| Snapshot |
| A 45-year-old African American man presents to his primary care physician for an annual wellness exam. He reports to feeling well and has no acute concerns. Medical history is unremarkable. He occasionally drinks a glass of wine every few days and does not smoke cigarettes. He exercises regularly and tries to maintain a healthy diet by incorporating more fruits, vegetables, and lean proteins. Physical examination is significant for a blood pressure of 155/105 mmHg. In his next two consecutive office visits, his blood pressures are 150/100 mmHg and 146/96 mmHg. He is started on hydrochlorothiazide. |
| Introduction |
| Clinical definitiona sustained increased systemic arterial pressuretypically defined as asystolic blood pressure ≥ 140 mmHg OR diastolic blood pressure ≥ 90 mmHgEpidemiologyriskageage-related vascular stiffening is a common cause of isolated systolic hypertension in the elderly racefamily historyphysical inactivityobesityexcessive alcohol usehigh-sodium dietEtiologyprimary (essential) hypertension (accounts for ~95% of cases) idiopathicsecondary hypertension renal disease (e.g., fibromuscular dysplasia and renal artery stenosis)pregnancy (e.g., eclampsia)obstructive sleep apneahyperaldosteronismthyroid diseasePathogenesisbackgroundblood pressure is the product of cardiac output and peripheral vascular resistance (BP = CO X SVR)cardiac outputa function of stroke volume and heart ratesodium homeostasis affects stroke volume (e.g., high sodium diet increases the amount of water retained and thus increasing filling pressure, which determines stroke volume)systemic vascular resistancedetermined by the neural and hormonal inputs to the arteriolethe kidneys, heart, and adrenal glands work together to regulate vascular tone and blood volumekidneyse.g., renin-angiotensin-aldosterone systemhearte.g., myocardial natriuretic peptidesadrenal glandse.g., aldosteronepathologyessential hypertensiona multifactorial processed influenced by genetics, the environment, reduced sodium excretion, and vasoconstrictive influencessecondary hypertensiondepends on the underlying etiologye.g., renal artery stenosis decreases the amount of glomerular flow and pressure sensed by the kidneysthis upregulates the renin-angiotensin-aldosterone system to increase blood pressurePrognosis↑ risk of stroke and cardiovascular disease |
| Presentation |
| Symptomsasymptomaticmost patients are not aware they have hypertension |
| Studies |
| Blood pressure measurementsthe diagnosis should be based on ≥ 2 blood pressure readings in ≥ 2 visitsPathophysiological changes decreased diastolic fillingnormal ejection fractionincreased renin production |
| Treatment |
| Managment approachin secondary hypertension, it is important to address the underlying problemcertain antihypertensive medications are indicated if it addresses a comorbid condition Conservativeweight lossindicationfor all patientsexerciseindicationfor all patientsdietary modificationsindicationfor all patientsMedicalfirst-line treatment options in patients without a specific indication for a particular agent that would address a comorbid conditionthiazide diureticsangiotensin-converting enzyme inhibitorscough is an important side effectangiotensin receptor blockerslong-acting calcium channel blocker lower extremity edema is an important side effect |
| Complications |
| Ischemic or hemorrhagic stroke and transient ischemic attacksLeft ventricular hypertrophy Heart failure Chronic kidney diseaseVisual disturbances (e.g., retinal hemorrhages and exudates)Peripheral vascular diseaseAortic dissectionAortic aneurysm |
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