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Resistant and Pseudoresistant Hypertension

Questions 1 What is the prevalence of resistant hypertension? Resistant hypertension (RH) is an emerging clinical and public health problem with increasing incidence because of increasing life expectancy and the growing global epidemic of obesity, diabetes mellitus, and obstructive sleep apnea. Likewise, the excessive dietary salt ingestion reported globally in most countries can contribute substantially to the risk of RH. RH carries a considerable public health…

Hypertension in the Patient with Aortic Dissection

Questions 1 What are the acute aortic syndromes? Acute aortic syndromes (AAS) are a group of emergent aortic pathologies with similar clinical characteristics. AAS occur when blood penetrates the medial layer of the aorta either from a tear or ulceration of the intima or rupture of the vessels within the media. These syndromes include aortic dissection (AoD), penetrating atherosclerotic ulcer (PAU), and intramural hematoma (IMH). AoD…

Hypertension in Stroke

Questions 1 What is the epidemiology of stroke? A stroke refers to the development of focal neurological symptoms such as the sudden loss of movement, sensation, or coordination that arises due to impaired blood flow to the brain or spinal cord. A transient ischemic attack (TIA) is a temporary period of symptoms similar to those of a stroke that resolves spontaneously. A TIA usually lasts only…

Hypertension in Heart Disease

Questions Treatment of Hypertension in Patients with Coronary Artery Disease and Stable Angina Pectoris 1 How does hypertension and its management contribute to coronary artery disease? There is overwhelming evidence that hypertension plays a role in the development of coronary atherosclerosis. Furthermore, there is abundant evidence that the treatment of hypertension reduces the development of the adverse consequences of coronary artery disease (CAD) including myocardial infarction…

Hypertension in Pregnancy

Questions 1 How does pregnancy normally affect blood pressure? Renin, angiotensin, and aldosterone are all increased in normal pregnancy so you might predict blood pressure (BP) would increase. However, systolic blood pressure (SBP) and diastolic blood pressure (DBP) are both significantly lower as early as 6 to 7 weeks from the last menstrual period, suggesting that these hormonal changes are secondary. Arterial pressure usually declines until 24…

Hypertension in the Elderly

Questions 1 What is the epidemiology of hypertension in the elderly? In this chapter, we will refer to the “elderly” as those individuals aged 65 years or older, as this is the definition used by the United Nations in its reports on aging. This rapidly growing segment of the population accounts for 9% of individuals globally and 16.5% in the United States and is expected to reach…

Hypertension in Blacks

Questions 1 What is the prevalence of hypertension in Blacks in the United States? According to (the National Health and Nutrition Examination Survey from 2017–18, the age-adjusted prevalence of hypertension in adults was noted to be higher in non-Hispanic Blacks (57.1%) as compared with non-Hispanic Whites (43.6%) and Hispanics (43.7%). When looking at men and women separately, the age-adjusted prevalence of hypertension was also found to…

Treatment of Hypertension in Obesity

Questions 1 What is the epidemiology of obesity and hypertension? Overweight and obesity are defined as abnormal or excessive fat accumulation that may impair health (World Health Organization). Body mass index (BMI) is the simplest way to classify overweight (BMI between 25 and 29.9 kg/m 2 ) and obesity (BMI > 30 kg/m 2 ) in adults. Worldwide obesity has nearly tripled since 1975, and almost a third…

Hypertension After Transplantation

Questions 1 What is the definition of hypertension in transplant recipients? The definition of hypertension in transplant recipients follows that of the general population. Most guidelines for the general population define hypertension as a persistent systolic blood pressure on two separate days of 140 mm Hg or higher and/or diastolic blood pressure of 90 mm Hg or higher if age is 18 years or older. More recent hypertension guidelines…

Hypertension in Diabetes

Questions 1 Is hypertension common in patients with diabetes? Diabetes and hypertension share pathophysiologic mechanisms of vascular dysfunction, so they commonly coexist, and hypertension is an important contributor to diabetes-associated vascular complications including kidney disease. According to the Centers for Disease Control and Prevention, about 74% of those with type 2 diabetes mellitus (T2DM) have hypertension, and in the San Antonio Heart Study, 85% of participants…

Hypertension in Chronic Kidney Disease and End-Stage Kidney Disease

Questions Hypertension in chronic kidney disease 1 What is the prevalence of hypertension in chronic kidney disease? Hypertension is common in patients with chronic kidney disease (CKD). In the 2015–16 National Health and Nutrition Examination survey, 61.4% of patients with CKD had hypertension; 37.4% of patients had controlled blood pressure (BP). 2 How should BP be measured in the office in patients with CKD? BP measurement…

Hypertension in Children and Adolescents

Questions 1 How is hypertension defined in children and adolescents? The definition of hypertension in adults is based on data from large clinical trials, which show that as blood pressure (BP) rises, the risk of cardiovascular endpoints such as stroke, myocardial infarction, and mortality increases. As these events are rare in the pediatric age group, a statistical definition has been adopted that is based upon the…

Hereditary Causes of Hypertension

Questions 1 How common are hereditary forms of hypertension? Evidence from family studies, including monozygotic and dizygotic twins, reveal that up to 50% of hypertension is heritable. However, the collective effect of all the known monogenic causes of hypertension and blood pressure (BP) loci identified through genome-wide association and exome sequencing studies explain only ∼2% of BP heritability. Monogenic causes of hypertension are rare, with fewer…

Obstructive Sleep Apnea and Hypertension

Questions 1 What is obstructive sleep apnea? Obstructive sleep apnea (OSA) is a sleep disorder characterized by recurrent episodes of upper airway inspiratory collapse during sleep causing hypopnea and apnea leading to oxygen desaturation and arousals from sleep. 2 How common is OSA? It has been estimated that 2% to 5% of the adult population in Western countries have symptomatic OSA. Prevalence of asymptomatic or minimally…

Drug-Induced Hypertension

1 What are the four main mechanisms by which drug-induced hypertension may occur? See Fig. 13.1 : Sympathomimetic activation Volume retention via mineralocorticoid activation Direct vasoconstriction via increased vasoconstrictors, decreased vasodilators, or upregulation of the angiotensin II receptor type 1 (AT 1 ) Drug withdrawal 2 What drug classes cause hypertension by sympathomimetic activation? See Fig. 13.1 3 What drug classes cause hypertension by mineralocorticoid activation? See Fig. 13.1…

Renovascular Hypertension

Questions 1 What is renovascular hypertension? Renovascular hypertension (RVH) is the elevated blood pressures resulting from significant obstruction to renal artery blood flow and decreased renal perfusion pressure. 2 What is the prevalence of RVH? RVH accounts for 1% to 2% of all hypertension (HTN) in the general population and up to 6.8% of those older than 65 years old with greater than 60% renal artery stenosis…

Other Endocrine Causes of Hypertension

Questions 1 How does acromegaly cause hypertension, and when should it be suspected? Acromegaly is caused by hypersecretion of growth hormone (GH) usually from the pituitary with peripheral target organ mediation through the excess production of insulin like growth factor 1 (IGF-1). In addition to the classical features of this disease like acral growth, jaw prognathism, and gigantism, IGF-1 causes hypertrophy and growth of multiple other…

Pheochromocytoma and Paraganglioma

Questions 1 What are pheochromocytoma and paraganglioma? Pheochromocytomas and paragangliomas are differentiated based on anatomical location. Pheochromocytomas are neuroendocrine tumors that arise from the adrenal medulla. Paragangliomas are neuroendocrine tumors that arise from extraadrenal sympathetic or parasympathetic paraganglia. Therefore paragangliomas can be found anywhere from the base of the skull to the pelvis. 2 What are the differences between pheochromocytoma and paraganglioma? Beyond the anatomical differences…

Glucocorticoid Hypertension

Questions 1 What are glucocorticoids? The adrenal cortex secretes three major types of steroid hormones, each produced in one of three concentric cortical layers, also known as zones. Glucocorticoids are steroid hormones produced by the zona fasciculata of the adrenal cortex ( Fig. 9.1 ). Cortisol is the major glucocorticoid in humans, and it is a pivotal regulator for a wide variety of functions, such as metabolic…

Primary Aldosteronism and Mineralocorticoid Hypertension

Questions 1 What is the most common identifiable cause of resistant hypertension? Resistant hypertension, defined as elevated blood pressure (BP) despite the concurrent use of three antihypertensive drug classes at maximum tolerated dose or controlled BP on four or more antihypertensive medications, affects approximately 15% of the hypertensive population. Primary aldosteronism (PA) is the most common secondary cause, accounting for up to 15% to 30% of…