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HTN

Aug 24, 20255 min read

Internal Medicine

Professor Salih Bin Salih

HTN & RENAL ARTERY STENOSIS

LATEST DEFINITIONS

According to A.C.C. ( American college of cardiology) & AHA ( American heart association)

  • Normal BP : 120/80 or less
  • If systolic BP is between 120 & 130, its now called “elevated BP”.
  • Stage 1 HTN: Sys. 130 -140 , diastolic 80 to 90
  • Stage 2 HTN: Sys. 140 or more, diastolic 90 or more

The diagnosis of HTN is made if BP is high on 2 different days, and the person should not be under stress or acutely sick.

CORRECT WAY OF BP CHECKING

  • Beware of “ White Coat Hypertension” ( high BP in doctor’s office).
  • Sometimes, you may need 24 hrs continuous BP monitoring at home ( ambulatory BP monitoring) to diagnose HTN.

24 hrs BP monitoring

EPIDEMIOLOGY

  • In K.S.A, more than 25% of the adult population has HTN ( saudi medical journal, 2007)
  • In the U.S., 29% of the adults have HTN
  • Incidence is rising throughout the world
    • (? Due to lifestyle)

WHY IS HTN HARMFUL?Z

TERMS IN HTN

  • Elevated B.P. : Systolic between 120-130

  • Stage 1 HTN : Systolic between 130-140 and/or diastolic b/w 80 & 90

  • Stage 2 : Systolic 140 or more and/or diastolic 90 or more

  • Hypertensive Crisis : Systolic usually more than 180 and diastolic more than 120 ⇒ Hypertensive urgency X Hypertensive Emergency

Hypertensive Urgency:

  • Very high BP. DBP usually >120, but NO acute
    end organ damage (encephalopathy, angina,
    papilloedema etc)

Hypertensive Emergency :

  • Very high BP ( SBP > 210, and DBP> 130) + end organ damage begins ( eg encephalo- -pathy, angina/MI/blurred vision etc)

TYPES OF HTN

Primary hypertension

(no known cause) Also called essential HTN ( most cases are prim.)

  • Also called Essential HTN. Etiology not known
  • Most cases are primary HTN( >90%)
  • Not due to any underlying disease, but the following may contribute to it :
    • genetics, obesity, high salt intake, alcohol,
    • smoking.

Secondary Hypertension

(secondary to an underlying disease)

  • Secondary to some other disease
  • Accounts for less than 10% of HTN cases

Renal etiologies: Commonest etiology of secondary HTN is renal disease :

2) Endocrine Causes :

  • Excess cortisol (Cushing’s disease)
  • Excess aldosterone ( Conn’s syndrome)
  • Excess noradrenaline ( Pheochromocytoma) ( all above are adrenal diseases)

3) Drugs & Meds. :

  • NSAIDS, Steroids, Estrogens, Flu & cold meds ( will worsen HTN), Cocaine

WHEN TO SUSPECT SEC. HTN?

  1. Young age ( less than 30 yrs)
  2. HTN not responding to max. therapy
  3. Clinical features of the secondary causes ( acromegaly, Cushing’s etc)

S/S of HTN

  • Very non-specific
  • Asymptomatic
  • Headache, dizziness, body pain
  • Sec. HTN: features of the underlying disease
  • Severe rise in BP can present as angina/MI, CHF, stroke/TIA, altered mental status (encephalopathy) hypertensive crisis

Physical Exam

  • Do a detailed examination at the first visit.
  • Check the pulses, cardiac examination
  • Examine for any S/S of Strokex
  • Examine the eyes for retinopathy
  • Examine the heart for murmurs, CHF
  • Auscultate the abdomen for renal artery bruit ( occurs in renal artery stenosis)
  • Look for features of Cushing’s, acromegaly etc. if you suspect these.

HYPERTENSIVE RETINOPATHY

Divided into 4 grades , based on severity

  • Grade 1: Retinal vessels become less clear
  • Grade 2: A-V nipping
  • Grade 3: Edema, hemorrhages, Copper wiring
  • Grade 4: Optic disc edema, silver wiring #x

Routine investigations

  • CBC, urea, creatinine, electrolytes, lipid profile, ECG, blood sugar, urinalysis
  • If secondary HTN is suspected order further tests accordingly
  • ECG may show left ventricular hypertrophy
  • High creatinine suspect renal pathology

MED

Diagnosis of HTN is made with prolonged High blood pressure without outside stressors, e.g. sickness

Correct way of Blood Pressure measurement

  • Must not be in any effect of drugs or actions that may raise BP such as caffeine, talking to patient, smoking prior to the test would report high reading; its best to measure and monitor at home for better diagnosis
  • Sitting, back, arm, hand supported

Types & Stages

  • Primary Hypertension; Non known cause, may be *genetics, alcohol, smoking, *

  • Secondary Hypertension;

  • Essential Hypertension; Situational

  • Stage 1 HTN: 130-140 / 80-90

  • Stage 2 HTN: 140 / >90

  • Hypertensive crisis: systolic usually >180 / >120

  • CO = SV x HR
  • BP = CO * PRZ

Risk factors of HTN

  • Transient ischemic attack
  • Strokes
  • Retinopathy
  • Renal Failure
  • Left ventricular Failure ⇒ CHD ⇒ HF

Routine Investigations

  • Full CBC
  • If 2ry, order more tests

Treatment

  • Aim below 120/80

First trial: diet & exercise 2 months with (Low salt, wt. reduction, exercise, healthy fibers, stop smoking)

  • Add medicine if 2 months with no progress - start with one medication
  • .
  • .

Drugs: ABCD

  • Diuretics; Thiazide; Action on distal convoluted tubules (moderate celing diueretic) lowers preload = less PR (cc); causes hypercalcemia, Hyperglycemia contraindicated in DM, Parathyroidism tumour,

  • ACE inhibitors; Hyperkalemia, contraindicated

    • renal artery stenosis - may result in acute renal failure
    • Pregnancy; renal failure in child, limb deformities Cat. X

  • ARBS

  • Beta Blockers; Contraindicated in Asthma, COPD due B action Masking of hypoglycemia by DM/Obesity Hypoglycemic drugs Not stopped suddenly; may cause increased & Upshoot hypertension

  • Ca. Channel blockers; may result constipation

  • Others; Alpha blockers (first dose hypotension),

Guidelines Rx

Old / Afro-Arabian:

  • Diuretics
  • Calcium Channel Blockers; (May cause Headache)

Young / White:

  • ACE inhibitors
  • Beta blockers (may not be used due sexual dysfunction)

Pregnancy:

  • Avoid ACE & ARBS

in Hypertensive crisis Gradually reduce bloop pressure, to avoid cerebral ----

Lingual vein absorption due to nitroglycerin in acute attack

Graph View

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