Hypertension Overview
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Questions and Answers

Which antihypertensive should be avoided in patients with reactive airway disease?

  • Beta-blockers (correct)
  • ACE inhibitors
  • Thiazides
  • Calcium Channel Blockers

    • What is defined as blood pressure greater than 180/120 without evidence of target organ damage?

  • Hypertensive Emergency
  • Hypertensive Urgency (correct)
  • Hypertensive Crisis
  • Isolated Systolic Hypertension

    • Which agents are classified as IV bolus antihypertensives?

  • Esmolol and Nitroprusside
  • Nitroprusside and Nicardipine
  • Nicardipine and Esmolol
  • Hydralazine and Labetalol (correct)

    • What is the initial goal for reducing mean arterial pressure in a hypertensive emergency?

    <p>25% within the first one to two hours</p> Signup and view all the answers

    Which medications should be avoided in patients with acute kidney injury or hyperkalemia?

    <p>ACE inhibitors and ARBs</p> Signup and view all the answers

    What blood pressure goal should be achieved in the first one to two days of treating hypertensive urgency?

    <p>160/100</p> Signup and view all the answers

    What defines a hypertensive emergency?

    <p>High blood pressure accompanied by target organ damage</p> Signup and view all the answers

    Which condition is primarily associated with left ventricular hypertrophy due to high blood pressure?

    <p>Diastolic heart failure</p> Signup and view all the answers

    Which antihypertensive medication is considered a first-line agent for stage 2 hypertension?

    <p>Amlodipine</p> Signup and view all the answers

    What is the primary sign of acute kidney injury related to hypertension?

    <p>Hematuria</p> Signup and view all the answers

    Which factor increases the risk of stroke due to hypertension?

    <p>Carotid stenosis</p> Signup and view all the answers

    What is the recommended initial approach for diagnosing hypertension?

    <p>Measure blood pressure in both arms</p> Signup and view all the answers

    What lifestyle modification is essential for managing hypertension?

    <p>Weight loss and a healthy diet</p> Signup and view all the answers

    What class of medications is preferred for treating hypertension in African-American patients?

    <p>Calcium channel blockers and thiazides</p> Signup and view all the answers

    What complication can arise from high blood pressure that involves the aorta?

    <p>Aortic dissection</p> Signup and view all the answers

    Which substance is classified as a sympathomimetic drug that can increase blood pressure?

    <p>Cocaine</p> Signup and view all the answers

    What is the most common cause of secondary hypertension?

    <p>Chronic kidney disease</p> Signup and view all the answers

    Which factor is primarily associated with essential hypertension?

    <p>Age</p> Signup and view all the answers

    Which condition is NOT associated with secondary hypertension?

    <p>Stress-induced vasoconstriction</p> Signup and view all the answers

    What is the effect of a high sodium diet on blood pressure?

    <p>Increases sodium and water retention</p> Signup and view all the answers

    What characterizes Cushing's Triad in neurological hypertension?

    <p>Bradycardia, hypertension, irregular respirations</p> Signup and view all the answers

    Which statement regarding essential hypertension is TRUE?

    <p>It accounts for about 90% of hypertension cases.</p> Signup and view all the answers

    Which of the following endocrine disorders can lead to hypertension?

    <p>Hyperthyroidism</p> Signup and view all the answers

    What is the primary physiological effect of thickened blood vessel walls?

    <p>Increased systemic vascular resistance</p> Signup and view all the answers

    What condition is characterized by high upper extremity blood pressure and low lower extremity blood pressure?

    <p>Coarctation of the aorta</p> Signup and view all the answers

    Study Notes

    Hypertension

    • Two types of hypertension:
      • Essential hypertension (primary): 90% of cases, typically caused by aging, smoking, diabetes, stress, and obesity.
      • Secondary hypertension: Less common (approximately 10% of cases), often refractory to three or more antihypertensive medications.
    • Essential hypertension causes:
      • Thickened blood vessel walls:
        • Age, smoking, diabetes, stress, and obesity contribute to thickening, reducing vessel diameter and increasing systemic vascular resistance, thus increasing blood pressure.
      • Vasoconstriction:
        • Increased sympathetic tone or stress causes vasoconstriction which reduces vessel diameter and raises blood pressure.
      • High sodium diet:
        • Leads to sodium and water retention, increasing preload, stroke volume, cardiac output, and blood pressure.
    • Essential hypertension generally presents in individuals aged 25 to 55 years old.
    • Secondary hypertension causes:
      • Renal (most common cause):
        • Chronic kidney disease (CKD)
        • Renal artery stenosis
        • These conditions increase renin-angiotensin-aldosterone system (RAAS) activity, causing sodium and water retention, vasoconstriction, and elevated blood pressure.
      • Endocrine:
        • Thyroid disorders:
          • Hyperthyroidism (high T3 and T4): Increases cardiac output, leading to systolic hypertension.
          • Hypothyroidism (low T3 and T4): Causes vasoconstriction, leading to diastolic hypertension.
        • Adrenal gland disorders:
          • Hyperaldosteronism (high aldosterone): Increases sodium and water retention.
          • Cushing syndrome/disease (high cortisol): Increases sympathetic activity.
          • Pheochromocytoma (high epinephrine and norepinephrine): Increases sympathetic activity.
        • All these endocrine disorders elevate blood pressure.
      • Neurological:
        • Increased intracranial pressure:
          • Caused by bleeds, edema, tumors, or increased cerebral spinal fluid.
          • Leads to Cushing's Triad: Bradycardia, hypertension, and irregular respirations.
      • Aortic:
        • Coarctation of the aorta:
          • Narrowing of the aorta often after the left subclavian artery causing high upper extremity blood pressure and low lower extremity blood pressure.
      • Preeclampsia/Eclampsia:
        • Pregnancy-related condition with proteinuria, edema, and hypertension.
        • Placental vasoconstriction caused by the release of vasoactive chemicals elevates maternal blood pressure.
        • Eclampsia is preeclampsia with seizures.
      • Substances:
        • Sympathomimetic drugs:
          • Cocaine, amphetamines, PCP.
          • Increase sympathetic nervous system activity, leading to elevated blood pressure.
      • Sleep apnea:
        • Causes periodic low oxygen levels during sleep, activating the sympathetic nervous system, leading to vasoconstriction and hypertension.
    • Hypertension blood pressure classification:
      • Normal: Systolic < 120 mm Hg and Diastolic < 80 mm Hg
      • Prehypertension: Systolic 120-139 mm Hg or Diastolic 80-89 mm Hg
      • Stage 1 hypertension: Systolic 130-139 mm Hg or Diastolic 80-89 mm Hg
      • Stage 2 hypertension: Systolic >140 mm Hg or Diastolic >90 mm Hg

    High Blood Pressure

    • Blood pressure readings of at least 140/90 mmHg for two or more readings are considered hypertension.
    • Blood pressure readings greater than 180/120 mmHg are considered hypertensive crisis.

    Hypertensive Urgency vs. Emergency

    • Hypertensive urgency: High blood pressure but no target organ damage.
    • Hypertensive emergency: High blood pressure with target organ damage.

    Target Organ Damage

    • Target organ damage in hypertensive emergencies often involves the cardiovascular system, nervous system, kidneys, or retinas.

    Cardiovascular Disease

    • High blood pressure increases afterload, forcing the left ventricle to work harder, resulting in left ventricular hypertrophy.
    • Left ventricular hypertrophy can lead to diastolic heart failure (heart failure with preserved ejection fraction), a frequent cause of heart failure.
    • In acute cases, high blood pressure hinders blood outflow from the heart, potentially causing acute pulmonary edema.
    • Hypertension triggers atherosclerosis, plaque formation, impacting vessel health and function.
    • Atherosclerosis in coronary arteries reduces oxygen supply to the myocardium, causing ischemia, coronary artery disease, or myocardial infarction (MI).
    • Atherosclerosis in peripheral arteries causes peripheral artery disease, leading to pain, skin lesions, and tissue ischemia.
    • High blood pressure's shearing forces can damage the aorta, resulting in aortic dissection (tear allowing blood flow into a false lumen) or aortic aneurysm (ballooning or weakening).

    Neurological Disease

    • Atherosclerosis in cerebral vessels causes:
      • Carotid stenosis: Narrowing of carotid arteries, causing transient ischemic attack (TIA) or cerebrovascular accident (stroke).
      • Cerebral ischemia: Reduced brain blood flow, leading to stroke.
      • Cerebral hemorrhage: Rupture of brain vessels, resulting in intracerebral or subarachnoid hemorrhage.

    Renal Disease

    • High blood pressure increases glomerular filtration rate (GFR) but leads to afferent arteriole thickening (sclerosis), reducing blood flow to glomeruli.
    • This causes ischemia, renal injury, acute kidney injury (AKI), or chronic kidney disease (CKD).
    • Hematuria (blood in the urine) can signify AKI.

    Retinal Disease

    • Retinal disease associated with hypertension is hypertensive retinopathy, progressing through four grades, grade four being the most severe.
    • Damage includes retinal vessel sclerosis, reducing oxygen supply, retinal hemorrhaging, and edema. Severe cases can lead to papilledema (optic disc swelling).

    Diagnostic Approach to Hypertension

    • Measure blood pressure in both arms.
    • Obtain at least two blood pressure readings, spaced at least two office visits.
    • Consider ambulatory blood pressure monitoring to rule out white coat hypertension.
    • Assess for target organ damage to differentiate between hypertensive urgency and emergency.

    Treatment of Hypertension

    • Lifestyle modifications (weight loss, healthy diet, exercise, reduced sodium and alcohol) are crucial for all patients.
    • Antihypertensives may be necessary for stage 1 hypertension if cardiovascular disease risk is 10% or higher.
    • Common antihypertensives: ACE inhibitors, ARBs, thiazide diuretics, and calcium channel blockers (amlodipine or nifedipine).
    • Antihypertensives are also needed for stage 2 hypertension.

    Lifestyle Modifications and Antihypertensives

    • Start antihypertensive medications immediately if blood pressure remains consistently above 140/90 despite lifestyle changes.
    • Use ACE inhibitors, ARBs, thiazides, or calcium channel blockers as first-line agents.
    • For African-American patients, calcium channel blockers (amlodipine and felodipine) and thiazides are more effective than ACE inhibitors and ARBs due to lower renin levels.

    Antihypertensive Medications Based on Comorbidities

    • Myocardial Infarction: Beta-blockers, ACE inhibitors, and ARBs to reduce ventricular remodeling and arrhythmia risk.
    • Heart Failure: Beta-blockers, ACE inhibitors, ARBs, and aldosterone antagonists.
    • Coronary Artery Disease: Beta-blockers, ACE inhibitors, ARBs, and calcium channel blockers. Add nitrates (isosorbide dinitrate and isosorbide mononitrate) for angina.
    • Atrial Fibrillation: Beta-blockers and calcium channel blockers.
    • Diabetes and CKD: ACE inhibitors and ARBs to reduce proteinuria and kidney disease progression.
    • Pregnancy: Hydralazine, methyldopa, labetalol, and nifedipine are safe and effective for pregnancy-related hypertension.

    Specific Considerations for Different Antihypertensives

    • Beta-blockers: Avoid in reactive airway disease (COPD, asthma) and acute decompensated heart failure.
    • Calcium Channel Blockers: Avoid in acute decompensated heart failure.
    • ACE inhibitors and ARBs: Avoid in acute kidney injury or hyperkalemia.
    • Aldosterone Antagonists: Avoid in acute kidney injury or hyperkalemia.
    • Thiazides: Avoid in gout due to hyperuricemia.

    Hypertensive Urgency

    • Blood pressure greater than 180/120 mmHg without target organ damage.
    • Aim for blood pressure reduction to less than 160/100 mmHg within one to two days with oral medications.
    • Avoid rapid blood pressure reduction to prevent ischemia.

    Hypertensive Emergency

    • Blood pressure greater than 180/120 mmHg with target organ damage (neurological deficits, chest pain, acute heart failure, aortic dissection, aneurysm, or acute kidney injury).
    • Reduce mean arterial pressure (MAP) approximately 25% within the first one to two hours with IV agents.
    • Target blood pressure of less than 160/100 mmHg within two to six hours.
    • Gradually normalize blood pressure over the next one to two days. Rapid blood pressure reduction can worsen organ damage by decreasing perfusion.

    IV Antihypertensive Agents

    • Titratable: Nicardipine, Esmolol, Nitroprusside.
    • IV Bolus: Hydralazine, Labetalol.

    Summary

    • Early antihypertensive therapy is important for managing high blood pressure.
    • Different medications, including ACE inhibitors, ARBs, thiazides, calcium channel blockers, beta-blockers, nitrates, and aldosterone antagonists, are beneficial based on comorbidities.
    • Hypertensive urgency and emergency are distinguished, with emergency requiring gradual blood pressure reduction using IV agents. IV antihypertensive agents are outlined.

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    Description

    Explore the two main types of hypertension: essential and secondary. This quiz delves into the causes and contributing factors of essential hypertension, highlighting the physiological mechanisms that elevate blood pressure. Test your knowledge on how lifestyle choices and age can impact vascular health.

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