Hypertension Review

MEDICINE COURSE 442: 2020 - 2021

DR. TALAL ALFAADHEL
Notes by Aseel Alsulimani.
Outline
• Presentations
• Introduction
• Definitions
• Evidence
• Summary
Case 1
• 35-year-old woman was referred to your clinic after undergoing
screening for employment. Her blood pressure was found to be
high (149/93 mmHg). She has no complaints and is otherwise
healthy.
• PMH: nil
• Meds: nil
• FHx: High BP in father and brother
• SHx: Single, works as a nurse, no illicit drug use.
Case 1
• On physical exam: BMI 29, looks well, not in distress
• BP: 145/93, HR: 78
• CVS: S1 + S2 + 0
• Chest: clear
• Abd: Soft, Lax, no bruit
• Rheum and Neuro: normal
 Case 1
• What is your next step in management?
A. Advise for lifestyle modification and follow up in 3 months
B. Repeat blood pressure measurement in the office after 2 weeks
C. Perform a 24-hour ambulatory blood pressure monitor
D. Ask for home blood pressure readings over one week

ANS: C because she has family history so this is most correct, but B and D could also be correct
How is blood pressure measured? classic OSCE station

** **avoid wrist measurement

*crossing legs will increase

* blood pressure
Other types blood pressure measurement devices :
• Mercury based manometer (phasing out)
• Oscillometer based measurements (most automated BP machines)
Epidemiology
• 1 in 3 adults (>20 years old) have high blood pressure
• Incidence increases with aging
• 5 – 10% of all hypertension is secondary
• Searching for secondary hypertension is expensive and
cumbersome This is why we have guidlines to minimize wasting resources
• Need better selection of who to screen and offer specific
treatments
Before 1960 they always associated HTN with bad outcomes, then on 1960 this
study came out in the journal of medical association: they treated people with BP
115-129 and compared patients with active treatment and no treatment.
You can see the reduction in diastolic
blood pressure around 26 mmHg
(stroke, heart failure, MI, death)

people who are treated had better outcome.

the higher BP the worst the outcome
as you age and as your blood pressure
goes up you are most likely to die.
even high
normal BP
has worse
outcome than
normal BP
 Hypertension definitions
• Prehypertension
• Hypertension
• Stages
• Urgency
• Emergency
• White Coat syndrome
• Masked Hypertension

Prehypertension: office BP 130-140/80-90 (this name is no longer used)

Masked hypetrension: normal BP at office but high on home 24hr ambulatory
 *most commonly the diagnosis is made using office BP
measured in 2 or 3 settings, however if you have symptoms of
HTN or evidence of hypertensive disease or end organ damage,

Criteria for HTN diagnosis

you only need 1 high reading.

** this is diagnostic

**
 Ambulatory BP measurement

People often have variable readings during the same visit

*Not always available and some patients may not tolerate it so u can replace it with home monitoring NICE
Ambulatory BP measurement

avoid this!!

Australian guidelines
 Ambulatory BP

when starting new medication

in sleep apnea or chronic kidney disease or DM is

they have nocturnal hypertension (non-dipping.)
typically during sleep BP should go down, in this
case there is absence of this.

Australian guidelines
Nocturnal Blood pressure
*Someone with HTN and they are young and have risk factors like hyperthyroidism, SLE, DM you should screen them for OSA
**You should do urine analysis
***Do duplex, CT or MRI, in textbooks they mention abdominal bruit but it is difficult to identify and not very specific
****Keep in mind in young women
Secondary HTN

*
**

***

****
****

Last 2 are not seen often but they can be stressful to the patient.
This is not her image sign of fibromascular dysplasia
Case 1
• 35 F, BP 149/98 mmHg, FHx father, brother. No significant PMHx
• Labs: CBC normal, Urea 4, Cr 56, Na 143, K 3.1, Cl 89, HCO3 30
• LFT Normal, TSH Normal
• US Kidneys: R kidney 11.2 cm, L kidney 12 cm, Dopplers Normal
renal artery flow
some evideince of hypokalemia and alkalosis and because of her age
she might have primary aldosteronisim so order aldosterone ratio
ARR
ARR
It is very hard to interpret because most of the patients who have HTN are already on
treatment, and most hypertensive treatment can alter the reading of the test so it is not the
best test but it can give you some idea.
so whatever the reading is whether its high or low you need to do some confirmatory tests.
 PA Confirmatory tests
• Try to inhibit Aldosterone (demonstrate that it is regulated)
• Oral salt loading (1 g po od x3days) it wont be supressed in case of PA
• NS infusion (500 ml)
• Captopril challenge
• Fludrocortisone + Na

PA= primary aldosteronism

PA testing
• Imaging
• Venous sampling invasive so its not done anymore except in specialized centers
Case 1

• Results:
• High Aldosterone
• Low Renin

• CT Abdomen: No adenoma, normal adrenal glands

• 24-hour K excretion: high

• What to do next? start aldosterone antagonist, like spironolactone or epleronone

start aldosterone antagonist, like spironolactone or epleronone
difference b/w is in young men avoid spironolactone cuz of gynocomatsia and ?affects androgens
both of them is potassium sparing
 Case 2
• A 67-year-old man presents to the emergency department with
headache. He has a history of uncontrolled hypertension as he is
not compliant on medications.
• On physical examination: He is conscious, tired but oriented.
• BP is 230/120 mmHg, HR 89 bpm, O2 saturation is 95% on RA. CVS
reveals S1+S2+S4, Chest is clear.
• Remaining exam is unremarkable.
abnormal findings: High BP, headache, S4
S4 indicates stiffness of ventricles
 Case 2
• Which one of the following is the most appropriate next step in
management?
A. ECG ECG takes priority

B. Fundoscopy
C. Urinalysis
D. CT Scan of the head he has headache which is worrisome

E. None of the above

F. All the above
ANS: F
 sinus rhythm, rate is around 60-70, there is left axis deviation (lead 2 and 3 or aVf)
Case 2 - ECG prominent s wave in v2 and prominent r wave in v6 so it is left ventricular hypertrophy
 Case 2 - Fundoscopy
Cotton wool spots,
hemorrhage and optic
edema and copper wire
indicates hypertensive
retionopathy.

malignant hypertension in
previous terminology it is
not used anymore.
Case 2 – CT Scan - Brain
This is a normal CT head,
there is no hemorrhage.

in cerebral hemorrhage u
would see shifting and
compression of surrounding
tissue
Blood is white in CT u will see
hyper-density in the
distriubution of the arteries .
Hypertensive Crisis it can be classified into 2:
Explanation in the next slide

1
2

and HTN retinopathy

A Piani et al, Definitions and Epidemiological Aspects of Hypertensive Urgencies and Emergencies,
High Blood Pressure & Cardiovascular Prevention volume 25, pages241–244(2018)
1- Hypertensive emergency you have to admit the patient for treatment under monitoring.
2- worsening organ damage like a patient who has history of MI or IHD and is stable but
now he complains of severe chest pain this is worsening of his angina.
3- End-organ damage can be classified as changes in CNS or CVS, renal changes, eye
disease.
Eclampsia and pre-eclampsia are important and often forgotten.
-perioperative HTN is considered as hypertensive emergency and you need to treat them
so they do not bleed to death.
 Which one of the following treatments is given for
Hypertensive Emergencies
A. Metoprolol IV infusion it affects the rate of the heart mostly not the blood pressure
B. Labetalol IV infusion
C. Nifedipine IV infusion There is no IV formulation of nifepidine

ANS: B
 Explanation in the next 2 slides

5
6
7
8
9

10

11
12
13
 Hypertensive emergency treatment:
1- do not confuse nicardapine with nifepidine, they are both CCB but we do not use nifipedine for hypertensive emergency because it only comes in an oral
formulation.
3- The one we use the most is labetalol, it is widely available, the only down side is that it causes bradycardia, so if that happens switch to another agent.
4- Esmolol has a significant effect on the rhythm so avoid it in heart failure.
7- Furosemide is not used for HTN emergency, it is only used for special cases, like heart failure with HTN emergency.
8-Hydralazine is not often used because it is associated with tachycardia which can precipitate coronary artery disease.
9- Nitroglycerin can be used but you might have tolerance after 24 hrs.
10- Nitroprusside is associated with cyanide toxicity.
In summary:
- Labetalol is the first choice.
- if nicardipine is available use it.
- In case of heart failure use furosemide + labetalol.
- In hypertensive emergency you have to decrease the BP by 25 mmHg within 1 hour because of end organ damage, you start with 1 medication if the BP
does not reach the goal within an hour then you increase the dose until the maximum, if still it is not improved you can add another agent.

Hypertensive urgency treatment:

13- CCB is the first choice of treatment because of lower risk of side effects.
12- Captopril is used because it has a short half-life so it can build up in the system fast and it can be used every 8-12 hrs, but it can precipitate renal function.
11- Clonidine is listed in the books but we don’t use it because it has central activity, some people use it for anxiety related HTN.
- You have to decrease the BP gradually, because the organs are used to the high BP, so if you lower the BP fast it may lead to renal ischemia or cerebral
ischemia
 comorbidities

Summary
*

*do ECG, urine analysis, fundoscopy,

echo, no need for CT head if they are
asymptomatic.
**medications that cause HTN: NSAIDS
very commonly, and OCP among young
women. and also pseudoephedrine,
cocaine, caffeine.
Most common and most important is
NSAIDs and OCP.
***Cushing and hyperthyroidism **

***
Summary Important slide

when to screen:

* Renal artery stenosis is often associated with resistant hypertension.