Primary and Secondary Hypertension (JNC 8 Guidelines)

by Carlo Raj, MD

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    00:01 As you very well know, there is a continuous association between high blood pressure and cardiovascular disease.

    00:07 In an attempt to classify the different stages of high blood pressure, the American College of Cardiology and the American Heart Association Task force published new guidelines in 2017 that are different from the JNC 7 report.

    00:22 According to the current recommendations normal blood pressure is defined as systolic blood pressure lower than 120 milimeter Hg and diastolic blood pressure lower than 80 milimeter Hg.

    00:35 Blood pressure is considered elevated when the systolic pressure is 120-129 milimeter Hg and the diastolic pressure lower than 80 milimeter Hg.

    00:46 Any values above 130/80 milimeter Hg are considered hypertension - in contrast with the previous guidelines that defined hypertension as blood pressure greater than 140/90 milimeter Hg.

    01:00 The idea behind this new categorization rests on multiple studies that suggest that there is increased risk for cardiovascular and cerebrovascular disease in levels lower than 140/90 milimeter Hg.

    01:14 This, of course, doesn’t necessarily mean that people with elevated blood pressure or stage 1 hypertension will receive pharmacotherapy.

    01:22 This classification suggests that these individuals are at increased risk for adverse outcomes due to high levels of blood pressure and would benefit from appropriate lifestyle - and, if necessary, pharmacologic - interventions.’ 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.

    01:51 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.

    02:00 What are you going to an increase when you have increase in volume within the heart? I believe it is called systole.

    02:05 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.

    02:19 So as primary, your focus there should be on sodium. You know that and you will be in good shape.

    02:24 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.

    02:35 We shall go through the most common causes of secondary.

    02:38 We will walk through the pathogenesis so that you understand what is going on with your patient.

    02:42 Onset, prior to age of 30. We talked about this being bimodal and this will make sense to you as you move on.

    02:48 Secondary change in hypertension, what does that mean? Well, once again as I said we are looking for underlying cause.

    02:54 Male patient, as a general rule of thumb, as a male patient, in the United States, obese.

    03:02 That is the problem. Obese patient, what do we say this was called? Most of the patients that may present with? Metabolic syndrome.

    03:09 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.

    03:32 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.

    03:42 Just maybe you are increasing the sensitivity of the insulin receptors.

    03:48 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.

    03:59 Atherosclerosis, secondary hypertension. What does atherosclerosis mean? Accumulation of lipid.

    04:04 Where might this be taking place? It might be taking place in the renal vasculature.

    04:09 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.

    04:20 What about female? What do you know about estrogen, please? Prothrombotic, antithrombotic.

    04:26 What? Prothrombotic. Really? Ya.

    04:30 What is one of the risk factors for DVT? Estrogen. DVT, deep vein thrombosis. Estrogen, prothrombotic.

    04:39 So what if you ended up developing thrombus because of oral contraceptive pills that might have estrogen.

    04:44 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.

    04:55 You are thinking about something called fibromuscular dysplasia.

    04:59 We will talk about this in a second. What is our topic? Secondary hypertension.

    05:03 Elderly, without history of prior hypertension, consider atherosclerosis you must.

    05:07 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.

    05:19 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.

    05:37 I want you to focus upon the afferent arteriole.

    05:39 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.

    05:52 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.

    06:04 What do you mean by renin and company? Welcome to RAAS. Renin angiotensin aldosterone system.

    06:09 So as we move through here, we will then take a look at the RAAS system in greater detail.

    06:13 What is my topic? Secondary hypertension, different patients presenting with most common diseases.

    About the Lecture

    The lecture Primary and Secondary Hypertension (JNC 8 Guidelines) by Carlo Raj, MD is from the course Hypertension.

    Included Quiz Questions

    1. 120 - 129 mmHg SBP and less than 80 mmHg DBP
    2. 120 - 129 mmHg SBP and more than 80 mmHg DBP
    3. 120 - 129 mmHg SBP and at least 80 mmHg DBP
    4. 130 - 139 mmHg SBP and less than 80 mmHg DBP
    5. 120 - 129 mmHg SBP and less than 90 mmHg DBP
    1. Management is focused on limiting sodium intake.
    2. It is also known as secondary hypertension.
    3. There is a known etiology.
    4. The preload is decreased.
    5. Antihypertensives are the only way of managing primary hypertension.
    1. Onset after the age of 30 or before the age of 55
    2. Onset before the age of 30 or after the age of 55
    3. Sudden change in hypertension
    4. Atherosclerosis of the renal arteries is the most common cause of secondary hypertension in the elderly.
    5. Oral contraceptives contribute to the development of secondary hypertension in women.
    1. Fibromuscular dysplasia
    2. Renal artery atherosclerosis
    3. Fibromyalgia
    4. Systemic lupus erythematosus
    5. Polycystic kidney disease
    1. At least 140 mmHg SBP or 90 mmHg DBP
    2. At least 140 mmHg SBP and 90 mmHg DBP
    3. Less than 140 mmHg SBP or 90 mmHg DBP
    4. More than 140 mmHg SBP or 90 mmHg DBP
    5. At least 140 mmHg SBP or more than 80 mmHg DBP

    Author of lecture Primary and Secondary Hypertension (JNC 8 Guidelines)

     Carlo Raj, MD

    Carlo Raj, MD

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    Very high yield information, excellently presented. Wonderful instructor character.
    By WAFAA M. on 18. May 2020 for Primary and Secondary Hypertension (JNC 8 Guidelines)

    Outstanding lecture presentation. Very high yield information, excellently presented. Wonderful instructor character.

    Poorly structured lectures and an arrogant teacher
    By Oddny G. on 04. April 2020 for Primary and Secondary Hypertension (JNC 8 Guidelines)

    I really don't like this teacher. He's probably trying to be funny or memorable but it comes out as arrogance. I think you should considering remaking these videos.

    excellent professor
    By bertha s. on 06. September 2019 for Primary and Secondary Hypertension (JNC 8 Guidelines)

    I am studying for step one and I can honestly say, you have to be at a higher intellectual level to appreciate the teaching style of Dr. Raj. if one focus and pay attention to his content, one will surley pass step 1. remember the boards are not organized notes, its absolute integration. what dr raj does is golden

    What is happening?
    By Zahid C. on 04. May 2019 for Primary and Secondary Hypertension (JNC 8 Guidelines)

    Why is everything all over the place, Im not trying to have a conversation, jumping from place to place just makes me confused. Im not against joking in between but keep it in between. Im not having a monologue here, Im trying to understand and remember a concept that I dont know, Im not discussing something I already know. You cant deliever symptoms like a story, they need to be seperated so it gets organized in my head. Need structure.