Cardiology · Hypertension
The facts most likely to be tested
The ACC/AHA guidelines define Stage 1 Hypertension as a systolic blood pressure of 130–139 mmHg or a diastolic blood pressure of 80–89 mmHg.
Lifestyle modifications including the DASH diet, sodium restriction, and weight loss are the first-line interventions for all patients with elevated blood pressure.
First-line pharmacotherapy for non-Black patients includes thiazide diuretics, ACE inhibitors, ARBs, or calcium channel blockers.
Thiazide diuretics or calcium channel blockers are the preferred initial antihypertensive agents for Black patients.
ACE inhibitors and ARBs are strictly contraindicated in pregnancy due to the risk of fetal renal dysgenesis and oligohydramnios.
Target organ damage from chronic hypertension includes left ventricular hypertrophy, hypertensive retinopathy (e.g., AV nicking), and chronic kidney disease.
Hypertensive emergency is defined as severe hypertension (typically >180/120 mmHg) with evidence of acute end-organ damage requiring immediate reduction with IV medications.
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A 54-year-old male presents for a routine physical examination. He has no complaints and denies chest pain, shortness of breath, or vision changes. His past medical history is significant for obesity and a sedentary lifestyle. On physical exam, his blood pressure is 142/92 mmHg in the right arm and 140/90 mmHg in the left arm. Funduscopic exam reveals arteriovenous nicking. Laboratory studies show a serum creatinine of 1.1 mg/dL and a normal urinalysis.
What is the most appropriate initial management for this patient?
Lifestyle modifications and initiation of pharmacotherapy
The patient meets the criteria for Stage 2 hypertension (>140/90 mmHg), necessitating both lifestyle changes and the initiation of antihypertensive medication to prevent further end-organ damage.
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Etiology / Epidemiology
Primary (essential) HTN accounts for 95% of cases; age, obesity, and high sodium intake are primary drivers.
Clinical Manifestations
Usually asymptomatic silent killer; end-organ damage (retinopathy, LVH) is the primary clinical finding.
Diagnosis
Diagnosis requires ≥140/90 mmHg on two separate office visits; ambulatory blood pressure monitoring is the gold standard.
Treatment
First-line therapy includes thiazide diuretics, ACE inhibitors, ARBs, or CCBs; avoid ACE/ARB in pregnancy.
Prognosis
Major risk factor for stroke, MI, and heart failure; target BP is generally <130/80 mmHg.
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Epidemiology & Etiology
Primary HTN is idiopathic, strongly linked to genetics, sedentary lifestyle, and excessive alcohol consumption. Prevalence increases significantly with age and is higher in African American populations. Secondary causes must be excluded if onset is <30 or >55 years old.
Pertinent Anatomy
Chronic pressure overload leads to left ventricular hypertrophy and concentric remodeling. Vascular changes include arteriolar hyaline arteriolosclerosis in the kidneys and retina.
Pathophysiology
Increased systemic vascular resistance is driven by overactivity of the renin-angiotensin-aldosterone system and sympathetic nervous system. Chronic endothelial dysfunction impairs vasodilation, leading to a self-perpetuating cycle of vascular remodeling and increased peripheral resistance.
Clinical Manifestations
Most patients are asymptomatic until advanced stages. Look for hypertensive retinopathy (AV nicking, cotton wool spots, papilledema) or S4 gallop on cardiac auscultation. Hypertensive emergency is defined as BP >180/120 with evidence of end-organ damage (e.g., encephalopathy, acute kidney injury, or aortic dissection).
Diagnosis
The gold standard for confirming diagnosis is ambulatory blood pressure monitoring (ABPM) to rule out white coat hypertension. Clinical diagnosis is confirmed by ≥140/90 mmHg on at least two separate occasions. Always perform a urinalysis and EKG to screen for baseline end-organ damage.
Treatment
Initiate thiazide diuretics, ACE inhibitors, ARBs, or CCBs as monotherapy or combination therapy. ACE inhibitors and ARBs are strictly contraindicated in pregnancy due to fetal renal dysgenesis. In patients with diabetes or CKD, ACE inhibitors or ARBs are preferred for renal protection.
Prognosis
Uncontrolled HTN is the leading cause of stroke and congestive heart failure. Patients require lifelong monitoring of serum creatinine and potassium to assess for medication-induced electrolyte disturbances or renal decline.
Differential Diagnosis
Renal artery stenosis: abdominal bruit
Primary aldosteronism: hypokalemia
Pheochromocytoma: episodic palpitations/headache
Cushing syndrome: moon facies/striae
Coarctation of the aorta: brachial-femoral pulse delay