Hypertension Quiz

Hypertension: Understanding the Disease and Treatment Options

• Hypertension is a leading cause of death and disability, and risk is higher in non-Hispanic Black adults.

• Starting at 115/75 mm Hg, the risk of cardiovascular disease doubles with every 20/10 mm Hg increase.

• Blood pressure is determined by cardiac output and systemic vascular resistance, and an increase in cardiac output leads to an increase in blood pressure.

• Mean arterial pressure is calculated as 2/3 diastolic pressure + 1/3 systolic pressure.

• Hypertension is when the force of blood flowing through blood vessels is consistently too high.

• Risk factors for hypertension include smoking, age, diabetes mellitus, male sex, hyperlipidemia, family history, overweight/obesity, physical inactivity, low socioeconomic/educational status, unhealthy diet, obstructive sleep apnea, and psychosocial stress.

• Primary hypertension (90-95%) is idiopathic, while secondary hypertension (5-10%) can be caused by chronic kidney disease, Cushing’s syndrome, drug-induced or drug-related factors, obstructive uropathy, pheochromocytoma, primary aldosteronism or other mineralocorticoid excess, renovascular disease, sleep apnea, and thyroid or parathyroid disease.

• Drug-induced hypertension can be caused by NSAIDs, pseudoephedrine, phenylephrine, and oral contraceptives.

• Antihypertensive medications include thiazide diuretics, beta blockers, ACEI/ARBs, CCBs, aldosterone antagonists, alpha 1 blockers, central alpha 2 agonists, and direct vasodilators.

• The BP goal for patients with hypertension is <130/80 mm Hg, but it may differ based on comorbidities such as diabetes mellitus, chronic kidney disease, chronic kidney disease after renal transplantation, heart failure, stable ischemic heart disease, secondary stroke prevention, secondary stroke prevention (lacunar), and peripheral arterial disease.

• Non-pharmacological interventions such as weight loss, a heart-healthy diet, sodium reduction, potassium supplementation, and increased physical activity can help reduce blood pressure.

• First-line options for uncomplicated hypertension include thiazide diuretics, ACEI/ARBs, and CCBs, but the choice of medication may depend on individual patient factors such as age, race, comorbidities, and medication side effects.Overview of Hypertension Treatment Options

• Mineralocorticoid antagonists work by inhibiting the interaction of aldosterone with mineralocorticoid receptor and are used to treat resistant hypertension and patients with hypertension and HFrEF or HFpEF.

• Loop diuretics work by inhibiting the Na+/K+/2CL- pump cotransporter in the thick ascending loop of Henle, leading to decreased sodium and chloride reabsorption, and are used to treat heart failure and severe CKD.

• ACE inhibitors compete with angiotensin I for its binding site on the angiotensin-converting enzyme, blocking the conversion of angiotensin I to angiotensin II and reducing cardiovascular morbidity and mortality in patients with left ventricular dysfunction.

• AT1 antagonists inhibit angiotensin receptors (AT1) and interfere with the binding of formed angiotensin II to its endogenous receptor, making them a first-line hypertension drug therapy option.

• Calcium channel blockers bind to L-type voltage-gated channels located on the vascular smooth muscle, cardiac myocytes, and cardiac nodal tissue to inhibit Ca2+ influx, leading to dilation of coronary and peripheral arteries and decreased myocardial force generation and heart rate.

• Calcium channel blockers can be dihydropyridines (dipine) or non-dihydropyridines (verapamil and diltiazem), with the former acting by relaxing the smooth muscle in the arterial wall and reducing blood pressure, and the latter acting as a potent vasodilator of coronary and peripheral vessels.

• The urine albumin-to-creatinine ratio (UACR) is used to diagnose albuminuria, with normal levels being below 30 mg/g.

• In case 1, the patient's blood pressure is elevated at 138/88 mmHg, and additional information is needed to determine treatment options.

• The patient in case 1 falls under the category of stage 1 hypertension, with a blood pressure goal of <130/80 mmHg.

• To evaluate the patient's risk and determine treatment options, clinical ASCVD or estimated 10-year CVD risk must be assessed.

• The 2017 ACC/AHA HTN Treatment Algorithm provides BP thresholds and recommendations for treatment and follow-up, with normal BP being <120/80 mmHg, and elevated BP being 120-129/<80 mmHg.

• Non-pharmacologic therapy should be promoted for patients with elevated or stage 1 hypertension, while pharmacologic therapy is recommended for patients with stage 2 hypertension or clinical ASCVD or estimated 10-year CVD risk ≥10%.Overview of Hypertension Management and Antihypertensive Agents

• Hypertension affects 1 in 3 adults in the US and is a major risk factor for cardiovascular disease.

• Lifestyle modifications, such as weight loss, exercise, and dietary changes, are recommended for all patients with hypertension.

• The 2017 ACC/AHA HTN Treatment Algorithm recommends different treatment thresholds and follow-up intervals based on blood pressure category and cardiovascular risk.

• Antihypertensive agents include diuretics, ACE inhibitors, ARBs, calcium channel blockers, beta-blockers, alpha-blockers, and centrally acting sympatholytics.

• Hydralazine is a direct vasodilator primarily used for resistant hypertension, acute hypertensive emergencies, and preeclampsia.

• Beta-blockers, which selectively or non-selectively block beta-adrenergic receptors, are generally third or fourth line for hypertension, but may be first line for patients with cardiovascular comorbidities.

• Alpha-blockers block sympathetic activity and are generally reserved for hypertensive male patients with concomitant benign prostatic hyperplasia.

• Centrally acting sympatholytics decrease sympathetic outflow and are often used for resistant hypertension or hypertension in pregnancy.

• Antihypertensive agents have specific dosing, contraindications, and monitoring parameters that must be considered.

• Hypertension in pregnancy is a major cause of maternal and perinatal morbidity and mortality and requires careful management with specific antihypertensive agents.

• Common side effects of antihypertensive agents include dizziness, fatigue, and hypotension.

• When managing hypertension, it is important to accurately measure blood pressure, identify other causes of hypertension, establish realistic goals, and use appropriate therapy based on patient-specific factors.