Hypertension

Source: Saseen JJ, MacLaughlin EJ. Hypertension. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, eds. Pharmacotherapy: A Pathophysiologic Approach. 8th ed. http://accesspharmacy.com/content.aspx?aid=7969921. Accessed June 29, 2012.

• High blood pressure

• Persistently elevated arterial blood pressure (BP).

• Primary (essential) hypertension: unknown cause.
• Secondary hypertension
  • Chronic kidney disease (CKD) or renovascular disease
  • Cushing’s syndrome
  • Coarctation of aorta
  • Obstructive sleep apnea
  • Hyperparathyroidism
  • Pheochromocytoma
  • Primary aldosteronism
  • Drugs, including:
    • Corticosteroids
    • Estrogens
    • Nonsteroidal anti-inflammatory drugs (NSAIDs)
    • Amphetamines
    • Sibutramine
    • Cyclosporine
    • Tacrolimus
    • Erythropoietin
    • Venlafaxine

• Abnormalities involving renin–angiotensin–aldosterone system, natriuretic hormone, or insulin resistance.
• Disturbance in the central nervous system (CNS), autonomic nerve fibers, adrenergic receptors, or baroreceptors.
• Abnormalities in renal or tissue autoregulatory processes for:
  • Sodium excretion
  • Plasma volume
  • Arteriolar constriction
• Deficiency in synthesis of vasodilators in vascular endothelium (prostacyclin, bradykinin, nitric oxide) or excess vasoconstrictors (angiotensin II, endothelin I).
• High sodium intake or lack of dietary calcium.

• Approximately 31% of Americans (74.5 million people) have elevated BP.
• Overall incidence is similar between men and women, but varies depending on age.
• Prevalence rates are highest in non-Hispanic blacks, followed by non-Hispanic whites, Mexican Americans, American Indians/Alaska Natives, and Asians.
• Most diagnoses occurring between third and fifth decades.

• Increase physical activity.
• Limit alcohol consumption.
• Limit sodium intake.
• Consume diet rich in fruits, vegetables, and low-fat dairy products.

• Increasing age
• Race
• Family history
• Obesity
• Physical inactivity
• Smoking
• Excessive sodium or inadequate potassium intake
• Excessive alcohol consumption
• Chronic conditions (e.g., kidney disease)

Signs and Symptoms

• Symptoms
  • Uncomplicated primary hypertension usually asymptomatic initially.
  • Patients with pheochromocytoma may have:
    • Headaches
    • Sweating
    • Tachycardia
    • Palpitations
    • Orthostatic hypotension
  • In primary aldosteronism, hypokalemic symptoms of muscle cramps and weakness may be present.
  • Patients with Cushing’s syndrome may complain of:
    • Weight gain
    • Polyuria
    • Edema
    • Menstrual irregularities
    • Acne
    • Muscular weakness
    • Moon face
    • Buffalo hump
    • Hirsutism
• Signs
  • Funduscopic exam:
    • Arteriolar narrowing
    • Arteriovenous nicking
    • Retinal hemorrhages and exudates
    • Papilledema
  • Heart:
    • Abnormal rate or rhythm
    • Left ventricular (LV) hypertrophy
    • Coronary heart disease
    • Heart failure (HF)
  • Peripheral vascular:
    • Aortic or abdominal bruits
    • Distended veins
    • Diminished or absent peripheral pulses
    • Lower-extremity edema

Means of Confirmation and Diagnosis

• Diagnosis based on average of ≥2 readings taken at each of ≥2 visits (Table 1).

Laboratory Tests

• First-line tests:
  • Blood urea nitrogen (BUN)/serum creatinine
  • Fasting lipid panel
  • Fasting blood glucose
  • Serum electrolytes
  • Spot urine albumin-to-creatinine ratio
  • Estimated glomerular filtration rate
  • Urinalysis
• For secondary hypertension:
  • Plasma norepinephrine and urinary metanephrine levels
  • Plasma and urinary aldosterone concentrations
  • Plasma renin activity
  ...