Hypertension - Revision history

Aidan: /* Secondary Hypertension */

2022-02-27T17:58:44Z

Secondary Hypertension

← Older revision		Revision as of 17:58, 27 February 2022
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	**** [[OCP]]		**** [[OCP]]

	== Secondary Hypertension ==		== [[Secondary hypertension\|Secondary Hypertension]] ==

	* Consider in patients with strong family history, who present with hypertensive urgency or emergency, or other clinical features		* Consider in patients with strong family history, who present with hypertensive urgency or emergency, or other clinical features

Aidan: /* Secondary Hypertension */

2021-12-31T18:38:52Z

Secondary Hypertension

← Older revision		Revision as of 18:38, 31 December 2021
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	\|[[Cushing syndrome]]		\|[[Cushing syndrome]]
	\|Cushingoid appearance, bruising, striae, osteoporosis, glucose intolerance, thin skin, neuropsychiatric abnormalities, hypokalemia,		\|Cushingoid appearance, bruising, striae, osteoporosis, glucose intolerance, thin skin, neuropsychiatric abnormalities, hypokalemia,
	\|
	\|-
	\|
	\|
	\|		\|
	\|}		\|}

Aidan: /* Management */

2021-10-15T18:00:38Z

Management

← Older revision		Revision as of 18:00, 15 October 2021
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	* Pregnancy: see also [[Hypertension in pregnancy]]		* 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		* 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 ==		== Further Reading ==

Aidan: /* Diagnosis */

2021-10-15T17:54:56Z

Diagnosis

@@ Line 89: / Line 89: @@
 ** Masked hypertension: check ambulatory or home BP
 * Secondary hypertension (5%):
-** Endocrine
+**Endocrine
 *** [[Cushing syndrome]]
-*** [[Conn syndrome]]
+*** '''[[Conn syndrome]] or [[primary aldosteronism]]'''
 *** [[Pheochromocytoma]]
 *** [[Hypothyroidism]]/[[hyperthyroidism]]
@@ Line 98: / Line 99: @@
 *** [[Chronic kidney disease]]
 *** [[Glomerulonephritis]]
-*** [[Renovascular disease]]
+*** [[Renovascular disease]], including atherosclerotic disease and [[Fibromuscular dysplasia|'''fibromuscular dysplasia''']]
 ** Other
 *** [[Obstructive sleep apnoea]]
@@ Line 107: / Line 108: @@
 **** [[Licorice]]
 **** [[OCP]]
 == Diagnosis ==

Aidan at 17:37, 15 October 2021

2021-10-15T17:37:13Z

Show changes

Aidan at 17:16, 15 October 2021

2021-10-15T17:16:32Z

Show changes

Aidan: Text replacement - "Clinical Presentation" to "Clinical Manifestations"

2020-07-15T15:24:48Z

Text replacement - "Clinical Presentation" to "Clinical Manifestations"

← Older revision		Revision as of 15:24, 15 July 2020
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	* Family history		* Family history

	== Clinical ~~Presentation~~ ==		== Clinical Manifestations ==

	* Usually detected on routine physical exam		* Usually detected on routine physical exam

Maintenance script: Imported from text file

2020-07-04T01:17:39Z

Imported from text file

New page

== Definition ==

* Elevation in blood pressure that predisposes to cardiovascular disease

== Etiology ==

== Pathophysiology ==

== Differential Diagnosis ==

* White coat hypertension: check ambulatory or home BP
* Primary or essential hypertension (95%): onset 20-50 years, family history
** Masked hypertension: check ambulatory or home BP
* Secondary hypertension (5%):
** Endocrine
*** Cushing syndrome
*** Conn syndrome
*** Pheochromocytoma
*** Hypo/hyperthyroidism
*** Hyperparathyroidism
** Renal
*** Chronic kidney disease
*** Glomerulonephritis
*** Renovascular disease
** Other
*** Obstructive sleep apnea
*** Aortic coarctation
*** Drug- and medication-induced
**** Exogenous corticosteroids
**** Cocaine
**** Licorice
**** OCP

== Epidemiology ==

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

== Risk Factors ==

* Family history

== Clinical Presentation ==

* 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
|}

== 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

== Targets ==

* General population: <140/90
* High CV risk: ≤120 (SPRINT study)
** Framingham >15%, age ≥75, cardiovascular disease; excluded patients with diabetes
** Be careful in resistant hypertension or in frail elderly
* Diabetes: <130/80 (ACCORD study)
* PKD:
* Pregnancy: see [[Hypertension in pregnancy]]
* ABPM targets are 5/5 mmHg (daytime average) or 10/10 mmHg (24h average) lower than office BP targets

== Management ==

* Rule out white coat hypertension with ABPM, if suspected
* Hypertension without compelling indications
** Lifestyle changes first
*** Weight reduction, at least 10lbs
*** Exercise 30min for 5 days weekly
*** Low-sodium diet
*** Restrict alcohol intake
** 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 ACE/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
|}

== Further Reading ==

* [https://guidelines.hypertension.ca/ Hypertension Canada Guidelines 2018]

[[Category:Cardiology]]