3.Hypertension Variants
  • Info
    Click 'Save & Edit' to enable all features
    Export
    Study
    Edit
    Manage
Public
Save & Edit
Searching...
Flashcards in this deck (13)

  • What is 'white coat hypertension'?

    Elevated blood pressure in clinical settings due to anxiety or stress from seeing providers or needles, with lower home readings on ambulatory monitoring.

    hypertension measurement

  • What measurement technique is recommended for suspected white coat hypertension?

    Take blood pressure measurements several minutes apart and allow patients time to relax before measurement.

    hypertension measurement

  • What characterizes isolated systolic hypertension?

    Very high systolic pressures with normal diastolic pressures, commonly seen in elderly patients due to increased arterial stiffness.

    hypertension elderly

  • Which vessels are primarily involved in isolated systolic hypertension pathology?

    Large vessels such as the aorta with stiff walls; arterioles are not the primary site.

    pathology vascular

  • How is pulse pressure calculated?

    \(\text{Pulse pressure} = \text{systolic BP} - \text{diastolic BP}\)

    physiology calculations

  • Name three main causes of elevated pulse pressure.

    • Aortic regurgitation
    • High-output states (eg, beriberi, hyperthyroidism)
    • Isolated systolic hypertension in elderly patients
    cardiology causes

  • What blood pressure threshold defines hypertensive urgency and emergency?

    A blood pressure of 180/120 mmHg or higher.

    emergency threshold

  • What distinguishes hypertensive emergency from hypertensive urgency?

    Emergency has evidence of end organ damage; urgency has no end organ damage.

    emergency diagnosis

  • Which organs/systems should be assessed for end organ damage when systolic BP reaches about 190–200+?

    • Heart: troponin elevation, STEMI, aortic dissection
    • Kidneys: creatinine elevation
    • Brain: confusion or encephalopathy
    • Eyes: retinopathies, papilledema
    • Liver: elevated liver enzymes
    endorgan assessment

  • What are the receptor effects of labetalol?

    • Beta-1 blockade: decreases heart rate and contractility
    • Beta-2 blockade: reduces vasodilation
    • Alpha-1 blockade: reduces vasoconstriction; net effect is vasodilation
    pharmacology labetalol

  • Why does labetalol avoid reflex tachycardia?

    Its combined alpha-1 and beta blockade prevents reflex tachycardia that commonly occurs with alpha-1 blockers alone.

    pharmacology labetalol

  • Which hypertensive emergency medications are favored for chest pain?

    • Nitrates: nitroglycerin (venodilation) and sodium nitroprusside (arterial and venous vasodilation).
    treatment nitrates

  • For which scenario is fenoldopam commonly tested and what is its mechanism?

    • Scenario: acute kidney injury
    • Mechanism: dopamine-1 receptor agonist causing peripheral vasodilation, increasing renal perfusion.
    pharmacology fenoldopam
Study Notes

Quick overview

  • This document summarizes important concepts in hypertension relevant for clinical care and exams, focusing on special patterns, complications, and acute management.

Blood pressure measurement and White Coat Hypertension

  • White coat hypertension: clinic BP elevated due to anxiety; home/ambulatory BP is lower.
  • Diagnosis: confirm with repeated measurements and ambulatory or home monitoring.
  • Practical tip: take multiple readings several minutes apart and allow the patient to rest before measuring.

Isolated systolic hypertension (ISH)

  • Definition/phenotype: markedly elevated systolic BP with normal or near-normal diastolic BP (e.g., 190/78).
  • Pathophysiology: increased arterial stiffness and decreased compliance of large arteries (aorta), common in older adults.
  • Clinical consequence: increased pulse pressure and greater shear stress on large vessels.

Pulse pressure (PP)

  • Formula: \(PP = SBP - DBP\).
  • Example: \(PP = 190 - 78 = 112\) mmHg.
  • Main causes of elevated PP:
  • Aortic regurgitation: increased stroke volume raises systolic BP.
  • High-output states: e.g., beriberi, hyperthyroidism; increased contractility disproportionately raises systolic BP.
  • Isolated systolic hypertension in the elderly due to arterial stiffness.

Hypertensive urgency vs hypertensive emergency

  • Threshold: both often use a BP cutoff of ≥ 180/120 mmHg (important exam value).
  • Key distinction:
  • Urgency: severe BP elevation without signs of acute end-organ damage.
  • Emergency: severe BP elevation with evidence of acute end-organ injury.

Assessment for end-organ damage (what to check)

When systolic BP approaches or exceeds ~190–200 mmHg, evaluate for:

  • Heart: troponin elevation, acute coronary syndrome, aortic dissection (high shear stress at very high SBP).
  • Kidneys: rising creatinine indicating acute kidney injury.
  • Brain: confusion, encephalopathy, stroke.
  • Eyes: hypertensive retinopathy, papilledema.
  • Liver: elevated liver enzymes (less common but possible).

Medications for hypertensive emergency

Labetalol (first-line agent)

  • Combined alpha-1, beta-1, and beta-2 blocker.
  • Effects: lowers heart rate and contractility (beta-1), reduces vasoconstriction (alpha-1), and limits beta-2 mediated vasodilation.
  • Net effect: vasodilation with reduced reflex tachycardia because beta blockade offsets reflexes.
  • Rapid onset and commonly used for initial control in emergencies.

Nitrates

  • Indicated when chest pain or myocardial ischemia coexists with severe hypertension.
  • Sodium nitroprusside: potent arterial and venous vasodilator.
  • Nitroglycerin: primarily venodilator; useful when ischemia is present.

Fenoldopam

  • Dopamine-1 receptor agonist that produces peripheral vasodilation, especially in renal vasculature.
  • Useful in patients with acute kidney injury since it can improve renal perfusion.
  • Frequently tested on board exams for AKI with severe hypertension.

Practical exam and clinical points

  • Remember 180/120 mmHg as the key threshold for urgency vs emergency.
  • Differentiate white coat hypertension with ambulatory/home BP monitoring before labeling chronic hypertension.
  • In elderly patients, isolated systolic hypertension and widened pulse pressure are common and reflect arterial stiffness.
  • For hypertensive emergencies, rapidly assess for organ damage and choose therapy based on target organs (e.g., nitrates for ischemia, fenoldopam for renal protection, labetalol for general rapid control).

High-yield formulas / reminders

  • Pulse pressure: \(PP = SBP - DBP\).
  • Example calculation: \(PP = 190 - 78 = 112\) mmHg.