essential hypertension review| usmle step 2

7/22/2019 Essential Hypertension Review| USMLE Step 2

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Cardiology

HYPERTENSION

USMLE Step 2 ReviewMarc Imhotep Cray, M.D.

BMS and CK Teacher

http://www.imhotepvirtualmedsch.com /
http://www.imhotepvirtualmedsch.com/http://www.imhotepvirtualmedsch.com/http://www.imhotepvirtualmedsch.com/http://www.imhotepvirtualmedsch.com/http://www.imhotepvirtualmedsch.com/http://upload.wikimedia.org/wikipedia/commons/4/47/Grade_1_hypertension.jpg


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Cardiology| Hypertensive Vascular Disease

Marc Imhotep Cray, M.D.

Topics Covered

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Definition Classification

BMS Concepts

RAAS

Causal Conditions

Target Organ Damage

Approach

Management HTN in Elderly
http://www.imhotepvirtualmedsch.com/


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DEFINITION of HTN

A BP of >140/90 mm Hg on two separate occasions

If there is end-organ damage, diagnosis is made on

the first visit

3

HY Points:

HTN is not diagnosed until two separate measurements on two separate

occasions are above 140/90 mm Hg (except in pregnancy, when

preeclampsia may be cause of hypertension)

Also, if hypertension is severe (>210 mm Hg systolic, >120 mm Hg diastolic,

or end-organ effects), immediate treatment with medication is warranted
http://www.imhotepvirtualmedsch.com/http://www.imhotepvirtualmedsch.com/


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JNC Classification of HTN

4

National High Blood Pressure Education Program. The Seventh Report of the Joint NationalCommittee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.

Bethesda (MD): National Heart, Lung, and Blood Institute (US); 2004 Aug. Classification of

Blood Pressure.

Available at http://www.ncbi.nlm.nih.gov/books/NBK9633/
http://www.ncbi.nlm.nih.gov/books/NBK9633/http://www.ncbi.nlm.nih.gov/books/NBK9633/http://www.imhotepvirtualmedsch.com/http://www.imhotepvirtualmedsch.com/


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BMS CONCEPTS OF HTN

Effect of CO and SVR on BP:

CO = HR SV

MAP = TPR CO

BP CO TPR

CO = MAP / TPR

MAP = dBP + 1 / 3 pulse pressure

AUTOREGULATION

CO MAP, detected by aortic and carotid baroreceptors

vasodilation TPR and hence CO (to balance the initial CO)

PRESSURE NATRIURESIS

MAP = renal perfusion, GFR, and aldosterone Na +

H2O excretion (natriuresis)5


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Marc Imhotep Cray, M.D.6

RAAS plays an important role in regulating blood volume and

systemic vascular resistance, which together influence cardiac

output and arterial pressure

Three important components to this system: 1) renin,

2) angiotensin, and 3) aldosterone Renin, which is primarily released by kidneys, stimulates

formation of angiotensin in blood and tissues, which in turn

stimulates the release of aldosterone from the adrenal cortex

Renin-angiotensin-aldosterone

system (RAAS)


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RAAS cont.

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Renin is a proteolytic enzyme that is released into the

circulation primarily by the kidneys.

Its release is stimulated by:

i. sympathetic nerve activation (acting through 1-

adrenoceptors)

ii. renal artery hypotension (caused by systemic hypotensionor renal artery stenosis)

iii. decreased sodium delivery to distal tubules of kidney


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RAAS schematic

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http://en.wikipedia.org/wiki/File:Renin-angiotensin-aldosterone_system.png
http://en.wikipedia.org/wiki/File:Renin-angiotensin-aldosterone_system.pnghttp://en.wikipedia.org/wiki/File:Renin-angiotensin-aldosterone_system.pnghttp://en.wikipedia.org/wiki/File:Renin-angiotensin-aldosterone_system.pnghttp://en.wikipedia.org/wiki/File:Renin-angiotensin-aldosterone_system.pnghttp://en.wikipedia.org/wiki/File:Renin-angiotensin-aldosterone_system.pnghttp://en.wikipedia.org/wiki/File:Renin-angiotensin-aldosterone_system.pnghttp://en.wikipedia.org/wiki/File:Renin-angiotensin-aldosterone_system.pnghttp://en.wikipedia.org/wiki/File:Renin-angiotensin-aldosterone_system.pnghttp://en.wikipedia.org/wiki/File:Renin-angiotensin-aldosterone_system.pnghttp://en.wikipedia.org/wiki/File:Renin-angiotensin-aldosterone_system.pnghttp://www.imhotepvirtualmedsch.com/http://www.imhotepvirtualmedsch.com/


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CAUSAL CONDITIONS of HTN

1. 1(essential HTN95% of cases)2. 2HTN

Renal/vascular ( CO)

RF, polycystic kidney disease, CoA, RAS

Endocrine ( SVR)

Hyperthyroidism, adrenal adenoma ( aldosterone, cortisone),

pheochromocytoma, Hyperparathyroidism

Reversible RF: obesity, poor dietary habits, high Na+ intake,

sedentary lifestyle, high EtOH and/or coffee consumption, highstress, high normal BP, illicit drug use (e.g., cocaine),

herbal med (e.g., ma huang, ginseng, licorice, ginger)

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Target Organ Damage in HTN

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Cerebrovascular disease

TIA Ischemic or hemorrhagic stroke

Vascular dementia

Hypertensive retinopathy

LV dysfunctionCAD

MI

Angina

CHF

CKD

Hypertensive nephropathy

Albuminuria

Peripheral artery disease

Intermittent claudication


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APPROACH

Hx

Age of onset, duration, prior Rx and response, Hx of refractory

HTN? associated Sx (chest pain, palpitations, SOB, renal problems,

headaches, diaphoresis, polyuria, hematuria, edema), Hx, or

symptom of sleep apnea

Family Hx, meds, diet, coffee intake, and EtOH End-organ damage

(stroke/TIA, MI, CHF, renal disease, retinal disease), CV risk

stratification

Elicit hypertensive emergency (hypertensive encephalopathy,

strokes, dissecting thoracic aortic aneurysm, malignant HTN, acute

LV failure, acute glomerulonephritis)

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APPROACH

PE BP measurement with calibrated instrument and appropriate

cuff size

Fundi (copper wire, cotton wool spots, AV nicking,

papilledema)

Complete CV exam (clubbing, cyanosis, peripheral pulses,

bruits, JVP, apex beat, parasternal heave, heart sounds and

murmurs, compare U/E and L/E BP),

Lungs auscultation,

Abdo exam for renal mass and bruits, edema, weight

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APPROACH

Standard Workup

Electrolytes, BUN, CR, fasting gluc., U/A, lipid profile (fasting total

cholesterol, HDL, LDL, triglycerides), EKG (to evaluate LVH s)

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APPROACH2Causes Workup

1. Renal and vascular

Renovascular (older pt, Hx of atherosclerosis, renal artery bruit) Captopril renal scan/duplex U/S, MRI, angiography

Unilateral RAS: normal Cr

Bilateral RAS: hypervolemia, Cr

Renal parenchymal BUN, Cr, Cr clearance

CoA

LE pulses, radiofemoral delay, systolic murmur, LVH, rib

notching on CXR

ECHO, aortogram

2. Endocrine

TSH, cortical, urinary VMA, PTH, aldosterone, renin, renin /

aldosterone ratio

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MANAGEMENT

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Annual F/U with high normal BP is recommended as 40% of pts

with sBP 130 to 39 mm Hg or dBP 85 to 89 mm Hg develop HTNin 2 years

Home BP monitoring

Goal BP to


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MANAGEMENT

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HTN Alone

Thiazide diuretics, -blockers, ACEIs, ARBs, long-acting CCBs asfirst-line Rx

If still response to Rx despite max tolerated dose or Rx-

related adverse effect, add CCB/ARB/-receptor blocker/centrally

acting agents (methyldopa)

HY Point:

For HTN that is nonresponsive to Rx, consider noncompliance, 2

HTN, drug interactions

ACEIs and ARBs are contraindicated in pregnancy

-Blockersare not recommended for pts older than 60 years without

indication

Avoid diuretic-induced hypokalemia by using K+ sparing agent

C di l | H i V l Di


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Antihypertensives in Pt with

Other Comorbidities

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Whalen KL, Stewart RD. Pharmacologic management of hypertension in patients

with diabetes. Am Fam Physician. 2008 Dec 1;78(11):1277-82.

Available at http://www.aafp.org/afp/2008/1201/p1277.html#abstract

Which agent you choose is often based on comorbidities

C di l | H t i V l Di
http://www.imhotepvirtualmedsch.com/http://www.aafp.org/afp/2008/1201/p1277.htmlhttp://www.aafp.org/afp/2008/1201/p1277.htmlhttp://www.imhotepvirtualmedsch.com/http://www.imhotepvirtualmedsch.com/


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Exogenous Aggravators of HTN

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Prescription Drugs

NSAIDs, including coxibs OCP and sex hormones

Corticosteroids and anabolic steroids

Vasoconstricting / sympathomimetics

Calcineurin inhibitors(cyclosporin, tacrolimus)

EPO and analogs

MAOIs

Midodrine

Other Salt

Excessive EtOH use

Sleep apnea

Licorice root

Stimulants including

cocaine

HY Point:

Urinary Albumin Secretion

Identify urinary albumin secretion for DM and CKD:

Rx differs without proteinuria

albumin/ creatinine ratio (ACR) >30 mg/mmol is AbN

C di l | H t i V l Di
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Lifestyle Therapies in HTN

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Refer to United States food guide



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HYPERTENSION IN ELDERLY

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DEFINITION

A BP of >140/90 mm Hg

Isolated systolic HTN (sBP >140; dBP


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BMS of HTN in Elderly

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Age-related s in aortic vascular property

Age progressive thickening of arterial wallspredominantly

in the intimal

layerintimal to medial thickness ratio

Fragmentation and depletion of arterial elastin coupled with

medial deposition of matrix metalloproteins and collagen Collectively, this leads to thicker and stiffer arteries, predominantly

central elastic arteries

In elderly, sBP is characterized by widened arterial pulse

pressure or s in vascular morphology associated with age

small artery constriction that reflected component of the pulse

wave

Large artery stiffening that velocity of reflected wave, where it

moves from diastole to systole hence sBP



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HTN in Elderly cont.

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CAUSAL CONDITIONS

1HTN 2HTN

Med related (Na+ retaining agents e.g.,mineralocorticoids, anabolic

steroids, NSAIDs, antidepressants, sympathomimetics e.g.,

pseudoephedrine, herbal agents)

Endocrine: thyrotoxicosis, pheochromocytoma, Cushing disease,

1aldosteronism, hyperparathyroidism, hyper/hypothyroidism

Renal: renovascular disease (RAS), renal parenchymal disease

Vascular: aortic coarctation

Sleep apneaOther causes

White coat HTN

Pseudohypertension also prevalent in the elderly population due

to thickening and calcification of the arteries



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APPROACH

HxIn addition to usual Hx taking for HTN:

Meds: Prescribed, OTC and herbal drugs

Past medical history: DM, CRF, pre-HTN, hyperlipidemia, CAD

Social Hx: smoking, EtOH intake, dietary habits ( salt & fat diet)PE

Vitals: BP (compare for both arms), weight, height, BMI, waist

circumference (assess for MS)

Head and Neck: funduscopy for retinal s, thyroid exam, JVP, carotid

bruit Chest: signs of CHF, palpable murmur

CV exam: murmurs, Abdo aorta bruit, renal artery bruit,

Abdo. aorta aneurysm



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MANAGEMENTsBP and pulse pressure should be regarded as major

predictor of outcome Rx should be initiated when sBP >160 mm Hg or >140 mm Hg

when pt has other RF like diabetes and smoking

Nonpharmacologic Rx: lifestyle modification, achieve target

BMI through diet and exercise, Na restriction, cessation of

smoking, judicious consumption of EtOH

Pharmacologic Rx: initiated if the above is inadequate

Benefit in treating systolic HTN in the elderly is two to fourtimes greater than in younger pt with 1HTN



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HTN in Elderly Mx cont.

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Thiazide diuretic-First-line choice for elderly pt

Use lower doses (half of what is usually used in younger

population) to minimize side effects like postural

hypotension due to sluggish autoregulation in elderly

population

Periodically monitor lytes; hypokalemia may negate CV benefit

Dihydropyridines (nifedipine ) may also be used as an

alternative

William JE, Black HR Treatment of Hypertension in the Elderly

Am J Geriatr Cardiol. 2002;11(1)

Available at http://www.medscape.com/viewarticle/423503_1

http://www.medscape.com/viewarticle/423503_1http://www.medscape.com/viewarticle/423503_1http://www.medscape.com/viewarticle/423503_1http://www.imhotepvirtualmedsch.com/http://www.imhotepvirtualmedsch.com/


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Marc Imhotep Cray M D

Further Study

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Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of the JointNational Committee on Prevention, Detection, Evaluation, and Treatment of

High Blood Pressure: The JNC 7 Report.JAMA. 2003;289(19):2560-2571.

Available at http://jama.jamanetwork.com/article.aspx?articleid=196589

Kotchen TA Hypertensive Vascular Disease Ch. 247In Kasper DL, Braunwald E, Fauci AS, et al.Harrison's Principles of Internal

Medicine (18th ed.). New York, NY: McGraw-Hill 2013. pp. 204058.

For more like this visit IVMSs latest Website/ Blog

http://drimhotepmd.wordpress.com/

Medscape Meena SM Hypertension

Available at http://emedicine.medscape.com/article/241381-overview

Nikolaos Lionakis et. al.Hypertension in the elderly World J Cardiol. May 26,2012; 4(5): 135147. Published online May 26, 2012.

Available at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3364500/
http://jama.jamanetwork.com/article.aspx?articleid=196589http://drimhotepmd.wordpress.com/http://emedicine.medscape.com/article/241381-overviewhttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC3364500/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3364500/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3364500/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3364500/http://emedicine.medscape.com/article/241381-overviewhttp://emedicine.medscape.com/article/241381-overviewhttp://emedicine.medscape.com/article/241381-overviewhttp://emedicine.medscape.com/article/241381-overviewhttp://drimhotepmd.wordpress.com/http://drimhotepmd.wordpress.com/http://drimhotepmd.wordpress.com/http://jama.jamanetwork.com/article.aspx?articleid=196589http://www.imhotepvirtualmedsch.com/

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