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
- 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
- Endocrine
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
- Automated office BP measurement (AOBP) ≥135/85
- Any one-time measurements ≥180/110
- Any hypertensive emergency
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 ACEi/thiazide or ARB/thiazide combo pill
- Uptitrate combo pill
- Add amlodipine
- Lifestyle changes first
- 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
- 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
