 50 million people USA  SBP>115 incr risk CAD/CVA  Pseudo-HTN  Secondary HTN 2

hypertension 3  Most common HBP( > 90 %)--multifactorial  increased peripheral resistance perpetuates the process of high blood pressure and all of its secondary effects  pressure varies throughout the day (every1)  major risk factor for coronary, renal, and cerebrovascular disease (50% of all USA deaths)  leading cause of doctor’s visit  carries prognostic value: 16X increased risk cardiac death in 40 y.o. smokes

hypertension 4  Patient seated/back supported/feet on floor  Should rest 5 minutes prior  Arm at heart level  No recent caffeine, tobacco, cocaine  Take medications as directed  Cuff size important  Orthostatics  Standing BP drops 20-30mmHg fluid depleted

 Determine lifestyle/CV risk factors  ID and Tx secondary causes  ID target end organ damage brain, heart, kidney, eyes, arteries 5

 Cigarette smoking  Obesity  Inactivity  Dyslipidemia  Diabetes mellitus  Male>55; Female>65  Fam Hx: male<55; female<65  Metabolic syndrome 6

 Endocrine  Cardiac  A lot of times in the young  Renal  A lot of times untreated HTN can Lead to kidney problems and vice versa 7

 Coarctation  Illness of young  Obstructive sleep apnea  Obesity  Small chin or jaw  Silent killer 8

 Constriction beyond subclavian  Cutting off blood flow to subclavian (L)  Weak,delayed,absent FA pulse  Rib notching on CXR  Childhood  Tx surgical 9

 Obese, retrognathia,large neck  Loud snoring  Daytime hypersomnolence, morning headache  Polysomnography test 10

hypertension 11  Abdominal bruit: renal artery stenosis  Palps,HA,pallor,perspiration: pheochromocytoma  Obesity,moon face,purple striae: Cushing’s  Abd mass: polycystic kidney,hydroneph  Obesity,hypersomnolence: OSAS  Agitation, sweating: cocaine, ethanol,narc w/d  Hypokalemia: hyperaldosteronism  Hypercalcemia: hyperparathyroidism

hypertension 12 Simple Guide to work up secondary causes of HTN

 BCPs – not always but can  EtOH – 10mmHG increase potentially per 6oz  Decongestants,diet pills  Raise HR  NSAIDs  MOA inhibitors  Cocaine  Marijuana  Licorice (black, glycerilic acid pseudoaldosteronism)  cyclosporine 13

Patient SubgroupTarget SBPTarget DBP > 60 years<150<90 <60 years<140<90 >18 years w CKD<140<90 >18 years w DM<140<90 14 James PA, et al.,JAMA,2013 Dec18

hypertension 15  Urine analysis  Chemistry panel  Cholesterol  CBC  Drug screen

 <140/90  Diabetics/CKD/High risk CAD <130/80  Stay tuned for AHA/ACC update

hypertension 17  Familiarity with target end-organ damage  What is ideal BP?  Causes of secondary hypertension  Ideal agents for condition(s)  Familiarity with treatment options