Hypertension written by ChatGPT (Dr. Nehad Jaser Ahmed)

🔹 Introduction

  • Hypertension = persistent elevation of blood pressure (BP).

  • Major modifiable risk factor for cardiovascular (CV) morbidity and mortality.

  • Often called the “silent killer” because it is usually asymptomatic.

🔹 Epidemiology

  • 2017 ACC/AHA guideline lowered the threshold for hypertension to ≥130/80 mmHg.

  • Prevalence: ~46% of U.S. adults; higher in non-Hispanic Blacks.

  • Lifetime risk >90% by age 55 for normotensive individuals.

  • More common in men before age 65; in women after 74.

🔹 Etiology

  1. Primary (essential) hypertension

    • Accounts for >90% of cases.

    • Multifactorial: genetics, sodium balance, sympathetic overactivity, RAAS dysregulation.

  2. Secondary hypertension (~10%)

    • Causes: CKD, renovascular disease, endocrine disorders (Cushing’s, hyperaldosteronism, thyroid disease), obstructive sleep apnea, medications (NSAIDs, corticosteroids, contraceptives, stimulants), alcohol, illicit drugs.

🔹 Pathophysiology

  • BP = Cardiac Output × Total Peripheral Resistance.

  • Mechanisms:

    • RAAS activation → vasoconstriction, Na⁺/H₂O retention.

    • Sympathetic nervous system overactivity.

    • Endothelial dysfunction (↓ nitric oxide, ↑ endothelin).

    • Electrolyte imbalance (high sodium, low potassium/calcium).

    • Vascular remodeling & stiffness → ↑ peripheral resistance.

🔹 Classification (ACC/AHA 2017)

  • Normal: <120/<80 mmHg

  • Elevated: 120–129/<80 mmHg

  • Stage 1 HTN: 130–139 or 80–89 mmHg

  • Stage 2 HTN: ≥140 or ≥90 mmHg

  • Hypertensive crisis: >180/120 mmHg (emergency if end-organ damage present).

🔹 Clinical Presentation

  • Usually asymptomatic.

  • Detected via routine BP measurement.

  • Complications:

    • Brain: stroke, TIA, dementia

    • Heart: LVH, MI, HF

    • Kidneys: CKD, failure

    • Eyes: retinopathy

    • Vessels: PAD, atherosclerosis

🔹 Diagnosis

  • Requires ≥2 elevated BP readings on ≥2 visits.

  • Confirm with out-of-office measurements (home or ambulatory monitoring).

  • Rule out white coat or masked hypertension.

  • Evaluate for secondary causes and CV risk factors.

🔹 Management Goals

  • Target BP <130/80 mmHg for most patients.

  • Aim: reduce CV morbidity & mortality.

  • Individualized approach depending on comorbidities.

🔹 Treatment

1. Lifestyle Modifications

  • Weight loss, DASH diet, ↓ sodium, exercise, limit alcohol, smoking cessation.

  • Can reduce systolic BP by 2–20 mmHg depending on intervention.

2. Pharmacologic Therapy

  • First-line agents:

    • ACE inhibitors (ACEi)

    • ARBs

    • Calcium channel blockers (CCBs)

    • Thiazide diuretics

  • β-blockers: not first-line (except if CAD, HF, or other compelling indications).

  • Stage 1 HTN: usually 1 drug.

  • Stage 2 HTN: start 2 drugs.

  • Resistant HTN: ≥3 drugs (including diuretic).

3. Special Considerations

  • Older adults: start low doses to avoid adverse effects.

  • Specific comorbidities guide drug choice:

    • CKD → ACEi/ARB

    • HF → ACEi/ARB + β-blocker

    • Diabetes → ACEi/ARB preferred

🔹 Key Concepts

  • Hypertension is chronic, common, and treatable.

  • Early diagnosis is critical.

  • Both lifestyle and pharmacotherapy are essential for control.

  • BP control prevents stroke, MI, kidney disease, and premature death.

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