Hypertension
Hypertension is one of the most commonly made diagnoses in the United States. It is a condition that, with appropriate treatment, can be well-controlled, with significant benefits to the patient in both expected morbidity and mortality.

 

Risks:

Hypertension significantly increases the risks of the following conditions:

Diagnosis:

Hypertension is defined as

Workup:

The basic workup is focused on both determining underlying cause and on assessing any damage. The most common sites for end-organ damage include the heart, kidneys, eyes, brain, and vascular system.

The vast majority of patients have "essential," or primary, HTN, although in a patient with refractory HTN, other causes must be considered. Basic assumptions should include a need for reduced weight, increased activity, cessation of smoking and reduction of alcohol.

History should include prior treatment, family Hx, prior BP readings, tobacco use, EtOH use, weight gain, exercise, meds, diet, and evidence of end-organ damage (see above).

Physical exam should include:

Baseline labs can include:

Possible "zebras" include, but are not limited to:

Treatment:

Start with lifestyle as outlined above.

Major classes of antihypertensive medications include ACE inhibitors, Beta blockers, Calcium channel blockers, and Diuretics.

General rule of thumb is to pick a drug (usually start with a beta-blocker or diuretic) and gradually increase to either desired effect (BP < 140/90) or to maximum dose, then add additional agent and repeat.

First line treatment for diabetics or patients with CHF should be an ACE inhibitor

First line treatment post MI should be a beta blocker. If systolic dysfunction exists, add an ACE.

If first-line therapy was not a diuretic, consider it as an adjunct - diuretics improve the effects of all other antihypertensive medications.

Note: Normotensive patients in the hospital can occasionally develop high blood pressures. These rarely need to be addressed acutely - the guidelines for acceptable BP refer to chronic HTN. When writing orders, be careful NOT to include a low threshold for "Call HO if BP >..." - many transient BP readings with no clinical significance have led to use of unnecessary medication. SBP of 200 is not unreasonable nor dangerous in otherwise healthy patients for short periods of time.