Essential hypertension: Clinical sciences

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Introduction0:00–1:05

Essential hypertension is a chronic condition that occurs when an individual's BP is persistently elevated without an identifiable cause.
It's a significant contributor to the development of atherosclerotic cardiovascular disease or a S CBD diagnosis also includes assessing for the presence of other A S CBD risk factors, ruling out secondary causes with screening history, physical and labs and classifying your patient's BP readings into one of three groups, elevated BP, formally known as pre hypertension with a systolic BP between 1 21 29 and diastolic BP less than 80 millimeters of mercury.
Stage one hypertension with a systolic BP between 131 139 or diastolic BP between 8089 millimeters of mercury or stage two hypertension with a systolic BP greater than or equal to 140 or diastolic BP greater than or equal to 90 millimeters of mercury.

Unstable patient1:05–3:37

Now, if you suspect essential hypertension, perform an ABCDE assessment to determine if the patient is stable or unstable if unstable, stabilize their airway breathing and circulation.
Additionally, obtain IV access, provide supplemental oxygen and put them on continuous vital sign monitoring including BP, heart rate and pulse oximetry.
Next. Proceed with a focused history and physical examination and obtain cmp troponin and urinalysis.
Also don't forget to order an ECG and chest X ray together, these will help you identify target organ damage. Now, your patient might report vision changes, headache, shortness of breath, chest pain or back pain.
Their physical exam may reveal a systolic BP of 180 or a diastolic BP of 120 or greater. Additionally, the exam might reveal altered mental status, respiratory crackles or decreased peripheral pulses.
As for labs, you may see an elevated creatinine on C MP, an elevated troponin and proteinuria on the urinalysis. The ecg might show ST segment changes, atrial fibrillation or left ventricular hypertrophy.
While the chest x-ray may reveal a widened mediastinum or pulmonary edema. These findings indicate target organ damage.
The combination of severely elevated BP often with systolic BP over 180 or diastolic BP over 120. And evidence of target organ damage indicates hypertensive emergency treatment consists of IV anti hypertensive medications such as certain beta blockers, like labetalol calcium channel blockers like niCARdipine or vasodilators like hydrALAZINE.
Here's a high yield fact when there's severely elevated BP without evidence of target organ damage. That's hypertensive urgency in these patients, BP can be reduced gradually with oral antihypertensives.

Stable patient3:37–4:30

Ok. Let's go back and take a look at stable patients if your patient is stable.
Proceed with a focused history and physical exam. Your patient might be asymptomatic or could report nonspecific symptoms like nose bleeds or headaches.
Additionally, there might be a family history of hypertension. They may also have other a CVD risk factors including obesity, physical inactivity, tobacco use, hyperlipidemia and diabetes.
They may also have other comorbidities like coronary artery disease, heart failure, chronic kidney disease and obstructive sleep apnea.
And don't forget to assess for use of medications that can cause high BP such as contraceptives, corticosteroids and nsaids.
Finally, let's take a look at the physical exam. Be sure to check the BP in both arms and listen for murmurs, gallops and bruits to screen for cardiovascular abnormalities.

Labs & ECG4:30–5:55

If the BP is greater than 1 20/80 millimeters of mercury, you should suspect either elevated BP or hypertension. Ok.
Now that you suspect this order, screening labs which include TSH CBC CMP, lipid panel and urinalysis as well as an ECG.
These will help identify other cardiovascular risk factors. Assess for target organ damage and rule out secondary causes of hypertension such as hyperthyroidism, polycythemia, vera hypercalcemia and renal disease.
If it's not secondary TSH will typically be normal while the remaining labs might reveal abnormalities due to comorbidities.
For example, CBC may show anemia due to chronic kidney disease while C MP might reveal an elevated creatinine indicating kidney injury or elevated glucose indicating diabetes.
Additionally, lipid panel may show elevated low density lipoprotein, elevated triglycerides as well as decreased high density lipoprotein, which indicates hyperlipidemia.
While urinalysis might show proteinuria suggestive of kidney injury. Finally, the ECG can help you evaluate cardiac complications like left ventricular hypertrophy or ischemic heart disease.

Elevated BP5:55–6:40

After considering secondary causes and end organ damage. Your next step is to classify the patient's BP.
If systolic BP is between 1 21 29 and diastolic BP is less than 80 diagnose elevated BP. In this case, be sure to treat preexisting comorbidities and encourage lifestyle modifications such as weight loss.
A low sodium heart healthy diet like a dietary approaches to stop hypertension or dash diet and exercise routine and reducing alcohol intake of these interventions.

Stage 1 HTN6:40–9:04

A low sodium heart healthy diet will result in the biggest reduction in BP. On the other hand, if BP is greater than 1 30/80 you can diagnose essential hypertension.
This can be divided into stage one and stage two hypertension. Let's say the systolic BP is between 1 31 39 or diastolic BP is between 8089 millimeters of mercury.
This is stage one hypertension. Your next step is to assess whether or not the patient has known clinical ASCVD or if their calculated 10 year risk of ASCVD is 10% or greater.
This is the risk of having a major ASCVD event like myocardial infarction within 10 years and is based on factors like age sex, BP, lipid panel, history of smoking, hypertension, and current medications like statins or Aspirin.
If the individual doesn't have clinical A S CVD and their 10 year risk is less than 10%. Treat preexisting comorbidities and encourage lifestyle modifications.
Then assess the patient's response after 3 to 6 months. If BP goes below 1 30/80 continue the current management.
However, if it's 1 30/80 or greater, consider adding an antihypertensive medication such as a thiazide diuretic like chlorthalidone, an ace inhibitor like Lisinopril, an angiotensin receptor blocker like valsartan or a calcium channel blocker like amLODIPine.
Now, let's look at the patient that has clinical A S CVD or their A CVD risk is 10% or greater. In this case, treat preexisting comorbidities encourage lifestyle modifications and start an antihypertensive medication immediately.
Next, assess the patient's response after one month. If BP goes below 1 30/80 continue the current management.
If it's 1 30/80 or greater, assess their adherence to therapy. If adherence is confirmed, then either increase the dose of their current medication or add a second antihypertensive from a different class.

Stage 2 HTN9:04–10:21

Now, let's go back and discuss when systolic BP is greater than or equal to 140 or diastolic BP is greater than or equal to 90.
This is stage two hypertension and these individuals treat preexisting comorbidities, encourage lifestyle modifications and prescribe two antihypertensive medications of different classes such as a thiazide diuretic and an ace inhibitor.
Next, reassess the patient's response after one month and if BP goes below 1 30/80 continue the current management. However, if it's 1 30/80 or greater, assess the patient's adherence to therapy and make adjustments by either increasing the dose of their current medications or adding another antihypertensive from a different class.
Here's a clinical pearl. If chronic kidney disease and hypertension coexist use an ace inhibitor or angiotensin receptor blocker when possible as it helps slow the progression of CKD.
In addition, carefully monitor potassium levels as the combination of CKD and an ace inhibitor or ARB can result in hyperkalaemia and lead to issues like cardiac arrhythmias.

Review10:21–13:08

All right. As a quick recap, if you suspect essential hypertension, first, perform an ABCD E assessment to determine whether your patient is unstable or stable, unstable patients typically present with hypertensive emergencies.
So treat them with IV anti hypertensives. Instable patients assess other A S CBD risk factors.
Order screening labs and diagnostic tests to rule out secondary causes and identify end organ damage and classify the patient's BP for patients with elevated BP with a systolic BP between 1 21 29 and diastolic BP, less than 80 treat preexisting comorbidities and encourage lifestyle modifications for stage one hypertension with a systolic BP between 1 31 39 or diastolic BP between 80 to 89 assess for clinical as CVD or their calculated 10 year risk of as CVD if there's no clinical as CVD, and the 10 year risk is less than 10%.
Treat preexisting comorbidities encourage lifestyle modifications and assess the patient's response after 3 to 6 months.
If the response is adequate, continue the current management. And if it's inadequate, consider adding an anti hypertensive medication on the flip side.
If there's clinical A S CVD or the patient's A S CVD, risk is 10% or greater treat preexisting, comorbidities encourage lifestyle modifications and start an antihypertensive medication immediately.
Next, assess the patient's response after one month. If BP drops below 1 30/80 continue the current management.
And if it remains 1 30/80 or greater, assess adherence to therapy and if needed, increase the dose of their current medication or add a second antihypertensive from a different class.
Finally, if the patient has stage two hypertension with a systolic BP, greater than or equal to 140 or diastolic BP, greater than or equal to 90 treat, preexisting comorbidities encourage lifestyle modifications and prescribe two antihypertensive medications of different classes.
Next, assess the patient's response after one month and if adequate, continue the current management. However, if it's inadequate, assess the patient's adherence to therapy and if needed, make adjustments
Essential hypertension: Video, Causes, Symptoms | Osmosis