Hypertension: Difference between revisions

Jump to navigation Jump to search
VisualWikitext
No edit summary
Line 7: Line 7:
{{CMG}}; {{AE}} {{USAMA}}
{{CMG}}; {{AE}} {{USAMA}}
==Overview==
==Overview==
[[Hypertension]] is a major risk factor for [[cardiovascular disease]] and is a major public health problem. The prevalence of [[hypertension]] increased among the united states patients according to the 2017 ACC/AHA Guideline. The previous cut-off 140/90 mmHg has been changed.
[[Hypertension]] is a major risk factor for [[cardiovascular disease]] and is a major public health problem. The prevalence of [[hypertension]] increased among the united states patients due to changing The previous cut-off 140/90 mmHg.


==Historical Perspective==
==Historical Perspective==
Line 538: Line 538:
*[[Hypokalemia]] ( [[diuretic-induced]]),
*[[Hypokalemia]] ( [[diuretic-induced]]),
* Incidentally discovered [[adrenal mass]]
* Incidentally discovered [[adrenal mass]]
*[[ Family history]] of [[early-onset hypertension]] or [[stroke]] at a young age (<40 years)
*[
|}
 
=== History and Symptoms ===
*[Disease name] is usually asymptomatic.
*Symptoms of [disease name] may include the following:
:*[symptom 1]
:*[symptom 2]
:*[symptom 3]
:*[symptom 4]
:*[symptom 5]
:*[symptom 6]
=== Physical Examination ===
*Patients with [disease name] usually appear [general appearance].
*Physical examination may be remarkable for:
:*[finding 1]
:*[finding 2]
:*[finding 3]
:*[finding 4]
:*[finding 5]
:*[finding 6]
{| style="border: 2px solid #4479BA; align="left"
! style="width: 200px; background: #4479BA;" | {{fontcolor|#FFF|Conditions}}
! style="width: 300px; background: #4479BA;" | {{fontcolor|#FFF| Physical examination}}
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Renal parenchymal disease]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[Abdominal mass]] ([[polycystic kidney disease]])
*[[Skin pallor]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Renovascular disease]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
* [[Abdominal systolic or diastolic bruit]]
* [[Femoral]] or [[carotid]] arteried bruits
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Primary aldosteronism]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
* [[Arrhythmias]] with [[hypokalemia]]
* [[ Atrial fibrillation]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Obstructive sleep apnea]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
* [[Overweight]]
* [[ Short, thick neck]]
* loss of normal [[nocturnal blood pressure]] fall
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Drug]] or [[alcohol]] induced
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
* [[Fine tremor]], [[Tachycardia]], [[Sweating]] ([[cocaine]], [[ephedrine]], [[MAO inhibitors]])
* [[Acute abdominal pain]] ([[cocaine]])
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Pheochromocytoma]]/[[paraganglioma]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
* [[Skin stigmata]] of [[neurofibromatosis]] ([[cafe-au-lait spots]], [[neurofibromas]])
* [[Orthostatic hypotension]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Cushing syndrome]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
* [[Central obesity]]
* [[Moon face]]
* [[Dorsal and supraclavicular fat pads]],
* [[Violaceous striae]]
* [[Hirsutism]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Hypothyroidism]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[Delayed ankle reflex]]
*[[Periorbital puffiness]]
*[[Coarse skin]]
*[[Cold skin]]
*[[Slow movement]]
*[[Goiter]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[ Hyperthyroidism]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
* [[Lid lag]]
* [[Fine tremor]]
* [[ Warm]], [[moist skin]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Coarctation of aorta]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[Blood pressure]] higher in upper extremities than in lower extremities
*[[Absent femoral pulses]]
*[[continuous murmur]] over patient’s back, [[chest]]
*[[Abdominal bruit]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Congenital adrenal hyperplasia]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[Signs]] of [[virilization]] (11-beta-OH) or incomplete [[masculinization]] (17-alpha-OH)
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |[[Acromegaly]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[Acral features]]
*[[Large hands and feet]]
*[[Frontal bossing]]
|}
 
=== Laboratory Findings ===
:*Basic  laboratory test  should be taken in patients  with the diagnosis of [[hypertension]] include:
*[[Fasting blood sugar]]
*[[Complete blood count]]
*[[Lipid profile]]
*[[Serum creatinine]] with [[eGFR]]
*[[Serum]] [[sodium]], [[potassium]], [[calcium]]
*[[Thyroid-stimulating hormone]]
*[[Urinalysis]]
:*Optional laboratory test in [[hypertensive]] patients include:
*[[Uric acid]]
*[[Urinary albumin]] to [[creatinine]] ratio
 
===Electrocardiogram===
There are no ECG findings associated with [disease name].
 
OR
 
An ECG may be helpful in the diagnosis of [disease name]. Findings on an ECG suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
 
===X-ray===
There are no x-ray findings associated with [disease name].
 
OR
 
An x-ray may be helpful in the diagnosis of [disease name]. Findings on an x-ray suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
 
OR
 
There are no x-ray findings associated with [disease name]. However, an x-ray may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].
 
===Echocardiography or Ultrasound===
There are no echocardiography/ultrasound  findings associated with [disease name].
 
OR
 
Echocardiography/ultrasound  may be helpful in the diagnosis of [disease name]. Findings on an echocardiography/ultrasound suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
 
OR
 
There are no echocardiography/ultrasound  findings associated with [disease name]. However, an echocardiography/ultrasound  may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].
 
===CT scan===
There are no CT scan findings associated with [disease name].
 
OR
 
[Location] CT scan may be helpful in the diagnosis of [disease name]. Findings on CT scan suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
 
OR
 
There are no CT scan findings associated with [disease name]. However, a CT scan may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].
 
===MRI===
There are no MRI findings associated with [disease name].
 
OR
 
[Location] MRI may be helpful in the diagnosis of [disease name]. Findings on MRI suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
 
OR
 
There are no MRI findings associated with [disease name]. However, a MRI may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].
 
===Other Imaging Findings===
There are no other imaging findings associated with [disease name].
 
OR
 
[Imaging modality] may be helpful in the diagnosis of [disease name]. Findings on an [imaging modality] suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
 
===Other Diagnostic Studies===
There are no other diagnostic studies associated with [disease name].
 
OR
 
[Diagnostic study] may be helpful in the diagnosis of [disease name]. Findings suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
 
OR
 
Other diagnostic studies for [disease name] include [diagnostic study 1], which demonstrates [finding 1], [finding 2], and [finding 3], and [diagnostic study 2], which demonstrates [finding 1], [finding 2], and [finding 3].
 
== Treatment ==
=== Medical Therapy ===
*There is no treatment for [disease name]; the mainstay of therapy is supportive care.
*The mainstay of therapy for [disease name] is [medical therapy 1] and [medical therapy 2].
*[Medical therapy 1] acts by [mechanism of action 1].
*Response to [medical therapy 1] can be monitored with [test/physical finding/imaging] every [frequency/duration].
 
{{familytree/start}}
{{familytree | | | | | | | | | A01 | | | | | | | | | |A01= Treatment strategy}}
{{familytree | | | | | | | | | |!| | | | | | | | | | |}}
{{familytree | |,|-|-|-|-|v|-|-|^|-|-|-|v|-|-|-|-|.| |}}
{{familytree | |!| | | | |!| | | | | | |!| | | | |!| | |}}
{{familytree | B01 | | | B02 | | | | | B03 | | | |B04| |B01=Nomal [[BP]] ([[BP]]<120/80 mmHg)|B02=Elevated [[BP]]([[BP]]120-129/<80mmHg|B03=Stage1 [[hypertension]](BP 130-139/80-89mmHg|B04=Stage 2 [[hypertension]] ([[BP]]≥ 140/90}}
{{familytree | |!| | | | |!| | | | | | |!| | | | |!| }}
{{familytree | C01 | | | C02 | | | | | C03 | | | |C04| |C01=Life style modifications|C02=Nonpharmocological therapy(class1)|C03= 10 years [[CVD]] risk≥ 10%|C04=Non pharmacological therapy and [[BP]]lowering medication}}
{{familytree | |!| | | | |!| | | | |,|-|^|-|.| | |!| | | | | | | | |}}
{{familytree | |D01| | | D02 | | | D03 | | D04 | |!| | | | | | D01=Reevaulation in 1 year (class 2a)|D02=Reevaulation in 3-6 months(class 1)|D03=Nonpharmocological therapy(class1)|D04=Non pharmacological therapy and [[BP]]lowering medication}}
{{familytree | | | | | | | | | | | |!| | | |!| | |!| | | | |}}
{{familytree | | | | | | | | | | | E01 | | E02 |-|'| | | E01=Reevaulation in 3-6 months(class 1)|E02=Reevaulation in 1 months(class 1)}}
{{familytree | | | | | | | | | | | | | | | |!| | | | |}}
{{familytree | | | | | | | | | | | | | | | F01 | | | | F01= [[BP]]goal reached|}}
{{familytree | | | | | | | | | | | | | |,|-|^|-|.| | | | | | | | |}}
{{familytree | | | | | | | | | | | | |G01| | |G02| |G01=NO, Evaluation and optimization the adherence to medical therapy|G02=Yes,Reevaulation in 3-6 months(class 1)}}
{{familytree | | | | | | | | | | | | |!| | | | | | |}}
{{familytree | | | | | | | | | | | | |H01| | | | | | |H01=Intensification of medical therapy}}
{{familytree/end}}
 
 
 
 
 
{| border="1"
! style="background:#efefef;" | First line of treatment
! style="background:#efefef;" | Drug_ Dosage(mg/day)_ Frequency
! style="background:#efefef;" | Comments
|-
| [[Thiazide]] or [[thiazidetype]] [[diuretics]]
| align="center" |
{| border="2"
|-
|[[Chlorthalidone]]||12.5–25||1
|-
| [[Hydrochlorothiazide]]||25–50||1
|-
| [[Indapamide]]||1.25–2.5||1
|-
|[[Metolazone]]||2.5–5||1
|-
|}
| valign="bottom" |
*[[Chlorthalidone]] is a prolonged half-life drug and reduces cardiovascular risk
*[[Hyponatremia]], [[ hypokalemia]], [[uric acid]] and [[calcium]] levels should be monitored
|-
| [[ACE inhibitors]]
| align="center" |
{| border="2"
|-
|[[Benazepril]]||10–40||1-2
|-
| [[Captopril]]||12.2-150||2-3
|-
| [[Enalapril]]||5-40||1-2
|-
|[[Fosinopril]]||10–40||1
|-
|[[Lisinopril]]||10-40||1
|-
|[[Moexipril]]||7.5–30||1-2
|-
|[[Perindopril]]||4-16||1
|-
|[[Quinapril]]||10-80||1-2
|-
|[[Ramipril]]||2.5-20||1-2
|-
|[[Trandolapril]]||1-4||1
|-
|}
| valign="bottom" |
*Avoidance of using in combination with [[ARB]] and direct renin inhibitor
* Using with caution in [[CKD]] or in patients are on [[K ]] sparing agents due to the risk of [[hyperkalemia]]
* Avoidance in [[pregnancy]]
* Avoidance in patients with a history of [[angioedema]] with [[ACEI]]
*Avoidance in severe bilateral [[renal artery stenosis]]
|-
| [[ARB]]
| align="center" |
{| border="2"
|-
|[[Azilsartan]]||40-80||1
|-
| [[Candesartan]]||8–32||1
|-
| [[Eprosartan]]||600-800||1-2
|-
|[[Irbesartan]]||150-300||1
|-
|[[Losartan]]||50-100||1-2
|-
|[[Olmesartan]]||20-40||1
|-
|[[Telmisartan]]||20-80||1
|-
|[[Valsartan]]||80-320||1
|-
|}
| valign="bottom" |
* Avoidance of using in combination with [[ACEI]] or [[direct renin inhibitor]]
* Using with caution in [[CKD]] or in  patients are on [[K]] sparing drugs due to the risk of [[hyperkalemia]]
* Avoidance in [[pregnancy]]
* Avoidance in patients with a history of [[angioedema]] with [[ARB]]
* It can be used in patients with a history of [[angioedema]] with [[ACEI]] after 6 weeks of discontinuation of [[ACEI]]
*Avoidance in severe bilateral [[renal artery stenosis]]
 
 
|-
|[[CCB]]—[[dihydropyridines]]
| align="center" |
{| border="2"
|-
|[[Amlodipine]]|| 2.5–10 ||1
|-
| [[Felodipine]]|| 2.5–10 ||1
|-
| [[Isradipine]]|| 5–10 ||2
|-
|[[Nicardipine SR]] ||60–120|| 2
|-
|[[Nifedipine LA]]|| 30–90 ||1
|-
|[[Nisoldipine]]|| 17–34 ||1
|-
|}
| valign="bottom" |
* Avoidance of using in [[heart failure reduced EF]] except [[amlodipine]],[[felodipine]]
* Pedal edema is dose associated, more common in [[women]]
|-
| [[CCB—nondihydropyridines]]
| align="center" |
{| border="2"
|-
|[[Diltiazem ER ]]||120–360 ||1
|-
| [[Verapamil IR]] ||120–360 ||3
|-
| [[Verapamil SR]]|| 120–360 ||1-2
|-
|[[Verapamil]]-delayed onset ER ||100–300 ||1 (in the evening)
|-
|}
| valign="bottom" |
*Avoidance of using in combination with [[betablocker]] due to the risk of [[bradycardia]]
* Avoidance of using in [[heart failure reduced EF]]
* Avoidance of using [[diltiazem ]]with [[verapamil]] due to drug interaction via [[CYP3A4]]
|-
!  style="background:#efefef;" | Second line of treatment
!  style="background:#efefef;" | Drug_ Dosage(mg/day)_ Frequency
!  style="background:#efefef;" | Comments
|-
| [[Diuretics—loop]]
| align="center" |
{| border="2"
|-
|[[Bumetanide]] ||0.5–2|| 2
|-
| [[Furosemide]] ||20–80 ||2
|-
| [[Torsemide]] ||5–10|| 1
|-
|}
| valign="bottom" |
* Preferred [[diuretic]] in symptomatic [[heart failure]]
* Preffered [[diuretic]] in moderate to severe CKD (GFR<30 cc/min)
|-
| [[Diuretics—potassium sparing]]
| align="center" |
{| border="2"
|-
|[[Amiloride]]|| 5–10|| 1-2
|-
| [[Triamterene]]|| 50–100 ||1-2
|-
|}
| valign="bottom" |
*Mild [[antihypertensive]] effect
* Useful for treatment of [[hypokalemia]] due to [[thiazide]] monotherapy
*Avoidance of using in patients with significant [[CKD]] (GFR <45 mL/min).
|-
| [[Diuretics—aldosterone antagonists]]
| align="center" |
{| border="2"
|-
|[[Eplerenone]]|| 50–100|| 1-2
|-
| [[Spironolactone]] ||25–100|| 1
|-
|}
| valign="bottom" |
* Preferred for primary [[aldostronism]] and [[resistant hypertension]]
* Add-on therapy in [[resistant hypertension]]
* Lesser  risk of [[gyncomasty]]  and [[impotence]] with [[eplerenone]]
* Avoidance of combination therapy with [[K sparing agents]]
|-
| [[Betablocker]]-[[cardioselective]]
| align="center" |
{| border="2"
|-
|[[Atenolol]] ||25–100|| 2
|-
| [[Betaxolol]] ||5–20|| 1
|-
|[[Bisoprolol]] ||2.5–10 ||1
|-
|[[Metoprolol tartrate]]|| 100–200 ||2
|-
|[[Metoprolol succinate]]|| 50–200|| 1
|}
| valign="bottom" |
* [[Beta-blocker]]s are not first-line therapy of hypertension unless in the presence of [[IHD]] or[[heart failure]]
* Preferred[[ beta-blocker]]s in [[bronchospastic airway disease]]
*  preferred [[Bisoprolol]], [[metoprolol succinate]] in [[heart failure reduced EF]]
|-
| [[Betablocker-cardioselective and vasodilatory]]
| align="center" |
{| border="2"
|-
|[[Nebivolol]] ||5–40 ||1
|}
| valign="bottom" |
* Induction of [[nitric oxide]]
* [[Vasodilarory effect]]
|-
| [[Beta blockers—noncardioselective]]
| align="center" |
{| border="2"
|-
|[[Nadolol]]|| 40–120 ||1
|-
| [[Propranolol]] IR ||80–160|| 2
|-
| [[Propranolol]] LA ||80–160|| 1
|-
|}
| valign="bottom" | Not recommended, especially in [[IHD]] or [[heart failure]]
|-
| [[Beta blockers—intrinsic sympathomimetic activity]]
| align="center" |
{| border="2"
|-
|[[Acebutolol]]|| 200–800|| 2
|-
|[[Penbutolol]] ||10–40|| 1
|-
| [[Pindolol]]|| 10–60|| 2
|-
|}
| valign="bottom" |Not recommended , especially in [[IHD]] or [[heart failure]]
|-
| [[Beta blockers—combined alpha-beta receptor]]
| align="center" |
{| border="2"
|-
|[[Carvedilol]] ||12.5–50|| 2
|-
|[[Carvedilol phosphate]]|| 20–80|| 1
|-
| [[Labetalol]]|| 200–800|| 2
|-
|}
| valign="bottom" | [[Carvedilol]] is preferred in  [[heart failure reduced EF]]
|-
| [[Direct renin inhibitor]]
| align="center" |
{| border="2"
|-
|[[Aliskiren]]|| 150–300|| 1
|-
|}
| valign="bottom" |
*Avoidance of using in combination with [[ARB]] or [[ACEI]]
* Using with caution in [[CKD]] or patients are on [[ K]] sparing agents due to the risk of [[hyperkalemia]]
* Avoidance in [[pregnancy]]
*Avoidance in severe bilateral [[renal artery stenosis]]
|-
| [[Alpha-1 blockers]]
| align="center" |
{| border="2"
|-
|[[Doxazosin]]|| 1–16 || 1
|-
|[[Prazosin]]|| 2–20 || 2-3
|-
|[[Terazosin]]|| 1–20 || 1-2
|-
|}
| valign="bottom" |
* Side-effect is [[orthostasis hypotension]], especially in old patients
* Seconde line of treatment, preferred in [[BPH]] and [[hypertension]]
|-
| [[Central alpha2-agonist and other centrally acting drugs]]
| align="center" |
{| border="2"
|-
|[[Clonidine]] oral ||0.1–0.8|| 2
|-
|[[Clonidine]] patch ||0.1–0.3|| 1 weekly
|-
|[[Methyldopa]]|| 250–1000|| 2
|-
|[[Guanfacine]] || 0.5–2|| 1
|-
|}
| valign="bottom" |
* Last line of treatment due to [[CNS]] adverse effect on elderly patients
* Avoidance of abrupt discontinuation of [[clonidine]] because of [[rebound hypertension]]
|-
| [[Direct vasodilators]]
| align="center" |
{| border="2"
|-
|[[Hydralazine]] ||100–200 ||2-3
|-
|[[Minoxidil]] ||5–100|| 1-3
|-
|}
| valign="bottom" |
* Recommended to use with [[betablocker]] and [[diuretic]] due to [[sodium]] and [[water]] retention and [[reflex tachycardia]]
* Side effect of [[hydralazine]] is [[drug]]-induced [[lupus]]-like syndrome at higher doses
* Side effect of [[minoxidil] is [[hirsotism]],[[pericardial effusion]]
|}
 
 
 
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[AHA guidelines classification scheme#Classification of Recommendations|Class I, Level of evidence:A]]
|-
|bgcolor="LemonChiffon"|In patients with [[atherosclerotic]] [[renal artery stenosis]], [[medical therapy]] is recommended
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[AHA guidelines classification scheme#Classification of Recommendations|Class IIb, Level of evidence:C]]
|-
|bgcolor="LemonChiffon"|Revascularization ([[percutaneous renal artery angioplasty]] and/ or stent placement) indicates in patients with refractory [[hypertension]], worsening
[[renal function]], intractable [[heart failure]], nonatherosclerotic disease ([[fibromuscular dysplasia]])
|-
|}
 
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:PaleGreen"|[[AHA guidelines classification scheme#Classification of Recommendations|Class IIb, Level of evidence:B]]
|-
|bgcolor="PaleGreen"| The effectiveness of [[continuous positive airway pressure]] ([[CPAP]]) to decrease [[blood pressure]] in patients with [[obstructive sleep apnea]] and [[hypertension]] is not verified
|-
|}
 
=== Surgery ===
*Surgery is the mainstay of therapy for [disease name].
*[Surgical procedure] in conjunction with [chemotherapy/radiation] is the most common approach to the treatment of [disease name].
*[Surgical procedure] can only be performed for patients with [disease stage] [disease name].
=== Prevention ===
*There are no primary preventive measures available for [disease name].
*Effective measures for the primary prevention of [disease name] include [measure1], [measure2], and [measure3].
 
*Once diagnosed and successfully treated, patients with [disease name] are followed-up every [duration]. Follow-up testing includes [test 1], [test 2], and [test 3].
{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' [[Recommendations for masked hypertension and white coated hypertension]] : ([[ACC AHA guidelines classification scheme|Class IIa, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑  Screening [[white coated hypertension]] in patients with [[ systolic blood pressure]] 130-160 mmHg and [[diastolic blood pressure]] 80=-110 mmHg by using  ABPM or HBPM before diagnosis of [[hypertension]]<br>
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' ([[ACC AHA guidelines classification scheme|Class IIa, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Periodic monitoring [[blood pressure]] with ABPM or HBPM  for detection of transient or sustained [[hypertension]] in [[ white coated hypertension]]
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''  ([[ACC AHA guidelines classification scheme|Class IIa, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑  Finding  [[ white coated hypertension]] by HBPM and  ABPM in high office  [[blood pressure]] inspite of receiving treatment,is recommended<br>
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''  ([[ACC AHA guidelines classification scheme|Class IIa, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑  Finding [[mask hypertension ]] by HBPM or ABPM in office [[blood pressure]] 120-129 /75-79 mmHg  <br>
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''  ([[ACC AHA guidelines classification scheme|Class IIb, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Finding [[white coated hypertension]] by HBPM or ABPM  if office [[blood pressure]] 10 mmHg higher than normal in spite of receiving multiple medications<br>
❑ Finding [[masked hypertension]]  by HBPM in patients with  end organ damage or high  cardiovascular risk but office reading [[blood pressure]] at goal <br>
❑ Finding [[masked hypertension]] by ABPM  in patients with high HBPM  inspite of receiving medications<br>
|}
 
==References==
{{Reflist|2}}
[[Category:Pick One of 28 Approved]]
 
{{WS}}
{{WH}}
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
==Overview==
Hypertension is generally defined as an elevated systolic blood pressure (SBP) ≥ 140 mmHg and/or diastolic blood pressure (DBP) ≥ 90 mmHg.  Hypertension can be chronic or acute.  While 95% of the cases of chronic hypertension  are primary, 5% of [[chronic hypertension]] is secondary to other underlying causes.  Hypertensive crisis is the acute elevation of [[blood pressure]] and it can be classified into [[hypertensive emergency]] or [[hypertensive urgency]] when end organ damage is present or absent respectively.
 
==Causes==
When a full evaluation yields no clear etiology for the elevated blood pressure:
* [[chronic hypertension|Primary hypertension]], also called essential hypertension.
 
Secondary hypertension can be caused by:
*[[Apnea]]
*[[Hyperaldosteronism]]
*[[Renal failure]]
*[[Coarctation of aorta]]
*[[Cushing's syndrome]]
*[[Drugs]]
*[[Diet]]
*[[Pheochromocytoma]]
*[[Obesity]]
*[[Hyperparathyroidism]]
 
For detailed causes of secondary hypertension, click ''' [[Chronic hypertension causes#Causes in Alphabetical Order|here]]'''.
 
==Classification==
For more details about each specific type of hypertension, click on the links in blue in the algorithm below.<br>
In order to distinguish primary hypertension from secondary hypertension, click [[chronic hypertension causes|here]].
 
{{Familytree/start}}
{{Familytree | | | | | | | A01 | | | | | | A01= '''Hypertension'''}}
{{Familytree | | | |,|-|-|-|^|-|-|-|.| | | }}
{{Familytree | | | B01 | | | | | | B02 | | | B01= '''[[Chronic hypertension]]'''
|B02=  '''[[Hypertensive crisis]]''' <br> ''Acute elevation of blood pressure''<br> - Systolic blood pressure >180 mm Hg<br> OR <br> - Diastolic blood pressure >120 mm Hg}}
{{Familytree | |,|-|^|-|.| | | |,|-|^|-|.| }}
{{Familytree | C01 | | C02 | | C03 | | C04 | |C01= '''[[Primary hypertension]]''' <br>(also known as [[essential hypertension]]) <br> (95% of the cases)| C02= '''[[Secondary hypertension]]'''<br> <br> (5% of the cases)
| C03= '''[[Hypertensive emergency]]''' <br>
Evidence of end organ damage
| C04= '''[[Hypertensive urgency]]'''<br>
No evidence of end organ damage }}
{{Familytree/end}}
 
==Screening==
The age to begin screening for hypertension varies between 13-20 years of age, according to different authorities. Generally, hypertension is defined as SBP > 140 mmHg and/or DBP > 90 mmHg. In specific populations, however, routine follow-up target BP may be different; and initiation of treatment may be considered at even lower BP values than those considered for the normal population.

Revision as of 12:13, 13 December 2020

Hypertension Main page

Overview

Causes

Classification

Primary Hypertension
Secondary Hypertension
Hypertensive Emergency
Hypertensive Urgency

Screening

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Usama Talib, BSc, MD [2]

Overview

Hypertension is a major risk factor for cardiovascular disease and is a major public health problem. The prevalence of hypertension increased among the united states patients due to changing The previous cut-off 140/90 mmHg.

Historical Perspective

  • [Disease name] was first discovered by [scientist name], a [nationality + occupation], in [year] during/following [event].
  • In [year], [gene] mutations were first identified in the pathogenesis of [disease name].
  • In [year], the first [discovery] was developed by [scientist] to treat/diagnose [disease name].

Classification

Hypertension may be classified according to the underlying disorder into two groups:


Hypertension Guidline ACC/AHA ESC/ESH
Definition of hypertension (mmHg) ≥130/80 ≥140/90
Normal blood pressure range (mmHg)
  • Normal: <120/80
  • Elevated:120-129/<80
  • Optimal:<120/80
  • Normal:120-129/80-84
  • High normal:130-139/85-89
Hypertension stage (mmHg)
  • Stage1:130-139/80-89
  • Stage2: ≥140/90
  • Grade1:140-159/90-99
  • Grade2:160-179/100-109
  • Grade3: ≥180/110
Age specific blood pressure targets(9mmHg)
  • <65 years:<130/80
  • ≥65 years:<130/80
  • <65years:<120-129/70-79
  • >65 years:<130-139/70-79
Blood pressure category Systolic blood pressure Diastolic blood pressure
Normal <120/80 mmHg <80 mmHg
Elevated 120-129 mmHg <80 mmHg
Stage 1 hypertension 130–139 mm Hg 80–89 mm Hg
Stage 2 hypertension ≥140 mm Hg ≥90 mm Hg

Pathophysiology

  • The pathogenesis of [disease name] is characterized by [feature1], [feature2], and [feature3].
  • The [gene name] gene/Mutation in [gene name] has been associated with the development of [disease name], involving the [molecular pathway] pathway.
  • On gross pathology, [feature1], [feature2], and [feature3] are characteristic findings of [disease name].
  • On microscopic histopathological analysis, [feature1], [feature2], and [feature3] are characteristic findings of [disease name].

Causes

Common causes of hypertension include:

Environmental exposure

  • Inverse relation with BP
  • Inverse relation with stroke
  • Higher level of [[potassium] may reduce the effect of sodium on BP


Pharmacological causes of hypertension

Management:

  • Alcohol
  • Limiting alcohol to ≤1 drink daily for women and ≤2 drinks for men
  • Discontinue or decrease dose
  • Behavior therapy for ADHD
  • Avoid use
  • Avoide use
  • Using alternative agents ( inhaled, topical)

Differentiating [disease name] from other Diseases

  • [Disease name] must be differentiated from other diseases that cause [clinical feature 1], [clinical feature 2], and [clinical feature 3], such as:
  • [Differential dx1]
  • [Differential dx2]
  • [Differential dx3]

Epidemiology and Demographics

  • The prevalence of [disease name] is approximately [number or range] per 100,000 individuals worldwide.
  • In [year], the incidence of [disease name] was estimated to be [number or range] cases per 100,000 individuals in [location].

Age

  • Patients of all age groups may develop [disease name].
  • [Disease name] is more commonly observed among patients aged [age range] years old.
  • [Disease name] is more commonly observed among [elderly patients/young patients/children].

Gender

  • [Disease name] affects men and women equally.
  • [Gender 1] are more commonly affected with [disease name] than [gender 2].
  • The [gender 1] to [Gender 2] ratio is approximately [number > 1] to 1.

Race

  • There is no racial predilection for [disease name].
  • [Disease name] usually affects individuals of the [race 1] race.
  • [Race 2] individuals are less likely to develop [disease name].

Risk Factors


Modifiable risk factors Fixed risk factors
Current smoker, secondhand smoking Chronic kidney disease
Diabetes mellitus Family history
Dyslipidemia/hypercholesterolemia Increased age
Obesity Low socioeconomic/educational status
Physical inactivity/low fitness Male sex
Unhealthy diet

Natural History, Complications and Prognosis

  • The majority of patients with [disease name] remain asymptomatic for [duration/years].
  • Early clinical features include [manifestation 1], [manifestation 2], and [manifestation 3].
  • If left untreated, [#%] of patients with [disease name] may progress to develop [manifestation 1], [manifestation 2], and [manifestation 3].
  • Common complications of [disease name] include [complication 1], [complication 2], and [complication 3].
  • Prognosis is generally [excellent/good/poor], and the [1/5/10­year mortality/survival rate] of patients with [disease name] is approximately [#%].
 
 
 
 
 
 
 
 
 
New onset or uncontrolled hypertension in adult
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
* Drug resistance hypertension
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Screening for secondary hypertension
 
 
 
 
 
 
 
 
 
 
 
 
No need for screening



Conditions Clinical features
Renal parenchymal disease
Renovascular disease
Primary aldosteronism
Obstructive sleep apnea
Drug or alcohol induced
Pheochromocytoma/paraganglioma
 Cushing syndrome
 Hypothyroidism
 Hypethyroidism
 Coarctation of aorta Hypertension before 30 years old
 Primary hyperparathyroidism Hypercalcemia
 Congenital adrenal hyperplasia
  Mineralocorticoid excess syndromes other than primary aldosteronism
 Acromegaly

Diagnosis

Diagnostic Criteria

  • The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met:
  • [criterion 1]
  • [criterion 2]
  • [criterion 3]
  • [criterion 4]
Blood pressure measurement Definition
Systolic blood pressure (SBP) First Korotkoff sound
Diastolic blood pressure(DBP) Fifth Korotkoff sound
Pulse pressure SBP minus DBP
Mean arterial pressure DBP plus one third pulse pressure
Mid- blood pressure (SBP+DBP) divided by 2


Key steps for accurate blood pressure measurement Educations
Properly prepare the patient
  • Have the patient relax, sitting on a chair, feet on the floor, back supported for more than 5 minutes
  • Avoidance of coffeine, smoking, exercise for at least 30 minutes before measurement
  • Emptying bladder before measurement
  • No talk during measurement
  • Removing all clothing covered the cuff location
Using proper technique cuff size 80 % of arm
Taking proper measurement
  • Recording blood pressure in both arms at the first visit
  • Using the arm with higher blood pressure for the latter measurement
  • 1-2 minutes between two measurements
  • Cuff inflation 20-30 mmHg above the palpable radial pulse and deflation with the speed of 2 mmHg/seconds
Documentation of reading blood pressure [[ Systolic blood pressure] is the onset of the first Korotkoff sound and [[diastolic blood pressure] is the disappearance of all Korotkoff sounds
Average the reading using ≥2 readings obtained on ≥2 occasions for determination the level of blood pressure
Providing blood pressure reading to patient Providing patients the SBP/DBP readings both verbally and in writing


Arm circumference cuff size
22-26 cm Small adult
27-34 cm Adult
35-44 cm Large adult
45-52 cm Adult thigh





 
 
 
Office BP≥130/80 mm Hg, but < 160/100 mmHg after 3 months of life style modification, suspected white coat hypertension
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Daytime ABPM or HBPM, BP<130/80 mmHg
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
NO
  • Hypertension
  • Life style modification and starting antihypertensive drug therapy (class 2a)


    •  
     
     
    		Office BP: 120-129/<80 mmHg after 3 months of lifestyle modification, suspected masked hypertension
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    		Daytime ABPM or HBPM, BP≥130/80 mm Hg
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Yes
     
     
     
    		NO
  • Elevated BP
  • Lifestyle modification
  • Annual ABPM or HBPM (class2a)


    • 2017 ACC/AHA Guideline

    Screening for Primary adlostronism:

    • Class of recommendation:I
    • Level of evidence:C
    1. ↑ Carey, Robert M.; Calhoun, David A.; Bakris, George L.; Brook, Robert D.; Daugherty, Stacie L.; Dennison-Himmelfarb, Cheryl R.; Egan, Brent M.; Flack, John M.; Gidding, Samuel S.; Judd, Eric; Lackland, Daniel T.; Laffer, Cheryl L.; Newton-Cheh, Christopher; Smith, Steven M.; Taler, Sandra J.; Textor, Stephen C.; Turan, Tanya N.; White, William B. (2018). "Resistant Hypertension: Detection, Evaluation, and Management: A Scientific Statement From the American Heart Association". Hypertension. 72 (5). doi:10.1161/HYP.0000000000000084. ISSN 0194-911X.
    Retrieved from "https://www.wikidoc.org/index.php?title=Hypertension&oldid=1678423"