Hypertension

Hypertension: Excerpt from In a Page: Signs and Symptoms

Elevated blood pressure is defined as diastolic BP 90 mmHg or systolic BP ≥140 mmHg. A diagnosis of hypertension requires three separate elevated blood pressure measurements. High normal: 130/85 to 139/89; stage 1: 140/90 to 159/99, stage 2–3: ≥160/100.

Differential Diagnosis

• Essential hypertension (95% of cases)
  –Associated with obesity, decreased physical activity, stress, and diets high in sodium or low in potassium, calcium, and/or magnesium
• Medications (e.g., oral contraceptives, pseudoephedrine, steroids, ephedrine, NSAIDs)
• Sleep apnea
• Secondary hypertension
  –Chronic renal disease
  –Renal vascular disease (e.g., renal artery atherosclerosis, fibromuscular dysplasia)
  –Cushing's disease
  –Pheochromocytoma
  –Primary hyperaldosteronism
  –Hyperthyroidism
  –Coarctation of aorta: Arm pulses are stronger than leg pulses and blood pressure is significantly higher in arms than in legs
  • “White coat” hypertension
  • Pain, stress (e.g., surgery, emotional), and postexercise
  • Isolated systolic hypertension
    –More common in elderly
    –Stronger risk factor for heart disease than
    diastolic hypertension in patients >50
  • Excessive alcohol use
  • Cocaine use
  • Malignant hypertension
    –Markedly elevated blood pressure (diastolic BP >120–140 mmHg associated with papilledema)
  • Preeclampsia/eclampsia
  • Pregnancy-induced hypertension
  • Congenital adrenal hyperplasia

  Workup and Diagnosis

  • History and physical examination, including evaluation of risk factors (e.g., history of diabetes, family history of heart disease, smoking, elevated cholesterol, drug use, stress, pain, obesity, body mass index)
  • Evaluate for end organ disease (target organ damage): CAD symptoms, vascular disease, retinal hemorrhage, retinal venous crossing changes, heart exam (murmurs, gallops), lung exam (signs of CHF)
    –Labs may include urinalysis, basic metabolic panel (electrolytes, glucose, BUN/creatinine), calcium, lipids, ECG, echocardiogram, glomerular filtration rate measurement, and urinary albumin (albumin:creatinine ratio)
    • Consider secondary causes of hypertension if sudden onset of hypertension, significant hypertension (>180/110), abnormally young (<30) or old (>50) patient, presence of end-organ symptoms, or poor response to treatment (not controlled with three medications)
      –Elevated creatinine suggests renal parenchymal disease
      –Abdominal bruits and hypokalemia suggest renal vascular disease
      –Cushing's disease is associated with osteoporosis, obesity, muscle weakness, moon facies, hirsutism, elevated lipids and sugar, low potassium
      –Pheochromocytoma is associated with extremely labile blood pressure (episodic or paroxysmal HTN), headaches, palpitations, and diaphoresis
      –Primary hyperaldosteronism is associated with isolated low potassium and non-anion gap metabolic alkalosis

    Treatment

    • Essential hypertension: Lifestyle changes are the initial interventions unless significant hypertension, end-organ damage, or diabetes is present (smoking cessation; dietary changes, e.g., DASH diet =low in sodium, rich in potassium and calcium; increased exercise)
    • Pharmacologic therapy usually begins with a diuretic or β-blocker (ACE inhibitor in diabetics)
      –Diuretics are usually first-line agents, especially in CHF, diabetes, and risk of coronary artery disease
      –Use ACE inhibitors in patients with CHF, MI, renal disease, and diabetes
      –Use β-blockers in CAD, recent MI, angina, CHF, atrial fibrillation, migraines, hyperthyroidism
      –Additional drugs may include angiotensin receptor blockers (especially in patients with cough when using ACE inhibitors), calcium channel blockers, and β-blockers
      –Preferred drugs in pregnancy include methyldopa, β-blockers, and vasodilators (do not use ACE/ARBs)
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Book Source Details

• Book Title: In a Page: Signs and Symptoms
• Author(s): Scott Kahan, Ellen G. Smith
• Year of Publication: 2004
• Copyright Details: In a Page: Signs and Symptoms, Copyright © 2004 Lippincott Williams & Wilkins.

More About Pheochromocytoma

• Back to disease: Pheochromocytoma: Introduction
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: In a Page: Signs and Symptoms Authors: Scott Kahan, Ellen G. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2004 ISBN: 1-4051-0368-X

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