular or renal parenchymal disease
- Aortic Coarctation
- Sleep Apnea
History taking
Organ system history:
- Hyperparathyroidism (Hypercalcemia)
- Confusion
- Major Depression
- Abdominal Pain
- Constipation
- Nephrolithiasis
- Cushing’s Disease
- Acne Vulgaris
- Osteoporosis
- Bone Fractures
- Glucose Intolerance
- Aldosteronism
- Hypokalemia
- Muscle Weakness
- Paresthesias
- Tetany
- 11-Hydroxylase deficiency
- Premature virilization in males
- Masculinization in females
- 17-Hydroxylase deficiency
- Failed sex maturation
- Pheochromocytoma
- Sweating
- Tremor
- Panic
- Facial pallor
- Headache
- Weight loss
- Sleep Disorder
- Sleep Apnea
- Exaggerated snoring
Past Medical History:
- Onset and severity of Hypertension
- Average Blood Pressure
- Recurrent UTI
- Diabetes Mellitus
- Hyperthyroidism
- Hypothyroidism
- Hyperparathyroidism (Hypercalcemia)
- Cushing’s Disease
- Aldosteronism
- Premature virilization in males
- Masculinization in females
- Failed sex maturation
- Pheochromocytoma
Family History
- Hypertension
- Kidney disease
- Pheochromocytoma
- Cushing’s disease
SOCIAL HISTORY:
- Alcohol
- Smoking
- Salt intake
- Fat intake
- High caloric intake contributing
- Obesity
- Physical activity
Physical exam
- Vitals
- BP Examination in both arms
- Pulse both radials and femoral
- Assess for Obesity
- Weight, height
- BMI
- Waist circumference
- Retinal Exam
- Retinal Hemorrhage
- Neck Exam
- Thyroid exam
- Carotid Bruits
- Neck vein exam
- JVP
- Chest exam:
- Congestive Heart Failure signs
- Palpable intercostal pulses
- Cardiovascular Exam:
- S4 Gallop rhythm (decreased LV compliance)
- Tachycardia
- Accentuated S2 Heart Sound
- Aortic Insufficiency murmur
- Abdominal Exam:
- Abdominal bruit
- Abdominal Aortic Aneurysm
- Abdominal mass (flank)
- Striae
- Hirsutism
- Genitourinary exam in youth for abnormal sexual development
- Peripheral Vascular Disease
- Femoral bruits
- Symmetrical pulses
- Lower extremity shin Hair Loss
- Neurologic
- Peripheral Neuropathy
- Skin examination
- Stigmata of Cirrhosis
- Neurofibromata
- Hair atrophy
- Akin atrophy
- Cushing’s Disease
- Striae
- Acne Vulgaris
- Hirsutism
- Moon face
- Central obesity
- Pigmentation
Laboratory work up
- Urinalysis
- Urine protein (microalbuminuria)
- Complete Blood Count
- Fasting lipid profile
- FBS
- Electrolytes, BUN, Cr
- TG, Cholesterol, LDL, HDL
- eGFR or abnormal urinalysis:
- renal ultrasound of kidney assessment
- phosphate
- electrolytes
- urinalysis
- Serum Calcium
- Uric Acid
- 24 hour Urine Creatinine
- 24 Hour Urine Protein
- Sleep apnea:
- Overnight pulse oximetry
- Cushing’s Disease
- 24 hour Urine Cortisol or Salivary cortisol
- Overnight 1 mg dexamethasone suppression test
- Pheochromocytoma
- 24h Urine Metanephrine
- Vanillylmandelic Acid (VMA)
- Renal parenchymal disease
- Renal Ultrasound
- Renal Artery Stenosis
- MR Angiography
- Primary Aldosteronism
- K (Hypokalemia)
- Aldosterone to plasma renin ratio
Diagnostic tests
- Chest X-Ray (evaluate for coarctation, heart size)
- ECG
- Echocardiogram
- Kidney ultrasound
- Renal artery MR Angiography
Management
- General Guidelines
- Smoking cessation
- Avoid alcohol and stimulant drugs such as cocaine
- Weight reduction
- Salt intake reduction
- Physical activity 30-45 min daily 4 to 7 days a week
- Dietary advice
- Ensure compliance
Treatment
ACEi:
- The best medications in hypertensive patients with any type of background illness (DM, CHF, Post-MI, prevention of recurrent CVA, Chronic Kidney Disease)
- Agents:
- Captopril
- Enalapril
- Lisinopril
- Ramipril
- Losartan
- Valsartan
- Side effects:
- Mania
- Anxiety
Hallucinations
- Beta-Blockers:
- Avoid in Asthmatics/COPD
- Avoid in 2 and 3 heart block
- Avoid in depression
- Side effects:
- Fatigue
- Depression
- Anxiety
- sexual dysfunction
- nightmares
- hallucinations
Furosemide
- HTN: 40 mg po BID (max 6 mg/kg)
- CHF: up to 2-2.5 gr/day po or IV
- Chronic renal Failure: up to 2-2.5 gr/day po or IV
- Acute pulmonary edema: 40 mg IV in 1 hr up to 80 mg
- Edema: 20-80 mg OD PO; 20-40 mg BID IV/IM
- Side effects:
- Sexual dysfunction
- Depression
Thiazides:
- Avoid in Gout
Calcium Channel Blockers:
- Warning:
- Avoid in 2 and 3 heart block
- Avoid in heart failure
- Agents:
- Nifedipine
- Verapamil
- Diltiazem
- Side effects:
- Dizziness
- Headache
- Flushing
- Tachycardia
- Depression
Alpha-adrenergic blockers
- Agents:
- Prazosin
- Terazosin
- Doxazosin
- Side effects:
- Syncope
- Dizziness and vertigo
- Palpitations
- Drowsiness
- Weakness
- Confusion
Central alpha-adrenergic agonists
- Agents:
- Clonidine
- Methyldopa
- Side effects:
- Drowsiness
- Sedation
- Fatigue
- Depression
- Impotence
- Delirium
- Psychosis
- Nightmares
- Amnesia
Direct vasodilators
- Agents:
- Hydralazine, minoxidil
- Side effects:
- Tachycardia
- Headache
- Dizziness
Peripheral adrenergic neuron antagonists
- Agents:
- Reserpine,
- Guanadrel
- Side effects:
- Drowsiness
- Depression
- Nightmares
- Tardive dyskines