Board & Wards [2nd ed.]

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1、1INTERNALMEDICINECARDIOLOGYHYPERTENSION(HTN)Definition=BP=140/90measuredon3separatedaysCAUSES1.95%ofallHTNisidiopathic,call“essentialHTN”o2.Mostof2HTNcausescanbedividedinto3organsystems&drugsCAUSESOFSECONDARYHYPERTENSIONCardiovascularvAorticregurgitationcauseswidepulsepressurevAorticcoarctationcause

2、sHTNinarmswith¯BPinlegsRenalvGlomerulardzcommonlypresentswithproteinuriavRenalarterystenosiscausesrefractoryHTNinoldermen(atherosclerosis)oryoungwomen(fibromusculardysplasia)vPolycystickidneysEndocrinevHypersteroidism,typicallyCushing’s&Conn’ssyndromes,whichcauseHTNwithhypokalemia(aldosterone)vPheoc

3、hromocytomacausingepisodicautonomicsymptomsvHyperthyroidismcausingisolatedsystolicHTNDruginducedvOralcontraceptives,glucocorticoids,phenylephrine,NSAIDsMALIGNANTHYPERTENSION1.Canbehypertensiveurgencyoremergency2.Hypertensiveurgencya.HighBP(e.g.,systolic>200ordiastolic>110,butnumbersvarydependingupon

4、source)withoutevidenceofend-organdamageb.Tx=oralBPmedicationswithgoalofslowlyreducingBPoverseveraldays3.HypertensiveemergencyDefinedassevereHTNwithevidenceofend-organcompromise(e.g.,encephalopathy,renalfailure,CHF/ischemia)Si/Sx=AMS,papilledema,focalneurologicfindings,anuria,chestpain,orevidenceofCH

5、F(e.g.,lowerextremityedema,elevatedJVP,ralesonpulmonaryexam)ThisisamedicalemergencyandimmediatetherapyisneededTx=IVdripwithnitroprussideornitroglycerin(thelatterpreferredforischemia),butdonotlowerBPbymorethan¾atfirstorthepatientwillstrokeoutHYPERTENSIONTREATMENTLifestylemodificationsfirstlineinptswi

6、thoutcomorbiddzWeightloss,exercise,quittingalcohol&smokingcaneachsignificantlylowerBPindependently—saltrestrictionmayhelp¯fatintaketo¯riskofcoronaryarterydz(CAD);HTNisacofactor2.ModicationsIndications1.Failureoflifestylemodificationsafter6moto1yr2.Immediateusenecessaryifcomorbidorgandiseasepresent(e

7、.g.,stroke,angina,renaldisease)3.Immediateuseinemergentorurgenthypertensivestates(e.g.,neurologicimpairment,ICP)First-linedrugsNocomorbiddzDiureticorb-blocker(provento¯mortality)DiabetesACEinhibitors(