Hypertension - Dr. Nehad Jaser

 

Hypertension

Dr. Nehad Jaser

Overview

  • Hypertension is defined as persistently elevated arterial blood pressure (BP) and is a leading risk factor for cardiovascular (CV) morbidity and mortality.
  • Diagnosis requires ≥2 properly measured BP values on ≥2 separate occasions; home or ambulatory BP monitoring is recommended for confirmation.
  • The 2017 ACC/AHA guideline defines hypertension as BP ≥130/80 mmHg.

Epidemiology

  • About 46% of U.S. adults are hypertensive under the 2017 criteria.
  • Prevalence rises with age; lifetime risk after age 55 is >90%.
  • More common in non-Hispanic Blacks.
  • Hypertension is often asymptomatic (“silent killer”).

Etiology

  • Primary (essential) hypertension: >90% of cases; multifactorial (genetics, sodium retention, sympathetic overactivity, RAAS dysfunction, endothelial dysfunction).
  • Secondary hypertension (~10%): due to conditions (CKD, sleep apnea, hyperaldosteronism, thyroid disease, pheochromocytoma, etc.) or drugs (NSAIDs, corticosteroids, decongestants, stimulants, oral contraceptives).

Pathophysiology

  • BP = cardiac output × total peripheral resistance (TPR).
  • Key systems involved:
    • Renin–angiotensin–aldosterone system (RAAS)
    • Sympathetic nervous system
    • Endothelial factors (e.g., nitric oxide deficiency, endothelin excess)
    • Electrolytes (sodium, potassium, calcium balance)

Classification (2017 ACC/AHA)

  • Normal: <120/<80
  • Elevated: 120–129/<80
  • Stage 1: 130–139 / 80–89
  • Stage 2: ≥140 / ≥90
  • Hypertensive crisis: >180/120 (emergency if organ damage present).

Clinical Presentation

  • Usually asymptomatic.
  • Complications: CV disease (MI, HF, LVH), stroke/TIA, CKD, retinopathy, PAD.
  • Risk rises progressively starting at 115/75 mmHg.

Treatment Goals

  • BP target: <130/80 mmHg for nearly all patients.
  • Aim: reduce CV events, organ damage, and mortality.

Management

  1. Lifestyle modifications (for all patients):
    • Weight loss
    • DASH diet (low sodium, high fruits/vegetables)
    • Physical activity
    • Limit alcohol
    • Smoking cessation
  2. Pharmacologic therapy (first-line):
    • Thiazide diuretics
    • ACE inhibitors (ACEi)
    • Angiotensin II receptor blockers (ARBs)
    • Calcium channel blockers (CCBs)
    • Choice depends on comorbidities, tolerability, and evidence of CV risk reduction.
  3. Other considerations:
    • β-blockers not first-line unless compelling indication (e.g., post-MI, HF).
    • Stage 1 HTN: usually start with one drug.
    • Stage 2 HTN: usually start with two drugs.
    • Resistant hypertension: BP uncontrolled with ≥3 agents (including diuretic).

Special Populations

  • Older adults: start with lower drug doses; monitor for orthostatic hypotension.
  • African Americans: respond better to thiazides and CCBs.
  • CKD or diabetes: ACEi/ARBs preferred (renal protection).
  • Pregnancy: methyldopa, labetalol, nifedipine are safer choices.

Key Takeaways

  • Hypertension is common, asymptomatic, and a major CV risk factor.
  • Most patients require lifelong therapy, often with multiple agents.
  • Lifestyle + drug therapy reduces stroke, MI, HF, kidney failure, and death.
  • Early detection and strict control (<130/80) are essential to prevent complications.

 

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