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Primary and Secondary Hypertension (JNC 7 Guidelines)

by Carlo Raj, MD
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    00:01 being affected is to know. Now with hypertension, how important is this for you to know? My goodness gracious. Are you kidding me? Hypertension is part of what? Metabolic syndrome X. Is that a problem in the United States? Of course, it is. 85-90 percent of our patients are obese, aren't they? Those are type of patients that you are going to see. What do they have? They've got hyper, hyper, hyper. Hypertension, hyperglycemia, hyperlipidemia. Hypertension is a huge concept. So far we have introduced the normal, we've gone into the cut off point of 140/90 and there it would be and we got into urgency and emergency.

    00:36 You focus upon please anything beyond 140 and 90 you are in stage 1. All the other categories that we see here. Well, you take a look at it on your own time. Once you get into emergency in such, well not only are we going to use thiazides. Think about thiazides. What did they do? Get rid of some of that fluid. Is it a diuretic, is it not? Where does it work? DCT, distal convulated tubule. What is there? Is it the sodium, potassium, two chlorides, yes or no? Good, no. It is the sodium chloride channel, is it not, in the DCT? That is where the thiazides work. What receptor works in the DCT, in which perhaps thiazide might influence? Just to make sure that we're clear. PTH, parathyroid hormone. Keep those in mind as you move forward. We are focusing upon the pathology, but understand the pathology is not just path is it? You need to make sure that you know what normal is the physio and to make sure what the disease is and how do you manage your patient.

    01:35 So, primary is what we talk about. What does primary mean to you? It is a fact that your focus should be on sodium. Why? Because if sodium comes in and you are retaining it, then what are you going to do with the volume? You are going to retain that as well. You retain your volume and so therefore you increased the amount of fluid or preload in the heart and what is this relationshop called? Called Frank-Starling relationship. What are you going to an increase when you have increase in volume within the heart? I believe it is called systole. The active portion of you blood pressure, is it not? And could you also have your diastole affected? Of course, you can. But with diastole, what are you looking? Are you looking at the heart, are you looking at the blood vessels? You are looking at the vasculature, people. So as primary, your focus there should be on sodium. You know that and you will be in good shape. Let us go onto secondary. What does that mean? We are looking at an underlying issue in which now the patient has developed secondary hypertension. We shall go through the most common causes of secondary. We will walk through the pathogenesis so that you understand what is going on with your patient. Onset, prior to age of 30. We talked about this being bimodal and this will make sense to you as you move on. Secondary change in hypertension, what does that mean? Well once again as I said we are looking for underlying cause. Male patient, as a general rule of thumb, as a male patient, in the United States, obese. That is the problem. Obese patient, what do we say this was called? Most of the patients that may present with? Metabolic syndrome.

    03:05 What is the prefix that you are thinking about metabolic syndrome, reflex of you, you should be thinking about hyper, hyper, hyper. Like what I am experiencing when I talk about medicine? I get all hyper. As you do, it is hypertension, hyperlipidemia, hyperglycemia. Is that clear? What is your point of reference? Hypertension. So with the male patient, obese, atherosclerosis.

    03:29 Why not recommend your patient to lose weight and when they do so, you should be able to knock out a few things at the same thing. You should may be take care of that hyperglycemia.

    03:38 Just maybe you are increasing the sensitivity of the insulin receptors. Welcome to management of diabetes. Maybe by controlling the diet, you should be able to control the lipid and also by losing weight, you should be able to control some of this hypertension. Atherosclerosis, secondary hypertension. What does atherosclerosis mean? Accumulation of lipid. Where might this be taking place? It might be taking place in the renal vasculature. We will get into this in a second. You will see as to how if there is a blockage to the renal vasculature that it may result in secondary hypertension in males, alcohol abuse. What about female? What do you know about estrogen, please? Prothrombotic, antithrombotic. What? Prothrombotic. Really? Ya.

    04:26 What is one of the risk factors for DVT? Estrogen. DVT, deep vein thrombosis. Estrogen, prothrombotic.

    04:34 So what if you ended up developing thrombus because of oral contraceptive pills that might have estrogen. May you result in secondary hypertension? Sure you could. What about renal vascular disease? What particular renal vascular disesase should come to mind when you are thinking about a young female, 30s perhaps. You are thinking about something called fibromuscular dysplasia. We will talk about this in a second. What is our topic? Secondary hypertension.

    04:59 Elderly, without history of prior hypertension, consider atherosclerosis you must. Atherosclerosis is something from the date that we were born, we pretty much are developing fatty acids, aren't we? You are what you eat. And this is so incredibly true when you are talking about hypertension. Atherosclerosis, what if it took place in renal artery? Now let me give you a little bit of prefix as to what is to come, meaning what? You decrease the amount of blood flow to your blood vessels, where? In the glomerulus. Are you there? Picture the afferent please and picture the efferent. I want you to focus upon the afferent arteriole. Would you tell me what vasculature or blood vessel is proximal to the afferent arteriole? I believe it is renal artery. That is a huge blood vessel undergoing atherosclerosis. It decrease your blood vessel. What then happens of juxtaglomerular apparatus? It becomes very very active, doesn't it? It doesn't like the fact that it is receiving decreased perfusion. What are you going to release? Renin and company. What do you mean by renin and company? Welcome to RAAS. Renin angiotensin aldosterone system. So as we move through here, we will then take a look at the RAAS system in greater detail. What is my topic? Secondary hypertenion, different patients presenting with most common diseases.


    About the Lecture

    The lecture Primary and Secondary Hypertension (JNC 7 Guidelines) by Carlo Raj, MD is from the course Hypertension.


    Included Quiz Questions

    1. Thiazide diuretics
    2. Calcium channel blockers
    3. Beta blockers
    4. ACE inhibitors
    5. Angiotensin-II receptor blockers

    Author of lecture Primary and Secondary Hypertension (JNC 7 Guidelines)

     Carlo Raj, MD

    Carlo Raj, MD


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