Hypertensive Disorders

Primary Hypertension

• BP measurement procedures:
  • White coat HTN: 15-20% =lifestyle changes
    
  • Masked HTP 10-15% =tretment
    
  • Use home BP/24hour BP for diagnosis of hypertension

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  When to start high BP treatment:
  • 120/80 start non-pharmacological therapy
    
  • >140/90 start treatment or >130/80 with CVD or great live time risk

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  Lifestyle modifications for HTN (5):
  • Weight reduction
    
  • DASH eating plan
    
  • Na+reduction
    
  • Exercise
    
  • Moderation of alcohol

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  BP target for HTN patients:
  • 130/80

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  Medication for HTN:
  
  1. NO DM or CKD
     
     1. Nonblack: ACEI, ARB, or CCB
        
     2. Black: Thiazide or CCB
        
  2. DM/CKD
     1. ACEI or ARB

Secondary hypertension

• Presentation:
  • 1. Young-onset
    
  • 2. Sudden onset
    
  • 3. Refractory hypertension (drug-resistant)
    
  • 4. Malignant hypertension (super high BP, with quick onset

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  Endocrine Causes:
  • Primary Aldosteronism
    
  • Causing Syndrome
    
  • Pheochromocytoma
    
  • Renin Secreting Tumors
    
  • Hyperthyroidism

Primary Aldosterone

• Presentation:
  • Primary: High Aldo but low Renin
    
  • -unregulated secretion of aldosterone by the adrenal gland (adenoma, adrenal hyperplasia, Conn’s syndrome)
    
  • -New refractory HTN
    
  • -Hypokalemic
    
  • -metabolic alkalosis

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  Diagnosis:
  • Aldosterone/Renin ratio 20:1
    
  • -confirm after salt loading
    
  • CT of adrenal
    
  • Adrenal vein sampling: determines unilateral or bilateral
    

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  Management:
  • Adrenal Hyperplasia: Medical management, blocks aldosterone receptor (Aldactone or eplerenone)
    
  • Adrenal Adenoma: surgical removal if unilateral, medical if bilateral

Cushing Syndrome

• Presentation:
  • -HTN, buffalo hump, moon fancies, hirsutism, easy brusing

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  Path:
  • Glucocorticoids (cortisol) excess from adrenal gland due to overproduction of ACTH by pituitary adenoma -> unchecked activation of mineralocorticoid receptor

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  Diagnosis:
  • absence of cortisol suppression following dexamethasone administration

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  Treatment:
  • remove adenoma

Pheochromocytoma

• Presentation:
  • Headaches, sweating, HTN, tachycardia caused by sudden release of catecholamines

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  Path:
  • Rare neuroendocrine tumor that produces norepinephrine, epinephrine, and dopamine
    
  • 90% in adrenal glands and benign
    
  • Can occur on their own or part of a syndrome

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  Diagnosis:
  • Biochemical testing
    
  • -plasma free catecholamine metabolites
    
  • Ct or MRI of the abdomen
    

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  Treatment:
  • Surgical removal of the tumor

Hyperthyroidism

• Elevated TH stimulates sympathetic nervous system and HTN

Renovascular Hypertension

• Features:
  • Most common cause of secondary hypertension, 10-15% of refractory hypertension
  • Unilateral or Bilateral
  • Episodic malignant hypertension
  • Flash pulmonary edema
  • Significant rise in creatinine when started on RAAS blocking in bilateral

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  Causes:
  
  • 1. Fibromuscular dysplasia
    
    • Non-atherosclerotic
    • A string of beads on Radiographic of renal artery
    • -congested/twisty renal artery
    • Commonly seen in young females
  • 2. Atherosclerosis
    • Most common cause of renovascular hypertension
    • Generally patients greater than 50 with known atherosclerosis
    • Typically occurs in the optimum or proximal portion of renal artery
    • -closer to the aorta

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  Unilateral vs. Bilateral:
  • Unilateral:
    • -constant elevation of renin/angiotensin/aldosterone out runs the normal kidney
    • compensation
    • -normal kidney keeps volume low
    • -secondary aldosterone
    • -treat with hormone blockers
  • Bilateral:
    • -high BP maintained by retention of salt and water
    • -treat with diuretics
    • -can have significant rise in creatinine with RAAS blocker

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  Diagnosis:
  • Blood test: elevated renin and aldosterone
  • Imaging: ultrasound, CT, MRI
  • Percutaneous catheter placement to measure Intravascular pressure

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  Treatment:
  • RAAS, CCB, Diuretics
  • Fibromuscular: balloon dilation
  • Atherosclerotic: only use balloon dilation with stents in extreme cases

Renal Parenchymal Hypertension

• Presentation:
  • Renal Failure Hypertension
  • Elevated Na, increase in RAAS activity, overactivity of a sympathetic nervous system

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  Treatment:
  
  • -low Na diet
  • -diuretics
  • -RAAS blockers (ACE-I, Angio REceptor blockers)
  • -Beta-Blockers
  • -Dialysis

Sleep Apnea

• HTN occurs due to activation of the sympathetic nervous system and RAAS
• Suspect if snore, or ease, thick neck, or daytime sleepiness
• Treat:
  • CPAP: continuous positive airway pressure

Coarctation of the aorta

• Congenital narrowing of the aorta, on the downturn
• Hypertension in upper limbs, with reduced BP in lower limbs
• Delayer femoral pulses
• Kids diagnosed with imaging, surgical treatment