Hypertension

From IDWiki

Background

  • Elevation in blood pressure that predisposes to cardiovascular disease

Epidemiology

  • Based on the new American guidelines, about 40% of Americans have hypertension

Risk Factors

  • Family history

Clinical Manifestations

  • Usually detected on routine physical exam

History and Physical Examination

History

  • Confirm the diagnosis
  • Causes
    • Cardiovascular disease risk factors (smoking, obesity, exercise, family history)
    • Family history of hypertension
    • Secondary causes: age of onset, renal disease, pheo (headache, palpitations, diaphoresis), hypothyroidism, OSA (snorking daytime fatigue), drugs (OCP, NSAIDs, corticosteroids, nasal deocongestants, calcineurin inhibitors), licorice use
  • Complications
    • Target organ damage: CAD, CHF, CKD, stroke, peripheral vascular disease, visual changes
  • Comorbidities
    • Diabetes, dyslipidemia
  • Other: routine history

Physical Examination

System Confirm Causes Consequences
General BMI, Cushing syndrome (lemon-on-toothpicks) LOC
Vitals Gold-standard bilateral BP BMI
HEENT Thyroid exam, Cushing syndrome (moon facies, buffalo hump), OSA (thick neck, retrognathia, Mallampati) Fundoscopy for retinal hemorrhages and papilledema, carotids for bruits
CVS LVH (displaced apex with sustained impulse, S4), CHF (JVP, S3, periphedema), PAD (shiny hairless legs)
Resp Pulmonary edema
GI Renal and aortic bruits, AAA, striae, abdominal obesity
MSK
Neuro Assess for signs of stroke
Skin Striae, ecchymoses Shiny hairless shins

Differential Diagnosis

Secondary Hypertension

  • Consider in patients with strong family history, who present with hypertensive urgency or emergency, or other clinical features
    • Drug-resistant hypertension, onset in age under 30 years, accelerated or malignant hypertension, unprovoked or excessive hypokalemia, abrupt onset, exacerbation of previously controlled hypertension, disproportionate TOD for degree of hypertension, onset of diastolic hypertension in age ≥65 years
  • Approach
  • Medications: alcohol, NSAIDS, OCP, antidepressants (MAOIs, some SSRIs and SNRIs), stimulants (including illicit drugs), corticosteroids and anabolic steroids, erythropoietin, natural licorice, herbal product (e.g. ma huang and bitter orange)
Cause Signs and Symptoms Screening Tests
Primary aldosteronism cramps, weakness, low K (minotiry) Aldo/renin ratio
Renovascular disease aneuryms, known atherosclerosis, cardiovascular risk factors, bruit CT angiography
Cushing syndrome Cushingoid appearance, bruising, striae, osteoporosis, glucose intolerance, thin skin, neuropsychiatric abnormalities, hypokalemia,

Diagnosis

  • Out-of-office
    • Ambulatory blood pressure monitor (gold standard), with the 24h average usually 10/10 mmHg lower than office and the daytime average 5/5 mmHg lower than office
    • Home BP monitoring (HBPM), usually 5/5 mmHg lower than office
  • In-office
    • Automated office BP measurement (AOBP) ≥135/85
      • Preferred office measurement
    • Office BP measurement (OBPM), preferring electronic ≥140/90
      • Casual office BP measurement
      • Research-grade, Royal College-style office BP measurement
  • Any one-time measurements ≥180/110
  • Any hypertensive emergency

Management

  • Rule out white coat hypertension with ABPM, if suspected

Lifestyle Changes

  • Consider doing these before starting medications if patient is low risk
  • Weight reduction, at least 10lbs
  • Exercise 30min for 5 days weekly
  • Low-sodium diet
  • Restrict alcohol intake

Medications

  • Thiazide, ACEi, ARB, CCB, beta-blocker, or single-pill combos (ACEi/ARB + thiazide/CCB)
    • Avoid alpha-blocker, avoid ACEi/ARB combos, and avoid beta-blockers in age >60
    • If more than 20/10 above target, start a combo pill right away
  • Fewer adverse events with lower-dose combo pills than high-dose single-drug pill
  • Per STITCH trial
    • Start with low-dose ACEi/thiazide or ARB/thiazide combo pill
    • Uptitrate combo pill
    • Add amlodipine
  • Diabetes: prefer ACEi/ARB
  • Pregnancy: see Hypertension in pregnancy
Intervention Details SBP/DBP
Salt reduction 100 mmol/day -6/-2.5
Weight loss -4.5kg -7/-6
Alcohol reduction -2.7 drinks/day -5/-2
Exercise 3 times per week -10/-7.5
Diet DASH -11/-5.5

Targets

  • In general, lower is probably better
Population Threshold Target Notes
General population or low risk ≥160/100 <140/90
Diabetes mellitus ≥130/80 <130/80
High risk (TOD or CV risk factors) ≥140/90 <140/90
High risk (SPRINT eligible) ≥130 ≤120 based on AOBP
US guidelines for 10-year risk ≥10% ≥130/80 <130/80
US guidelines for 10-year risk <10% ≥140/90 <140/90
  • SPRINT study
    • Included patients age ≥50 years with high risk status
      • Clinical or sub-clinical cardiovascular disease
      • CKD (non-diabetic nephropathy, proteinuria <1 g/d)
      • Framingham 10-year risk >15%
      • Age ≥75 years
    • Excluded patients with diabetes and those with resistant hypertension
    • Be careful in resistant hypertension or in frail elderly
  • Pregnancy: see also Hypertension in pregnancy
  • ABPM targets are 5/5 mmHg (daytime average) or 10/10 mmHg (24h average) lower than office BP targets

Drug-Resistant Hypertension

  • Diagnosed based on ongoing hypertension despite at least 3 agents, including at least one diuretic
  • Approach
    • Step 1: Assess adherence and perform 24-hour ABPM. Discontinue interfering drugs, rule out secondary causes, and optimize health behaviours.
    • Step 2: Optimize regimen, including switching to long-acting synergistic combinations (ACEi or ARB, DHP CCB, and thiazide-like diuretic). Simplify dosing schedule and minimize costs.
    • Step 3: Consider spironolactone 12.5 to 50 mg daily (preferred), an alpha blocker (e.g. doxazosin), or a beta blocker (e.g. bisoprolol)
    • Step 4: Consider last-line medications, including aliskiren, hydralazine, and clonidine

Further Reading

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