HYPERTENSION

Classification of Hypertension

Normal BP

Elevated BP

Stage 1

Stage 2

Systolic BP: < 120 mmHg

Diastolic BP: < 80 mmHg

SBP: 120-129 mmHg

DBP: < 80 mmHg

SBP: 130-139 mmHg

DBP: 80-89 mmHg

SBP: > 140 mmHg

DBP: > 90 mmHg

Etiology

Primary Hypertension

Secondary Hypertension

Elevated BP without an identified cause

90-95% of all cases of hypotension

UNKNOWN CAUSE

Elevated BP with a specific cause that often can be identified and corrected

5-10% of hypertension adults

Suddenly develop high BP, especially if severe

Pathophysiology

PRIMARY: BP rises with any CO or SVR

Common Causes for Secondary Hypertension

Cirrhosis

congenital narrowing of the aorta

Pregnancy induced hypertension

Endocrine: pheochromocytoma, Cushing Syndrome, thyroid disease

Neurological disorders: brain tumor, quadriplegic, traumatic brain injury

Renal disease: renal artery stenosis, glomerulonephritis

Sleep apnea

Drug related: estrogen replacement therapy, oral contraceptives, corticosteroids, nonsteroidal anti-inflammatory drugs (cyclooxygenase-2 inhibitors), SNS stimulants (cocaine, monoamine oxidase)

Clinical Manifestations

Called a “silent killer” because it is often asymptomatic until it becomes severe and target organ disease

Secondary symptoms

Fatigue

Dizziness

Palpitations

Angina

Dyspnea

Complications

Most common complications of hypertension are target organ disease

Hypertensive Heart Disease

Cerebrovascular Disease

Peripheral Vascular Disease

Nephrosclerosis

Retinal Damage

Coronary Artery Disease

Left Ventricular Hypertrophy

Heart Failure

Significant risk factor for coronary artery disease (CAD)

The “response to injury” theory of atherogenesis suggests that hypertension disrupts the coronary artery endothelium—> results in a rigid arterial wall with a narrowed lumen and may account for the high rate of CAD, angina, and MI

Sustained high BP increases the cardiac workload and produces left ventricular hypertrophy

HF occurs when the heart’s compensatory mechanisms are overwhelmed and the heart can no longer pump enough blood to meet the body’s demands

Contractility depressed, SV and CO decreased

May have shortness of breath on exertion, paroxysmal nocturnal dyspnea, and fatigue

Atherosclerosis is the most common cause of cerebrovascular disease

Risk factor for cerebral atherosclerosis and stroke

Adequate BP control decreases the risk of stroke

Hypertension speeds up the process of atherosclerosis in the peripheral blood vessels. This leads to peripheral vascular disease, aortic aneurysm, and aortic arch dissection

The appearance of retina gives essential information about the severity and duration of hypertension. We can directly see the blood vessels of the retina with an ophthalmoscope. Damage to the retinal vessels indicates related vessel damage in the heart, brain, and kidneys. Manifestations of severe retinal damage include blurring of vision, retinal hemorrhage, and vision loss

Hypertension is one of the leading causes of chronic kidney disease (CKD). Some degree of renal disease is usually present even with mild hypertension

Renal disease results from ischemia caused by the narrowing of the renal blood vessels. This leads to atrophy of the tubules, destruction of the glomeruli, and eventual death of nephrons

Diagnostic Studies

History and physical examination, including an opthalmic examination

Fasting blood glucose

Routine urinanalysis

Basic metabolic panel with eGFR

Complete blood count

Serum Lipid Profile (HDL, LDL, triglycerides, total lipids)

Serum Uric acid, magnesium, and calcium

12 lead ECG