Hypertension is one of the most common conditions in which the force of the blood against the artery walls is too high (140/90 mmHg or higher). While it is quite common, it can be serious if not treated. Usually patients are unable to feel that they are suffering from hypertension. The only way to know is to get the blood pressure checked.
Hypertension is one of the most common topics for Medicine. Read this blog post thoroughly to learn everything about Hypertension and elevate your NEET PG preparation.
Introduction
Normally nocturnal dip around 4-6 am with approximately 10% of fall in blood pressure
Early feature: loss of nocturnal dip
Systolic blood pressure variation shows an increase in incidence of cardiovascular mortality.
Good control of HTN: Acute coronary syndrome incidence reduced by 25%, stroke by 30%, heart failure by 50%
Important Information
Antihypertensives should be taken either in early morning or at night, so that morning increase in BP due to vasoconstriction can be prevented.
In patient with good control of HTN, incidence of:
Acute coronary syndrome to be reduced by 25%
Stroke to be reduced by 30%
Heart failure to be reduced by by 50%
Blood Pressure
Optimal BP < 11575mm of Hg
Race dependent value: If Systolic blood pressure (SBP) more than 20 mm, diastolic blood pressure (DBP) by 10 mmhg then the cardiovascular mortality risk increases
Morning hours will have higher chances of increased blood pressure.
Classification
AHA guidelines
Harrison guidelines
Elevated
120-129/ < 80 mm of Hg
120-139/80-89 mmHg
Stage I
130-139/ 80-89 mm of Hg
140-159/90-99 mmHg
Stage II
> 140/90 mm of Hg
> 160/100 mmHg
Automated office Blood Pressure
Ambulatory Blood Pressure monitoring
3 readingsDiscard 12 reading = average> 135/85 mm Hg
Average awake BP= > 135/85 mm of HgAverage sleep BP= > 120/75 mm of Hg
Home based BP monitoring (HBPM)
>135/85mm Hg
7 days: Morning / Evening
Discard 1st day value
6 days: average
Cuff size: 80% of arm circumference
Width: >40%
Rest: 5 min
After smoking / coffee consumed: wait 30 min
BP measure both arms
BP measure legs
White coat HTN
BP normal at home but increase in clinic
Can develop HTN in future
Masked HTN
BP normal in clinic but elevated at home (stage1)
Need anti-hypertensive medicine
Causes Of Hypertension (HTN)
Most common cause of HTN: Essential HTN/ idiopathic
Most common cause of secondary HTN: Renal Parenchymal disease
Secondary HTN (America): Obstructive sleep apnea
Most common congenital cause of HTN is Coarctation of Aorta
In Coarctation of Aorta (Post ductal), BP in upper limb is higher and BP in lower limbs is lower
Important Information
Normally BP in upper limb = < 120/80, & BP in lower limb < 140/80, range of 20 mmhg
Reverse scenario is seen in coarctation of aorta, where BP in legs is lower and upper limb has higher.
Unequal Blood Pressure in left/right arm is seen in
Takayasu’s arteritis (Important cause of renal artery stenosis in India)
Supravalvular AS (Aortic Stenosis): William syndrome (Conda Effect)
Coarctation of Aorta (Pre ductal)
Aortic Dissection: (acute) antegrade
Secondary Causes of HTN
Renal parenchymal disorder
Chronic Kidney disease
Chronic glomerulonephritis
Renovascular HTN
Fibromuscular dysplasia in young age
Atherosclerosis in old age
Metabolic syndrome/ syndrome X 5 components of metabolic syndrome:
Centripetal obesity
Insulin resistance
Hypertriglyceridemia
Low HDL
HTN 3 out of 5 should be present for diagnosis
Obstructive Sleep Apnea (OSA)
Fluctuation of heart rate during sleep increases the stress on the heart and that manifests into HTN and left ventricular hypertrophy
During apnea episode there is bradycardia (oxygen cut off from body) and due to hypoxia, the person tries to breathe in and then there is cortical arousal – oxygen goes inside and there is sudden increase in the HR
Endocrinological
Hypothyroidism (Isolated diastolic HTN)
Thyrotoxicosis
Pheochromocytoma episodic HTN
CONN syndrome
OCP: due to secondary aldosteronism
Acromegaly: increased Growth hormone
Neurogenic: Spinal cord transection (At T6 or above: unopposed sympathomimetic outflow to heart)
Cushing reflex: decreased HR and increased BP
Mendelian causes
Liddle syndrome (Autosomal Dominant)
Overactivity of ENac – causes more salt/H2O to retain in the body
HTN with loss of K+/H+ causing hypokalemia alkalosis
Low aldosterone, low renin, and high blood pressure
Treatment: Amiloride (ENac blocker)
Gordan syndrome
Autosomal Dominant
Mutations are WNK-1/ WNK-4: gain of function - Thiazide dependent
Na/Cl cotransport in Distal Convoluted Tubule
HTN due to more Na/Cl retaining in the body
Polycystic kidneys
Autosomal Dominant in adults, Autosomal Recessive in pediatrics USG criteria:
Should have 2 or more cyst in kidney
Adults: hepatic cyst
Pediatric: hepatic fibrosis
Destruction of parenchyma in kidney causes reduction in GFR and Renin levels increases resulting in HTN
Abdominal pain
GI manifestations
Pheochromocytoma
Autosomal Dominant
Associated with MEN-2A (Sipple Syndrome), MEN-2B, Von hippel lindau, Neurofibromatosis-1
Congenital adrenal hyperplasia (CAH)
17-α hydroxylase deficiency (Autosomal Recessive), causes increase in Aldosterone and thus HTN
11 – hydroxylase deficiency (Autosomal Recessive) causes increase in Deoxycortisol which stimulates ENaC and cause HTN
Used in patients of heart failure with preserved ejection fraction
α- Blockers
HTN in patients having BPH use Prazosin
HTN in Pheochromocytoma use Phenoxybenzamine
End stage renal disease (diabetic nephropathy) use α-blocker
Hypertensive Urgency
If BP > 220/130 mm Hg but life-threatening end-organ damage is absent
Hypertensive Emergency/ Crisis
If BP > 220/130 mm of Hg + target organ damage is present
Goal/ Objective:
Reduce MAP by 25% within 2 hours (Mean Arterial Pressure) or maintain BP 160 / 100 mmHg
Presence or absence of target organ damage defines the urgency or emergency than recorded numerical values.
Malignant HTN
Fibrinoid necrosis occurs in the vessels supplying various parts in the body and the mortality rate increases ↑↑ by 50% in 6-12 months
Retina: hemorrhage
Brain: putamen bleed intra parenchymal bleed
Kidney: nephrosclerosis
Blood vessel: Microangiopathic hemolytic anemia
Hypertensive encephalopathy, sodium nitroprusside is used
Stroke + HTN
Thrombolysis (Reteplase < 4.5 hours)
Ischemic stroke
Thrombolytic candidate
To initiate thrombolysis, BP <185/110
To lower BP, Give: Nicardipine
Not a thrombolytic candidate
If BP is 220/130 mmHg (first lower BP)
Intracerebral Hemorrhage
Target BP 130-140mmHg
In patients with postoperative HTN / MI/ Unstable Angina/ Acute decompensated CHF
Give: IV Nitroglycerin
In patients of “Adrenergic Crisis” in pheochromocytoma surgery
Nitroprusside is used along with Phentolamine
Pheochromocytoma
Pre op: Oral phenoxybenzamine
Intra op: Phentolamine
Intra op + HTN crisis: Nitroprusside
Heart failure: IV Nitroglycerin
Target Blood Pressure
Target BP/ Goal to be maintained in patients with HTN: < 135-140/ 85-90 mm of Hg
Target HTN along with Diabetic nephropathy = < 130/80 mm of Hg
BP Malignant HTN: 160/110 mm of Hg to be maintained by using antihypertensives or Mean Arterial Pressure should be reduced by 25% over 2 hours
CKD grade I-III: ACEI/ARB + Thiazide + CCB
eGFR< 30ml/min: Diuretic, Metazolone
ESRD
CCB/amlodipine
alpha blocker.
That is everything you need to know about Hypertension for your Medicine preparation. For more interesting and informative blog posts like this download the PrepLadder App and keep reading our blog!
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