Hypertension: General Treatment

00:01 And what about secondary hypertension? When do you see that? I think a secondary hypertension, it's rare.

00:07 It's only up to 10% of cases of hypertension.

00:10 It’s probably less than that.

00:11 But especially, in a middle-aged adult, when they come in with a very high blood pressure, and particularly a blood pressure that’s not well controlled on initial therapy, you can consider some differential diagnosis.

00:23 Thyroid disease is very easy to test for and pretty common, but oftentimes it will also be associated with other symptoms and a pulse if they're hyperthyroid that's high.

00:33 So, therefore, you can ferret out that they have thyroid disease from other historical factors.

00:38 It’s rare when it’s just sitting there.

00:40 And the only symptom it's really causing is high blood pressure.

00:44 Hyperaldosteronism can be a problem.

00:46 Conn syndrome.

00:47 So, look for electrolyte abnormalities associated with that.

00:51 Renal artery stenosis is the most common cause of secondary hypertension.

00:55 And if it’s middle-aged adults, you're probably talking about acquired renal artery stenosis as opposed to congenital renal artery stenosis.

01:03 This – watch what their GFR, their glomerular filtration rate, is doing.

01:09 Watch their creatinine levels.

01:11 But it often needs analysis with something like either a CT or magnetic resonance angiography of the renal arteries.

01:20 And pheochromocytoma, we all worry about it.

01:22 It's actually incredibly rare.

01:24 And again, these patients usually have other symptoms – tremor, sweating and weight loss – that can give away the fact that they have this excess of catecholamines.

01:34 It's rare that it’s just – oh, the blood pressure is elevated by itself.

01:40 What do you to evaluate patients once they are diagnosed with hypertension? Everybody gets a baseline electrocardiogram, looking for things like left ventricular hypertrophy or prior cardiac damage, glucose level or an HbA1c, something to screen for diabetes, something to screen for hyperlipidemia, a check of their electrolytes along with their kidney function, as well as a hemoglobin level and urinalysis or a microalbumin creatinine ratio to check for the possibility of proteinuria and early kidney disease.

02:09 That's your baseline.

02:10 And these essentially should be repeated at least when we talk about the electrolytes, the urinalysis on an annual basis.

02:21 At least. At least on an annual basis.

02:24 Remember the lifestyle changes are still at the foundation for the treatment of hypertension.

02:30 And actually if you look at something like the dietary approaches to stop hypertension, that reduction on average with 11.5 over 5.5 points of mercury is really remarkable.

02:43 That's more powerful than most anti-hypertensive agents.

02:46 And, obviously, patients can do a DASH.

02:49 That’s going to yield other good things in terms of their cholesterol and their metabolism, their body weight.

02:55 So, there are side benefits to that diet that are really wonderful.

02:59 But that reduction in blood pressure values is outstanding.

03:04 Weight loss certainly promotes a lower blood pressure as well.

03:09 So, that's one of the benefits of, say, bariatric surgery.

03:12 A lot of patients are cured of hypertension, following the significant weight loss they experience with bariatric surgery.

03:19 But even following a good diet and exercise and losing 4 kilos can result in a significant reduction in blood pressure.

03:27 And exercise, as I mentioned, in and of itself can reduce blood pressure as well.

03:31 So, these are the keys.

03:33 And you can see that, if you put all of these things together, many patients wouldn't – could avoid medical therapy completely if they really embraced diet and exercise.

03:47 So, let’s return to our case. She has actually come back to clinic now.

03:51 And a repeat blood pressure, unfortunately, despite trying to do her lifestyle changes in the past two weeks, is 150/94.

03:58 Her pulse is 86 bpm.

04:00 So, now, what do you want to do? Do you want to allow six months for lifestyle changes to have an affect since she started them? Do you want to start a thiazide diuretic, start an alpha adrenergic blocker or start a beta blocker? Which one would you choose? I would go with a thiazide diuretic.

04:16 That is recommended as a first-line therapy by JNC 8.

04:20 So, here are the first-line treatments after lifestyle for hypertension.

04:25 And JNC 8 left this fairly open.

04:28 And again, these are only recommendations, but the recommendations are broad and catch most patients, I think.

04:34 Thiazide diuretics are a great option for patients.

04:39 One thing, whenever I prescribe a diuretic, is that I will ask them if they have any urinary issues.

04:45 Many older adults have overactive bladder or benign prostatic hypertrophy, and therefore, already may be struggling with genitourinary issues.

04:55 I don't want to exacerbate that by giving them a thiazide diuretic.

04:59 I would choose something else for those patients.

05:02 The other thing is prescribing a thiazide alone – watch closely for the potassium because thiazide promotes hypokalemia.

05:10 Whereas ACE inhibitors and ARBs, also considered a first-line agent, can promote hyperkalemia.

05:16 So, therefore, a combination of one of those agents with a thiazide is helpful in terms of maintaining normokalemia.

05:24 And calcium channel blockers have their own range of side effects, but one thing they don't do much is affect electrolytes.

05:31 It’s also worth noting that atenolol is not recommended by JNC 8.

05:34 It doesn't confer overall the same mortality benefit for cardiovascular disease that these other agents maintain.