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Hypertension
Case:
A 45 year-old African American man is seen in the outpatient department complaining of
intermittent throbbing headaches that have occurred every morning for 2 weeks. He
has a history of untreated, asymptomatic, sustained high blood pressure (150-
160/100mmhg) of 10 years’ duration. He has no history of palpations, sweating, tremor,
or periodic paralysis. His father was also hypertensive and died from a stroke at age
67. The patient has smoked cigarettes, tow packs per day, for 30 years.
His physical examination reveals a blood pressure of 180/120 mmHg and a heart rate
of 90 beats per minute and regular. Fundal examination reveals the presence of arterial
vasoconstriction. Cardiac examination reveals a laterally displaced PMI (Point of
Maximal Impulse), S4, no S3, and no murmur. During abdominal examination, no bruit
or mass is found and the neurologic and other systems are unremarkable.
After 2 weeks of treatment, the patient is lost to follow-up. Five years later, he presents
to the ER complaining of blurring vision and severe headaches. His physical
examination at that time reveals a blood pressure of 270/140 mmHg and a heart rate
HR 100 bpm. His sensorium and orientation are normal, but fundal examination reveals
retinal hemorrhage, exudates and papiledema. Heart examination shows left
ventricular lift and S4. On a chest x-ray film, mild to moderate cardiomegaly is noted.
His creatinine level is 2.4 mg/dl. (Normal is 1.5)
Is HT primary or secondary.? Will come back to case at the end of class. (THIS CASE
WAS DISCUSSED IN NOVMEBER 10TH CLASS)
PAGE 1
Isolated systolic hypertension: increase in systolic BP, but diastolic BP may still be in
normal range. Most often in elderly patient with incompliant arterial tree.
Suboptimal blood pressure: if pt. with suboptimal BP: 115, but has an accumulation risk
factors, they are still at risk.
Even if the pt. has just suboptimal pressure, but have accumulation of risk factors, they
are still at risk (unclear if “suboptimal” it WHO definition of HT which is 160, not >120)
PAGE 2
HT: most common cause for visit to physician. Can affect all ages.
Treatable at early stages, important for us to be able to recognize it.
What is BP?
• result of cardiac output and peripheral vascular resistance.
• Have to wait at least 2 minutes before taking blood pressure a second time. Will get
false result if you do it again right away.
• After inflating cuff to occlude radial pulse, wait 2 minutes before taking BP or you will
get a false reading. Could also switch arms, but this may be more awkward for
patient.
• If you take BP on both sides and you get different readings, take the higher one, or
record both, esp. if patient is at risk.
PAGE 3
Severe elevation : immediate referral. Can’t wait until next day. >200 SBP, 120 DBP.
Risk Factors:
• Why age? Hardened arteries, decreased elasticity, increased resistance
• Smoking: vasoconstriction. Have higher incidence of malignant hypertension.
Quickly developing complications, refractory (non-responsive) to treatment
• Male
• Obesity: increased peripheral resistance, increased blood volume, stroke volume.
Increased weight contributes to hyperlipidemia
• Family history: there is a genetic predisposition to HT. Also want to know personal
history: drug (NSAIDs may increase BP), smoking
• Sodium intake: leads to retention of water. 1 molecule of sodium retains 2 of water.
• Alcohol use: will interfere with metabolism of drugs. Vasoconstrictor
• Psychological stress: eg. Exams, family circumstances, finances, etc.) Sympathetic
activation, (early vasodilation, but later –> vasoconstriction, elevated blood pressure.
• Race: more cases among African Americans, increased sensitivity to sodium
• Contraceptive pills: activates renin-angiotensin-aldosterone system.
Same risk factors play role in dev. of other CV diseases. Diabetes, stroke, transient
ischemic attacks.
PAGE 4
Primary is a DIAGNOSIS OF EXCLUSION! You have to rule out all possible secondary
causes of HT.
Secondary HT: has to be ruled out. There is an underlying disease that causes the HT.
This only causes 5% of hypertensive conditions.
Even seeing this in people less than 20 years of age.
Very severe: numbers tend to be very high.
Red flag: no family history of hypertension.
Unresponsive to treatment because there is another cause of the HT.
PAGE 5
PAGE 6
Normal renal arteriogram: aorta is in the middle of slide. Renal arteries originate from
aorta.
To Dx renal artery stenosis, listen for bruit over renal artery. Must refer to specialist for
renal arteriogram. Could be the cause of hypertention.
Renal arteriogram of a nonsmoking white man with hypertension see stenosis of renal
artery. Kidney is very sensitive to changes in blood pressure, delivery of blood.
Renal arteriogram in a white woman with hypertension see twisted renal arteries
causing extreme hypertension.
PAGE 7
Acromegaly: can ask pt. to bring picture from several years ago to compare.
For Ddx: see chart called “clinical features of other secondary causes of hypertension”
PAGE 8
Clinical manifestations:
no pathoneumonic (SP) signs of ht. Can have many different sys.
Target organs: the organs that HT will affect sooner or later. We want to avoid these
consequences through treatment.
PAGE 9-10
Brain:
very sensitive! Every part resp. for very specific function. Pressure on brain tissue
Transient Ischemic attack or stroke may happen
2 types of stroke:
ischemic: lack of blood due to blockage, vasoconstriction
hemorrhagic: bleeding due to increased permeability (contriction of bv plus high bp,
increased permeability: blood goes into blood tissue. Tissue is now under pressure, will
damage function of brain. Can assess damage through function.
Transient ischemic attack, it comes and goes. Dt constriction, spasm of bv. Lasts for
15-30 minutes.