Hypertension

Definition/Etiology:

2017 ACA/AHA guidelines:

• Normal blood pressure (BP) <120/80
• Elevated BP: 120-129/<80
• Hypertension (HTN) stage I: 130-139/80-89
• Hypertension stage II: at least 140/ at least 90
• If isolated systolic HTN or diastolic HTN, go by the higher of the two.

• White coat HTN: BP high in the medical office and normal at home.
• Masked HTN: BP normal in the medical office and high at home or at work.

Risk factors:

• age, obesity, family history, excessive alcohol, high salt diet, sedentary lifestyle, Black race, kidney disease, methamphetamines, cocaine, sleep apnea.

Medications that increase BP:

• NSAIDs, pseudoephedrine, ADD meds, antipsychotics, antidepressants, steroids, oral contraceptives, Abrupt discontinuation of Clonidine.

Pathophysiology:

End organ damage:

• Kidneys–hypertensive nephrosclerosis
• Heart–left ventricular hypertrophy, troponin leak from strain, MI
• Blood vessels–atherosclerosis
• Eyes–hypertensive retinopathy

Secondary hypertension:

• Sleep apnea–secretion of stress hormones when apneic
• Renal artery stenosis–relative hypotension of kidney creates renovascular hypertension via activation of the renin-angiotensin-aldosterone-system (RAAS)
• Pheochromocytoma–secretion of norepinephrine
• Medications or withdrawal thereof (Clonidine)
• Meth/cocaine, anabolic steroid use

Clinical Presentation:

Depends on end organs, or can be asymptomatic:

• Acute coronary syndrome (chest pain)
• Aortic dissection (chest pain, back pain)
• Left ventricular dysfunction (pulmonary edema)
• Hypertensive encephalopathy (headache, confusion, nausea, vomiting)
• Hemorrhagic stroke (headache, facial asymmetry, arm drift, slurred speech–FAST)

Collaborative Management:

• Labs: CMP, Troponin, urine for microalbumin and HCG
• Rad: CXR to assess cardiomegaly, width of aorta, pulmonary edema
• 12 lead EKG: strain, MI, LVH
• If neuro changes or n/v, CT/MRI head to look for bleed
• If chest pain, Echocardiogram and/or CT angio chest to look for aortic dissection
• Accurate medication list and recreational drug assessment

Treatments in ER:

• Nitroprusside IV gtt
• Nitroglycerin IV, SL, topical
• Nicardipine IV gtt
• Fenoldopam IV gtt–maintains renal perfusion while lowering BP, dopamine-1 receptor agonist
• Labetolol IVP or gtt
• Esmolol IV gtt–fast on, fast off
• Phentolamine IVP–for pheochromocytoma

Evaluation | Patient Monitoring | Education:

• Frequent BPs (don’t lower BP too fast)
• Notify provider of new/changing symptoms and any observed apnea
• Educate re: salty foods, recreational drugs, anabolic steroids, home monitoring of BP, importance of medications

Linchpins: (Key Points)

• Kidneys are greedy
• Presentation will vary based on end organ
• Accurate med list and recreational assessment
• Be alert for changes
• Don’t lower BP too fast