Hypertension

Question 1

What is hypertension, and how is it classified in adults?

Answer 1

Definition: A chronic condition of elevated arterial blood pressure (BP), often asymptomatic (“silent killer”).

Classification (≥18 years):
· Normal: <120/<80 mm Hg
· Prehypertension: 120–139/80–89 mm Hg
· Stage 1: 140–159/90–99 mm Hg
· Stage 2: ≥160/≥100 mm Hg
· Diagnosis requires average of ≥2 readings from ≥2 visits.

Question 2

What are the two main categories of hypertension?

Answer 2

1. Essential (Primary) Hypertension:
   · 90% of cases.
   · No identifiable cause; multifactorial (genetics, sodium balance, RAAS).
2. Secondary Hypertension:
   · <10% of cases.
   · Caused by identifiable conditions or drugs:
   · Renal disease (CKD, renal artery stenosis)
   · Endocrine disorders (pheochromocytoma, hyperaldosteronism, Cushing’s)
   · Drugs (NSAIDs, stimulants, alcohol, corticosteroids)
   · Coarctation of the aorta.

Question 3

What are the key pathophysiologic mechanisms in hypertension?

Answer 3

BP = Cardiac Output × Total Peripheral Resistance

· Increased Cardiac Output:
· ↑ Preload (Na retention, volume overload)
· Venous/arterial constriction (RAAS, sympathetic overactivity)

· Increased Peripheral Resistance:
· Vascular hypertrophy/remodeling
· Endothelial dysfunction (↓ NO, ↑ endothelin)

· RAAS Dysregulation: Major regulator of Na, volume, vascular tone.

· Neuronal & Humoral Factors: Sympathetic overactivity, natriuretic hormone imbalance, hyperinsulinemia.

Question 4

What are the major risk factors for hypertension?

Answer 4

· Age (≥55 men, ≥65 women)
· Family history of premature CVD
· Overweight/Obesity (BMI ≥27)
· Physical inactivity
· Tobacco use
· Diabetes
· Dyslipidemia
· High sodium intake
· Excessive alcohol
· Chronic stress
· Non-modifiable: Genetics, age, ethnicity (higher in African Americans).

Question 5

What are the major complications of untreated hypertension?

Answer 5

· Cardiac: LVH, angina/MI, heart failure, arrhythmias.
· Cerebrovascular: Stroke, TIA, dementia.
· Renal: CKD, nephrosclerosis, proteinuria, ESRD.
· Vascular: PAD, aortic aneurysm, atherosclerosis.
· Ocular: Retinopathy (arteriolar narrowing, hemorrhages, papilledema).
· Accelerated atherosclerosis in all vascular beds.

Question 6

What are the BP treatment goals in hypertension?

Answer 6

· Most patients (including diabetes/CKD): <140/90 mm Hg
· Frail elderly at high risk: <150/90 mm Hg
· Optional lower goals (if achievable):
· Some with diabetes or CKD + albuminuria: <130/80 mm Hg
· Some high-CV-risk patients without diabetes: SBP <120 mm Hg
· Overall goal: Reduce CV morbidity/mortality.

Question 7

What lifestyle modifications are recommended for hypertension?

Answer 7

· Weight loss (5–10% of body weight)
· DASH diet: Rich in fruits/vegetables, low saturated fat.
· Sodium restriction: <2.4 g/day (further reduction beneficial).
· Moderate alcohol: ≤1 drink/day (women), ≤2/day (men).
· Regular aerobic exercise (≥150 min/week moderate).
· Smoking cessation.
· Stress management.

-Used for all patients, but not a substitute for drugs in established hypertension.

Question 8

What are the first-line drug classes for hypertension?

Answer 8

ACEs / ARBs / CCBs / Thiazides

· ACEIs: lisinopril, enalapril
· ARBs: losartan, valsartan
· CCBs (dihydropyridine): amlodipine, nifedipine
· Thiazide diuretics: hydrochlorothiazide, chlorthalidone
· Combination therapy preferred for Stage 2 HTN (e.g., ACEI/ARB + CCB or thiazide).

Question 9

When are specific antihypertensive classes preferred?

Answer 9

· Heart failure: ACEI/ARB, β-blocker, diuretic, aldosterone antagonist
· Post-MI: β-blocker, ACEI, aldosterone antagonist
· High CVD risk: ACEI, CCB
· Diabetes: ACEI/ARB (renal protection)
· CKD: ACEI/ARB (reduce proteinuria)
· Recurrent stroke prevention: ACEI + thiazide

Question 10

What are alternative or add-on antihypertensive drugs?

Answer 10

· β-blockers: metoprolol, atenolol (not first-line unless compelling indication)
· Loop diuretics: furosemide (in HF or advanced CKD)
· Aldosterone antagonists: spironolactone (resistant HTN, HF)
· α-blockers: doxazosin (BPH, adjunct)
· Centrally acting: clonidine (resistant HTN)
· Vasodilators: hydralazine (use limited by side effects)

Question 11

What is the stepwise management approach for hypertension?

Answer 11

1. Confirm diagnosis (≥2 visits, proper measurement).
2. Assess CV risk, complications, secondary causes.
3. Start lifestyle modifications for all.
4. Stage 1 HTN: Start monotherapy or 2-drug combo (if high risk).
5. Stage 2 HTN: Start 2-drug combo (usually ACEI/ARB + CCB/thiazide).
6. Titrate/add drugs every 2–4 weeks until goal BP.
7. Consider ABPM/home monitoring for white coat/masked HTN.
8. Avoid clinical inertia—intensify regimen if uncontrolled.

Question 12

List major antihypertensive drug classes with examples.

Answer 12

· ACEIs: lisinopril, enalapril, ramipril
· ARBs: losartan, valsartan, irbesartan
· CCBs: amlodipine, nifedipine, diltiazem
· Thiazides: HCTZ, chlorthalidone
· β-blockers: metoprolol, atenolol, carvedilol
· Loop diuretics: furosemide, bumetanide
· Aldosterone antagonists: spironolactone, eplerenone
· α-blockers: doxazosin, prazosin
· Centrally acting: clonidine, methyldopa
· Vasodilators: hydralazine, minoxidil

Question 13

What should be monitored in hypertensive patients?

Answer 13

· BP: Clinic, home, or ABPM. Watch for white coat/masked HTN.
· Renal function: Serum Cr, eGFR, urine albumin-to-creatinine ratio.
· Electrolytes: Na, K (especially on diuretics, ACEIs/ARBs).
· Glucose & lipids: Fasting blood glucose, lipid panel.
· ECG: For LVH, ischemic changes.
· Symptoms: Hypotension, edema, cough (ACEI), hyperkalemia.
· Adherence & side effects.
· Target organ damage: Eye exam, cardiac echo if indicated.