HTN

Rule out secondary causes – TRAC PADo

Isolated systolic HTN is common. Therapy has been shown to be effective and beneficial at preventing stroke and cardiovascular morbidity and all-cause mortality

Examination –

Body mass index (BMI), waist circumference, BP in both arms,

peripheral pulse exam:

RFD  in volume and timing (evaluation for CAA (especially in young persons)

Funduscopic exam –  arteriolar narrowing, AV compression, hemorrhages, exudates, and papilledema

Precordial examination

DIFFERENTIAL DIAGNOSIS

  • Secondary HTN: ( low incidence of reversible secondary HTN)

special tests should be considered only if the history, physical exam, or basic laboratory evaluation suggest a higher likelihood.

Also, consider patients who prove nonresponsive to treatment.

  • Whitecoat HTN: elevation of BP in the office setting and normal BP outside the office
  • Masked HTN: elevated BP at home and normal BP in office

Initial Tests (lab, imaging)

  • FBE
  • MSU (may reveal proteinuria, hematuria/nephritis)
  • EUC and uric acid
  • LP – CTHL
  • FBS, HB A1c
  • ECG – (LVH) or rhythm abnormalities

Consider –

A sleep study, 24-hour ambulatory BP monitoring,

Treatment based on CV risk

CVS risk >15% – straight away start with statin

Mild<10% to mod 10-15% – after lifestyle except for BP > 160/100 — start

The potential harms of therapy must be weighed against the potential benefits. More intensive therapy may be considered for certain high-risk individuals.

Individual treatment goals should be jointly established with patients after discussion of the anticipated potential benefits and harms (shared decision making)

SNAPS C- salt

For initial monotherapy, choose from 1 of 4 classes of medications:

*ACE inhibitors, ARBs, calcium channel blockers (CCBs), or diuretics

* β-Blockers often benefit patients with ischemic heart disease, atrial fibrillation, CHF, migraine, and patients with a history of ST-segment elevation myocardial infarction (STEMI).

*ACE inhibitors should be used in patients with diabetes, proteinuria, atrial fibrillation, or heart failure with reduced ejection fraction (HFrEF) but not in pregnancy.

*α-Adrenergic blockers are not the first choice for monotherapy but remain as second-line after combination therapy of first-line agents; might benefit males with benign prostatic hypertrophy (BPH). α-Adrenergic antagonists: prazosin 1 to 10 mg BID, terazosin 1 to 20 mg/day, or doxazosin 1 to 16 mg/day

*CCB could be considered in patients with isolated systolic HTN, atherosclerosis, angina, migraine, or asthma; well documented to reduce risk of stroke

Contraindications

  • Thiazide diuretics may worsen gout.
  • β-Blockers  in asthma, heart block, diabetes, and peripheral vascular disease; probably should be avoided in patients with metabolic syndrome or insulin-requiring diabetes
  • Diltiazem or verapamil: Do not use with systolic dysfunction or heart block.
  • Amlodipine may cause peripheral edema.

*Medication-refractory HTN (see Secondary and Resistant Hypertension): Spironolactone 25 to 100 mg/day or eplerenone 50 mg once to twice daily are especially effective.

*Centrally acting α-2 agonists: clonidine 0.1 to 1.2 mg BID or weekly patch 0.1 to 0.3 mg/day, guanfacine 1 to 3 mg daily, or methyldopa 250 to 2,000 mg BID

Vasodilators

*Hydralazine: 10 to 25 mg QID; (SE: drug-induced systemic lupus erythematosus (SLE) ) risk of tachycardia, so generally combined with β-blocker;

*Minoxidil: rarely used due to adverse effects; may be more effective than other medications in renal failure and refractory HTN

*Metolazone and loop diuretics may be used with more severe renal impairment, but outcomes data are absent; loop diuretics (for volume overload): furosemide 20 to 320 mg/day or bumetanide 0.5 to 2 mg/day

*K+-sparing diuretics in patients with hypokalemia while taking thiazides: amiloride 5 to 10 mg/day or triamterene 50 to 150 mg/day

Aim to reduce CBV risk –

Risk factor modifications –

Modifiable – Lipids, BP, BMI, DM,

Smoking, nutrition, alcohol, physical activity, Stress, caffeine , salt ( SNAPS C salt )

Nonmodifiable – FH, Age, ethnicity, Sex, socioeconomic status

Other- OSA, Drugs, treat secondary causes, lack of education, cultural and religious

COMPLICATIONS

Heart failure, renal failure, LVH, myocardial infarction, retinal hemorrhage, stroke, hypertensive heart disease, drug side effects, erectile dysfunction