HYPERTENSION CHEAT SHEET A chronic disease of elevated arterial pressure- a measurement of how hard the heart has to work. “Primary” hypertension accounts for 95% of hypertension –mechanism is not understood.

Systolic – arterial pressure when heart contracts | Diastolic – arterial pressure when heart relaxes

How to take an ideal blood pressure- No nicotine/caffeine for 30 minutes- Patient should be sitting for 5 minutes

- Free of restrictive clothing- Appropriate cuff size

Other factors that BP: full bladder, unsupported back/feet, crossed legs, cuff over clothing, unsupported arm, conversation.

Risk factors for hypertension- Ethnicity (Black) - Family history

- Excess sodium intake- Sedentary lifestyle

- Obesity- High cholesterol

Classification and Treatment GuidelinesClassification of HTN is based on the average of 2 or more properly measured readings after an initial BP screening. Treatment is then based on the classification.

Hypertension Stage BP Reading TreatmentSystolic Diastolic

Normal < 120 < 80 No treatment.Pre-HTN 120-139 80-89 Lifestyle Modification

Stage 1 140-159 90-99Add 1 anti-HTN medication + lifestyle modifications

Stage 2 160-200 100+Start 2 anti-hypertension medications + lifestyle modification

Hypertensive emergency 200+ with symptoms Call ER (labetalol, nitroprusside)*If patients remain hypertensive, resistant to multiple oral treatments, consider secondary causes of HTN

Questions to AskElevated pressures, over time, wear down organs that have smaller vasculature e.g. eyes & kidneysThe heart is also forced to work harder and can therefore become overworked, leading to heart failure.Some of the primary concerns of chronic HTN are stroke, heart attack, retinopathy, nephropathy

Vision changes Chest pain

Shortness of breath Headache

Physical Exam Findings AV nicking on eye exam Displaced PMI (point of maximal impact) Carotid bruit (if atherosclerosis)

Peripheral edema Pulmonary edema (if heart failure)

Secondary causes of hypertension Cushing’s disease

(hypercortisolism) Hyperthyroidism Renal artery stenosis

Pheochromocytoma Aortic coarctation Conn’s syndrome

(hyperaldosteronism)

“White coat hypertension” Oral Contraceptive Pills Sympathomimetics (e.g

decongestants)

Revised 8/17/14. Email justin.berk@ttuhsc.edu with any feedback.

Laboratory / DiagnosticsInitial: CBC, CMP, TSH, urinalysis, microalbumin, EKG

EKG Findings: LVH, past MIFollow-up: BMP (bi-annually)

TREATMENTPHARMACOTHERAPY - FIRST LINE MEDS: diuretics, ACEI/ARBs, CCBs

Class Example Mechanism Notes

ACE-Inhibitor LisinoprilBlock Angiotensin converting enzyme

Dry cough, angioedema (2/2 inhibition of bradykinin). Cr , K+

Angiotensin 2 receptor blockers (ARBs)

Losartan Blocks AT2 receptors K+

Renin is secreted by kidneys when they perceive hypoperfusion. Renin stimulates AT1 which is converted to AT2 by ACE in the lung. AT2 is a vasoconstrictor and stimulates formation of aldosterone (which increases BP through sodium retention).

Calcium Channel Blocker (CCB)*

NifedipineBlocks smooth muscle vasoconstriction

Edema

Thiazide DiureticHydrochlorothiazide (HCTZ)

Increases natriuresisGood in AA population – salt sensitive. Lose K.

Beta Blockers** Atenolol, MetoprololMAP = CO x TPRDecrease CO via HR and inotropy

Can mask hypoglycemia

Alpha antagonists DoxasozinBlock a1 receptors which vasoconstrict

Used for co-morbid BPH

Others: hydralazine, nitroprusside, methyldopa, clonidine*Heart selective vs. vessel selective: Dihydropyridines (Amlodipine, Nifedipine) work preferentially on the vessels. (Thus, they can cause rebound tachycardia.) Non-dihydropyridines (Verapamil, Diltiazem) work preferentially on the myocardium of the heart**Selective vs. non-selective: e.g carvedilol (non-selective alpha and beta blockade)

Revised 8/17/14. Email justin.berk@ttuhsc.edu with any feedback.

LIFESTYLE MODIFICATION: DASH Diet: Rich in fruits, vegetables, low-fat. Limit carbs. Eat whole grains.Exercise: 40 minutes a day. Can include 3 bouts of 10 minutes walkingSmoking cessation: Reduces CVD risk associated with HTN. Consider pharmacotherapy.Reduce salt intake: Choose “no salt added” foods, do not add salt.Increase potassium intake: through fruits and nuts (only if renal function is normal)Limit alcohol to 1 drink (women) or 2 drinks (men) per dayMaintain normal weight: Every 1% weight loss can decrease BP by 1mmHg.Stress reduction / Good sleep: Consider yoga, meditation, prayer. Encourage good sleep habits.