PC HTN
causes
Diagnosis
HIGH circulating catecholamines, arteriolar stretch SNS activity,
Renin Release
acts on angiotensinogen to cleave off the ten-amino-acid peptide Angiotensin I.
High renin activity only 10% of patients. 60% have normal levels, and 30% have low levels.
multiple BP reading
Tx
Intracellular Na+ is elevated in primary (essential) hypertension. An increase in intracellular Na+ may lead to increased intracellular Ca2+
Alcoholism
Cigarette smoking raises blood pressure by increasing plasma norepinephrin
NSAIDs increases blood pressure averaging 5 mm Hg.
Resources
primary HTN
secondary HTN
genetic
Glucocorticoid remediable aldosteronism
autosomal dominant cause of early-onset hypertension with normal or high aldosterone and low renin levels
aldosterone antagonists are effective in controlling hypertension
Liddle syndrome
autosomal dominant condition characterized by early-onset hypertension, hypokalemic alkalosis, low renin, and low aldosterone levels.
causes renal disease
hyperaldosteronism
adrenal adenoma or bilateral adrenal hyperplasia
≥60/100 mm Hg
140–159/90–99 mm Hg
EMERGENCY
220/125 mm
Population Specific
women more strokes
delay tx 3 mo = baaad
Rx
nonpharma
African American #
diabetes
more osmlality
LOW renal perfusion pressure, low intravascular volume, & hypokalemia. #
Angiotensin-converting enzyme (ACE) acts on this peptide to create peptide Angiotensin II,
vasoconstriction
Adrenl Cortex-aldosterone secretion
Aging
Diastolic less of a factor at age 50+
more HTN, less repsonse to ACE inhibitors
rest 5min in clinic at home best
men more heart attacks
Black persons with hypertension and older patients tend to have lower plasma renin activity, which may be associated with expanded intravascular volume.
Low K+ intake associated with HTN; an intake of 90 mmol/day is recommended.
JNC 8
age 60, non-diabetic, no chronic kidney disease goal= <150/90
< age 60, all diabetics, all with chronic kidney disease goal= <140/90
ACE Inhibitor #
disrupt RAAS
click to edit
if dystolic and systolic are different classes, choose higher class
90-95% Idiopathic
an intake of 90 mmol/day K+ is recommended.
Intracellular Na+ is elevated
if goal not reached in 1 mo, add Rx or up dose
caused by these
Kidney disease
Pheochromocytoma-benign adrneal tumor
Coarctation of aorta
Thyroid/parathyroid disease
Primary aldosteronism (often in patients with DMT2)
Obstructive sleep apnea
Rx related (e.g., NSAIDs, cold remedies, some antidepressants)
steroid therapy
associated w/ aldosteronism
BP normal but doesn't dip at night
Maybe stroke. Need Tx
genetic
Glucocorticoid remediable aldosteronism (genetic)- aldosterone antagonist #
only randomized clinical trials (5-8 yrs)
JNC 8
Tests
rational De Novo
Obtain a blood pressure every visit.
Recheck in clinic if >130/>80.
Leave alone if <130/<80
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Creatinine, BUN, serum Na+ K+
Fasting serum glucose
CBC
urinalysis w/ mmicroscopic reading
albumin
creatinine
Organ Damage
Reitnopathy
Cotton wool spots
Heart
hypertrophy
Fasting serum TC, triglycerides, HDl, LDL
sphygmometer best, computer does pulse wave
12 lead EKG
effect readings according to KP 2012
10
pt talking
5-10
Full bladder
feet not on floor
back unsupported
forearm BP
legs crossed
small cuff
140-159/90-99 ->Repeat in ~2 weeks. Educate TLC x 3 months w/wo anti-HTN Rx
≥160/≥100->Repeat in ~2 weeks. HTN, Educate TLC, Initiate anti-HTN Med
macular star
optic disc edema
AV nicking or crossing
swollen axons
CHF
weight loss
5-20 mmHg per 10 kg
DASH diet
8-14 mmHg
Excercise
4-9 mmHg 30+ min most days if not already doing it
Don't increase f, intensity & duration all on same day
if incrèments at least 10 min
AHA no more than 2 drinks day men 1 for women
perhaps by increasing plasma catecholamine
3 medications or more, consider divided dosing (AM/PM). Increasing evidence links sleep-time blood pressure and incidence of CV disease.
AHA
Viet Le
risk of CVD doubles for every 20/10 mmhg over 115/75. That means that at 135/85 we are presumably already at risk
Pre- Hypertension
120–139/80–89 mm Hg
Framingham cohort: 50% of affected individuals do so within 4 years
130-139/81-89 ->Borderline HTN, Counsel TLC
cushing's
purple straiae
hirsutism in women, ED in men
buffalo hump
clonidine
SEE RX MAP