# Hypertension - ***
-- BP: ***
-- Stage: *** Elevated (SBP >120), Stage 1 (>130/80), Stage 2 (>140/90)
-- At goal? *** (generally <130/80)
-- Co-Morbidities: *** CHF, CAD, DM, obesity, OSA, gout
-- Symptoms: *** headache, dizziness, tinnitus
-- Lifestyle: *** diet, salt, caffeine, alcohol, exercise, smoking
-- Medications: *** NSAIDs, steroids, OCPs, stimulants
-- Anti-HTN Adherence: ***
Secondary HTN DDx:
Consider if BP controlled with 4 agents, uncontrolled on 3+ agents (including diuretic), if an acute rise in previously well controlled BP, age <30 without known risk factors, elevated disatolic BP, labile BP, serious electrolyte derangements
-- Medications: NSAIDs, steroids, OCPs, stimulants, d/c HTN meds
-- OSA: sleep study
-- Renal Artery Stenosis: rise in creatinine after starting ACE, duplex doppler US
-- Primary Aldosteronism: hypokalemia, aldo:renin ratio >30
-- Pheochromocytoma: 24-hour urine metanephrines, plasma metanephrines
-- Rare: Cushing Disease, Hyperthyroidism, coarctation of the aorta
-- Lifestyle: *** exercise (5-8 mmHg), weight loss (1mmHg per kg lost), DASH diet (8-14 mmHg), salt<2g/day (2-8 mmHg), caffeine <2 cups/day (2-5mmHg), alcohol <2-3 drinks/day (2-4 mmHg), smoking cessation (3-5 mmgHg 1 year, 6-7mmHg 3 years)
-- Medical: *** if BP >140/90 or >130/80 with other risk factors (ASCVD >10%); start 1 drug if <150/90, 2 if >150/90
First Line: CCB (amlodipine 2.5-10mg daily), ACE/ARB (valsartan 80-320mg daily, losartan 50-100 daily, lisinopril 10-40mg daily), thiazide (chlorthalidone 12.5-25mg daily, HCTZ 25-50mg daily)
Second Line: BB, hydralazine (50-100mg in 2-3 doses), isosorbide dinitrate, clonidine, alpha blockers (prazosin, doxazosin)
-- Initial Workup: *** BMP, UA, Protein/Creatinine Ratio, CBC, glucose, TSH, lipids, EKG
-- Monitoring: *** next BP check, next BMP; check BP and BMP/Mg (for ACE/ARB and diuretic) 2-4 weeks after any change, then once yearly
-- Secondary HTN: *** meds, TSH, sleep study, aldo:renin, renal artery dopplers
-- Referral: *** consider referral to HTN expert if resistant or secondary HTN suspected
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High blood pressure affects almost half the population in the United States. Unless severely high, elevated blood pressure does not usually cause any symptoms, but over time can lead to damage in the blood vessels. This is why high blood pressure is the most common cause of cardiovascular disease including heart disease, stroke, and kidney failure.
Treatment is based around loweing blood pressure to reduce the long-term risk of developing the above diseases. All patients with high blood pressure should consider lifestyle changes including diet (lower salt, alcohol, caffiene intake), exercise/weight loss, and quitting smoking. However, despite our best intentions, many patients will need to take medicines that can help lower their blood pressure.
Hello ***. You have high blood pressure, also called hypertension. Lifestyle changes that can help lower blood pressure include weight loss, exercise (moderate activity for 40 minutes 3-4 times per week), the DASH diet, reducing salt, caffeine, and alcohol intake, and quitting smoking.
Taking Blood Pressure at Home
We would like you to monitor your blood pressure at home. Steps to most accurately record your blood pressure:
Here is a YouTube video that includes some of these tips for your reference.
To help control your blood pressure, we'd like to start a new medication called ***.
Please take *** mg, ***.
We will plan to have you back in clinic in *** 2-4 weeks to recheck your blood pressure and check labwork. At that time, we may decide to increase the dosage.
Side effects of this medicine can include ***. Please let us know if you develop any of these symptoms.
Amlodipine - pedal edema, nausea, flushing
ACE - dry cough, angioedema, prerenal AKI
ARB - prerenal AKI
Thiazide - urgency, electrolyte derangements
Hypertension is one of the most common outpatient condiditions you will manage. Unless severely high, elevated blood pressure does not usually cause any symptoms, but over time can lead to damage of the blood vessels. This is why high blood pressure is the most common cause of cardiovascular disease including heart disease, stroke, and kidney failure. Most cases are from essential hypertension, but patients with severely elevated BP or those who are resistant to initial treatments should be worked up for secondary hypertension which can be caused by medications, OSA, renal artery stenosis, primary aldosteronism, and other rare tumors. Proper blood pressure reading includes sitting quietly for 5 minutes, arm supported at heart-level, using a properly sized cuff over the patient's bare arm. Lifestyle modifications include weight loss, exercise (moderate activity for 40 minutes 3-4 times per week), the DASH diet, reducing salt, caffeine, and alcohol intake, and quitting smoking. Medications should be considered if BP >140/90 or >130/80 with other risk factors (ASCVD >10%). Start 1 drug if <150/90, 2 if >150/90. First Line treatments include calcium channel blockers, ACE/ARBs, and thiazides. Second Line treatments include beta blockers, hydralazine, isosorbide dinitrate, clonidine, and alpha blockers.