Hypertension (Essential/Primary)
Evaluation
General—essential/primary hypertension is idiopathic and a risk factor for cardiovascular disease.
Epidemiology—25% of adults in the United States have hypertension (” class=LK href=”javascript:void(0)” target=right xpath=”/CT{06b9ee1beed59419a81e5e1e1a4f60b0cc8cd1057525de73425b2b43f4df7f1b5f5104f2480c94b2f4023254e02c7b4f}/ID(AB1-M10)”>>140/90 mm Hg).
Risk assessment—risk for cardiovascular disease in hypertensive patients is determined by the following factors:
Level of blood pressure (classification as per Seventh Report of the Joint National Committee) (see Table 2.36.1)
Major risk factors
Smoking
Diabetes mellitus (DM)
Hyperlipidemia
Age older than 60 years
Sex (men and postmenopausal women)
Family history of cardiovascular disease (men younger than 55 years, women younger than 65 years)
Target organ damage
Heart disease (left ventricular hypertrophy, angina, myocardial infarction [MI], congestive heart failure [CHF])
Cerebrovascular disease (stroke, transient ischemic attack)
Peripheral arterial disease
Nephropathy
Retinopathy
Diagnostic algorithm
Routine laboratory tests—urinalysis, complete blood counts (CBC), Chem-7, fasting blood sugar, lipid profile, and electrocardiogram (EKG)
Lifestyle modification and medication considerations
BP 130 to 139/85 to 89
Stage 1 hypertension
No risk factors or target organ disease—modify lifestyle × 1 year, then medications if BP is still ≥140/90
More than one risk factor; no target organ disease—modify lifestyle × 6 months, then medications if BP is still ≥140/90
Target organ disease or DM—modify lifestyle and medication
Stage 2 hypertension—modify lifestyle and medication
Treatment
Lifestyle modification
Physical activity (30 minutes of aerobic exercise on most days of the week)
Weight loss (target body mass index [BMI] is 18-24.9)
Dietary Approaches to Stop Hypertension (DASH) diet
Increase fruits and vegetables, low-fat dairy products, decrease saturated and total fat
Limit alcohol use (less than two drinks/day for men, less than one drink/day for women)
Limit sodium consumption (<A onclick="get_content(event,'AB1-M12'); return false;" onmouseover="window.status=this.title; return true;" onmouseout="window.status=''; return true;" title="<2.4 g/day)
Pharmacotherapy
Diuretics
Indications
First line for uncomplicated hypertension, particularly in older African Americans
Systolic hypertension
If used as a second-line agent, diuretics can enhance effects of other agents
Contraindications
Gout (diuretics cause hyperuricemia)
Additional side effects
↓ Na
Glucose intolerance (high-dose diuretic may be unfavorable with DM.)
Hyperlipidemia (high-dose diuretic may be unfavorable with hyperlipidemia.)
Impotence (with thiazide diuretics)
Medications
β-Blockers
Indications
First line for uncomplicated hypertension, particularly in young whites
Angina and previous MI
Tachyarrhythmias (atrial tachycardia, atrial fibrillation, etc.)
Migraine headache
Contraindications
Bronchospastic disease (asthma, chronic obstructive pulmonary disease [COPD])
Second or third degree heart block
Additional side effects
Bradycardia
Heart failure (avoid in acute CHF exacerbation)
Peripheral vascular disease
↑ Triglycerides (therefore, may have an unfavorable effect on dyslipidemia)
Fatigue, insomnia, decreased exercise tolerance
Depression
Medications
