HYPERTENSION
ACC/AHA Classification for Office-Based BP (HTN 2018;71:e13)
Category Systolic (mmHg) Diastolic (mmHg)
Normal <120 <80
Elevated 120–129 <80
Stage 1 hypertension 130–139 80–89
Stage 2 hypertension 直接治療 ≥140 ≥90
Average ≥2 measurements >1–2 minutes apart. If disparity in a category between systolic and diastolic, higher value
determines stage. Elevated office BP should be confirmed with out-of-office (ABPM or home cuff) to confirm; can
treat stage 2 immediately. White coat (≥Stage 1 in office but <at home) at heightened risk of developing HTN.
Masked (<Stage 1 in office but ≥at home), if persistent, treat as HTN.
Epidemiology (Circ 2021;143:e254; Lancet 2021;398:957)
• Prevalence 47% in U.S. adults, higher in African-Americans; M = F
• Of those with HTN, ~40% unaware of dx; of those dx w/ HTN, only ½ achieve target
BP
Etiologies (JACC 2017;71:127)
• Essential (95%): onset 25–55 y; ⊕ FHx. Unclear mechanism but ? additive microvasc
renal injury over time w/ contribution of hyperactive sympathetics (NEJM 2002;346:913).
Age art compliance HTN. Genetics + environment involved (Nature
2011;478:103).
• Secondary: Consider if Pt <20 or >50 y or if sudden onset, severe, refractory HTN
Secondary Causes of Hypertension
Diseases Suggestive Findings Initial Workup
Renal parenchymal 最常⾒ h/o DM, polycystic kidney CrCl, albuminuria
(2–3%) disease, See “Kidney Disease”
glomerulonephritis
RENAL Renovascular (1–2%) Acute renal failure ARF induced by ACEI/ARB MRA (>90% Se & Sp, less
Athero (90%) Recurrent flash pulm for FMD), CTA, duplex
FMD (10%, young women) edema U/S, angio,
PAN, scleroderma Renal bruit; hypokalemia plasma renin (low Sp)
(NEJM 2009;361:1972)
Hyperaldo or Hypokalemia See “Adrenal Disorders”
Cushing’s (1–5%) 留鈉排鉀 Metabolic alkalosis
Pheochromocytoma (<1%) Paroxysmal HTN, H/A,
ENDO palp.
Myxedema (<1%) See “Thyroid Disorders” TFTs
Hypercalcemia (<1%) Polyuria, dehydration, ∆ iCa
MS
↓( *咳]
Obstructive sleep apnea (qv); alcohol 9
/ eReGially cyClosporim
Medications: OCP, steroids, licorice; NSAIDs (espec COX-2); Epo; CsA; TKI
OTHER
Aortic coarctation: LE pulses, systolic murmur, radial-femoral delay; abnl TTE, CXR
Polycythemia vera: Hct
H/A :
Headache
pallp : palpicalion
OMs :
EHange of Mendal Scaus
iCa ;
游離 ,鈣
Standard workup (JAMA 2021;325:1650 & 326:339)
• Goals: (1) identify CV risk factors; (2) consider 2° causes; (3) assess for target-organ
damage
• History: CAD, HF, TIA/CVA, PAD, DM, renal insufficiency, sleep apnea, preeclampsia;
⊕ FHx for HTN; diet, Na intake, smoking, alcohol, prescription and OTC meds, OCP
• Physical exam: BP in both arms; funduscopic exam, BMI, cardiac (LVH, murmurs),
vascular (bruits, radial-femoral delay), abdominal (masses or bruits), neuro exam
• Testing: K, BUN, Cr, Ca, glc, Hct, U/A, lipids, TSH, urinary albumin:creatinine (if Cr,
DM, peripheral edema), ? renin, ECG (for LVH), CXR, TTE (eval for valve abnl, LVH)
• Ambulatory BP monitoring (ABPM): consider for episodic, masked, resistant, or white
coat HTN; stronger predictor of mortality than clinic BP (NEJM 2018;378:1509); 24 h
target <130/80
Complications of HTN
• Neurologic: TIA/CVA, ruptured aneurysms, vascular dementia
• Retinopathy: stage I = arteriolar narrowing; II = copper-wiring, AV nicking; III =
hemorrhages and exudates; IV = papilledema 動脈壓迫靜脈
• Cardiac: CAD, LVH, HF, AF
• Vascular: aortic dissection, aortic aneurysm (HTN = key risk factor for aneurysms)
• Renal: proteinuria, renal failure
Treatment (J Clin HTN 2014;16:14; Circ 2018;138:e426; NEJM 2018;378:636)
• Every 5 mmHg ~10% ischemic heart disease, stroke, and HF (Lancet
2021;397:1625)
• Lifestyle modifications (each may SBP ~5 mmHg)
weight loss: goal BMI 18.5–24.9; aerobic exercise: 90–150 min exercise/wk
diet: rich in fruits & vegetables, low in saturated & total fat (DASH, NEJM 2001;344:3)
limit Na: ideally ≤1.5 g/d or 1 g/d; K intake / use salt substitute (NEJM 2021;385:1067)
limit alcohol: ≤2 drinks/d in men; ≤1 drink/d in women & lighter-wt Pts; avoid NSAIDs
⽤藥時機 • ACC/AHA: initiate BP med if BP ≥130/80 & either clinical ASCVD, HF, CKD, T2DM,
≥65 yrs old or 10-y ASCVD risk ≥10%; otherwise if BP ≥140/90 ASEUD A 1herosclerotic cardiorascllaradisease
:
• In high CV risk w/o DM, SBP target <120 (via unattended automated cuff) MACE &
mortality vs. <140 mmHg, but w/ HoTN, AKI, syncope, electrolyte abnl (NEJM 步 , 耍⼼⾎管名良事彼
2021;384:1921 & 385:1268) 沒有DM的⾼⾎壓但有⾼度⼼⾎管風險的⼈，⾎壓控制在120以下筆140以下預後還要好
• Pharmacologic options
Pre-HTN: ARB prevents onset of HTN, no in clinical events (NEJM 2006;354:1685)
HTN: choice of therapy controversial, concomitant disease and stage may help
guide Rx; ? improved control with nighttime administration (EHJ 2020;41:4564)
Uncomplicated: CCB, ARB/ACEI, or thiazide (chlorthalidone preferred) are 1st line;
βB not.
For black Pts, reasonable to start with CCB or thiazide.
+ CAD (Circ 2015;131:e435): ACEI or ARB; ACEI+CCB superior to ACEI+thiazide (NEJM
2008;359:2417) or βB+diuretic (Lancet 2005;366:895); may require βB and/or nitrates for
anginal relief; if h/o MI, βB ± ACEI/ARB ± aldo antag (see “ACS”)
+ HF: ARNI/ACEI/ARB, βB, diuretics, aldosterone antagonist (see “Heart Failure”)
+ prior stroke: ACEI ± thiazide (Lancet 2001;358:1033)
+ diabetes mellitus: ACEI or ARB; can also consider thiazide or CCB
+ chronic kidney disease: ACEI or ARB (NEJM 2001;345:851 & 861)
) 130 > 140
• Tailoring therapy: if stage 1, start w/ monoRx; if stage 2, consider starting w/ combo
(eg, ACEI + CCB; NEJM 2008;359:2417); start at ½ max dose; after ~1 mo, uptitrate or
add drug Nifedipime Hydralazine CCB 5
• Pregnancy: methyldopa, labetalol, & nifed pref. Hydral OK; avoid diuretics; Ø
, ACEI/ARB. Targeting DBP 85 vs. 105 safe and severe HTN (NEJM 2015;372:407).
Resistant HTN (BP >goal on ≥3 drugs incl diuretic; HTN 2018;72:e53)
• Exclude: 2° causes (see table) and pseudoresistance: inaccurate measure (cuff size),
diet noncomp ( Na), poor Rx compliance/dosing, white coat HTN ( ABPM)
• Ensure effective diuresis (chlorthalidone or indapamide >HCTZ; loop >thiazide if
eGFR <30)
• Can add aldosterone antagonist (Lancet 2015;386:2059), β-blocker (particularly vasodilators
such as carvedilol, labetalol, or nebivolol), α-blocker, or direct vasodilator
• Consider renal denervation therapy (Lancet 2018;391:2346; 2021;397:2476)
腎交感神經阻斷術
HYPERTENSIVE CRISES
• Hypertensive emergency: BP (usually SBP >180 or DBP >120) target-organ
damage
Neurologic damage: encephalopathy, hemorrhagic or ischemic stroke, papilledema
Cardiac damage: ACS, HF/pulmonary edema, aortic dissection
Renal damage: proteinuria, hematuria, acute renal failure; scleroderma renal crisis
Microangiopathic hemolytic anemia; preeclampsia-eclampsia
• Hypertensive urgency: SBP >180 or DBP >120 (? 110) w/o target-organ damage
Precipitants α QGOMisc 2
• Progression of essential HTN ± medical noncompliance (espec clonidine) or ∆ in diet
• Progression of renovascular disease; acute glomerulonephritis; scleroderma;
preeclampsia
• Endocrine: pheochromocytoma, Cushing’s
• Sympathomimetics: cocaine, amphetamines, MAO inhibitors + foods rich in tyramine
經過發酵或醃漬的加⼯品，如：起司、優格、
Treatment – tailor to clinical condition (Circ 2018;138:e426) 臘腸、培根、⾹腸、紅酒、啤酒、味噌
• AoD, eclampsia/severe preeclampsia, pheo: target SBP <140 (<120 for AoD) in 1
hour ⼀⼩時內快速降壓 mormal
• Emerg w/o above: BP by ~25% in 1 h; to 160/100–110 over next 2–6 h, then nl over
1–2 d Symplom
中風⾎壓控制！• Acute ischemic stroke (w/in 72 hr from sx onset): <185/110 before lysis initiated, o/w
target <220/120 (same SBP goal for ICH)
• Watch UOP, Cr, mental status: may indicate a lower BP is not tolerated
urineoupt
IV Drugs for Hypertensive Crises (Circ 2018;138:e426; Stroke 2018;49:46)
Drug Dose Preferred for
Labetalol 20–80 mg IVB q10min or 0.4–2 AoD, ACS, Stroke, Eclampsia
mg/min
Esmolol 0.5–1 mg/kg load 50–200 µg/kg/min AoD, ACS
* 0.25–10 µg/kg/min Pulm edema
Nitroprusside
Nitroglycerin 5–500 µg/min Pulm edema, ACS
Elampsia Labetalo ) Nicardipine Hydralazine
: . .
IV Drugs for Hypertensive Crises (Circ 2018;138:e426; Stroke 2018;49:46)
Nicardipine 5–15 mg/h (can 2.5 mg/h q 5 min) Stroke, AKI, Eclampsia, Pheo
Clevidipine 1–32 mg/h (can titrate q 5–10 min) Stroke, Pulm edema, AKI, Pheo
Fenoldopam 0.1–1.6 µg/kg/min AKI
Hydralazine 10–20 mg q20–30min prn Eclampsia
Phentolamine 5–15 mg bolus q5–15min Pheo
*
Metabolized to cyanide ∆ MS, lactic acidosis, death. Limit use of very high doses (8–10 µg/kg/min) to <10 min.
• HTN urgency: goal to return to normal BP over hrs to days. Reinstitute/intensify anti-
HTN Rx. Additional PO options: labetalol 200–800 mg q8h, captopril 12.5–100 mg
q8h, hydralazine 10–75 mg q6h, clonidine 0.2 mg load 0.1 mg q1h.
