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50 million Americans have B/P > 140 systolic and > 90 diastolic.
20-30% of blacks and 15% of whites in the U.S.
Why Treat Hypertension? To avoid end organ disease.
Left ventricular hypertrophy results in CHF, ischemia, ventricular arrhythmias, and sudden death.
Nephrosclerosis results in end-stage renal disease, necessitating dialysis.
Stroke-either hemorrhagic or infarction.
Etiology
1. Essential HTN is multifactorial.
2. Salt intake alone may not be significant but if combined with strong genetics it may play an important role for a select group.
3. Exacerbating factors include obesity, salt intake, excessive alcohol (> 2 drinks a day) or alcohol binging, tobacco use and low K+ intake.
4. NSAIDS should be avoided especially in patients with borderline HTN as it can cause a 5 mm Hg or greater rise in B/P.
5. Secondary HTN: Consider in those <20 and >50 and a diagnosis of HTN or those with previous good control who become refractory to treatment.
6. Consider renal disease, hyperaldosterone states, Cushing's, hypercalcemia, pheochromocytoma, coartaction, or thyroid disease.
Laboratory Evaluation
1. Urinalysis (assess for protein, hematuria, casts), EKG, BUN, creatinine, and uric acid (assess risk for future diuretic use). Assess lipid profile, and screen for diabetes.
Indications for Medical Therapy
1. Goal is to prevent morbidity (end-organ disease) and mortality
2. Decision to treat with medications should be based on an individual assessment of risk factors versus B/P measurement alone.
3. Twenty randomized trials of Stage H and HI HTN showed ~incidence of stroke by 30-50% and bincidence of CHF by 40-50% and ,b fatal and nonfatal CHD by 10-15%.
4. Several studies in older adults with predominantly systolic HTN demonstrated that treatment prevents fatal and nonfatal MI and overall decrease in cardiovascular morbidity and mortality..
New Classification of Stages of HTN
Choosing Medication Treatments
1. Often times associated medical conditions point to use of a particular agent. See table
I. Specific HIV/AIDS drug interactions with PI's
1. Indinavir: Avoid diuretics of all classes. Hydration of 2-3L is often required.