Chronic hypertension resident survival guide

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ayokunle Olubaniyi, M.B,B.S [2]

Hypertension Resident Survival Guide Microchapters
Overview
Classification
Causes
Diagnosis
General
Complete
Treatment
Prehypertension
Stage 1
Stage 2
Medical Therapy
Choice of Regimen
Drug List
Do's
Don'ts

Overview

Hypertension (HTN) is defined as a systolic blood pressure (SBP) ≥ 140 mmHg and diastolic blood pressure (DBP) ≥ 90 mmHg.[1] It is usually detected during the screening of an asymptomatic individual, but the diagnosis is based on persistent elevation of blood pressure after the average of 2 or more blood pressure measurements taken on each of 2 or more hospital visits. Hypertension can either be primary or essential, whenever the etiology cannot be identified; or secondary, whenever the etiology (e.g., hyperthyroidism, pheochromocytoma, renal artery stenosis) is known. The presence of diabetes mellitus, cigarette smoking, excessive sodium intake, obesity, and sedentary lifestyle increases the risk of developing essential hypertension. Lifestyle modifications such as weight reduction, reduction in alcohol consumption, exercises, and reduction in salt intake are recommended to all patients in addition to pharmacological therapy, when required.

Classification

Classification Blood pressure (mmHg)
Normal < 120/80
Prehypertension SBP 120-139
DBP 80-89
Stage 1 hypertension SBP 149-159
DBP 90-99
Stage 2 hypertension SBP >160
DBP >110
Isolated systolic hypertension SBP ≥ 140
DBP < 90
Isolated diastolic hypertension SBP <140
DBP ≥90

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.

Common Causes

Primary or Essential Hypertension

Secondary Hypertension

Pseudohypertension

Click here for the complete list of causes.

FIRE: Focused Initial Rapid Evaluation

A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.

Boxes in red signify that an urgent management is needed.

 
 
 
 
For patient presenting with symptoms suggestive of the following:

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Measure the blood pressure
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
BP ≥ 180/120
 
BP < 180/120
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Does the patient have
any evidence of end organ damage?
 
Continue with the diagnosis below
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Diagnosis

Shown below is an algorithm summarizing the diagnosis of hypertension based on the seventh report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure and 2013 ESH/ESC guidelines for the management of arterial hypertension.[2][3]

Abbreviations: ABPM: Ambulatory blood pressure monitoring; BP: Blood pressure; CKD: Chronic kidney disease; DBP: Diastolic blood pressure; DM: Diabetes mellitus; SBP: Systolic blood pressure

General Approach

 
 
 
 
Suspected hypertension
BP > 140/90 mmHg
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Blood pressure measurement

Before taking the BP

❑ Sit patient quietly in a chair for 5 minutes
❑ Avoid caffeine, exercise, smoking for at least 30 minutes
❑ Ensure appropriate cuff size

❑ Take 2 readings and find the average
❑ Take repeated measurements in patients with arrhythmia
❑ Measure blood pressure at both arms at first visit to detect possible differences


Click here for more information regarding blood pressure measurement
 
 
 
 
 
 
 
 
 
 
 
 
 
 
For office BP >140/90 mmHg on 2-3 visits
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Does the patient have any evidence of target organ damage, DM, or CKD?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Proceed to hypertensive crisis resident survival guide
 
Perform home BP/out-of-office monitoring
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Is the average home BP measurement <140/90?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
Inconclusive
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Perform 24-hour ABPM
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Is the 24-hour ABPM ≤135/85?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Hypertension confirmed
 
 
 
 
 
 
 
 
 
 
 
 
 
 
White coat hypertension confirmed
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Classify the patient
based on the BP reading
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
SBP 120-139 mmHg
DBP 80-89 mmHg
 
SBP 149-159 mmHg
DBP 90-99 mmHg
 
SBP >160 mmHg
DBP >110 mmHg
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Stage 1 hypertension

Proceed to the complete diagnostic approach below
 
Stage 2 hypertension

Proceed to hypertensive crisis resident survival guide
 

Complete Diagnostic Approach

Shown below is an algorithm summarizing the diagnosis of hypertension based on the seventh report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure and 2013 ESH/ESC guidelines for the management of arterial hypertension.[2][3]

Abbreviations: BMI: Body mass index; BP: Blood pressure; CNS: Central nervous system; CT: Computed tomography; CVD: Cardiovascular disease; eGFR: Estimated glomerular filtration rate; EKG: Electrocardiogram; HTN: Hypertension; LVH: Left ventricular hypertrophy; MI: Myocardial infarction; NSAIDs: Non steroidal anti-inflammatory drugs; TSH: Thyroid stimulating hormone; UTI: Urinary tract infection

 
 
 
Obtain a detailed history:

History of present hypertension
❑ Time of first diagnosis
❑ Current and past BP measurements
❑ Current and past antihypertensive medications

Identify secondary causes of hypertension:
Family history:
Chronic kidney disease (suggestive of polycystic kidney disease)
❑ Premature CVD or HTN
History of renal disease:
Hematuria
UTI
Analgesic abuse (suggestive of renal parenchymal disease)
Flank pain
Medication/substance abuse:
Amphetamines
Cocaine
Cyclosporine
Erythropoietin
Liquorice
NSAIDs
Oral contraceptive pills
Steroids
History suggestive of pheochromocytoma:
❑ Recurrent episodes of sweating, palpitation and hypertension
History suggestive of hyperaldosteronism:
Muscle weakness and tetany
History suggestive of thyroid disease:
Hypothyroidism
Hyperthyroidism

History to assess risk factors
❑ Personal and family history of:

HTN and CVD
Dyslipidemia
Diabetes mellitus

❑ Excessive sodium intake >2.4g per day
Tobacco usage
Obesity
Alcoholism >1.5 drinks/day
Metabolic syndrome
Physical inactivity
Sleep apnea

History to assess presence of organ damage/complications
CNS:

Headache
Vertigo
Transient ischemic attack
Stroke

Eyes:

Loss or blurring of vision

Cardiovascular:

❑ History of MI or syncope
Chest pain
Shortness of breath
Leg swelling
Palpitation
Arrhythmia
Sexual dysfunction

Kidneys:

Polyuria
Hematuria
Proteinuria
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Examine the patient:

General examination:
❑ Calculate BMI
❑ Moon face, truncal obesity, striae (suggestive of Cushing's disease)
Goitre, exophthalmus, pretibial myxedema (suggestive of Graves' disease)
❑ Dry skin (suggestive of hypothyroidism)
Eyes:
Fundoscopy to diagnose hypertensive retinopathy

Hemorrhage
Papilledema
Cotton wool spots

Neck:
Carotid bruits
Thyroid gland enlargement (suggestive of hyperthyroidism)
Cardiovascular examination:
❑ Evidence of long-standing hypertension:

Cardiomegaly
❑ Displaced apex beat (suggestive of enlarged left ventricle)

Respiratory examination:
Crackles/crepitations/rales
Abdominal examination:
Bruits over abdominal aorta (suggestive of aortic aneurysm)
Bruits over renal artery (suggestive of renal artery stenosis)
Extremity examination:
❑ Absent or diminished femoral pulsation (suggestive of coarctation of aorta)
Pedal edema (suggestive of congestive heart failure)
Neurological examination:
❑ Delayed return of deep tendon reflexes (suggestive of hypothyroidism)
❑ Findings suggestive of hypertensive encephalopathy

Confusion
Altered mental status


 
 
 
 
 
 
 
 
 
 
 
 
Order tests:

Routine
12-lead EKG (for evidence of LVH or old infarct)
CBC

Anemia (associated with chronic renal failure)

Urinalysis

Proteinuria (suggestive of end organ damage)

Serum potassium

Hypokalemia (suggestive of hyperaldosteronism)

Serum calcium (high in hyperparathyroidism)
Serum creatinine with estimated glomerular filtration rate (eGFR)
Serum uric acid
Fasting blood sugar

Hyperglycemia (suggestive of diabetes mellitus)

Fasting lipid profile


Additional tests based on results of the routine tests above:
Echocardiography (may reveal LVH or left ventricular mass)
24-hour urinary metanephrine and normetanephrine (elevated in pheochromocytoma)
Plasma renin activity (PRA) (low renin suggests hyperaldosteronism)
Plasma aldosterone (elevated in hyperaldosteronism)
TSH (may be high or low in hypo- and hyperthyroidism, respectively)
Serum parathyroid hormone (PTH) (To evaluate parathyroid disease)
Dexamethasone suppression test

❑ Unchanged levels of cortisol to high dose dexamethasone suggests Cushing's syndrome

❑ 24-hour free urinary cortisol (elevated in Cushing's syndrome)
Renal duplex ultrasound and magnetic resonance angiography (MRA) of renal arteries

❑ To evaluate renal artery stenosis

Chest CT angiography (To evaluate aortic coarctation)
Sleep study with O2 saturation (To evaluate sleep apnea)

 
 
 
 
 
 
 
 
 
 
 
 
Does the patient have an identifiable secondary etiology?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
Primary hypertension
 
Secondary hypertension
 

Treatment

Shown below is an algorithm summarizing the treatment of hypertension based on the 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8), ESH/ESC guidelines for the management of arterial hypertension, and the seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.[1][2][4]

Prehypertension

 
 
Prehypertension
SBP 120-139 mmHg
DBP - 80-89 mmHg
 
 
 
 
 
 
 
 
 
 

❑ Initiate lifestyle modification
❑ Follow-up/recheck blood pressure in one year

❑ Ensure self-monitoring of blood pressure
 

Stage 1 Hypertension

Shown below is an algorithm summarizing the treatment of hypertension based on the 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8) and the 2013 ESH/ESC guidelines for the management of arterial hypertension.[4][2]

Abbreviations: ACEI: ACE inhibitors; ARBs: Angiotensin II receptor blockers; BMI: Body mass index; BP: Blood pressure; CCBs: Calcium channel blockers; CKD: Chronic kidney disease; DASH: Dietary Approaches to Stop Hypertension; DM: Diabetes mellitus

 
 
 
 
 
 
 
The following categories require pharmacological treatment according to JNC 8?:

BP ≥ 150/90 mmHg in patients ≥ 60 years
BP ≥ 140/90 mmHg in patients < 60 years
BP ≥ 140/90 mmHg in patients ≥ 18 years with
CKD or DM

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Review BP goals:

General population
BP < 150/90 mmHg in patients ≥ 60 years
BP < 140/90 mmHg in patients < 60 years
Patients with DM or CKD

BP < 140/90 mmHg
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Initiate lifestyle modification:

Weight reduction

❑ Maintain a waist circumference of
  • <40 inches (102cm) for men
  • <35 inches (88cm) for women
  • BMI of ≤25 kg/m2

❑ Adopt healthy diet

DASH diet (rich in fruits, vegetables, whole grains, low sodium, low-fat proteins)
❑ Dietary sodium intake of ≤ 100 mmol/day (2.4g Na or 6g NaCl)

❑ Limit alcohol consumption

❑ ≤ 2 drinks/day for men (24oz beer or 10oz wine or 3oz 40% whisky
❑ ≤ 1 drink/day for women

❑ Regular aerobic physical activity (brisk walking, jogging, cycling, swimming) for at least 30 mins per day

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Does the patient have DM or CKD?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
CKD ± DM
 
DM only
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider the race of the patient
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Black population
 
Non-black population
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Initiate:

ACE inhibitors alone, OR
ARBs alone, OR
ACEI or ARBs in combination with other drug class e.g.,

Avoid the combined use of ACEIs and ARBs in a patient
 
 
Initiate:

Thiazide diuretic alone, OR
CCB alone, OR
❑ Combination of the two classes

 
Initiate:

Thiazide diuretic alone, OR
ACEI alone, OR
ARBs alone, OR
CCB alone, OR
❑ Combination of all the classes

Avoid the use of ACEIs and ARBs in combination

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Has the target BP been reached?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Click here for
further therapeutic options

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Monitoring and follow-up:

Monitor:
❑ Serum potassium and creatinine at least 1-2 times per year
Follow-up visits
❑ Schedule 2-4 weekly visits to assess:

❑ Compliance and BP control
❑ Occurrence of side effects to medications
❑ Asymptomatic end organ damage

❑ 3-6 monthly visits when BP goal is achieved
❑ Reinforce strategies to improve compliance to medication usage

❑ Self-monitoring of blood pressure
❑ Simplification of drug regimen
❑ Telephone follow-up, reminders, home visits
❑ Consider low dose aspirin only when BP is controlled
 
 

Medical Therapy

Choice of Regimen

 
 
 
 
 
 
 
 
 
 
Assess BP and cardiovascular risk
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Mild elevation of BP
Low CV risk
 
Severe elevation of BP
High CV risk
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider starting with a single agent
 
Consider 2-drug combination
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Target BP achieved?
 
Target BP achieved?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Continue with current regimen
 
Yes
 
No
 
No
 
Yes
 
Continue with current regimen
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Switch to a different drug
Titrate until maximum dose is reached, if necessary
 
Increase dose of present drug and titrate accordingly
 
Increase dose of present combination
 
Add a third drug and
titrate to maximum dose, if necessary
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If BP goal is not achieved

Add a second drug
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Maximum dose of 2-drug combination reached
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If BP goal is not achieved

Switch to a different 2-drug combination and titrate to the maximum dose, if necessary
OR
Add a third drug and titrate to the maximum dose, if necessary
 

Drug List

Drug Class Drug Initial daily dose, target dose (mg) Preferred use Preferably combined with
Thiazide diuretics Chlorthalidone 12.5, 12.5-25 Heart failure, isolated systolic hypertension, black population ACE inhibitors, ARBs, calcium channel blockers
Hydrochlorothiazide 12.5-25, 25-100
Bendroflumethiazide 5, 10
Indapamide 1.25, 1.25-2.5
ACE inhibitors Enalapril 5, 20 Left ventricular hypertrophy, atherosclerosis, renal insufficiency, previous myocardial infarction, heart failure, atrial fibrillation (prevention), peripheral artery disease, metabolic syndrome, diabetes mellitus Calcium channel blockers, thiazide diuretics
Lisinopril 10, 40
Captopril 50, 150-200
ARBs Candesartan 4, 12-32 Left ventricular hypertrophy, renal insufficiency, previous myocardial infarction, heart failure, atrial fibrillation (prevention), metabolic syndrome, diabetes mellitus Calcium channel blockers, thiazide diuretics
Losartan 50, 100
Valsartan 40-80, 160-320
Eprosartan 400, 600-800
Irbesartan 75, 300
Beta blockers Atenolol 25-50, 100 Previous myocardial infarction, atrial fibrillation (prevention and ventricular rate control), heart failure, angina pectoris, aortic aneurysm, pregnancy Thiazide diuretics (with limitations)
Only dihydropyridine calcium channel blockers should be combined with beta blockers
Metoprolol succinate 50, 100-200
Calcium channel blockers Amlodipine 2.5, 10 Left ventricular hypertrophy, pregnancy (nifedipine), previous myocardial infarction, atrial fibrillation (verapamil, diltiazem), metabolic syndrome, peripheral artery disease, atherosclerosis, angina pectoris, isolated systolic hypertension, black population ACE inhibitors, ARBs, thiazide diuretics
Diltiazem extended release 120-180, 360
Nitrendipine 10, 20

Do's

Don'ts

References

  1. 1.0 1.1 Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL; et al. (2003). "Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.". Hypertension. 42 (6): 1206–52. PMID 14656957. doi:10.1161/01.HYP.0000107251.49515.c2. 
  2. 2.0 2.1 2.2 2.3 Mancia, G.; Fagard, R.; Narkiewicz, K.; Redán, J.; Zanchetti, A.; Böhm, M.; Christiaens, T.; Cifkova, R.; De Backer, G. (2013). "2013 Practice guidelines for the management of arterial hypertension of the European Society of Hypertension (ESH) and the European Society of Cardiology (ESC): ESH/ESC Task Force for the Management of Arterial Hypertension.". J Hypertens. 31 (10): 1925–38. PMID 24107724. doi:10.1097/HJH.0b013e328364ca4c.  Unknown parameter |month= ignored (help)
  3. 3.0 3.1 Chobanian, AV.; Bakris, GL.; Black, HR.; Cushman, WC.; Green, LA.; Izzo, JL.; Jones, DW.; Materson, BJ.; Oparil, S. (2003). "Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.". Hypertension. 42 (6): 1206–52. PMID 14656957. doi:10.1161/01.HYP.0000107251.49515.c2.  Unknown parameter |month= ignored (help)
  4. 4.0 4.1 James, PA.; Oparil, S.; Carter, BL.; Cushman, WC.; Dennison-Himmelfarb, C.; Handler, J.; Lackland, DT.; LeFevre, ML.; MacKenzie, TD. (2014). "2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8).". JAMA. 311 (5): 507–20. PMID 24352797. doi:10.1001/jama.2013.284427.  Unknown parameter |month= ignored (help)



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