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eMedicine Specialties > Pediatrics: Cardiac Disease and

Critical Care Medicine > Cardiology

Hypertension

Edwin Rodriguez-Cruz, MD,Assistant Professor, Department of Pediatrics, San Juan

Bautista Medical School and Medical Center; Consulting Interventional/Clinical Pediatric

Cardiologist, Department of Pediatrics, ospital !l Maestro and San Juan Bautista Medical

Center; Consulting Interventional/Clinical Pediatric Cardiologist, Department of Cardiolog",

Cardiovascular Center of Puerto #ico and the Cari$$ean and %eterans Affairs ospital and

Medical Center of Puerto #ico

Leig M Ettinger, MD, MS,Clinical Assistant Professor, Division of Pediatric &ephrolog",

'he Joseph M San(ari Children)s ospital, ac*ensac* +niversit" Medical Center; !drianSpitzer, MD,Professor, Department of Pediatrics, Al$ert !instein College of Medicine;

Director of &I 'raining Program, Children)s ospital at Montefiore Medical Center

+pdated &ov -, .0

"ntroduction

#ac$ground

"pertension is a ma1or cause of mor$idit" and mortalit" in the +nited States and in man"other countries2 'he prevalence of h"pertension in the +nited States for people aged 3435

"ears is more than 672 'his prevalence increases to appro8imatel" -67 among those aged

-6 "ears2 "pertension is no9 commonl" discovered in children2 'he long4term health ris*s

to these children 9ith h"pertension ma" $e su$stantial2

:or children in the +nited States, e8tensive normative data for $lood pressure BP< are

availa$le2 'he 'as* :orce on Blood Pressure Control in Children commissioned $" the

&ational eart, =ung, and Blood Institute &=BI< of the &ational Institutes of ealth

developed standards for BP $" using the results of >> surve"s of more than 0?, person

visits of infants and children2 Appro8imatel" e@ual num$ers of $o"s and girls 9ere surve"ed2

'he percentile curves 9ere first pu$lished in >50- and descri$e age4specific distri$utions of

s"stolic and diastolic BPs in infants and children 9ith corrections for height and 9eight2 >

'he 'hird #eport of the 'as* :orce, pu$lished in >553, provides further details regarding the

diagnosis and treatment of h"pertension in infants and children2. In ., the :ourth #eport

added normative data and adapted the data to gro9th charts from the Centers for Disease

Control and Prevention CDC< for .2? See . CDC ro9th Charts +nited States2

In accordance 9ith the recommendations of the 'as* :orce, BP is considered normal 9hen

the s"stolic and diastolic values are less than the 5th percentile for the child)s age, se8, and

height2

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'he :ourth #eport introduced a ne9 categor" called preh"pertension2 'he condition is

diagnosed 9hen a child)s average BP e8ceeds the 5th percentile $ut is less than the 56th

percentile2 An" adolescent 9hose BP is greater than >./0 mm g is also given this

diagnosis, even if their reading is less than the 5th percentile2 'his classification 9as created

to align the categories for children 9ith the categories for adults from the .?

recommendations of the Seventh #eport of the Joint &ational Committee on Prevention,Detection, !valuation, and 'reatment of igh Blood Pressure2

Stage I h"pertension is diagnosed if a child)s BP is greater than the 56th percentile $ut less

than or e@ual to the 55th percentile plus 6 mm g2 A child is classified as having stage II

h"pertension if their BP is greater than the 55th percentile plus 6 mm g2

If the s"stolic and diastolic classifications cause a discrepanc", the child)s condition should $e

categori(ed $" using the higher value2 'a$le > serves as a guide to the practicing ph"sician2

:ull ta$les from the &=BI ma" $e found at Blood Pressure 'a$les for Children and

Adolescents2

'a$le >2 'he 56th Percentiles of Blood Pressure in Children and Adolescents?

!ge, y

#P %or &irls 'y Percentile %or Heigt,

(( Hg

#P %or #oys 'y Percentile %or Heigt,

(( Hg

)*t +)t )*t +)t

> >/60 >6/65 >?/63 >/60

3 >>>/- >>?/- >>/- >>6/-6

>. >.?/0 >./0> >.?/0> >.6/0.

>- >.5/0 >?/06 >?3/0- >?0/0-

Patopysiology

BP is determined $" the $alance $et9een cardiac output and vascular resistance2 A rise in

either of these varia$les, in the a$sence of a compensator" decrease in the other, increases

mean BP, 9hich is the driving pressure2 Several factors regulate cardiac output and vascular

resistance2

:actors that affect BP include the follo9ing

Cardiac output

o Baroreceptors

o !8tracellular volume

o !ffective circulating volume

Atrial natriuretic hormones

Mineral corticoids

Angiotensin

o S"mpathetic nervous s"ndrome %ascular resistance

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o Pressors

Angiotensin II

Calcium intracellular

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o Bod" mass inde8 to assess for meta$olic s"ndrome

o 'ach"cardia to assess for h"perth"roidism, pheochromoc"toma, and

neuro$lastoma

o ro9th retardation to assess for chronic renal failure

o CafH au lait spots to assess for neurofi$romatosis

o A$dominal mass to assess for Films tumor and pol"c"stic *idne" diseaseo !pigastric and/or a$dominal $ruit to assess for coarctation of the a$dominal

aorta or renal arter" stenosis

o BP difference $et9een upper and lo9er e8tremities to assess for coarctation of

the thoracic aorta

o 'h"romegal" to assess for h"perth"roidism

o %irili(ation or am$iguit" to assess for adrenal h"perplasia

o Stigmata of Bardet4Biedl, von ippel4=andau, Filliams, or 'urner s"ndromes

o Acanthosis nigricans to assess for meta$olic s"ndrome

Causes

"pertension can $e primar" ie, essential< or secondar"2

In general, the "ounger the child and the higher the BP, the greater the li*elihood that

h"pertension is secondar" to an identifia$le cause2 A secondar" cause of h"pertension

is most li*el" to found $efore pu$ert"2 After pu$ert", h"pertension is li*el" to $e

essential2

A revie9 of literature revealed that -07 of 63? "oung patients 9ith secondar"

h"pertension had a renal parench"mal a$normalit"2 In the remaining ..7, the cause of

h"pertension, in order of fre@uenc", 9as renal arter" stenosis, coarctation of the aorta,

pheochromoc"toma, and a variet" of other conditions2 'a$le .2 Common Causes of "pertension $" Age

"n%ants

Cildren

!dolescents1-2 y +-13 y

o 'hrom$o

sis of renal arter"

or vein

o Congenit

al renal

anomalies

o Coarctati

on of the aorta

o Bronchop

ulmonar"

d"splasia

o #enal

arter" stenosis

o #enal

parench"mal

disease

o Films

tumor

o &euro

$lastoma

o Coarct

ation of the

aorta

o #enal

parench"mal

disease

o #eno

vascular

a$normalitie

s

o !ndo

crine causes

o !ssen

tial

h"pertension

o !ss

ential

h"pertensi

on

o #e

nal

parench"m

al disease

o !n

docrine

causes

Di%%erential Diagnoses

4ter Pro'le(s to #e Considered

Pheochromoc"toma

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5or$up

La'oratory Studies

In patients 9ith h"pertension, proceed from simple tests that can $e performed in anam$ulator" setting to comple8 noninvasive tests and finall" to invasive tests2

:indings from the patient)s histor" and ph"sical e8amination dictate the appropriate

order of tests2

o Gn urine dipstic* testing, a positive result for $lood and/or protein indicates

renal disease2

o +rine cultures are used to evaluate the patient for chronic p"elonephritis2

o 'he CBC count ma" indicate anemia due to chronic renal disease2

o Blood chemistr" ma" $e helpful2 An increased serum creatinine concentration

indicates renal disease2 "po*alemia suggests h"peraldosteronism2

o Blood hormone levels ma" $e measured2 igh plasma renin activit" indicates

renal vascular h"pertension, including coarctation of the aorta, 9hereas lo9activit" indicates glucocorticoid remedia$le aldosteronism, =iddle s"ndrome,

or apparent mineralocorticoid e8cess2 A high plasma aldosterone concentration

is diagnostic of h"peraldosteronism2 igh values of catecholamine

epinephrine, norepinephrine, dopamine< are diagnostic of pheochromoc"toma

or neuro$lastoma2

o igh urinar" e8cretion of catecholamines and catecholamine meta$olites

metanephrine< indicates pheochromoc"toma or neuro$lastoma2

o :asting lipid panels and oral PG< glucose4tolerance tests are performed to

evaluate meta$olic s"ndrome in o$ese children2

o Drug screening is performed to identif" su$stances that might cause

h"pertension2

o +rine sodium levels reflect dietar" sodium inta*e and ma" $e used as a mar*er

to follo9 up a patient after dietar" changes are attempted2

"(aging Studies

!chocardiograph"

o =eft ventricular h"pertroph" results from chronic h"pertension2 'his finding

confirms the chronicit" of the h"pertension and is an a$solute indication for

starting or intensif"ing treatment2

o =eft ventricular h"pertroph" is s"mmetric, consisting of e@uivalent increases inthic*ness of $oth the left ventricular portion of the ventricular septum and the

left ventricular posterior 9all2

o Also assess left ventricular function2

o !chocardiograph" is essential in the evaluation of suspected aortic coarctation2

Precise anatomic detail of the aortic arch and its $ranches must $e o$tained2

A$dominal ultrasonograph"

o 'his test ma" reveal tumors or structural anomalies of the *idne"s or renal

vasculature2

o #enal scarring suggests e8cessive renin release2

o As"mmetr" in renal si(e suggests renal d"splasia or renal arter" stenosis2

o #enal or e8trarenal masses suggest a Films tumor or neuro$lastoma,respectivel"2

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#adionuclide imaging 9ithout or 9ith captopril

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o Aero$ic and isotonic e8ercises have a direct $eneficial effect on BP2 'he" help

in reducing e8cess 9eight or maintaining appropriate $od" 9eight2 !ncourage

participation in sports2 Gnl" patients 9ith severe uncontrolled h"pertension or

cardiac a$normalities that re@uire e8ercise restriction are e8empt from aero$ic

and isotonic e8ercises2

o Salt restriction pro$a$l" $enefits onl" a su$group of patients 9ithh"pertension, particularl" African American patients, 9ho ma" have a defect

in the cellular handling of sodium2 o9ever, given the e8cessive amount of

salt in the t"pical American diet, reduced salt inta*e should $e recommended

to all patients 9ith h"pertension2

o 'he 'as* :orce recommends the Dietar" Approaches to Stop "pertension

DAS< eating plan see our uide 'o =o9ering our Blood Pressure Fith

DAS from the &=BI

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'he American Societ" of "pertension, Inc2 AS< identifies ph"sicians 9ith

e8pert s*ills and *no9ledge in the management of clinical h"pertension and

related disorders2 It also grants such ph"sicians the title Specialist in Clinical

"pertension2 AS provides a list of availa$le specialists $" cit", state, and

countr" see the AS Specialist Director"

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'he :ourth #eport provides a management algorithm see Media file >

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Lisinopril

Prinivil, Kestril mg/d @>4. 9*;

not to e8ceed mg/d

Drug Category:Beta-blockers44 Beta4$loc*ers are especiall" useful in the concurrenttreatment of h"pertension and migraine disorder2 Dosing is limited $" the $rad"cardia adverse

effect2 Drugs of this class should not $e prescri$ed to athletes $ecause their athletic

performance ma" $e compromised2 'his class should not $e used in patients 9ith insulin4

dependent dia$etes $ecause these drugs $lunt the normal 9arning s"mptoms of

h"pogl"cemia2 &oncardioselective agents ie, agents that elicit $eta> and $eta. $loc*ade, eg,

propranolol< are contraindicated in asthma and heart failure, due to their a$ilit" to cause

$rad"cardia and $ronchospastic actions2 Selective $eta>4adrenergic $loc*ers include atenolol

and metoprolol2 =a$etalol elicits a mi8ed alpha and $eta $loc*ade2 Another agent from this

class is propranolol2

#eta-#loc$ers Pediatric Dose 71-1+ y8 !dult Dose!tenolol

'enormin mg/*g/d PG @d or divided

$id initiall"; ma" graduall"

increase to . mg/*g/d; not to

e8ceed > mg/d

6 mg PG @d; ma" increase to >

mg/d

La'etalol

&ormod"ne,

'randate4? mg/*g/d PG divided $id

initiall"; ma" graduall" increase to

>4>. mg/*g/d; not to e8ceed >.

mg/d

> mg/d PG $id; ma" increase

@.4?d $" > mg until ade@uate

response; not to e8ceed .2 g/d

Metoprolol

=opressor, 'oprol L=4. mg/*g/d PG divided $id

initiall"; ma" graduall" increase to3 mg/*g/d; not to e8ceed . mg/d

> mg/d PG @d or divided $id/tid

initiall"; ma" increase @>9*; not toe8ceed 6 mg/d

Propranolol

Inderal, Betachron !4

#< nonselective $eta4

$loc*er

>4. mg/*g/d PG divided $id/tid

initiall"; ma" graduall" increase to

mg/*g/d; not to e8ceed 3 mg/d

> mg PG $id/tid prompt release5th and earl"

.th centuries2 'he names of Ir9ine, Page, van Sl"*e, old$latt, =aragh, and 'uttle

prominentl" appear throughout the h"pertension literature, and their 9or* enhances our

understanding of the $iochemical $asis of essential h"pertension2 Cushman and Gndetti

developed an orall" acting converting en("me inhi$itor from sna*e venom peptides and are

credited 9ith the successful s"nthesis of the modern antih"pertensive captopril2

De%inition

Defining a$normall" high $lood pressure is e8tremel" difficult and ar$itrar"2 :urthermore, the

relationship $et9een s"stemic arterial pressure and mor$idit" appears to $e @uantitative rather

than @ualitative2 A level for high $lood pressure must $e agreed upon in clinical practice for

screening patients 9ith h"pertension and for instituting diagnostic evaluation and initiating

therap"2 Because the ris* to an individual patient ma" correlate 9ith the severit" of

h"pertension, a classification s"stem is essential for ma*ing decisions a$out aggressiveness of

treatment or therapeutic interventions2

Based on recommendations of the Seventh #eport of the Joint &ational Committee of

Prevention, Detection, !valuation, and 'reatment of igh Blood Pressure J&C %II0 "ears or older is as

follo9s

&ormalQ 4 S"stolic lo9er than >., diastolic lo9er than 0

Preh"pertension 4 S"stolic >.4>?5, diastolic 0455

Stage > 4 S"stolic >4>65, diastolic 5455

Stage . 4 S"stolic e@ual to or more than >3, diastolic e@ual to or more than >

Based on the average of . or more readings ta*en at each of . or more visits after initialscreening

Q&ormal $lood pressure 9ith respect to cardiovascular ris* is less than >./0 mm g2

o9ever, unusuall" lo9 readings should $e evaluated for clinical significance2

Preh"pertension, a ne9 categor" designated in the J&C %II report, emphasi(es that patients

9ith preh"pertension are at ris* for progression to h"pertension and that lifest"le

modifications are important preventive strategies2

"pertension ma" $e either essential or secondar"2 !ssential h"pertension is diagnosed in the

a$sence of an identifia$le secondar" cause2 Appro8imatel" 567 of American adults haveessential h"pertension, 9hile secondar" h"pertension accounts for fe9er than 67 of the cases2

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Patopysiology

Arterial $lood pressure is a product of cardiac output and s"stemic vascular resistance2

'herefore, determinants of $lood pressure include factors that affect $oth cardiac output and

arteriolar vascular ph"siolog"2 'here is potential relevance of $lood viscosit", vascular 9all

sheer conditions rate and stress

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h"pertension in persons aged .4 "ears in 9hich increased peripheral resistance is

prominent< to esta$lished h"pertension in persons aged ?46 "ears, and, finall", to

complicated h"pertension in persons aged 43 "ears2

'he earl" stage of h"pertension has $een descri$ed as high4output h"pertension2 igh4output

h"pertension results from decreased peripheral vascular resistance and concomitant cardiacstimulation $" adrenergic h"peractivit" and altered calcium homeostasis2 In contrast, the

chronic phase of essential h"pertension characteristicall" has normal or reduced cardiac

output and elevated s"stemic vascular resistance2

'he vasoreactivit" of the vascular $ed, an important phenomenon mediating changes of

h"pertension, is influenced $" the activit" of vasoactive factors, reactivit" of the smooth

muscle cells, and structural changes in the vessel 9all and vessel cali$er, e8pressed $" a

lumen4to49all ratio2 Patients 9ho develop h"pertension are *no9n to develop a s"stemic

h"pertensive response secondar" to vasoconstrictive stimuli2 Alterations in structural and

ph"sical properties of resistance arteries, as 9ell as changes in endothelial function, are

pro$a$l" responsi$le for this a$normal $ehavior of vasculature2 :urthermore, vascularremodeling occurs over the "ears as h"pertension evolves, there$" maintaining increased

vascular resistance irrespective of the initial hemod"namic pattern2

&enetic %actors

"pertension is li*el" to $e related to multiple genes2 "pertension develops secondar" to

multiple environmental factors, as 9ell as to several genes, 9hose inheritance appears to $e

comple82 %er" rare secondar" causes are related to single genes2

Role o% te ?ascular endoteliu(

'he vascular endothelium is presentl" considered a vital organ, 9here s"nthesis of various

vasodilating and constricting mediators occurs2 'he interaction of autocrine and paracrine

factors ta*es place in the vascular endothelium, leading to gro9th and remodeling of the

vessel 9all and to the hemod"namic regulation of $lood pressure2

&umerous hormonal, humeral vasoactive, and gro9th and regulating peptides are produced in

the vascular endothelium2 'hese mediators include angiotensin II, $rad"*inin, endothelin,

nitric o8ide, and several other gro9th factors2 !ndothelin is a potent vasoconstrictor and

gro9th factor that li*el" pla"s a ma1or role in the pathogenesis of h"pertension2 Angiotensin

II is a potent vasoconstrictor s"nthesi(ed from angiotensin I 9ith the help of an angiotensin4converting en("me AC!

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Cardiac involvement in h"pertension manifests as =%, left atrial enlargement, aortic root

dilatation, atrial and ventricular arrh"thmias, s"stolic and diastolic heart failure, and ischemic

heart disease2 =% is associated 9ith an increased ris* of premature death and mor$idit"2 A

higher fre@uenc" of cardiac atrial and ventricular d"srh"thmias and sudden cardiac death ma"

e8ist2 Possi$l", increased coronar" arteriolar resistance leads to reduced $lood flo9 to the

h"pertrophied m"ocardium, resulting in angina despite clean coronar" arteries2 "pertension,along 9ith reduced o8"gen suppl" and other ris* factors, accelerates the process of

atherogenesis, there$" further reducing o8"gen deliver" to the m"ocardium2

"pertension remains the most common cause of congestive heart failure2 Antih"pertensive

therap" has $een demonstrated to significantl" reduce the ris* of death from stro*e and

coronar" heart disease2 '9o pu$lished meta4anal"ses have sho9n >7 and .37 reductions in

cardiovascular mortalit" rates2

Le%t ?entricular ypertropy

'he m"ocardium undergoes structural changes in response to increased afterload2 Cardiacm"oc"tes respond $" h"pertroph", allo9ing the heart to pump more strongl" against the

elevated pressure2 o9ever, the contractile function of the left ventricle remains normal until

later stages2 !ventuall", =% lessens the cham$er lumen, limiting diastolic filling and stro*e

volume2 'he left ventricular diastolic function is mar*edl" compromised in long4standing

h"pertension2

'he mechanisms of diastolic d"sfunction have $een elucidated onl" recentl"2 An a$erration in

the passive rela8ation of the left ventricle during diastole appears to e8ist2 Gver time, fi$rosis

ma" occur, further contri$uting to the poor compliance of the ventricle2 As the left ventricle

does not rela8 during earl" diastole, left ventricular end4diastolic pressure increases, further

increasing left atrial pressure in late diastole2 'he e8act determinants of left ventricular

diastolic d"sfunction have not $een 9ell studied; possi$l", the a$normalit" is governed $"

a$normal calcium *inetics2

6e central ner?ous syste(

=ong4standing h"pertension ma" manifest as hemorrhagic and atheroem$olic stro*e or

encephalopath"2 Both the high s"stolic and diastolic pressures are harmful; a diastolic

pressure of more than > mm g and a s"stolic pressure of more than >3 mm g have led

to a significant incidence of stro*es2 Gther cere$rovascular manifestations of complicated

h"pertension include h"pertensive hemorrhage, h"pertensive encephalopath", lacunar4t"peinfarctions, and dementia2

Renal disease

Despite 9idespread treatment of h"pertension in the +nited States, the incidence of end4stage

renal disease continues to rise2 'he e8planation for this rise ma" $e concomitant dia$etes

mellitus, the progressive nature of h"pertensive renal disease despite therap", or a failure to

reduce $lood pressure to a protective level2 A reduction in renal $lood flo9 in con1unction

9ith elevated afferent glomerular arteriolar resistance increases glomerular h"drostatic

pressure secondar" to efferent glomerular arteriolar constriction2 'he result is glomerular

h"perfiltration, follo9ed $" development of glomerulosclerosis and further impairment ofrenal function2

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'9o studies have demonstrated that a reduction in $lood pressure ma" result in improved

renal function2 'herefore, earlier detection of h"pertensive nephrosclerosis using means to

detect microal$uminuria and aggressive therapeutic interventions, particularl" 9ith AC!

inhi$itor drugs, ma" prevent progression to end4stage renal disease2

&ephrosclerosis is one of the possi$le complications of long4standing h"pertension2 'he ris*of h"pertension4induced end4stage renal disease is higher in $lac* patients, even 9hen the

$lood pressure is under good control2 :urthermore, patients 9ith dia$etic nephropath" 9ho

are h"pertensive are also at high ris* for developing end4stage renal disease2 'he renin4

angiotensin s"stem activit" influences the progression of renal disease2 Angiotensin II acts at

$oth the afferent and the efferent arterioles, $ut more so on the efferent arteriole, 9hich leads

to an increase of the intraglomerular pressure2 'he e8cess glomerular pressure leads to

microal$uminuria2 #educing intraglomerular pressure using an AC! inhi$itor has $een sho9n

to $e $eneficial in patients 9ith dia$etic nephropath", even in those 9ho are not h"pertensive2

'he $eneficial effect of AC! inhi$itors on the progression of renal insufficienc" in patients

9ho are nondia$etic is less clear2

Hypertension in renal disease

"pertension is commonl" o$served in patients 9ith *idne" disease2 %olume e8pansion is the

main cause of h"pertension in patients 9ith glomerular disease nephrotic and nephritic

s"ndrome

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9ith a state of chronic, lo94grade inflammation2 Although the meta$olic s"ndrome

une@uivocall" predisposes to t"pe . dia$etes mellitus, this s"ndrome is multidimensional ris*

factor for atherosclerotic cardiovascular disease2

reuency

.nited States

:ort"4three million people are estimated to have h"pertension, defined $" a s"stolic $lood

pressure of > mm g or greater and/or diastolic $lood pressure of 5 mm g or greater or

defined as those ta*ing antih"pertensive medications2 'he age4ad1usted prevalence of

h"pertension varies from >04?.7, according to data from the &ational ealth !8amination

Surve"s2 According to the &ational Center for ealth Statistic Surve"s, the a9areness for

h"pertension increased from 6?7 in >534>53. to 057 in >5004>55>2 'he percentage of

patients engaged in h"pertension treatment increased from ?67 to -57 during this period2

'he &ational igh Blood Pressure !ducation Program &BP!P< has reportedestimates of h"pertension prevalence in +nited States2 'he h"pertension surve" 9as

conducted from >5054>55, and actual $lood pressure and self4reported information

9as used2 "pertension 9as defined as s"stolic $lood pressure e@ual to or more than

> mm g, diastolic $lood pressure e@ual or more than 5 mm g, or ta*ing

medication for h"pertension2 'he data estimated ?2? million adults 9ith h"pertension

in &ovem$er >55>2 'he prevalence according to age group, se8, and race is sho9n in

'a$le >2

'a$le >2 Prevalence 7< of "pertension in the +nited States, >5054>55

!ge

&roups

!ll Races 5ite #lac$

Men

7 .02> .-25 .02.

Includes racial/ethnic groups not sho9n separatel" $ecause of small sample si(es

A .6 surve" in the +nited States found that in the population aged . "ears or older,

an estimated >25 million men and .-20 million 9omen have preh"pertension, >.20

million men and >.2. million 9omen have stage > h"pertension, and 2> million men

and 325 million 9omen have stage . h"pertension2 Age4 and se84ad1usted rates of

preh"pertension and stage I h"pertension increased among non4ispanic 9hite,

African American, and ispanic persons $et9een >5004>55. and >5554.2 Age4

and se84ad1usted rates of stage . h"pertension decreased among non4ispanic 9hites

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$et9een >5004>55. and >5554., $ut the" 9ere unchanged for African American

and ispanic persons2

"nternational

&ational health surve"s in various countries have sho9n a high prevalence of poor control ofh"pertension2 'hese studies have reported that prevalence of h"pertension is ..7 in Canada,

of 9hich >37 is controlled; .32?7 in !g"pt, of 9hich 07 is controlled; and >?237 in China,

of 9hich ?7 is controlled2 "pertension is a 9orld9ide epidemic; in man" countries, 67 of

the population older than 3 "ears has h"pertension2 Gverall, appro8imatel" .7 of the

9orld)s adults are estimated to have h"pertension2 'he .7 prevalence is for h"pertension

defined as $lood pressure in e8cess of >/5 mm g2 'he prevalence dramaticall" increases

in patients older than 3 "ears2

Mortality/Mor'idity

In the :ramingham eart Stud", the age4ad1usted ris* of congestive heart failure 9as

.2? times higher in men and ? times higher in 9omen 9hen highest $lood pressure

9as compared to the lo9est2 Multiple #is* :actor Intervention 'rial M#:I'< data

sho9ed that the relative ris* for coronar" heart disease mortalit" varied from .2?4325

times higher for persons 9ith mild4to4severe h"pertension compared to persons 9ith

normal $lood pressure2

'he relative ris* for stro*e ranged from ?234>52.2 'he population4attri$uta$le ris*

percentage for coronar" arter" disease varied from .2?4.6237, 9hereas the population4

attri$uta$le ris* for stro*e ranged from 320472

Race

Blac*s have a higher prevalence and incidence of h"pertension than 9hites2 'he prevalence of

h"pertension 9as increased $" 67 in African Americans2 In Me8ican Americans, the

prevalence and incidence of h"pertension is similar to or lo9er than in 9hites2 'he &ational

ealth and &utrition !8amination Surve" &A&!S< III reported an age4ad1usted prevalence

of h"pertension at .237 in Me8ican Americans and .?2?7 in non4ispanic 9hites2

Are there ethnic differences in the pathogenesis of h"pertension, and do these

differences influence the choice of treatment 'o understand ethnic influence, an

understanding of the renin angiotensin s"stem is essential2 #enin secretion is

suppressed 9hen the *idne" detects that the amount of sodium e8cretion is increased;thus, a clue to the e8cess sodium in the circulation2 Blac* people tend to develop

h"pertension at an earlier age and have lo9er rennin activit"; target organ damage also

differs in $lac* people from that in 9hite people2

Most studies in the +nited ingdom and the +nited States report a higher prevalence

and lo9er a9areness of h"pertension in $lac* people than in 9hite people2 Mortalit"

from h"pertension in African4Cari$$ean$orn people is ?26 times the national rate;

similar data have $een pu$lished for African American citi(ens2 Stro*es are more

common in $lac* people, $ut coronar" heart disease is more common in Asians2 Both

groups have a higher incidence of chronic renal failure than 9hite people, $ut this is

more due to h"pertension in $lac* people and dia$etes in Asians2

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Blac* people have a poorer response to treatment 9ith AC! inhi$itors compared to

9hite people; the evidence for $eta4$loc*ers $eing less effective in $lac* people is

also clear2 o9ever, diuretics are more effective at a "oung age in $lac* people2

Se0

'he age4ad1usted prevalence of h"pertension 9as ?7, .627, and .?2.7 for men and ?>7,

.>7, and .>237 for 9omen among African Americans, 9hites, and Me8ican Americans,

respectivel"2 In the &A&!S III stud", the prevalence of h"pertension 9as >.7 for 9hite

men and 67 for 9hite 9omen aged >045 "ears2 o9ever, the age4related $lood pressure rise

for 9omen e8ceeds that of men2 'he prevalence of h"pertension 9as reported at 67 for

9hite men and 667 for 9hite 9omen aged - "ears or older2

!ge

A progressive rise in $lood pressure 9ith increasing age is o$served2 'he third &A&!S

surve" reported that the prevalence of h"pertension gro9s significantl" 9ith increasing age in

all se8 and race groups2 'he age4specific prevalence 9as ?2?7 in 9hite men aged >04.5 "?2.7 in the group aged ?4?5 "ears2 'he prevalence further increased to

..7 in the group aged 45 "ears, to ?-267 in the group aged 6465 "ears, and to 6>7 in

the group aged 34- "ears2 In another stud", the incidence of h"pertension appeared to

increase appro8imatel" 67 for each >4"ear interval of age2 Age4related h"pertension appears

to $e predominantl" s"stolic rather than diastolic2 'he s"stolic $lood pressure rises into the

eighth or ninth decade, 9hile the diastolic $lood pressure remains constant or declines after

age "ears2>

Clinical

History

:ollo9ing the documentation of h"pertension, 9hich is confirmed after an elevated

$lood pressure, properl" measured, has $een documented on at least ? separate

occasions $ased on the average of . or more readings ta*en at each of . or more visits

after initial screening

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A histor" of cold or heat tolerance, s9eating, lac* of energ", and $rad"cardia or

tach"cardia ma" indicate h"poth"roidism or h"perth"roidism2

A histor" of 9ea*ness suggests h"peraldosteronism2 A$dominal $ruit suggests the

possi$ilit" of renal arter" stenosis2 A$sence of femoral pulses suggests coarctation of

aorta2

idne" stones raise the possi$ilit" of h"perparath"roidism2 'he presence ofpapilledema and other neurologic signs raises the possi$ilit" of increased intracranial

pressure2 A histor" of drug ingestion, including oral contraceptives, licorice, and

s"mpathomimetics, should $e o$tained2

Pysical

An accurate measurement of $lood pressure is the *e" to diagnosis2 Several determinations

should $e made over a period of several 9ee*s2

At an" given visit, an average of ? $lood pressure readings ta*en . minutes apart using a

mercur" manometer is prefera$le2 Blood pressure should $e measured in $oth the supine and

sitting positions, auscultating 9ith the $ell of the stethoscope2 Gn the first visit, $lood pressure

should $e chec*ed in $oth arms and in one leg to avoid missing the diagnosis of coarctation of

aorta or su$clavian arter" stenosis2

As the improper cuff si(e ma" influence $lood pressure measurement, a 9ider cuff is

prefera$le, particularl" if the patient)s arm circumference e8ceeds ? cm2

'he patient should rest @uietl" for at least 6 minutes $efore the measurement2

Although some9hat controversial, the common practice is to document phase % adisappearance of all sounds< of orot*off sounds as the diastolic pressure2

A funduscopic evaluation of the e"es should $e performed to detect an" evidence of

h"pertensive retinopath"2 'hese are flame4shaped hemorrhages and cotton 9ool

e8udates2

Palpation of all peripheral pulses should $e performed2

=oo* for renal arter" $ruit over the upper a$domen; the presence of a unilateral $ruit

9ith $oth a s"stolic and diastolic component suggests renal arter" stenosis2

A careful cardiac e8amination is performed to evaluate signs of =%2 'hese include

displacement of ape8, a sustained and enlarged apical impulse, and the presence of an

S2 Gccasionall", a tam$our S.is heard 9ith aortic root dilatation2

Causes

Primar" or essential h"pertension 545677< have a secondar"

cause2 'he follo9ing is a list of secondar" causes of h"pertension

o #enal .2643767 and the ris* of

coronar" arter" disease $" 37 in a given population2

J&C %II recommendations to lo9er $lood pressure and decrease cardiovascular disease ris*

include the follo9ing

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=ose 9eight if over9eight2

=imit alcohol inta*e to no more than > o( ? m=< of ethanol ie, . o( -. m=E of

$eer, > o( ? m=E of 9ine, . o( 3 m=E of >4proof 9his*e"< per da" or 26 >6

m=< ethanol per da" for 9omen and people of lighter 9eight2

Increase aero$ic activit" ?46 min most da"s of the 9ee* mmol/d .2 g sodium or 3 g sodiumchloride3, diastolic more than >

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:or the compelling indications, other antih"pertensive drugs eg, diuretics, AC!

inhi$itor, A#B, $eta4$loc*er, calcium channel $loc*er< ma" $e considered as needed2

Rando(ized trials

'9o randomi(ed controlled trials, the "pertension Detection and :ollo94up ProgramD:P< and the Medical #esearch Council M#C< trials, randomi(ed patients 9ith elevated

levels of diastolic $lood pressure to either diuretic4$ased stepped4care treatment or usual care2

'he usual care group received some form of therap" from their o9n ph"sicians, 9hereas the

stepped4care group received s"stematic care2 In $oth studies, stepped4care treatment reduced

diastolic $lood pressure $" 6 mm more than that reduced in the control group2 Both trials

sho9ed a $enefit from stepped4care therap" compared to the control group2 In the D:P trial,

stepped4care led to relative ris* reduction of >-7 for total mortalit"; -3 h"pertensive patients

needed to $e treated 9ith stepped4care therap" for 6 "ears to prevent one death2

A meta4anal"sis pu$lished in theJournal of the American Medical AssociationJAMA< in

>55- included several randomi(ed controlled clinical trials2 'he total num$er of participantsrandomi(ed to active therap" 9as .,.5, and the num$er for the control therap" 9as .?,5.32

Active treatment reduced diastolic $lood pressure $" at least 6 mm g2 'he meta4anal"sis

sho9ed a ris* reduction of coronar" heart disease of 04>7 and the reduction in stro*e

incidence of ?6472 Su$se@uent meta4anal"sis reported that $enefits of active treatment are

similar in men and 9omen2

Reco((endations %or (anage(ent o% ypertension

'he J&C recommends certain situations for 9hich a specific class of drug ma" $e

administered2 An AC! inhi$itor should $e the initial treatment in situations in 9hich

h"pertension is associated 9ith congestive heart failure, dia$etes mellitus 9ith proteinuria,

and postm"ocardial infarction 9ith s"stolic left ventricular d"sfunction2 In patients 9ho

develop persistent cough 9hile on AC! inhi$itor therap", an angiotensin II receptor

antagonist ma" $e su$stituted, $ut these agents) efficac" in lo9ering cardiovascular mortalit"

rates has not "et $een proven2 A $eta4$loc*er should $e prescri$ed follo9ing an acute

m"ocardial infarction2 A diuretic or a long4acting calcium channel $loc*er ma" $e more

effective in elderl" patients 9ith isolated s"stolic h"pertension2

'he . Canadian "pertension Societ" recommendations similar to J&C %II guidelines3>S>4S..

'a$le ?2 Considerations in the Individuali(ation of Antih"pertensive 'herap"

Ris$

actor/DiseasePre%erred 6erapy !lternati?e 6erapy !?oid 6erapy

+ncomplicated

h"pertension 3

"

mm g is a more important cardiovascular disease ris* factor than diastolicBP2

o Beginning at >>6/-6 mm g, the cardiovascular disease ris* dou$les for each

increment of ./> mm g2

o Individuals 9ho are normotensive at 66 "ears 9ill have a 57 lifetime ris* of

developing h"pertension2

o Preh"pertension s"stolic >.4>?5, diastolic 0405< re@uires health4promoting

lifest"le modifications to prevent the progressive rise in $lood pressure and

cardiovascular disease2

o In uncomplicated h"pertension, a thia(ide diuretic, either alone or com$ined

9ith drugs from other classes, should $e used for the drug treatment of most2o In specific high4ris* conditions, there are compelling indications for the use of

other antih"pertensive drug classes eg, AC! inhi$itors, angiotensin4receptor

$loc*ers, $eta4$loc*ers, calcium channel $loc*ers

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$e treated 9ith more aggressive diuretic therap" until clinical signs of

e8tracellular volume depletion eg, orthostatic h"potension< develop2

o Poor compliance &oncompliance 9ith medical therap" or dietar"

modifications eg, salt restriction< ma" pla" a role in causing resistant

h"pertension2 Address noncompliance 9ith e8tensive patient education,

simplification of the drug regimen, and use of drugs 9ith the fe9est adverseeffects2

o Secondar" h"pertension Fhenever confronted 9ith resistant h"pertension, tr"

to e8clude an" secondar" causes of h"pertension2 A reevaluation of the

patient)s histor", ph"sical e8amination, and la$orator" results ma" provide

clues to secondar" h"pertension eg, renal arter" stenosis, primar"

h"peraldosteronism

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Premenopausal 9omen have a higher resting heart rate, a higher cardiac inde8,

and a lo9er peripheral resistance than men2 'hese changes are not encountered

in postmenopausal females2 'herefore, in premenopausal situations, a

medication such as $eta4$loc*er ma" $e effective2 o9ever, postmenopausal

h"pertension is treated similarl" to that in men2

o #ace Blac*s have a higher prevalence of h"pertension and a much higher

fre@uenc" of end organ damage, such as occurs in end4stage renal

disease, stro*es, and heart failure2 Blac* patients also develop more

severe =% than 9hite patients2 #enal function in h"pertensive $lac*

patients continues to deteriorate over time despite aggressive

management of the $lood pressures2

Blac* patients respond less 9ell to $eta4$loc*ers, AC! inhi$itors, and

angiotensin receptor $loc*ers than 9hite patients2 At times, this relative

lac* of efficac" ma" $e overcome $" increasing the dosage of the

medications2 Blac*s ma" respond 9ell to treatment 9ith calcium

antagonists, diuretics, and posts"naptic alpha4$loc*ers2o G$esit"

"pertensive patients 9ho are o$ese have a higher cardiac output and a

lo9er peripheral vascular resistance than h"pertensive patients 9ho are

not o$ese2 'he increase in cardiac output manifests secondar" to

increased preload2 'he end4diastolic volume and pressure are elevated,

leading to left ventricular dilatation2 =eft ventricular 9all thic*ening

also occurs secondar" to increased afterload, 9hich increases the ris* of

congestive heart failure2 'he concomitant dia$etes often present in

patients 9ho are o$ese produces a devastating effect on *idne"s and

leads to a much higher incidence of renal failure2

&o class of drugs seems to $e of particular advantage in h"pertensive

patients 9ho are o$ese, $ut thia(ide diuretics ma" $e helpful, unless the

patient also has coe8isting dia$etes2 In patients 9ho are dia$etic and

9ho ma" have microal$uminuria, AC! inhi$itors or calcium

antagonists are recommended $ecause the" ma" slo9 declining renal

function2 Because of the high preload and afterload, drugs that have

negative inotropic effects, such as $eta4$loc*ers, should $e avoided2

'he management of secondar" h"pertension ma" result in cure $" the surgical

correction of the underl"ing pro$lem, such as removal of a pheochromoc"toma2

Surger" ma" not $e feasi$le in a su$stantial num$er of patients for 9hom medical

therap" is instituted to control h"pertension2o #enovascular h"pertension

'he goals of therap" are maintenance of normal $lood pressure and

prevention of end4stage renal disease2 'he therapeutic options include

medical therap", percutaneous transluminal renal angioplast", and

surgical revasculari(ation2 'hese options must $e individuali(ed

$ecause no randomi(ed studies document the superiorit" of one option

over the other2 'he indications for surger" or angioplast" include an

ina$ilit" to control $lood pressure 9hile on a medical regimen, the need

to preserve renal function, and intolera$le effects of medical therap"2

Aortal renal $"pass using saphenus vein or h"pogastric arter" is a

common revasculari(ation techni@ue2 A s"nthetic graft has also $eenused2 Percutaneous transluminal renal angioplast" P'#A< can $e

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effective treatment for $oth h"pertension and preservation of renal

function2 P'#A ma" $e the initial choice in "ounger patients 9ith

fi$romuscular lesions amena$le to $alloon angioplast"2 #enal arter"

stenting of osteal lesions has $een associated 9ith improved long4term

patenc"2 P'#A ma" also $e used for arthrosclerotic renal arter"

stenosis; the outcome ma" $e compara$le to surgical revasculari(ation2Medical therap" is re@uired in the preoperative phase of interventional

therap"2 Medical therap" is also indicated for high4ris* individuals and

for older patients 9ho have easil" controlled h"pertension2

AC! inhi$itors are @uite effective in patients 9ith unilateral renal

arter" stenosis; ho9ever, avoid AC! inhi$itors in patients 9ith $ilateral

renal arter" stenosis or stenosis of a solitar" *idne"2 A diuretic can $e

com$ined 9ith an AC! inhi$itor2 Because of their glomerular

vasodilator" effect, calcium antagonists are effective in renal arter"

stenosis and do not compromise renal function2

o Pheochromoc"toma

:ollo9ing suspicion of pheochromoc"toma, the presence of a tumorshould $e confirmed $iochemicall" $" measuring urine and plasma

concentrations of catecholamine or their meta$olites2 In most

situations, a C' scan or an M#I ma" $e used to locali(e the tumor in

the a$domen2 In the a$sence of a$dominal imaging, nuclear scan 9ith

metaiodo$en("lguanidine MIB< ma" further help 9ith the

locali(ation2

Surgical resection is the treatment of choice $ecause h"pertension is

cured $" tumor resection2 In the preoperative phase, com$ined alpha4

and $eta4adrenergic $loc*ade is recommended for h"pertension control2

Alpha4adrenergic $loc*ade is initiated 9ith pheno8"$en(amine or

pra(osin, and, follo9ing ade@uate alpha4adrenergic $loc*ade, $eta4

adrenergic $loc*ade is initiated2 'hese patients are often volume

contracted and re@uire saline or sodium ta$lets2 Catecholamines can $e

reduced further $" met"rosine2 :or adrenal pheochromoc"toma,

laparoscopic adrenalectom" is $ecoming the procedure of choice in

suita$le patients2 :ollo94up .4hour urinar" e8cretion studies of

catecholamines should $e performed . 9ee*s follo9ing surger" and

periodicall" thereafter< to detect recurrence, metastases, or

development of second primar" lesion2

o Primar" h"peraldosteronism

"per*alemia is an important clue to the presence of primar"aldosteronism2 o9ever, in a su$set of patients, the serum potassium

concentration ma" $e 9ithin the reference range2 Measurement of P#A

has $een used as a screening test2 A suppressed P#A value that fails to

rise a$ove . mg/m=/h after salt and 9ater depletion is considered a

positive test result2 'he $est initial test is the determination of the

aldosterone e8cretion rate during prolonged salt loading2

'he appropriate therap" depends on the cause of e8cessive aldosterone

production2 A C' scan ma" help locali(e an adrenal mass, indicating

adrenal adenoma2 If the results of the C' scan are inconclusive, adrenal

venous sampling for aldosterone and cortisol levels should $e

performed2 Medical therap" is indicated in patients 9ith adrenalh"perplasia, patients 9ith adenoma 9ho are poor surgical ris*s, and

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patients 9ith $ilateral adenomas2 'hese patients are $est treated 9ith

sustained salt and 9ater depletion2 "drochlorothia(ide or furosemide

in com$ination 9ith either spironolactone or amiloride corrects

h"po*alemia and normali(es the $lood pressure2 Some patients ma"

re@uire the addition of a vasodilator or a $eta4$loc*er for $etter control

of h"pertension2 Adrenal adenomas ma" $e resected via a laparoscopic procedure2

Surgical resection often leads to the control of $lood pressure and the

reversal of $iochemical a$normalities2 'hese patients ma" develop

h"poaldosteronism during the postoperative follo94up period and

re@uire supplementation 9ith fludrocortisone2

Surgical Care

Aortorenal $"pass using saphenus vein graft or h"pogastric arter" is a common

revasculari(ation techni@ue for renovascular h"pertension2 Surgical resection is the treatment

of choice for pheochromoc"toma $ecause h"pertension is cured $" tumor resection2 Inpatients 9ith fi$romuscular renal disease, angioplast" has a 3407 success rate for cure or

improvement of h"pertension2 Surgical correction of renal arter" stenosis has resulted in cure

of h"pertension in appro8imatel" 3>7 of patients and amelioration in .-7 of patients 9ith

fi$romuscular lesions2 Fith respect to renal arter" stenosis secondar" to atherosclerotic

lesions, surgical correction has resulted in cure of h"pertension in ?07 of patients and

amelioration in a$out >7 of patients2 See Medical Care for more details2

Consultations

Consultations 9ith a nutritionist and e8ercise specialist are often helpful in changing lifest"leand initiating 9eight loss2 Consultations 9ith an appropriate consultant are indicated for

management of secondar" h"pertension attri$uta$le to a specific cause2

Diet

A num$er of studies have documented an association $et9een sodium chloride inta*e and

$lood pressure2 'he effect of sodium chloride is particularl" important in individuals 9ho are

middle4aged to elderl" 9ith a famil" histor" of h"pertension2 A moderate reduction in sodium

chloride inta*e can lead to a small reduction in $lood pressure2 'he American eart

Association recommends that the average dail" consumption of sodium chloride not e8ceed 3

g, this ma" lo9er $lood pressure $" .40 mm g2

'he Dietar" Approaches to Stop "pertension DAS< eating plan encompasses a diet

rich in fruits, vegeta$les, and lo94fat dair" products and ma" lo9er $lood pressure $"

04> mm g2.

Dietar" potassium, calcium, and magnesium consumption have an inverse association

9ith $lood pressures2 =o9er inta*e of these elements potentiates the affect of sodium

on $lood pressure2 Gral potassium supplementation ma" lo9er $oth s"stolic and

diastolic pressure2 Calcium and magnesium supplementation have elicited small

reductions in $lood pressures2

In population studies, lo9 levels of alcohol consumption have sho9n a favora$le

effect on $lood pressure, 9ith reductions of .4 mm g2 o9ever, the consumption of

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? or more drin*s per da" is associated 9ith elevation of $lood pressure2 Alcohol inta*e

should $e restricted to less than > o( of ethanol in men and 26 o( in 9omen2

Feight reduction ma" lo9er $lood pressure $" 64. mm g per > *g of 9eight loss

in a patient 9ho 9eighs more than >7 of ideal $od" 9eight2

!cti?ity

+p to 37 of all individuals 9ith h"pertension are more than .7 over9eight2 'he

centripetal fat distri$ution is associated 9ith insulin resistance and h"pertension2 !ven modest

9eight loss 67< can lead to reduction in $lood pressure and improved insulin sensitivit"2

#egular aero$ic ph"sical activit" can facilitate 9eight loss, decrease $lood pressure, and

reduce the overall ris* of cardiovascular disease2 Blood pressure ma" $e lo9ered $" 45 mm

g 9ith moderatel" intense ph"sical activit"2 'hese activities include $ris* 9al*ing for ?

minutes a da", 6 da"s per 9ee*2 More intense 9or*outs for .4? minutes, ?4 times a 9ee*

ma" also lo9er $lood pressure and have additional health $enefits2

Medication

'he goals of pharmacotherap" are to reduce mor$idit" and to prevent complications2

Diuretics

Cause diuresis, 9hich decreases plasma volume and edema, there$" decreasing cardiac output

and $lood pressure2

Hydroclorotiazide 7Esidri0, HydroD".R"L, Microzide8

Inhi$its rea$sorption of sodium in distal tu$ules, causing increased e8cretion of sodium,

9ater, potassium, and h"drogen ions2

Dosing

Adult

.64> mg PG @d; not to e8ceed . mg/*g/d

Pediatric

3 months .4? mg/*g/d PG divided $id

N3 months . mg/*g/d PG divided $id

"nteractions

Ma" decrease effects of anticoagulants, antigout agents, and sulfon"lureas; ma" increase

to8icit" of allopurinol, anesthetics, antineoplastics, calcium salts, loop diuretics, lithium,dia(o8ide, digitalis, amphotericin B, and nondepolari(ing muscle rela8ants

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Contraindications

Documented h"persensitivit"; anuria; renal decompensation

Precautions

Pregnancy

C 4 :etal ris* revealed in studies in animals $ut not esta$lished or not studied in humans; ma"

use if $enefits out9eigh ris* to fetus

Precautions

Caution in renal and hepatic disease, gout, dia$etes mellitus, and lupus er"thematosus

Spironolactone 7!ldactone8

+sed for management of h"pertension2 Ma" $loc* effects of aldosterone on arteriolar smooth

muscles2

Dosing

Adult

.64. mg/d PG @d or divided $id

Pediatric

>264?26 mg/*g/d PG in divided doses @34.h

"nteractions

Ma" decrease effect of anticoagulants; potassium and potassium4sparing diuretics ma"

increase to8icit" of spironolactone

Contraindications

Documented h"persensitivit"; anuria; renal failure; h"per*alemia

Precautions

Pregnancy

D 4 :etal ris* sho9n in humans; use onl" if $enefits out9eigh ris* to fetus

Precautions

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Caution in renal and hepatic impairment

!(iloride 7Mida(or8

l4car$on"l4guanidine unrelated chemicall" to other *no9n anti*aliuretic or diuretic agents2

Potassium4conserving anti*aliuretic< drug that, compared 9ith thia(ide diuretics, possesses

9ea* natriuretic, diuretic, and antih"pertensive activit"2

Dosing

Adult

64. mg PG @d

Pediatric

&ot esta$lished

"nteractions

Concomitant therap" 9ith potassium supplementation ma" increase serum potassium levels

if concomitant use indicated $ecause of demonstrated h"po*alemia, use caution and monitor

serum potassium fre@uentl"

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monitor electrol"tes closel" if evidence of renal functional impairment present, B+& N?

mg/> m=, or serum creatinine levels N>26 mg/> m=

urose(ide 7Lasi08

Increases e8cretion of 9ater $" interfering 9ith chloride4$inding cotransport s"stem, 9hich,

in turn, inhi$its sodium and chloride rea$sorption in ascending loop of enle and distal renal

tu$ule2 Dose must $e individuali(ed to patient2 Depending on response, administer at

increments of .4 mg no sooner than 340 h after previous dose until desired diuresis occurs2

Fhen treating infants, titrate 9ith >4mg/*g per dose increments until satisfactor" effect

achieved2

Dosing

Adult

.40 mg/d PG/I%/IM; titrate up to 3 mg/d for severe edematous states

Pediatric

>4. mg/*g/dose PG; not to e8ceed 3 mg/*g/dose; not to administer more often than @3h

Alternativel", > mg/*g I%/IM slo9l" under close supervision; not to e8ceed 3 mg/*g

"nteractions

Metformin decreases furosemide concentrations; furosemide interferes 9ith h"pogl"cemic

effect of antidia$etic agents and antagoni(es muscle4rela8ing effect of tu$ocurarine; auditor"

to8icit" appears to $e increased 9ith coadministration of aminogl"cosides and furosemide;

hearing loss of var"ing degrees ma" occur; anticoagulant activit" of 9arfarin ma" $e

enhanced 9hen ta*en concurrentl" 9ith this medication; increased plasma lithium levels and

to8icit" possi$le 9hen ta*en concurrentl"

Contraindications

Documented h"persensitivit"; hepatic coma; anuria; state of severe electrol"te depletion

Precautions

Pregnancy



Precautions

Perform fre@uent serum electrol"te, CG., glucose, creatinine, uric acid, calcium, and B+&

determinations during first fe9 mo of therap" and periodicall" thereafter

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!lpa1-adrenergic 'loc$ers

Selectivel" $loc* posts"naptic alpha>4adrenergic receptors2 Dilate arterioles and veins, thus

lo9ering $lood pressure2

Prazosin 7Minipress8, 6erazosin 7Hytrin8

Pra(osin treats prostatic h"pertroph"2 Improves urine flo9 rates $" rela8ing smooth muscle,

9hich is caused $" $loc*ing alpha>4adrenoceptors in $ladder nec* and prostate2 Fhen

increasing dose, administer first dose of each increment at $edtime to reduce s"ncopal

episodes2 Although doses N. mg/d usuall" do not increase efficac", some patients ma"

$enefit from as much as mg/d2

'era(osin decreases arterial tone $" allo9ing peripheral posts"naptic $loc*ade2 as minimal

alpha. effect2

Dosing

Adult

Pra(osin > mg PG $id/tid initial; 34>6 mg/d PG $id/tid maintenance

'era(osin > mg PG hs; increase slo9l" to effect; not to e8ceed . mg/d

Pediatric

Pra(osin &ot esta$lished; suggested dose is 264- mg PG tid

'era(osin &ot esta$lished

"nteractions

Acute postural h"potensive reaction from $eta4$loc*ers ma" 9orsen; indomethacin ma"

decrease antih"pertensive activit"; verapamil ma" increase serum levels and ma" increase

patient)s sensitivit" to drug4induced postural h"potension; ma" decrease antih"pertensive

effects of clonidine

Contraindications

Documented h"persensitivit"

Precautions

Pregnancy



Precautions

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Caution in renal impairment; ma" cause mar*ed h"potension follo9ing first dose and

coadministration 9ith $eta4$loc*ers

#eta-adrenergic 'loc$ing agents

+sed to treat h"pertension as initial agents or in com$ination 9ith other drugs eg, thia(ides4receptors 9ith little or no effect on $eta.

t"pes2

Propranolol is a class II antiarrh"thmic, nonselective, $eta4adrenergic receptor $loc*er 9ith

mem$rane4sta$ili(ing activit" that decreases automaticit" of contractions2

&e$ivolol actions depend on meta$olic factors and dose2 In e8tensive meta$oli(ers ma1orit"

of the population< and doses > mg, preferentiall" elicits $eta> selective inhi$ition, 9hereas

in poor meta$oli(ers and at higher doses, inhi$its $oth $eta>4 and $eta.4receptors2

Dosing

Adult

Atenolol 6 mg PG @d; increase to > mg/d, if necessar"

Metoprolol > mg/d PG @d or divided $id/tid initial; increase at >49* intervals prn to a totalof 6 mg/d if necessar"

Propranolol 40 mg PG $id initial; increase to >34?. mg/d ma" re@uire up to 3 mg/d4. mg/*g/dose PG @d

Metoprolol >46 mg/*g/d PG divided $id

Propranolol 26 mg/*g/d PG divided $id/@id; increase graduall" @?4-d; range is .4 mg/*g/ddivided $id; not to e8ceed . mg/*g/d

&e$ivolol &ot esta$lished

"nteractions

Coadministration 9ith aluminum salts, $ar$iturates, calcium salts, cholest"ramine, &SAIDs,

penicillins, and rifampin ma" decrease effects; haloperidol, h"drala(ine, loop diuretics, and

MAGIs ma" increase to8icit"; coadministration 9ith m"ocardial depressants, A% conduction

inhi$itors eg, verapamil, diltia(em

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Contraindications

Documented h"persensitivit"; congestive heart failure; pulmonar" edema; cardiogenic shoc*;

A% conduction a$normalities; heart $loc* 9ithout a pacema*er4, and $eta.4adrenergic receptor sites, thus decreasing $lood pressure2

La'etalol 7=or(odyne, 6randate8, Car?edilol 7Coreg8

&onselective $eta4 and alpha4adrenergic $loc*ers2 Do not appear to have intrinsic

s"mpathomimetic activit"2 Ma" reduce cardiac output and decrease peripheral vascular

resistance2 +se in aortic dissection not advisa$le 9hen titrata$le drugs, such as esmolol and

nitroprusside, availa$le2

Dosing

Adult

=a$etalol .4? mg I% over . min follo9ed $" 40 mg at >4min intervals; not to e8ceed? mg/dose

Carvedilol 32.6 mg PG $id; maintain for >4. 9* if tolerated and increase to >.26 mg $id to

ma8imum .6 mg $id

Pediatric

=a$etalol &ot esta$lished; suggested dose is 24> mg/*g/h; not to e8ceed ? mg/*g/h

Carvedilol &ot esta$lished

"nteractions

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=a$etalol decreases effect of diuretics and increases to8icit" of methotre8ate, lithium, and

salic"lates; ma" diminish refle8 tach"cardia resulting from nitrogl"cerin use 9ithout

interfering 9ith h"potensive effects; cimetidine ma" increase la$etalol and carvedilol $lood

levels; glutethimide ma" decrease la$etalol effects $" inducing microsomal en("mes;

rifampin, $ar$iturates, cholest"ramine, colestipol, &SAIDs, salic"lates, and penicillins ma"

decrease carvedilol effects; carvedilol ma" increase effects of antidia$etic agents, digo8in,and calcium channel $loc*ers; concurrent administration 9ith clonidine ma" increase $lood

pressure and decrease heart rate; carvedilol ma" decrease effect of sulfon"lureas; fluo8etine,

paro8etine, and propafenone ma" increase carvedilol levels

Contraindications

Documented h"persensitivit"; cardiogenic shoc*; pulmonar" edema; $rad"cardia; A% $loc*;

uncompensated congestive heart failure; reactive air9a" disease; severe $rad"cardia

Precautions

Pregnancy



Precautions

Caution in impaired hepatic function; discontinue therap" if signs of liver d"sfunction

present; in elderl" patients, a lo9er response rate and higher incidence of to8icit" ma" $e

o$served; caution in congestive heart failure $eing treated 9ith digitalis, diuretics, or AC!inhi$itors A% conduction ma" $e slo9ed4. mg/dose I%/IM @43h prn initial; increase to mg/dose if necessar";

change to PG as soon as possi$le

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Mino8idil 6 mg PG @d; increase graduall" @?d; >4 mg/d PG @d or divided $id

maintenance; not to e8ceed > mg/d

Pediatric

&ot esta$lished

"nteractions

MAGIs and $eta4$loc*ers ma" increase h"drala(ine to8icit"; pharmacologic effects of

h"drala(ine ma" $e decreased $" indomethacin; concurrent use of mino8idil 9ith

guanethidine, diuretics, or h"potensive agents ma" result in additive h"potension

Contraindications

Documented h"persensitivit"; mitral valve, rheumatic heart disease h"drala(ine

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Dilacor

"pertension >04. mg PG @d

Angina >. mg/d PG; titrate slo9l" over -4> d up to 0 mg/d prn; not to e8ceed 6 mg/d

%erapamil .40 mg/d PG divided tid/@id

&ifedipine >4? mg I# cap PG tid; not to e8ceed >.4>0 mg/d ?43 mg S# ta$ PG @d; not

to e8ceed 54>. mg/d

Pediatric

Diltia(em &ot esta$lished

%erapamil &ot esta$lished

&ifedipine 2.6426 mg/*g/dose PG tid/@id prn

"nteractions

Ma" increase car$ama(epine, digo8in, c"closporine, and theoph"lline levels; 9hen

administered 9ith amiodarone, ma" cause $rad"cardia and a decrease in cardiac output; 9henadministered 9ith $eta4$loc*ers, ma" increase cardiac depression; cimetidine ma" increase

levels

Contraindications

Documented h"persensitivit"; severe C:; sic* sinus s"ndrome; second4 or third4degree A%

$loc*; h"potension 5 mm g s"stolic.264.6 mg PG $id/tid; ma" increase $" >.264.6 mg/dose at >4 to .49* intervals up

to 6 mg tid!nalapril .2646 mg/d PG increase as necessar"4 mg/d PG in >4. divided

doses

>2.6 mg/dose I% over 6 min @3h

=isinopril > mg/d PG; increase 64> mg/d at >4 to .49* intervals; not to e8ceed mg

#amipril .2646 mg PG @d; not to e8ceed . mg/d

Pediatric

Captopril 32.64>.26 mg/dose PG @>.4.h; not to e8ceed 3 mg/*g/d

!nalapril &ot esta$lished

=isinopril &ot esta$lished

#amipril &ot esta$lished

"nteractions

&SAIDs ma" reduce h"potensive effects; AC! inhi$itors ma" increase digo8in, lithium, and

allopurinol levels; rifampin decreases levels; pro$enecid ma" increase levels; h"potensive

effects of AC! inhi$itors ma" $e enhanced 9hen administered concurrentl" 9ith diuretics

Contraindications

Documented h"persensitivit"; histor" of angioedema

Precautions

Pregnancy



Precautions

Categor" D in second and third trimester of pregnanc"; caution in renal impairment, valvular

stenosis, or severe congestive heart failure

!ngiotensin "" receptor antagonists

:or patients una$le to tolerate AC! inhi$itors2

Losartan 7Cozaar8, 9alsartan 7Dio?an8

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&onpeptide angiotensin II receptor antagonists that $loc* vasoconstrictor and aldosterone4

secreting effects of angiotensin II2 Ma" induce more complete inhi$ition of renin4angiotensin

s"stem than AC! inhi$itors, do not affect response to $rad"*inin, and are less li*el" to $e

associated 9ith cough and angioedema2

Dosing

Adult

=osartan .64> mg PG @d/$id

%alsartan 0 mg/d PG; ma" increase to >3 mg/d if needed

Pediatric

&ot esta$lished

"nteractions

etocona(ole, troleandom"cin, sulfaphena(ole, and pheno$ar$ital ma" decrease effects;

cimetidine ma" increase effects

Contraindications


Precautions

Pregnancy



Precautions

Categor" D in second and third trimester of pregnanc"; caution in unilateral or $ilateral renal

arter" stenosis, severe hepatic insufficienc", $iliar" cirrhosis or o$struction, primar"

h"peraldosteronism, and h"per*alemia

Eprosartan 76e?eten8, 4l(esartan 7#enicar8

Angiotensin receptor antagonist that $inds to A'> angiotensin II receptor, $loc*ing

vasoconstrictor and aldosterone4secreting effects of angiotensin II2 Ma" induce a more

complete inhi$ition of renin4angiotensin s"stem than AC! inhi$itors and do not affect

response to $rad"*inin and, thus, is less li*el" to $e associated 9ith cough and angioedema2

:or patients una$le to tolerate AC! inhi$itors2

Dosing

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Adult

!prosartan 'eveten

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Adult

6 mg PG @d; ma" increase dose after 9*, not to e8ceed > mg/d

Pediatric

&ot esta$lished

"nteractions

CP6 ?A su$strate; potent CP?A inhi$itors eg, *etocona(ole< increase serum levels

a$out 64fold, less potent CP?A inhi$itors eg, er"throm"cin, sa@uinavir, verapamil,

flucona(ole< increase serum levels a$out .4fold; grapefruit 1uice increases serum levels a$out

.67; coadministration 9ith potassium supplements, salt su$stitutes, or drugs *no9n to

increase serum potassium eg, amiloride, spironolactone, triamterene, AC! inhi$itors,

angiotensin II inhi$itors< increases ris* of h"per*alemia

Contraindications

Documented h"persensitivit"; h"per*alemia or coadministration 9ith drugs causing increased

potassium; t"pe . dia$etes 9ith microal$uminuria; moderate4to4severe renal insufficienc" ie,

CrCl 6 m=/min or serum creatinine N. mg/d= malesE or N>20 mg/d= femalesE mg PG $id initial; 2.4>2. mg/d divided $id/@id maintenance; not to e8ceed >2. mg/d

Pediatric

&ot esta$lished

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"nteractions

'ric"clic antidepressants inhi$it h"potensive effects of clonidine; coadministration of

clonidine 9ith $eta4$loc*ers ma" potentiate $rad"cardia; tric"clic antidepressants ma"

enhance h"pertensive response associated 9ith a$rupt clonidine 9ithdra9al; h"potensive

effects of clonidine are enhanced $" narcotic analgesics

Contraindications


Precautions

Pregnancy



Precautions

Caution in cere$rovascular disease, coronar" insufficienc", sinus node d"sfunction, and renal

impairment

Renin ini'itor

&e9est class of antih"pertensive drugs2 Acts $" disrupting the renin4angiotensin4aldosterone

s"stem feed$ac* loop2

!lis$iren 76e$turna8

Direct renin inhi$itor2 Decreases plasma renin activit" and inhi$its conversion of

angiotensinogen to angiotensin I as a result, also decreasing angiotensin II< and, there$",

disrupts the renin4angiotensin4aldosterone s"stem #AAS< feed$ac* loop2 Indicated for

h"pertension as monotherap" or in com$ination 9ith other antih"pertensive drugs2

Dosing

Adult

>6 mg PG @d initiall"; if needed, ma" increase to ? mg/d

Pediatric

>0 "ears &ot esta$lished

"nteractions

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Coadministration 9ith ir$esartan decreases Cma8$" 67; coadministration 9ith atorvastatin

increases Cma8and A+C $" 67; *etocona(ole increases plasma levels $" a$out 07; does

not inhi$it CP6 isoen("mes or induce CP?A; coadministration 9ith furosemide

decreases furosemide Cma8and A+C $" ?7 and 67, respectivel"; high4fat meals

su$stantiall" decrease a$sorption; use 9ith ma8imal dose of AC! inhi$itors has not $een

studied

Contraindications


Precautions

Pregnancy

D 4 :etal ris* sho9n in humans; use onl" if $enefits out9eigh ris* to fetus

Precautions

Discontinue use in pregnanc" as soon as possi$le $ecause use of drugs affecting the renin4

angiotensin s"stem during second and third trimesters has $een associated 9ith fetal and

neonatal in1ur", including h"potension, neonatal s*ull h"poplasia, anuria, renal failure, and

fetal death; ma" cause angioedema; dose4related I adverse effects ma" occur

ollow-up

urter "npatient Care

"pertensive crisis "pertensive crisis rarel" occurs and is characteri(ed $"

e8tremel" high $lood pressure, diastolic pressure usuall" e8ceeding >? mm g, and

evidence of potentiall" life4threatening end organ d"sfunction2 'he clinical conditions

associated 9ith h"pertensive crisis include h"pertensive encephalopath", e8treme

h"pertension 9ith acute pulmonar" edema, e8treme h"pertension 9ith acute aortic

dissection, e8treme h"pertension 9ith intracere$ellar hemorrhage, e8treme

h"pertension 9ith an acute m"ocardial infarction, and malignant h"pertension2

"pertensive crisis should $e differentiated from ver" high $lood pressure 9ithout

evidence of acute, severe end organ d"sfunction2 Malignant h"pertension Malignant h"pertension ma" or ma" not $e associated 9ith

clinical conditions present in h"pertensive crisis2 A patient 9ith malignant

h"pertension al9a"s has retinal papilledema and flame4shaped hemorrhages and

e8udates2 Gther clinical features of malignant h"pertension ma" include

encephalopath", confusion, left ventricular failure, intravascular coagulation, and

impaired renal function, 9ith hematuria and 9eight loss2 'he pathological hallmar* of

malignant h"pertension is fi$rinoid necrosis of the arterioles, 9hich occurs

s"stemicall", $ut specificall" in the *idne"s2 'hese patients develop fatal

complications if untreated, and more than 57 9ill not survive $e"ond >4. "ears2

'reatment of h"pertensive crisis consists of the acute reduction of $lood pressure

using aggressive pharmacological therap", follo9ed $" maintenance therap" 9ith oralmedications2

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o Sodium nitroprusside is a commonl" used medication2 It is a short4acting

agent, and the $lood pressure response can $e titrated from minute to minute2

o9ever, patients must have constant monitoring in an intensive care unit2 'he

potential e8ists for thioc"anate and c"anide to8icit" 9ith prolonged use or if

the patient has renal or hepatic failure2

o Dia(o8ide ma" also $e used in h"pertensive crisis2 Small $oluses of > mgare administered ever" 6 minutes, as indicated2 Dia(o8ide is not preferred 9ith

concomitant congestive heart failure or lo9 cardiac output2

o =a$etalol, an alpha4 and $eta4$loc*ing agent, has proven to $e @uite $eneficial

in the treatment of patients 9ith h"pertensive emergencies2 =a$etalol is

particularl" preferred in patients 9ith acute dissection2 Boluses of >4. mg

ma" $e administered, or the drug ma" $e infused at > mg/min until the desired

$lood pressure is o$tained2 Gnce an ade@uate $lood pressure level is o$tained,

oral h"pertensive therap" should $e initiated, and patients are graduall"

9eaned from parenteral agents2

o Clevidipine, a dih"drop"ridine calcium channel $loc*er, is administered

intravenousl" for rapid and precise $lood pressure reduction2 Clevidipine israpidl" meta$oli(ed in the $lood and tissues and does not accumulate in the

$od"2 Initiate I% infusion at >4. mg/h; titrate the dose at short intervals ie, 5

seconds< initiall" $" dou$ling the dose2 As $lood pressure approaches its goal,

increase the dose $" less than dou$le and lengthen the time $et9een dose

ad1ustments to ever" 64> minutes2 An appro8imatel" >4 to .4mg/h increase

produces an additional .4 to 4mm g decrease in s"stolic pressure2 '"picall",

the therapeutic response is achieved 9ith 43 mg/h, although severe

h"pertension ma" re@uire higher doses2 Most patients have received ma8imum

doses of >3 mg/h or less; e8perience is limited 9ith short4term dosing as high

as ?. mg/h2 Because of lipid load restrictions, do not e8ceed > m= or an

average of .> mg/h 9ithin a .4hour period; e8perience is limited 9ith use

$e"ond -. hours2

urter 4utpatient Care

Interventions can $e used to improve the control of $lood pressure in patients 9ith

h"pertension2

o %arious interventions can $e implemented to treat uncontrolled h"pertension2

'hese interventions include the follo9ing >< self4monitoring, .< educational

interventions directed to the patient, ?< educational interventions directed to

the health professional, < health professional nurse or pharmacist

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A comprehensive strateg" for reduction in mortalit" and mor$idit" from h"pertension

must include prevention strategies, earlier detection, and ade@uate treatment2 Ideall", a

population strateg" should $e used in order to lo9er $lood pressure in the communit"2

More intensive efforts are re@uired to lo9er $lood pressure in high4ris* population

groups, 9hich include individuals 9ith a famil" histor" of h"pertension, $lac*

ancestr", o$esit", e8cessive sodium consumption, ph"sical inactivit", and/or alcoholconsumption2 !ven a small reduction in $lood pressure confers significant health

$enefits2 A .4mm g reduction in diastolic pressure is estimated to decrease the ris* of

stro*e $" >67 and the ris* of coronar" heart disease $" 372

Prevention of h"pertension ma" $e achieved $" the follo9ing interventions

o Feight control

o Increased ph"sical activit"

o Moderated sodium and alcohol inta*e

o Increased potassium inta*e

o A dietar" pattern rich in fruits and vegeta$les and lo94fat meat, fish, and dair"

products

Co(plications

Central nervous s"stem 4 Intracere$ral hemorrhage, lacunar infarcts, encephalopath",

throm$otic stro*e, transient ischemic attac*

Gphthalmologic 4 :undal hemorrhages, e8udates, papilledema

Cardiac 4 =%, congestive heart failure, angina pectoris, m"ocardial infarction

%ascular 4 Aortic dissection, diffuse arthrosclerosis

#enal 4 &ephrosclerosis, renal arter" stenosis

Prognosis

Most individuals diagnosed 9ith h"pertension 9ill have increasing $lood pressure as

the" age2

+ntreated h"pertension is notorious for increasing the ris* of mortalit" and is often

descri$ed as a silent *iller2

Mild4to4moderate h"pertension, if left untreated, is associated 9ith a ris* of

atherosclerotic disease in ?7 of people and organ damage in 67 of people after

onl" 04> "ears of onset2

Patient Education

"pertension is a lifelong disorder2 :or optimal control, a long4term commitment to

lifest"le modifications and pharmacological therap" is re@uired2 'herefore, repeated

in4depth patient education and counseling not onl" improve compliance 9ith medical

therap" $ut also reduce cardiovascular ris* factors2

%arious strategies to decrease cardiovascular disease ris* include the follo9ing

o Prevention and treatment of o$esit"

o Appropriate amounts of aero$ic ph"sical activit"

o Diets lo9 in salt, total fat, and cholesterol

o Ade@uate dietar" inta*es of potassium, calcium, and magnesium

o =imited alcohol consumptiono Avoidance of cigarette smo*ing

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:or e8cellent patient education resources, visit eMedicine)s Dia$etes Center and

Cholesterol Center2 Also, see eMedicine)s patient education articles igh Blood

Pressure, igh Cholesterol, Chest Pain, Coronar" eart Disease, and eart Attac*2

Miscellaneous

Medicolegal Pit%alls

"pertension is one of the most common modifia$le ris* factors for atherosclerotic

disease2

According to the J&C %I enrollment report, onl" 6?7 of patients 9ith h"pertension

are $eing treated in the +nited States2 Gf these, onl" .-7 have ade@uatel" controlled

$lood pressure, and onl" 67 of treated patients have a $lood pressure less than

>/5 mm g2

Despite an arra" of pharmaceutical agents to treat h"pertension, J&C %I recommends

diuretics and $eta4$loc*ers as the preferred initial agents $ecause of proven efficac"and lo9er cost2

Patients 9ith h"pertension should $e identified and staged $ased on $lood pressure

determinations and cardiovascular ris* and the presence or a$sence of target organ

damage2

J&C %I recommends lo9er target $lood pressure goals in . select populations >?/06 mm g< and .< patients 9ith

renal disease $lood pressure >?/06 mm g; if urinar" protein is N> g/d, a $lood

pressure >.6/-6 mm g

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o 'he 9or*up for renovascular h"pertension is recommended onl" in patients in

9hom further interventional therap", such as angioplast" or surger", is feasi$le

and 9ill $e pursued2

o Digital su$traction angiograph" DSA< is performed follo9ing intravenous

contrast in1ection to detect the a$dominal aorta and its $ranches2 'he

radioisotope renogram ma" $e performed as a screening test, $ut renalarteriograph" is re@uired for definitive diagnosis2 Duple8 ultrasonograph" of

the renal arteries has a sensitivit" of greater than 57 for $oth the presence

and degree of renal disease26 #enograph" using iodohippurate sodium I >?> or

technetium 'C 55m dieth"lenetriamine pentaacetic acid after administration of

the oral AC! inhi$itor captopril can identif" right ventricular h"pertroph" 9ith

a$out 07 sensitivit" and specificit"2

o Appropriate management of patients 9ith $ilateral or unilateral renal arter"

stenosis and significant renal d"sfunction is controversial2 Correction of

stenosis ma" not result in improvement of renal function or reduction in $lood

pressure $ecause renal d"sfunction and h"pertension ma" $e caused $" renal

parench"mal disease2 #ecent studies have sho9n onl" a modest improvementin $lood pressure control in medication reduction and in significant

improvement in renal function follo9ing percutaneous transluminal renal

angioplast"2

Pheochromoc"toma is an infre@uent cause of h"pertension, $ut cure often is possi$le

9ith surgical therap"2 'he incidence is not *no9n, $ut up to 2>7 of individuals 9ith

h"pertension ma" have these lesions2 Pheochromoc"tomas are chromaffin cell tumors,

9hich arise mainl" in the adrenal medulla, s"mptomatic ganglia, and paraganglia

along the s"mptomatic chain2 +p to 0457 of pheochromoc"tomas are found in one

or $oth adrenal glands2 Most patients 9ith pheochromoc"toma have headache,

s9eating, or palpitations2 "pertension ma" $e sustained or paro8"smal2 Patients ma"

manifest nervousness, nausea, vomiting, 9eight loss, and funduscopic changes of

h"pertension2 eadaches are paro8"smal, thro$$ing, and $ilateral2 S9eating is @uite

profuse and generali(ed2 Palpitations are due to the concomitant tach"cardia2

o 'he 9or*up of pheochromoc"toma includes measurement of urinar"

catecholamines and their meta$olites2 +rinar" e8cretion of metanephrine,

normetanephrine, free catecholamines, and vanill"lmandelic acid can $e

performed2 Measurement of catecholamines increases the sensitivit" from -4

57, compared to measuring metanephrine alone2 Fhen an a$normal value is

detected $" metanephrine or vanill"lmandelic acid assa", measurement of free

catecholamines should $e performed to confirm the diagnosis2

o Gnce the diagnosis of pheochromoc"toma is confirmed $" chemical anal"sis,the precise location and e8tent of the tumor is assessed 9ith an imaging stud"2

An a$dominal C' scan often allo9s locali(ation of the tumor, $ut the a$sence

of a lesion on C' scan re@uires adrenal venous sampling or e8plorator"

laparotom"2 Initial sta$ili(ation is 9ith medical therap"2 Surgical resection is

re@uired $ecause up to >7 of tumors ma" $e malignant2 In difficult cases,

plasma, catecholamine assa"s, and a clonidine suppression test ma" $e used2 In

normal and essential h"pertension, clonidine suppresses plasma norepinephrine

levels2 An ina$ilit" to suppress catecholamines ma" indicate

pheochromoc"toma; ho9ever, the sensitivit" and specificit" of this test is not

*no9n2

Mineralocorticoid4induced h"pertension Mineralocorticoid e8cess secondar" toprimar" aldosteronism is infre@uentl" o$served and is characteri(ed $" e8cessive

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production of aldosterone2 #enal sodium retention, *aliuresis, h"po*alemia, and

h"pochloremic meta$olic al*alosis are the common manifestations2 'hese patients

develop increased intravascular volume, resulting in h"pertension2 'he $lood pressure

increase ma" var" from mild h"pertension to mar*ed elevation in primar"

aldosteronism2 Patients ma" have underl"ing adenoma or h"perplasia of the adrenal

gland and rarel" have an e8tra4adrenal source for aldosterone2 Gral contraceptiveassociated h"pertension 'he most common form of secondar"

h"pertension is an endocrine cause oral contraceptive use2 Activation of the renin4

angiotensin4aldosterone s"stem is the li*el" mechanism $ecause hepatic s"nthesis of

angiotensinogen is induced $" the estrogen component of oral contraceptives2

Appro8imatel" 67 of 9omen prescri$ed oral contraceptives ma" develop

h"pertension, 9hich a$ates 9ithin 3 months of discontinuation2 'he ris* factors for

oral contraceptiveassociated h"pertension include mild renal disease, familial histor"

of essential h"pertension, age greater than ?6 "ears, and o$esit"2

:or the patient 9ho has h"pertension and is h"po*alemic, a .4hour urine specimen

should $e collected for sodium and potassium measurement2 If the urine sodium level

is more than > mmol/= and urine potassium is less than ? mmol/=, aldosteronismis unli*el"2 If urinar" potassium e8ceeds ? mmol/=, the patient should have P#A

measured2 If the P#A is high, the li*el" causes are estrogen therap", renovascular

h"pertension, malignant h"pertension, or salt49asting renal disease2 In the presence of

lo9 P#A, the serum aldosterone level can $e measured2 A lo9 aldosterone level

indicates licorice ingestion or other mineralocorticoid ingestions2 A high aldosterone

level indicates primar" aldosteronism2 A C' scan ma" identif" the presence of an

adenoma2 In the a$sence of C' scan findings, differentiating h"perplastic

aldosteronism from adenoma is often difficult2

#ecent advances in understanding of the regulation of $lood pressure and

pathoph"siologic events that result in h"pertension have led to the development of

ne9 classes of drugs2 'hese agents are in various stages of development and include

the follo9ing

o %asopressin antagonists

o Compounds to enhance the effects of endogenous vasodilators eg, natriuretic

peptides7 of people, high $lood pressure is caused $" another disease this is called

secondar" h"pertension

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actors tat can 'e canged

4?erweigt 7o'esity8: G$esit" is defined as having a$od" mass inde8BMI< greater

than ? *g/m.2 It is ver" closel" related to high $lood pressure2 Medical professionals

strongl" recommend that all o$esepeople 9ith high $lood pressure lose 9eight until

the" are 9ithin >67 of their health" $od" 9eight2 our health care provider can help"ou calculate "our BMI and health" range of $od" 9eight2

Sodiu( 7salt8 sensiti?ity:Some people have high sensitivit" to sodium salt

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Di((iness

Blurred vision

&ausea

People often do not see* medical care until the" have s"mptoms arising from the organ

damage caused $" chronic ongoing, long4term< high $lood pressure2 'he follo9ing t"pes oforgan damage are commonl" seen in chronic high $lood pressure

eart attac*

eart failure

Stro*e or Omini stro*eO transient ischemic attac*, 'IA mm g2

Malignant h"pertension ma" $e associated 9ith headache, light4headedness, or

nausea2

'his degree of high $lood pressure re@uires emergenc" hospitali(ation and lo9ering of

$lood pressure to prevent $rain hemorrhage or stro*e2

It is of utmost importance to reali(e that high $lood pressure can $e unrecogni(ed for

"ears, causing no s"mptoms $ut causing progressive damage to the heart, other organs, and

$lood vessels2

5en to See$ Medical Care

Call "our health care provider if a routine $lood pressure measurement during health

screening< reveals s"stolic $lood pressure higher than > mm g, diastolic $lood pressure

higher than 5 mm g, or $oth2

Call "our health care provider if "ou have an" of the follo9ing s"mptoms

+ne8plained severe headache

Sudden or gradual changes in vision

=ight4headedness or di((iness

&ausea associated 9ith severe headache

Chest pain or shortness of $reath upon e8ertion

'ell "our health care provider if an" famil" mem$er has or has had high $lood pressure, heart

attac*, stro*e, or *idne" failure2
http://www.emedicinehealth.com/script/main/art.asp?articlekey=59400http://www.emedicinehealth.com/script/main/art.asp?articlekey=26099http://www.emedicinehealth.com/script/main/art.asp?articlekey=4510http://www.emedicinehealth.com/script/main/art.asp?articlekey=21288http://www.emedicinehealth.com/script/main/art.asp?articlekey=3672http://www.emedicinehealth.com/script/main/art.asp?articlekey=59416http://www.emedicinehealth.com/script/main/art.asp?articlekey=4260http://www.emedicinehealth.com/script/main/art.asp?articlekey=5867

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