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HYPERTENSION
HYPERTENSION
Detection, Evaluation
and Non-pharmacologic Intervention
Misbah Keen, MD, FAAFP
Act. Asst. Professor Family Medicine
University of Washington School of Medicine
Seattle WA
Problem Magnitude
Hypertension( HTN) is the most common
primary diagnosis in America.
35 million office visits are as the primary
diagnosis of HTN.
50 million or more Americans have high BP.
Worldwide prevalence estimates for HTN may be
as much as 1 billion.
7.1 million deaths per year may be attributable to
hypertension.
Definition
A systolic blood pressure ( SBP) >139
mmHg and/or
A diastolic (DBP) >89 mmHg.
Based on the average of two or more
properly measured, seated BP
readings.
On each of two or more office visits.
Accurate Blood Pressure Measurement
www.nhlbi.nih
.gov
Prehypertension
SBP >120 mmHg and <139mmHg and/or
Isolated
Systolic
HTN
Systolic Diastolic
HTN
Isolated
Diastolic
HTN
Hypertensive Crises
( hypercortisolism)
Impaired TFT (Hypo-/hyper- thyroidism)
Secondary HTN-Screening
Tests
www.nhlbi.nih.gov
Renal Parenchymal Disease
Common cause of secondary HTN (2-5%)
HTN is both cause and consequence of
renal disease
Multifactorial cause for HTN including
disturbances in Na/water balance,
vasodepressors/ prostaglandins
imbalance
Renal disease from multiple etiologies.
Renovascular HTN
Atherosclerosis 75-90% ( more common in
older patients)
Fibromuscular dysplasia 10-25% (more
common in young patients, especially females)
Other
Aortic/renal dissection
Takayasus arteritis
Thrombotic/cholesterol emboli
CVD
Post transplantation stenosis
Post radiation
Complications of Prolonged
Uncontrolled HTN
Changes in the vessel wall leading to
vessel trauma and arteriosclerosis
throughout the vasculature
Complications arise due to the target
organ dysfunction and ultimately failure.
Damage to the blood vessels can be seen
on fundoscopy.
Target Organs
CVS (Heart and Blood Vessels)
The kidneys
Nervous system
The Eyes
Effects On CVS
Ventricular hypertrophy, dysfunction and
failure.
Arrhithymias
Coronary artery disease, Acute MI
Arterial aneurysm, dissection, and
rupture.
Effects on The Kidneys
Glomerular sclerosis leading to impaired
kidney function and finally end stage
kidney disease.
Ischemic kidney disease especially when
renal artery stenosis is the cause of HTN
Nervous System
Stroke, intracerebral and subaracnoid
hemorrhage.
Cerebral atrophy and dementia
The Eyes
Retinopathy, retinal hemorrhages and
impaired vision.
Vitreous hemorrhage, retinal detachment
Neuropathy of the nerves leading to
extraoccular muscle paralysis and
dysfunction
Retina Normal and Hypertensive
Retinopathy
A
B
Arteriolar
Narrowing
Stage II- AV Nicking
AV
AVNicking
Nicking
AV Nicking
AV Nicking
Stage III- Hemorrhages (H), Cotton
Wool Spots and Exudats (E)
H
E
Stage IV- Stage III+Papilledema
Patient Evaluation Objectives
(1) To assess lifestyle and identify other
cardiovascular risk factors or concomitant
disorders that may affect prognosis and guide
treatment
(2) To reveal identifiable causes of high BP
(3) To assess the presence or absence of
target organ damage and CVD
(1) Cardiovascular Risk factors
Hypertension
Cigarette smoking
Obesity (body mass index 30 kg/m2)
Physical inactivity
Dyslipidemia
Diabetes mellitus
Microalbuminuria or estimated GFR <60 mL/min
Age (older than 55 for men, 65 for women)
Family history of premature cardiovascular disease (men
under age 55 or women under age 65)
(2) Identifiable Causes of HTN
Sleep apnea
Drug-induced or related causes
Chronic kidney disease
Primary aldosteronism
Renovascular disease
Chronic steroid therapy and Cushings syndrome
Pheochromocytoma
Coarctation of the aorta
Thyroid or parathyroid disease
(3) Target Organ Damage
Heart
Left ventricular hypertrophy
Angina or prior myocardial infarction
Prior coronary revascularization
Heart failure
Brain
Stroke or transient ischemic attack
Chronic kidney disease
Peripheral arterial disease
Retinopathy
History
Angina/MI Stroke: Complications of HTN,
Angina may improve with b-blokers
Asthma, COPD: Preclude the use of b-blockers
Heart failure: ACE inhibitors indication
DM: ACE preferred
Polyuria and nocturia: Suggest renal
impairment
History-contd.
Claudication: May be aggravated by b-
blockers, atheromatous RAS may be present
Gout: May be aggravated by diuretics
Use of NSAIDs: May cause or aggravate HTN
Family history of HTN: Important risk factor
Family history of premature death: May have
been due to HTN
History-contd.
Family history of DM : Patient may also
be Diabetic
Cigarette smoker: Aggravate HTN,
independently a risk factor for CAD and
stroke
High alcohol: A cause of HTN
High salt intake: Advice low salt intake
Examination
Appropriate measurement of BP in both arms
Optic fundi
Calculation of BMI ( waist circumference also
may be useful)
Auscultation for carotid, abdominal, and femoral
bruits
Palpation of the thyroid gland.
Examination-contd.
Thorough examination of the heart and
lungs
Abdomen for enlarged kidneys, masses,
and abnormal aortic pulsation
Lower extremities for edema and pulses
Neurological assessment
Routine Labs
EKG.
Urinalysis.
Blood glucose and hematocrit; serum potassium,
creatinine ( or estimated GFR), and calcium.
HDL cholesterol, LDL cholesterol, and
triglycerides.
Optional tests
urinary albumin excretion.
albumin/creatinine ratio.
Goals of Treatment
Treating SBP and DBP to targets that are
<140/90 mmHg
Patients with diabetes or renal disease, the BP
goal is <130/80 mmHg
The primary focus should be on attaining the
SBP goal.
To reduce cardiovascular and renal morbidity
and mortality
Benefits of Treatment
Reductions in stroke incidence,
averaging 3540 percent
Reductions in MI, averaging 2025
percent
Reductions in HF, averaging >50 percent.
Lifestyle modifications
www.nhlbi.nih.gov
Lifestyle Changes Beneficial in Reducing Weight
Hyperlipedemia Information
Adult Treatment Panel 3 Guidelines
www.nhlbi.nih.gov/guidelines/cholesterol/index.htm
Questions
mkeen@fammed.washington.edu