Essential Hypertension

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Essential Hypertension

• Robert E. Manaker, Col, USAF, MC

Our Patients are our Bottom Line!
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Overview

• Board oriented review
• Reviewed 4 yrs of in-training exam questions plus
  recent review articles on HTN
• Diagnosis/Initial Evaluation
• Treatment
• Uncomplicated
• Compelling indications
• Secondary HTN
• HTN in pregnancy

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Sample Question 1

• 50 y.o AAM new patient. New to area no records.
  Hx of HTN and DM for 10 yrs last visit 18
  months ago
• Meds HCTZ 25mg qd, glyburide 10mg bid
• 71 inches, 240 lbs, BP 160/100, pulse 76
• Funduscopic mod atherosclerotic changes
• Otherwise normal neck, heart, abdomen, peripheral
  pulses, and neurological exam

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Sample Question 1 (cont.)

• In order to appropriately manage his problems,
  which of the following diagnostic tests should be
  ordered?
• EKG
• HgbA1C
• Fasting lipid panel
• Urine microalbumin
• Serum potassium

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Blood Pressure Classification
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BP Measurement Techniques
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Patient Evaluation

• Evaluation of patients with documented HTN has
  three objectives
• Assess lifestyle and identify other CV risk
  factors or concomitant disorders that affects
  prognosis and guides treatment.
• Reveal identifiable causes of high BP.
• Assess the presence or absence of target organ
  damage and CVD.

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CVD Risk Factors

• Hypertension
• Cigarette smoking
• Obesity (BMI 30 kg/m2)
• Physical inactivity
• Dyslipidemia
• Diabetes mellitus
• Microalbuminuria or estimated GFR
• Age (older than 55 for men, 65 for women)
• Family history of premature CVD
• (men under age 55 or women under age 65)

Components of the metabolic syndrome.
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Identifiable Causes of Hypertension

• Sleep apnea
• Drug-induced or related causes
• Chronic kidney disease
• Primary aldosteronism
• Renovascular disease
• Chronic steroid therapy and Cushings syndrome
• Pheochromocytoma
• Coarctation of the aorta
• Thyroid or parathyroid disease

10
Target Organ Damage

• Heart
• Left ventricular hypertrophy
• Angina or prior myocardial infarction
• Prior coronary revascularization
• Heart failure
• Brain
• Stroke or transient ischemic attack
• Chronic kidney disease
• Peripheral arterial disease
• Retinopathy

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Physical Exam

• BP in both arms
• Funduscopic
• Thyroid
• Cardiovascular - Auscultation, Carotids, Pulses
• Pulmonary
• Abdomen - Bruits, AAA, masses
• Extremities
• Neurological

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Laboratory Tests

• Routine
• ECG
• Urinalysis
• Blood Glucose
• Hematocrit, potassium, calcium, creatinine (or
  eGFR)
• Lipid profile (9-12 hour fast)
• Optional
• Urine albumin excretion or albumin/creatinine
  ratio
• More extensive testing not generally indicated
  unless BP control not obtained or secondary HTN
  suspected

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Sample Question 1 (cont.)

• In order to appropriately manage his problems,
  which of the following diagnostic tests should be
  ordered?
• EKG
• HgbA1C
• Fasting lipid panel
• Urine microalbumin
• Serum potassium

14
Sample Question 2

• 83 y.o. F, new patient. Excellent health, takes
  acetaminophen for OA of knees. Exam normal with
  age-related changes except BP 175/70 confirmed
  on f/u visit.
• In addition to lifestyle modifications, which
  would be most appropriate?
• a-blocker
• ACEI
• ß-blocker
• ARB
• Thiazide diuretic

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Classification and Management of BP for adults
Treatment determined by highest BP
category. Initial combined therapy should be
used cautiously in those at risk for orthostatic
hypotension. Treat patients with chronic kidney
disease or diabetes to BP goal of 16
Lifestyle Modification
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Algorithm for Treatment of Hypertension
Lifestyle Modifications
Not at Goal Blood Pressure ((kidney disease)
Initial Drug Choices
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Follow-up and Monitoring

• Patients should return for follow-up and
  adjustment of medications until the BP goal is
  reached.
• More frequent visits for stage 2 HTN or with
  complicating comorbid conditions.
• After BP at goal and stable, follow-up visits at
  3 to 6month intervals
• Serum potassium and creatinine monitored 12
  times per year.
• Comorbidities, such as heart failure, associated
  diseases, such as diabetes, and the need for
  laboratory tests influence the frequency of
  visits.

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Sample Question 2

• 83 y.o. F, new patient. Excellent health, takes
  acetaminophen for OA of knees. Exam normal with
  age-related changes except BP 175/70 confirmed
  on f/u visit.
• In addition to lifestyle modifications, which
  would be most appropriate?
• a-blocker
• ACEI
• ß-blocker
• ARB
• Thiazide diuretic

20
Sample Question 3

• 45 y.o. AAF in for f/u on type 2 DM, dxd 3 years
  ago. She has no other complaints, and is on no
  meds. BP is 135/85.
• HgbA1C 8.5, Chol 200, LDL 120, HDL 25, Trig 275
• 3 months later, despite reinforcing LSMs for DM,
  BP unchanged. At this point, appropriate
  management (T/F)
• ACEI
• A statin
• Metformin

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Sample Question 4

• Which one of the following drug classes is
  preferred for treating hypertension in patients
  who have diabetes mellitus?
• Central acting sympatholytics
• a-blocking agents
• ß-blocking agents
• ACE inhibitors
• Calcium channel blockers

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Sample Question 5

• 60 y.o. male with 10 yr. hx of type 2 DM, HLP.
  HTN. Presents with DOE, LE edema denies chest
  pains. Meds glyburide, atorvastatin, HCTZ,
  aspirin. BMI 29, BP 150/95, rales at bases,
  soft S3, 3 edema of LE. CXR cardiomegaly and
  cephalization. Echo EF of 25 w/ ant. Left
  dyskinesia and mild mitral insufficiency.

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Sample Question 5 (cont.)

• Therapeutic agents shown to improve survival in
  such cases include all of the following EXCEPT
• Lisinopril
• Valsartan
• Digoxin
• Metoprolol

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Compelling Indications for Individual Drug
Classes
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Compelling Indications for Individual Drug
Classes
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Minority Populations

• In general, treatment similar for all demographic
  groups.
• Socioeconomic factors and lifestyle important
  barriers to BP control.
• Prevalence, severity of HTN increased in African
  Americans.
• African Americans demonstrate somewhat reduced BP
  responses to monotherapy with BBs, ACEIs, or ARBs
  compared to diuretics or CCBs.
• These differences usually eliminated by adding
  adequate doses of a diuretic.

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Left Ventricular Hypertrophy

• LVH is an independent risk factor that increases
  the risk of CVD.
• Regression of LVH occurs with aggressive BP
  management weight loss, sodium restriction, and
  treatment with all classes of drugs except the
  direct vasodilators hydralazine and minoxidil.

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Peripheral Arterial Disease(PAD)

• PAD is equivalent in risk to ischemic heart
  disease.
• Any class of drugs can be used in most PAD
  patients.
• Other risk factors should be managed
  aggressively.
• Aspirin should be used.

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Hypertension in OlderPersons

• More than two-thirds of people over 65 have HTN.
• This population has the lowest rates of BP
  control.
• Treatment, including those who with isolated
  systolic HTN, should follow same principles
  outlined for general care of HTN.
• Lower initial drug doses may be indicated to
  avoid symptoms standard doses and multiple drugs
  will be needed to reach BP targets.

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Sample Question 3

• 45 y.o. AAF in for f/u on type 2 D, dxd 3 years
  ago. She has no other complaints, and is on no
  meds. BP is 135/85.
• HgbA1C 8.5, Chol 200, LDL 120, HDL 25, Trig 275
• 3 months later, despite reinforcing LSMs for DM,
  BP unchanged. At this point, appropriate
  management (T/F)
• ACEI
• A statin
• Metformin

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Sample Question 4

• Which one of the following drug classes is
  preferred for treating hypertension in patients
  who have diabetes mellitus?
• Central acting sympatholytics
• a-blocking agents
• ß-blocking agents
• ACE inhibitors
• Calcium channel blockers

32
Sample Question 5

• 60 y.o. male with 10 yr. hx of type 2 DM, HLP.
  HTN. Presents with DOE, LE edema denies chest
  pains. Meds glyburide, atorvastatin, HCTZ,
  aspirin. BMI 29, BP 150/95, rales at bases,
  soft S3, 3 edema of LE. CXR cardiomegaly and
  cephalization. Echo EF of 25 w/ ant. Left
  dyskinesia and mild mitral insufficiency.

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Sample Question 5 (cont.)

• Therapeutic agents shown to improve survival in
  such cases include all of the following EXCEPT
• Lisinopril
• Valsartan
• Digoxin
• Metoprolol

34
Sample Question 6

• At a routine visit, a 50 y.o. WF with a 10 yr hx
  of type 2 DM has a BP of 145/90 and
  microalbuminuria. Which one of the following
  would be an absolute contraindication to use of
  an ACEI in this pt.?
• A previous hx of angioneurotic edema
• Renal insufficiency
• Asthma
• A hx of recent MI
• An cardiac EF

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Sample Question 7

• 49 yr old male w/HTN presents w/4 week hx of
  swollen, painful knee. No hx of injury. Started
  on anti-HYN tx 2 months before problem developed.
  You suspect gout lab shows uric acid 10.5
  mg/dl. Whid agent most likely casued this
  problem?
• Metoprolol
• Enalapril
• Losartan
• HCTZ
• Terazosin

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Additional Considerations in Antihypertensive
Drug Choices

• Potential favorable effects
• Thiazide-type diuretics useful in slowing
  demineralization in osteoporosis.
• BBs useful in the treatment of atrial
  tachyarrhythmias/fibrillation, migraine,
  thyrotoxicosis (short-term), essential tremor, or
  perioperative HTN.
• CCBs useful in Raynauds syndrome and certain
  arrhythmias.
• Alpha-blockers useful in prostatism.

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Additional Considerations in Antihypertensive
Drug Choices

• Potential unfavorable effects
• Thiazide diuretics should be used cautiously in
  gout or a history of significant hyponatremia.
• BBs should be generally avoided in patients with
  asthma, reactive airways disease, or second- or
  third-degree heart block.
• ACEIs and ARBs are contraindicated in pregnant
  women or those likely to become pregnant.
• ACEIs should not be used in individuals with a
  history of angioedema.
• Aldosterone antagonists and potassium-sparing
  diuretics can cause hyperkalemia.

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Sample Question 6

• At a routine visit, a 50 y.o. WF with a 10 yr hx
  of type 2 DM has a BP of 145/90 and
  microalbuminuria. Which one of the following
  would be an absolute contraindication to use of
  an ACEI in this pt.?
• A previous hx of angioneurotic edema
• Renal insufficiency
• Asthma
• A hx of recent MI
• An cardiac EF

39
Sample Question 7

• 49 yr old male w/HTN presents w/4 week hx of
  swollen, painful knee. No hx of injury. Started
  on anti-HTN tx 2 months before problem developed.
  You suspect gout lab shows uric acid 10.5
  mg/dl. Which agent most likely caused this
  problem?
• Metoprolol
• Enalapril
• Losartan
• HCTZ
• Terazosin

40
Secondary and Other Hypertension Topics

• Robert E. Manaker, Col, USAF, MC

Our Patients are our Bottom Line!
41
Sample Question 8

• 72 y.o. WM with new-onset HTN with a BP 190/110.
  Which of the following agent can be used for
  diagnosing renovascular HTN but would incr. risk
  of azotemia?
• Captopril
• Metoprolol
• Clonidine
• Furosemide
• Amlodipine

42
Sample Question 9

• Sleep apnea is known to be associated with
• Hypertension
• Respiratory muscle dysfunction
• Carpal tunnel syndrome
• Hypercalcemia
• Previous tonsillectomy

43
Identifiable Causes of Hypertension

• Sleep apnea
• Drug-induced or related causes
• Chronic kidney disease
• Primary aldosteronism
• Renovascular disease
• Chronic steroid therapy and Cushings syndrome
• Pheochromocytoma
• Coarctation of the aorta
• Thyroid or parathyroid disease

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Sleep Apnea

• At least 50 of patients with OSA have HTN
• Findings Snoring, daytime somnolence, obesity,
  lower extremity edema (R-sided failure)
• Diagnostic Study Sleep study
• Therapy Surgery (UPPP) or CPAP reduces
  hypertension in these patients

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Drug-Induced HTN

• Many prescription and non-prescription drugs can
  cause or exacerbate HTN
• Findings on history use of medications known to
  increase BP
• Immunosuppressive agents (cyclosporine,
  corticosteroids)
• NSAIDs
• COX-2 inhibitors (Celecoxib)
• Estrogens (Oral contraceptives, not HRT)
• Weight loss medications (Sibutramine,
  phentermine, ephedra)

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Drug-Induced HTN (cont.)

• Findings (cont.)
• Stimulants (nicotine, amphetamines)
• Mineralocorticoids (fludrocortisone)
• Antiparkinsonian agents (bromocriptine)
• MAOIs (phenelzine)
• Anabolic steroids (testosterone)
• Sympathomimetics (pseudoephedrine)
• Diagnosis history
• Therapy removal/substitution for offending
  agent(s)

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Chronic Kidney Disease

• Can be a cause of and/or a consequence of
  hypertension progressive effects of mechanical
  and humoral effects of glomerular HTN
• Damage inhibits salt excretion (low renin state)
  hyperparathyroidism, incr. erythropoietin
  vicious cycle
• Findings elevated serum creatinine, decreased
  creatinine clearance
• Diagnosis see findings, renal ultrasonography
• Therapy aggressive tx, esp. ACEI (alt. ARB)

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Primary Aldosteronism

• Overproduction of aldosterone independent of the
  renin-angiotensin system causing salt/water
  retention which suppresses renin levels
• Findings hypernatremia, hypokalemia
• Diagnosis see findings, elevated plasma
  aldosterone to plasma renin activity CT of
  adrenals
• Therapy surgery (adenoma), spironolactone,
  eplerenone (aldosterone antagonists)

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Renovascular Disease

• Older patients due to atherosclerotic dz of renal
  arteries younger due to fibromuscular dysplasia.
  Although it makes up reversible.
• Findings 50 abdominal bruit, older patient with
  uncontrolled HTN, kidney function often made
  worse by treatment w/ACEIs
• Diagnosis MRA, captopril radioisotope study,
  renal arteriography
• Treatment surgical correction, angioplasty

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Chronic Steroid or Cushing's

• Mineralocorticoid effects of glucocorticoids lead
  to salt/water retention
• Findings History of chronic steroid therapy
  weight gain, weakness, hirsutism, moon facies,
  dorsal hump, purple striae, truncal obesity,
  hypokalemia
• Diagnosis Dexamethasone suppression test
• Treatment Removal/ablation of tumors, adrenal
  enzyme inhibitors

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Pheochromocytoma/Coartation

• Pheochromocytoma
• Findings paroxysmal HTN, diaphoresis,
  palpitations, tachycardia
• Diagnosis Urinary catecholamine metabolites
  (VMA, metanephrines, normetanephrines), plasma
  free metanephrines
• Therapy surgery after proper medical preparation

• Coarctation of Aorta
• Mild forms not apparent until young adulthood
• Findings upper ext. HTN, decreased LE pulses,
  DOE, notched ribs on CXR
• Diagnosis Aortagram
• Treatment Surgical

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Thyroid/Parathyroid Disease

• Hypothyroidism fatigue, weight gain, hair loss,
  diastolic HTN, muscle weakness
• Hyperthyroidsim weight loss, heat intolerance,
  palpitations, systolic HTN,
• Diagnosis TSH levels (T4)
• Therapy replacement/I131, surgery, medication
  ß-blocker

• Hyperparathyroidism
• Findings kidney stones, osteoporosis,
  depression, lethargy, muscle weakness
• Diagnosis calcium, parathyroid hormone levels
• Therapy parathyroidectomy does not always
  correct HTN

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Causes of Resistant Hypertension

• Improper BP measurement
• Excess sodium intake
• Inadequate diuretic therapy
• Medication
• Inadequate doses
• Drug actions and interactions (e.g.,
  nonsteroidal anti-inflammatory drugs (NSAIDs),
  illicit drugs, sympathomimetics, oral
  contraceptives)
• Over-the-counter (OTC) drugs and herbal
  supplements
• Excess alcohol intake
• Identifiable causes of HTN

54
Sample Question 8

• 72 y.o. WM with new-onset HTN with a BP 190/110.
  Which of the following agent can be used for
  diagnosing renovascular HTN but would incr. risk
  of azotemia?
• Captopril
• Metoprolol
• Clonidine
• Furosemide
• Amlodipine

55
Sample Question 9

• Sleep apnea is known to be associated with
• Hypertension
• Respiratory muscle dysfunction
• Carpal tunnel syndrome
• Hypercalcemia
• Previous tonsillectomy

56
Sample Question 10

• 34 y.o. AAF presents for preconception counseling
  regarding management of HTN. BP well controlled
  on benazepril 20 mg daily w/o side effects.
  During previous pregnancy, she was switched to
  Methyldopa (Aldomet), but suffered from
  drowsiness, but preg. was o/w uncomplicated

57
Sample Question 10 (cont.)

• Which of the following do you do when she becomes
  pregnant?
• D/C benazepril and monitor closely throughout
  pregnancy for signs/symptoms of preeclampsia or
  fetal growth restriction
• Continue benazepril throughout pregnancy
• Switch to atenolol until after delivery
• Switch to long-acting nifedipine until after
  delivery

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Sample Question 11

• 22 y.o. healthy F presents for prenatal check _at_
  38 wks. BP is 145/95, unchanged in 1 hr. BP
  normal before pregnancy. She has moderate ankle
  edema and 3 reflexes at knees/ankles. UA is neg
  for prot.
• What is the most likely diagnosis?
• Preeclampsia
• Unmasked chronic HTN
• Essential HTN
• Gestational HTN
• HELLP syndrome

59
Sample Question 12

• 25 yo AAF _at_ 32 wks EGA has BP 170/100. Previous
  BPs normal. BP remains elevated for remainder
  no HA, visual sx, chest pain, dyspnea, abd pain.
  edema, but no proteinuria. Delivery
  uneventful, BP returns to normal. Most likely dx
• Mild preeclampsia
• Severe preeclampsia
• Gestational HTN
• Preeclampsia superimpose on prehypertension
• Preeclampsia w/HELLP syndrome

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Sample Question 13

• 34 y.o G1P0 in 1st trimester had moderate HTN
  before pregnancy. Current BP is 168/108. You
  are considering how best to manage her HTN during
  the pregnancy.
• Which is associated with greatest risk of fetal
  growth retardation if used throughout pregnancy?
• Atenolol
• Nimodipine
• Methyldopa
• Hydralazine
• Nifedipine

61
Sample Question 14

• Which of the following is contraindicated for the
  treatment of hypertension in pregnancy?
• Methyldopa
• Lisinopril
• Labetolol
• Nifedipine

62
Hypertension in Pregnancy

• Preeclampsia/eclampsia
• After 20 wks, onset of HTN w/ proteinuria BP
  140/90 and 300 mg proteinuria in 24 hr
• Chronic Hypertension
• BP 140/90 antedating pregnancy, or before 20
  wks, or persisting beyond 12 weeks post-partum
• Gestational Hypertension
• After 20 wks, onset of HTN (BP 140/90) without
  proteinuria 300 mg in 24 hr.
• Preeclampsia superimposed on underlying HTN

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Tx of Chronic/Gestational HTN

• BP generally lower during pregnancy
• Those that have mild HTN (especially well
  controlled) may not need blood pressure
  medication
• Agents chosen based on risk/benefit profile,
  clinical situation

• Methyldopa C long history of use with relative
  safety
• Ca Channel Blockers C frequently used,
  especially long acting preparations, added
  benefit of tocolysis
• Hydralazine C excellent for acute mgmt
• ß-blockers C (labetolol) or D (atentolol)
  labetolol used for acute mgmt

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Tx of Chronic/Gestational HTN

• ACEIs C agents in 1st trimester, D in 2nd/3rd
  trimesters due to disturbances of fetal and
  neonatal renal function, such as oligohydramnios,
  neonatal anuria, renal failure and death
• ARBs same as ACEIs
• ß-blockers atenolol associated with fetal
  growth retardation
• Diuretics use with caution, avoid volume
  depletion
• If BP antihypertensives

65
Sample Question 10

• 34 y.o. AAF presents for preconception counseling
  regarding management of HTN. BP well controlled
  on benazepril 20 mg daily w/o side effects.
  During previous pregnancy, she was switched to
  Methyldopa (Aldomet), but suffered from
  drowsiness, but preg. was o/w uncomplicated

66
Sample Question 10 (cont.)

• Which of the following do you do when she becomes
  pregnant?
• D/C benazepril and monitor closely throughout
  pregnancy for signs/symptoms of preeclampsia or
  fetal growth restriction
• Continue benazepril throughout pregnancy
• Switch to atenolol until after delivery
• Switch to long-acting nifedipine until after
  delivery

67
Sample Question 11

• 22 y.o. healthy F presents for prenatal check _at_
  38 wks. BP is 145/95, unchanged in 1 hr. BP
  normal before pregnancy. She has moderate ankle
  edema and 3 reflexes at knees/ankles. UA is neg
  for prot.
• What is the most likely diagnosis?
• Preeclampsia
• Unmasked chronic HTN
• Essential HTN
• Gestational HTN
• HELLP syndrome

68
Sample Question 12

• 25 yo AAF _at_ 32 wks EGA has BP 170/100. Previous
  BPs normal. BP remains elevated for remainder
  no HA, visual sx, chest pain, dyspnea, abd pain.
  edema, but no proteinuria. Delivery
  uneventful, BP returns to normal. Most likely dx
• Mild preeclampsia
• Severe preeclampsia
• Gestational HTN
• Preeclampsia superimpose on prehypertension
• Preeclampsia w/HELLP syndrome

69
Sample Question 13

• 34 y.o G1P0 in 1st trimester had moderate HTN
  before pregnancy. Current BP is 168/108. You
  are considering how best to manage her HTN during
  the pregnancy.
• Which is associated with greatest risk of fetal
  growth retardation if used throughout pregnancy?
• Atenolol
• Nimodipine
• Methyldopa
• Hydralazine
• Nifedipine

70
Sample Question 14

• Which of the following is contraindicated for the
  treatment of hypertension in pregnancy?
• Methyldopa
• Lisinopril
• Labetolol
• Nifedipine

71
Children and Adolescents

• HTN defined as BP95th percentile or greater,
  adjusted for age, height, and gender.
• Use lifestyle interventions first, then drug
  therapy for higher levels of BP or if
  insufficient response to lifestyle modifications.
• Drug choices similar in children and adults, but
  effective doses are often smaller.
• Uncomplicated HTN not a reason to restrict
  physical activity.

72

• Questions?