An Overview of Hypertension

Case Presentation:

45 year old AA male presents to the emergency complaining about headache associated with blurry vision an epistaxis (nosebleeds) and dyspnea upon exertion (DOE).  Was told that he had borderline hypertension (HTN) but there was no follow up.  No significant past medical history. He smokes 1 pack a day for about 30 years and he drinks alcohol.  He has a family history of cerebral vascular accident and coronary artery disease.
 

Introduction:

• The prevalence of Cardiovascular Disease is about 65 million in the US alone. 
• When we talk about cardiovascular disease we are talking about a disease of the blood vessels that has an effect on the heart as well as the brain.
•  It is a disease that usually takes time to develop so it shows up in the aged (> 60 ) of our population for the most part (not so common in the 20’s and 30’s).
  • Actually, by the time we start to practice we might see a marked decrease in the affected populations because of the increasing incidence of obesity and diabetes (two diseases that are co-morbid with the development of HTN) in the population.
•  It is a major contributor of death worldwide. 
• It is the number one reason for doctor’s visits and the number one disease for which prescriptions are written.
•  Basically it is of great concern to the health care system in the U.S.
• Hypertension is a major risk factor for premature stroke or myocardial infarction.
• The worse thing about the disorder is that health professionals do a really bad job of keeping patients controlled (only about 30% of patients are controlled). 
  • Why do we hesitate? B/c we medicine is a popularity contest and we want our patients to like us….for most people the doses have to be really high and a lot of different medication may be needed for control.
  •  Patients are very disgruntle when told that they have to up their meds.
  •   In addition to our reluctance there is the fact that HTN is a silent killer and vigilance is needed for detection of the disease.

Blood Pressure Classification for Screening:

The new definition of normal is <120 (SP) and < 80 (DP)

Stage 1 hypertension is regarded as  a BP between 140-159 (SP) or 90-99 (DP) (note that both numbers need not be elevated for a diagnosis).

Stage 2 hypertension is a BP of ≥160 (SP) or ≥100 (DP).

There is now a stage called pre-hypertension which is a range of 120-139 or 80-89.

  With these patients HTN is inevitable; these are the patients in which behavioral and nutritional modifications can be made to help delay the development of HTN or decrease the amount of drugs needed for treatment. Note these persons do not have the disease yet.

Back to our case:

• Our patient did have a headache but he denies flushing (probably not pheochromocytoma)
• Denies chest, pain, and fatigue
• Denies palpitations and muscle cramps (so probably not due to potassium wasting [Primary hyperaldosteronism]).
• Does take lots of NSAID’s and snores (now here are some things that may be affecting his HTN!!)

 
Physical exam of our patient:

• HEENT: Left abdominal bruit: may mean artherosclerosis
• Mild JVD
• Chest: Fine rales at bases
• Heart: Strong apical impulse (PMI is thudding).
• Abdomen: Renal bruit.
• Extremities: some edema
   

Some test you may want to order:

• Electrocardiogram

• Note the increase in the voltage (pic on right) in leadsV1 and V2 compared to those of in normal (pic on left). [the ECG in her notes show an increase in V2,V3 and V5]
• This is a sign of left ventricular hypertrophy with expansion of the muscle walls due to increased force needed to push blood out.

• Urinalysis (protein in the urine is a good indicator of end organ damage)
• Blood glucose (make sure not diabetic) and hematocrit
• Serum potassium, calcium and creatine
• Lipid profile

 
 
So what is the benefit of lowering blood pressure?

• Studies have shown that small decreases (just a couple mmHG) in BP reduce the incidence of stroke, MI and HF. 
• The higher the mmHg drop the higher the average percentage of reduction.
   

 
Overview of Treatment:

• Treatment is a combination of lifestyle modification along with drugs (make sure meds are enough to combat Hypertension).
• For people with diabetes or chronic kidney disease the target ranges are different
  • >140/90 is normally the level that treatment is begun but for people with these chronic disease the target range for treatment is >130/90, because the progression of disease in these individuals is much quicker.
    
     

Lifestyle Modifications:

·         Weight reduction – 5-20 mmHg/10 kg weight loss

·         Adopt Dietary Approach to Stop Hypertension (Dash) – 8-14 mmHg reduction

·         Dietary Sodium Reduction – 2-8 mmHg reduction

·         Physical Activity – 4-9 mmHg reduction

·         Moderate Alcohol Consumption – 2-4 mmHg reduction.

·         Med’s used: β-Blockers and diuretics, ACE inhibitors, Calcium Channel Blockers

• Try to give drugs that can treat multiple disorders.

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