Chronic hypertension resident survival guide: Difference between revisions
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❑ Current and past [[antihypertensive medications]]<br><br> | ❑ Current and past [[antihypertensive medications]]<br><br> | ||
''Identify secondary causes of [[hypertension]]:''<br> | ''Identify secondary causes of [[hypertension]]:''<br> | ||
'''Family history'''<br> | '''Family history:'''<br> | ||
❑ [[Chronic kidney disease]] (suggestive of [[polycystic kidney disease]])<br> | ❑ [[Chronic kidney disease]] (suggestive of [[polycystic kidney disease]])<br> | ||
❑ Premature CVD or HTN<br> | ❑ Premature [[CVD]] or [[HTN]]<br> | ||
'''History of renal disease:'''<br> | '''History of renal disease:'''<br> | ||
❑ [[Hematuria]]<br> | ❑ [[Hematuria]]<br> | ||
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❑ [[Analgesic|Analgesic abuse]] (suggestive of renal parenchymal disease)<br> | ❑ [[Analgesic|Analgesic abuse]] (suggestive of renal parenchymal disease)<br> | ||
❑ [[Flank pain]]<br> | ❑ [[Flank pain]]<br> | ||
'''Medication/substance abuse'''<br> | '''Medication/substance abuse:'''<br> | ||
❑ [[Amphetamines]]<br> | ❑ [[Amphetamines]]<br> | ||
❑ [[Cocaine]]<br> | ❑ [[Cocaine]]<br> | ||
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❑ [[Oral contraceptive pills]]<br> | ❑ [[Oral contraceptive pills]]<br> | ||
❑ [[Steroids]]<br> | ❑ [[Steroids]]<br> | ||
'''History suggestive of [[pheochromocytoma]]'''<br> | '''History suggestive of [[pheochromocytoma]]:'''<br> | ||
❑ Recurrent episodes of [[sweating]], [[palpitation]] and [[hypertension]]<br> | ❑ Recurrent episodes of [[sweating]], [[palpitation]] and [[hypertension]]<br> | ||
'''History suggestive of [[hyperaldosteronism]]'''<br> | '''History suggestive of [[hyperaldosteronism]]:'''<br> | ||
❑ [[Muscle weakness]] and [[tetany]]<br> | ❑ [[Muscle weakness]] and [[tetany]]<br> | ||
'''History suggestive of thyroid disease'''<br><br> | '''History suggestive of thyroid disease:'''<br> | ||
❑ [[Hypothyroidism]]<br> | |||
❑ [[Hyperthyroidism]]<br> | |||
<br> | |||
''History to assess risk factors''<br> | ''History to assess risk factors''<br> | ||
❑ Personal and family history of:<br> | ❑ Personal and family history of:<br> | ||
:❑ HTN and CVD<br> | :❑ [[HTN]] and [[CVD]]<br> | ||
:❑ [[Dyslipidemia]]<br> | :❑ [[Dyslipidemia]]<br> | ||
:❑ [[Diabetes mellitus]]<br> | :❑ [[Diabetes mellitus]]<br> | ||
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:❑ [[Stroke]]<br> | :❑ [[Stroke]]<br> | ||
'''Eyes:'''<br> | '''Eyes:'''<br> | ||
:❑ Loss or blurring of vision<br> | :❑ [[Vision loss|Loss or blurring of vision]]<br> | ||
'''Cardiovascular:'''<br> | '''Cardiovascular:'''<br> | ||
:❑ History of [[MI]] or [[syncope]]<br> | :❑ History of [[MI]] or [[syncope]]<br> | ||
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❑ [[Goitre]], [[exophthalmus]], [[pretibial myxedema]] (suggestive of [[Graves' disease]])<br> | ❑ [[Goitre]], [[exophthalmus]], [[pretibial myxedema]] (suggestive of [[Graves' disease]])<br> | ||
❑ Dry skin (suggestive of [[hypothyroidism]])<br> | ❑ Dry skin (suggestive of [[hypothyroidism]])<br> | ||
'''Eyes'''<br> | '''Eyes:'''<br> | ||
❑ [[Fundoscopy]] to diagnose [[hypertensive retinopathy]]<br> | ❑ [[Fundoscopy]] to diagnose [[hypertensive retinopathy]]<br> | ||
:❑ [[Hemorrhage]] <br> | :❑ [[Hemorrhage]] <br> | ||
:❑ [[Papilledema]]<br> | :❑ [[Papilledema]]<br> | ||
:❑ [[Cotton wool spots]]<br> | :❑ [[Cotton wool spots]]<br> | ||
'''Neck'''<br> | '''Neck:'''<br> | ||
❑ [[Carotid bruit]]s | ❑ [[Carotid bruit]]s <br> | ||
❑ [[Thyroid gland]] enlargement (suggestive of [[hyperthyroidism]]) <br> | ❑ [[Thyroid gland]] enlargement (suggestive of [[hyperthyroidism]]) <br> | ||
'''Cardiovascular examination'''<br> | '''Cardiovascular examination:'''<br> | ||
❑ Evidence of long-standing [[hypertension]]:<br> | ❑ Evidence of long-standing [[hypertension]]:<br> | ||
:❑ [[Cardiomegaly]]<br> | :❑ [[Cardiomegaly]]<br> | ||
:❑ Displaced [[apex beat]] (suggestive of enlarged [[left ventricle]]) | :❑ Displaced [[apex beat]] (suggestive of enlarged [[left ventricle]]) | ||
'''Respiratory examination'''<br> | '''Respiratory examination:'''<br> | ||
❑ [[Crackles]]/[[crepitations]]/[[rales]]<br> | ❑ [[Crackles]]/[[crepitations]]/[[rales]]<br> | ||
'''Abdominal examination'''<br> | '''Abdominal examination:'''<br> | ||
❑ [[Bruit]]s over [[abdominal aorta]] (suggestive of [[aortic aneurysm]])<br> | ❑ [[Bruit]]s over [[abdominal aorta]] (suggestive of [[aortic aneurysm]])<br> | ||
❑ [[Bruit]]s over [[renal artery]] (suggestive of [[renal artery stenosis]])<br> | ❑ [[Bruit]]s over [[renal artery]] (suggestive of [[renal artery stenosis]])<br> | ||
'''Extremity examination:'''<br> | |||
'''Extremity examination'''<br> | |||
❑ Absent or diminished femoral pulsation (suggestive of [[coarctation of aorta]])<br> | ❑ Absent or diminished femoral pulsation (suggestive of [[coarctation of aorta]])<br> | ||
❑ [[Pedal edema]] (suggestive of [[congestive heart failure]])<br> | ❑ [[Pedal edema]] (suggestive of [[congestive heart failure]])<br> | ||
❑ Delayed return of [[deep tendon reflex|deep tendon reflexes]] (suggestive of [[hypothyroidism]])<br> | ❑ Delayed return of [[deep tendon reflex|deep tendon reflexes]] (suggestive of [[hypothyroidism]])<br> | ||
'''Neurological examination'''<br> | '''Neurological examination:'''<br> | ||
❑ Findings suggestive of [[hypertensive encephalopathy]]<br> | ❑ Findings suggestive of [[hypertensive encephalopathy]]<br> | ||
:❑ [[Confusion]]<br> | :❑ [[Confusion]]<br> | ||
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❑ [[calcium|Serum potassium]]<br> | ❑ [[calcium|Serum potassium]]<br> | ||
:❑ [[Hypokalemia]] (suggestive of [[hyperaldosteronism]])<br> | :❑ [[Hypokalemia]] (suggestive of [[hyperaldosteronism]])<br> | ||
❑ [[calcium|Serum calcium]]<br> | ❑ [[calcium|Serum calcium]] (high in [[hyperparathyroidism]])<br> | ||
❑ [[creatinine|Serum creatinine]] with estimated [[glomerular filtration rate]] (eGFR)<br> | ❑ [[creatinine|Serum creatinine]] with estimated [[glomerular filtration rate]] (eGFR)<br> | ||
❑ [[Uric acid|Serum uric acid]]<br> | ❑ [[Uric acid|Serum uric acid]]<br> | ||
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</div>}} | </div>}} | ||
{{familytree | | | | |!| | |}} | {{familytree | | | | |!| | |}} | ||
{{familytree | | | | D01 | | |D01=Does the patient have an identifiable secondary etiology?}} | {{familytree | | | | D01 | | |D01='''Does the patient have an identifiable secondary etiology?'''}} | ||
{{familytree | | |,|-|^|-|.| | |}} | {{familytree | | |,|-|^|-|.| | |}} | ||
{{familytree | | F01 | | F02 | |F01=Yes|F02=No}} | {{familytree | | F01 | | F02 | |F01=Yes|F02=No}} | ||
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{{familytree | | G01 | | G02 | |G01=[[Primary hypertension]]|G02=[[Secondary hypertension]]}} | {{familytree | | G01 | | G02 | |G01=[[Primary hypertension]]|G02=[[Secondary hypertension]]}} | ||
{{familytree | | |`|-|v|-|'| | |}} | {{familytree | | |`|-|v|-|'| | |}} | ||
{{familytree | | | | G01 | |G01=Proceed to treatment}} | {{familytree | | | | G01 | |G01=Proceed to treatment below}} | ||
{{familytree/end}} | {{familytree/end}} | ||
Revision as of 12:23, 29 April 2014
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ayokunle Olubaniyi, M.B,B.S [2]
Hypertension Resident Survival Guide Microchapters |
---|
Overview |
Classification |
Causes |
Diagnosis |
Treatment |
Medical Therapy |
Do's |
Don'ts |
Overview
Hypertension (HTN) is defined as a systolic blood pressure (SBP) ≥ 140 mmHg and diastolic blood pressure (DBP) ≥ 90 mmHg.[1] It is usually detected during the screening of an asymptomatic individual, but the diagnosis is based on persistent elevation of blood pressure after the average of 2 or more blood pressure measurements taken on each of 2 or more hospital visits. Hypertension can either be primary or essential, whenever the etiology cannot be identified; or secondary, whenever the etiology (e.g., hyperthyroidism, pheochromocytoma, renal artery stenosis) is known. The presence of diabetes mellitus, cigarette smoking, excessive sodium intake, obesity, and sedentary lifestyle increases the risk of developing essential hypertension. Lifestyle modifications such as weight reduction, reduction in alcohol consumption, exercises, and reduction in salt intake are recommended to all patients in addition to pharmacological therapy, when required.
Classification
Classification | Blood pressure (mmHg) |
---|---|
Normal | < 120/80 |
Prehypertension | SBP 120-139 DBP 80-89 |
Stage 1 hypertension | SBP 149-159 DBP 90-99 |
Stage 2 hypertension | SBP >160 DBP >110 |
Isolated systolic hypertension | SBP ≥ 140 DBP < 90 |
Isolated diastolic hypertension | SBP <140 DBP ≥90 |
Causes
Life Threatening Causes
Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.
- Aortic coarctation
- Cocaine or amphetamine overdose
- Pheochromocytoma
- Preeclampsia
Common Causes
Primary or Essential Hypertension
- No underlying cause is identified. Risk factors include: high sodium intake, obesity, sedentary lifestyle, and excessive alcohol intake.
Secondary Hypertension
- Aortic coarctation
- Chronic kidney disease
- Cocaine or amphetamine overdose
- Cushing's syndrome
- Hyperthyroidism
- Hypothyroidism
- Medications (e.g., oral contraceptive pills, NSAIDs)
- Nephrotic syndrome
- Pheochromocytoma
- Polycystic kidney disease
- Preeclampsia
- Renal artery stenosis
- Sleep apnea
Pseudohypertension
Click here for the complete list of causes.
Diagnosis
Shown below is an algorithm summarizing the diagnosis of hypertension based on the seventh report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure and 2013 ESH/ESC guidelines for the management of arterial hypertension.[2][3]
Abbreviations:
ABPM: Ambulatory blood pressure monitoring;
BP: Blood pressure;
CKD: Chronic kidney disease;
DBP: Diastolic blood pressure;
DM: Diabetes mellitus;
SBP: Systolic blood pressure
General Approach
Suspected hypertension BP > 140/90 mmHg | |||||||||||||||||||||||||||||||||||||||||
Blood pressure measurement Before taking the BP
❑ Take 2 readings and find the average Click here for more information regarding blood pressure measurement | |||||||||||||||||||||||||||||||||||||||||
For office BP >140/90 mmHg on 2-3 visits | |||||||||||||||||||||||||||||||||||||||||
Does the patient have any evidence of target organ damage, DM, or CKD? | |||||||||||||||||||||||||||||||||||||||||
Yes | No | ||||||||||||||||||||||||||||||||||||||||
Proceed to hypertensive crisis resident survival guide | Perform home BP/out-of-office monitoring | ||||||||||||||||||||||||||||||||||||||||
Is the average home BP measurement <140/90? | |||||||||||||||||||||||||||||||||||||||||
Yes | Inconclusive | No | |||||||||||||||||||||||||||||||||||||||
Perform 24-hour ABPM | |||||||||||||||||||||||||||||||||||||||||
Is the 24-hour ABPM ≤135/85? | |||||||||||||||||||||||||||||||||||||||||
White coat hypertension confirmed | Yes | No | Hypertension confirmed | ||||||||||||||||||||||||||||||||||||||
❑ Continue BP monitoring | Classify the patient based on the BP reading | ||||||||||||||||||||||||||||||||||||||||
SBP 120-139 mmHg DBP 80-89 mmHg | SBP 149-159 mmHg DBP 90-99 mmHg | SBP >160 mmHg DBP >110 mmHg | |||||||||||||||||||||||||||||||||||||||
Stage 1 hypertension Proceed to the complete diagnostic approach below | Stage 2 hypertension
Proceed to hypertensive crisis resident survival guide | ||||||||||||||||||||||||||||||||||||||||
Complete Diagnostic Approach
Shown below is an algorithm summarizing the diagnosis of hypertension based on the seventh report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure and 2013 ESH/ESC guidelines for the management of arterial hypertension.[2][3]
Abbreviations:
BMI: Body mass index;
BP: Blood pressure;
CNS: Central nervous system;
CT: Computed tomography;
CVD: Cardiovascular disease;
eGFR: Estimated glomerular filtration rate;
EKG: Electrocardiogram;
HTN: Hypertension;
LVH: Left ventricular hypertrophy;
MI: Myocardial infarction;
NSAIDs: Non steroidal anti-inflammatory drugs;
TSH: Thyroid stimulating hormone;
UTI: Urinary tract infection
Obtain a detailed history: History of present hypertension
❑ Excessive sodium intake >2.4g per day Eyes: Cardiovascular:
Kidneys:
| |||||||||||||||||||
Examine the patient: General examination: Neck:
Respiratory examination:
| |||||||||||||||||||
Order tests: Routine
❑ Serum calcium (high in hyperparathyroidism)
Additional tests based on results of the routine tests above:
❑ 24-hour free urinary cortisol (elevated in Cushing's syndrome)
❑ Chest CT angiography (To evaluate aortic coarctation) | |||||||||||||||||||
Does the patient have an identifiable secondary etiology? | |||||||||||||||||||
Yes | No | ||||||||||||||||||
Primary hypertension | Secondary hypertension | ||||||||||||||||||
Proceed to treatment below | |||||||||||||||||||
Treatment
Shown below is an algorithm summarizing the treatment of hypertension based on the 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8), ESH/ESC guidelines for the management of arterial hypertension, and the seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.[1][2][4]
Prehypertension
Does the patient have chronic kidney disease or diabetes mellitus? | |||||||||||||||||||
Yes | No | ||||||||||||||||||
❑ Commence lifestyle modification, THEN | ❑ Commence lifestyle modification | ||||||||||||||||||
Stage 1 Hypertension
Shown below is an algorithm summarizing the treatment of hypertension based on the 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8) and the 2013 ESH/ESC guidelines for the management of arterial hypertension.[4][2]
Abbreviations:
ACEI: ACE inhibitors;
ARBs: Angiotensin II receptor blockers;
BMI: Body mass index;
BP: Blood pressure;
CCBs: Calcium channel blockers;
CKD: Chronic kidney disease;
DASH: Dietary Approaches to Stop Hypertension;
DM: Diabetes mellitus
Determine who to treat: ❑ BP ≥ 150/90 mmHg in patients ≥ 60 years | |||||||||||||||||||||||||||||
Review BP goals: General population | |||||||||||||||||||||||||||||
Initiate lifestyle modification:
❑ Adopt healthy diet
❑ Limit alcohol consumption
❑ Regular aerobic physical activity (brisk walking, jogging, cycling, swimming) for at least 30 mins per day | |||||||||||||||||||||||||||||
Does the patient have DM or CKD? | |||||||||||||||||||||||||||||
Yes | No | ||||||||||||||||||||||||||||
CKD ± DM | DM only | ||||||||||||||||||||||||||||
Consider the race of the patient | |||||||||||||||||||||||||||||
Black population | Non-black population | ||||||||||||||||||||||||||||
Initiate: ❑ ACE inhibitors alone, OR | Initiate: ❑ Thiazide diuretic alone, OR | ||||||||||||||||||||||||||||
Has the target BP been reached? | |||||||||||||||||||||||||||||
Yes | No | ||||||||||||||||||||||||||||
Click here for further therapeutic options | |||||||||||||||||||||||||||||
Monitoring and follow-up: Monitor:
❑ 3-6 monthly visits when BP goal is achieved
| |||||||||||||||||||||||||||||
Medical Therapy
Choice of Regimen
Assess BP and cardiovascular risk | |||||||||||||||||||||||||||||||||||||||||||||||||
Mild elevation of BP Low CV risk | Severe elevation of BP High CV risk | ||||||||||||||||||||||||||||||||||||||||||||||||
Consider starting with a single agent | Consider 2-drug combination | ||||||||||||||||||||||||||||||||||||||||||||||||
Target BP achieved? | Target BP achieved? | ||||||||||||||||||||||||||||||||||||||||||||||||
Continue with current regimen | Yes | No | No | Yes | Continue with current regimen | ||||||||||||||||||||||||||||||||||||||||||||
Switch to a different drug Titrate until maximum dose is reached, if necessary | Increase dose of present drug and titrate accordingly | Increase dose of present combination | Add a third drug and titrate to maximum dose, if necessary | ||||||||||||||||||||||||||||||||||||||||||||||
If BP goal is not achieved Add a second drug | |||||||||||||||||||||||||||||||||||||||||||||||||
Maximum dose of 2-drug combination reached | |||||||||||||||||||||||||||||||||||||||||||||||||
If BP goal is not achieved Switch to a different 2-drug combination and titrate to the maximum dose, if necessary OR Add a third drug and titrate to the maximum dose, if necessary | |||||||||||||||||||||||||||||||||||||||||||||||||
Drug List
Do's
Don'ts
- The combination of ACE inhibitors and ARBs in a patient is not recommended.
References
- ↑ 1.0 1.1 Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL; et al. (2003). "Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure". Hypertension. 42 (6): 1206–52. doi:10.1161/01.HYP.0000107251.49515.c2. PMID 14656957.
- ↑ 2.0 2.1 2.2 2.3 Mancia, G.; Fagard, R.; Narkiewicz, K.; Redán, J.; Zanchetti, A.; Böhm, M.; Christiaens, T.; Cifkova, R.; De Backer, G. (2013). "2013 Practice guidelines for the management of arterial hypertension of the European Society of Hypertension (ESH) and the European Society of Cardiology (ESC): ESH/ESC Task Force for the Management of Arterial Hypertension". J Hypertens. 31 (10): 1925–38. doi:10.1097/HJH.0b013e328364ca4c. PMID 24107724. Unknown parameter
|month=
ignored (help) - ↑ 3.0 3.1 Chobanian, AV.; Bakris, GL.; Black, HR.; Cushman, WC.; Green, LA.; Izzo, JL.; Jones, DW.; Materson, BJ.; Oparil, S. (2003). "Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure". Hypertension. 42 (6): 1206–52. doi:10.1161/01.HYP.0000107251.49515.c2. PMID 14656957. Unknown parameter
|month=
ignored (help) - ↑ 4.0 4.1 James, PA.; Oparil, S.; Carter, BL.; Cushman, WC.; Dennison-Himmelfarb, C.; Handler, J.; Lackland, DT.; LeFevre, ML.; MacKenzie, TD. (2014). "2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8)". JAMA. 311 (5): 507–20. doi:10.1001/jama.2013.284427. PMID 24352797. Unknown parameter
|month=
ignored (help)