foreign engineers in this video today we're going to be talking about hypertension this is going to be a part of our clinical medicine section if you guys like this video you benefit from it it helps you please support us one of the ways that you can do that is by hitting the like button commenting down the comment section and please subscribe also highly suggest we got a link down in the description box to our website we got a lot of things there we got merchandise we have courses that we're starting to develop for step one step two your pants also we have great notes great illustrations that I think will be super helpful to follow along with during this lecture all right let's start talking about hypertension so hypertension first off there's two types there's essential sometimes we call primary hypertension it's about 90 of cases and secondary hypertension it's going to be less common anywhere from about 10 percent of cases so on your boards they love to test you on these but in real life most patients suffer with essential hypertension so causes of essential hypertension they're not well defined but the concept of essential hypertension is relatively like simple in the sense that okay patients who usually have essential hypertension are usually a little bit older all right and one of the problems with that is let's say here we have a normal vessel this is a normal blood vessel and what we're going to do is we are going to thicken this vessel up so now we're going to have a very thick walled vessel whenever you have a thick walled vessel what you do is is you reduce the actual diameter now it's a tiny little diameter because you thickened up the wall that's going to increase your systemic vascular resistance and whenever you increase systemic vascular resistance what that does is that increases your blood pressure all right so that's one concept here is that if you have a patient Who develops a very thick wall vessel it reduces the actual diameter which increases the resistance and when you increase resistance to blood flow you increase blood pressure all right same concept here some patients will have a very thick wall vessel so increase thick wall vessel what if I had a patient who had a normal blood vessel and it's super constricted so some patients have normal like blood vessel like give normal sympathetic tone to the actual blood vessel and in some people may have just a little bit more sympathetic tone where their blood vessels is a little bit over constricted and so let's say that here we have a patient who has a little bit of an increase in their Vaso constriction same concept exists that if you increase the vasoconstricted mechanism you make the diameter smaller you increase the systemic vascular resistance and increase the blood pressure so these are all things that can happen the question that then arises is okay this is what occurs what are the things that can stimulate this on thick walled vessels usually this can occur from people who are getting older unfortunately as you have advanced age it's definitely going to cause more calcifications and thickening of the vessels so age as you advance your age unfortunately another thing is smoking so smoking is another really big one and diabetes these are all things that can really thicken up those blood vessel walls for increased vasoconstriction these are your patients who are usually like very type A personality disorders they're always very stressed out so believe it or not stressing out that can definitely do it so increased stress is another one and here's another really interesting one obesity obesity happens to be one of the biggest like modifiable risk factors for patients who develop essential hypertension so obesity causes like a lot of cytokines to be released that really can stimulate this process as well so these are some of the things that I want you guys to think about the other concept here that's really really interesting is some patients who have a very high sodium diet so whenever you have a very high sodium diet or there's some type of weird like there's like these like syndromes called little syndrome and things like that but sometimes if patients have extremely high sodium diets it makes it difficult for the kidneys to be able to really kind of control that secretory function right and so what happens is if the kidneys are really struggling to be able to get rid of that sodium but they don't do a very good job of it sometimes you can have a lot of increased sodium in the bloodstream and increase sodium in the bloodstream keeps water in your bloodstream and so you have an increase in sodium and water retention that will then cause more blood to be returned to the heart so now you increase your preload which increases your stroke volume if you increase your preload and your stroke volume you're going to increase your cardiac output now whenever you increase your cardiac output what's the formula that we should actually remember blood pressure is equal to cardiac output time systemic vascular resistance so if you increase cardiac output a little bit what are you going to do to your blood pressure you're going to increase your blood pressure all right so if the sodium is having the kidneys are having a little bit of a difficult time in being able to get rid of some of that excess sodium or you have like a genetic condition that makes it harder you'll retain more of it and you'll cause your blood pressure to go up these happen to be some of the most common risk factors and usually a central hypertension presents and usually patients who are 25 to 55 years of age okay so this is something else that I want you guys to be thinking about now we're going to come back to this chart in a second it's going to wrap everything up together well we're going to come over here for secondary hypertension so secondary hypertension the age range is a little bit different they could fall in the 25 to 55 year old range but what's the bigger tip to think about is these patients generally have what's called refractory hypertension what does that mean that means that you put them on an antihypertensive agent and they don't get control of their blood pressure you put them on another one you put them on another one generally three antihypertensive medications and their blood pressure is not under control start thinking about these causes all right so if you have a patient who comes in with high blood pressure you kind of go follow them through then you have a patient you put them on antihypertensives and you put them on three or more and they're still not controlled think about these how do we remember these remember it's a little bit out of order here but renals okay I know it's a funky one but renals this is going to be by far the most common cause of secondary hypertension as renal disease some patients have renal vascular disease the concept is pretty straightforward maybe their disease process is something like chronic kidney disease or maybe they have something like renal artery stenosis either way regardless of the cause when the kidneys have some type of process where they are damaged they track up the actual GFR they mess up the GFR and when they do that it leads to an increase and the renin Angiotensin aldosterone system and these things get jacked up and you know what these do we don't need to go through the whole mechanism we should already know this from like our basic physiology is that Angiotensin II will lead to a lot of aldosterone ADH sodium water retention vasoconstrictive mechanisms which do what to your blood pressure shoot the blood pressure up and that's what happens to these particular patients all right so I want you to think about that so if you have a patient who has underlying chronic kidney disease or you're auscultating their abdomen you hear like a weird brewy think about renal artery stenosis think about CKD or renal vascular cause of their high blood pressure okay next one is endocrine endocrine is an interesting one and whenever we think about endocrine I think two particular organs the thyroid in the adrenal gland all right thyroid's funky and it kind of makes it easy to remember but it can be both whenever you got thyroid if it's too high T3 and T4 are too low both of these can cause hypertension you're like wait what this is weird man if you got high T3 T4 you got to stop being thyroid I'm just kidding all right but when you think about high thyroid levels what this does is it causes your cardiac output to go up it causes the heart to beat harder and beat faster and so that will push your systolic blood pressure up and so what happens with these is the increased cardiac output which increases your systolic blood pressure so you're gonna have an increase in cardiac output and an increase in your systolic blood pressure we call this systolic hypertension so the top number is going to be super high for whenever you have low T3 and T4 hypothyroidism this normally controls your vessel tone so it tries to play a role in kind of causing the vessels to dilate a little bit but if you have very low levels what do they start doing constricting when they constrict it increases your systemic vascular resistance which increases your diastolic blood pressure so the funky thing to remember about these is that this will cause diastolic hypertension the bottom number to be a lot higher and that's the weird thing about these all right all of these I'm not going to go through all of their mechanisms because we'll talk about them more in endocrine but the adrenal gland literally every possible hormone that you make here can cause this problem so usually it's due to high aldosterone High cortisol or high amounts of epinephrine and norepinephrine so if you have high aldosterone levels this is called hyperaldostrianism this will increase sodium and water retention cortisol whenever you have very high cortisol levels what do we call this one Cushing syndrome or Cushing's Disease this will cause increased sympathetic activity and then increase norepinephrine and epinephrine when these are higher it's called pheochromocytoma and all of these things will work through various mechanisms I don't want to kind of bog us down in but they will work to increase your blood pressure and that's that's something I want you guys to be able to think about here all right so let's quick recap again one of the causes of the endocrine problems that lead to secondary hypertension it could be thyroid disorders it could be hyperaldostrianism it could be Cushing syndrome or it could be a pheochromocytoma let's write those down all right guys so that is going to cover all of these parts for the endocrine disorders now let's come down for the neurological disorders so it's actually it's actually pretty straightforward so with the neurological diseases it usually has to be some type of like neurologic catastrophe usually anything that increases the intracranial pressure whether it's a bleed whether it's edema whether it's in cerebral spinal fluid however it may be a tumor anything that massively increases the intracranial pressure inside of the brain will lead to something called Cushing's Triad so this is something that they can definitely kind of mess with you on the exam if you have a patient with underlying like altered mental status and neurological deficits and they present with these particular findings one is bradycardia one is high blood pressure and the other one is irregular respirations this should key you off to really think about some kind of problem here that's leading to this so again it would be Cushing's Triads such as low heart rate high blood pressure and irregular respirations this is definitely a classic finding for someone having these particular findings so they have super high blood pressure a low heart rate irregular respirations and neurological deficits that could be the cause of their secondary hypertension all right the next one you really want to think about this one aortic diseases you want to think about something called a co-arcation of the aorta so co-arctation of the aorta this is usually going to be something in very young individuals That should kind of see this in but you see how it's a narrowing of the actual aortic Lumen usually this comes after the left subclavian artery and so what happens is is it Narrows and then all this kind of like look at this you see how blood is supposed to be moving here right supposed to go from the left ventricle supposed to go into the aorta and now all this has to squeeze through this tiny little Lumen now all the pressure proximal to that little constriction point is going to be crazy high so what you'll notice in these guys is that they will have an insanely High upper extremity blood pressure right they will have a very high upper extremity blood pressure because all of this is going to be super high and all the vessels proximal to this kind of like narrowing so all the vessels going off to your arms are going to be super high blood pressures but then you have very little blood going through the distal part here and so what you'll notice is is you'll notice a very low lower extremity blood pressure and this is something that you definitely want to be thinking about as a potential cause so if you see someone has like cyanosis of their lower extremities they have low lower extremity blood pressures High upper extremity blood pressures think about correctation of the aorta all right the last one here this is actually super interesting we're going to have to bring this guy over here a little bit but this is going to be little people just to finish this kind of like mnemonic a little bit so this is Little People and this is really particularly for people who have what's called preeclampsia or eclampsia so we're going to put here this is going to be something like pre eclampsia now preeclampsia is usually there's a patient who is usually in there uh like third trimester around that time frame and they have a lot of protein urea they have a lot of Edema and they have a lot of high blood pressure so whenever you see these kinds of findings such as edema proteinuria and hypertension in a patient who is pregnant you want to start thinking about could this be preeclampsia because if they start seizing then you know they have what's called eclampsia that's the only really difference between preeclampsia and eclampsia seizures so look for this and the reason behind this is super kind of interesting where they think that what happens is the baby is getting insufficient blood supply and so what happens is is the placental vessels start releasing chemicals whatever these vasoactive chemicals are we don't really know but these vasoactive chemicals what they do is they cause vasoconstriction so what they try to do is they really try to amp up the blood pressure and whenever they amp up the blood pressure by really vasoconstricting it's hopefully going to perfuse these placental vessels more and perfuse the baby so it's an unfortunate kind of response that increases the maternal blood pressure and can lead to a lot of complications but definitely something to think about in a patient who is pregnant all right we come to these last two to finish off the renal's mnemonic now substances you always want to be thinking about this if you have a patient with an altered mental status or they have some type of like weird activity like their diaphoretic hypertensive tachycardic and they have a history of drug abuse look for things that really like generally what they do is they amp up your sympathetic nervous system any kind of drug that really does that will definitely kind of like pump up the blood pressure so if you have increased sympathetic medications we call them sympathomimetics that would definitely be one what would be a potential drug that could do that cocaine would be one and amphetamines these are definitely going to be your big hitters that'll cause this type of effect here so think about amphetamines and think about cocaine or even like PCP these things will increase the sympathetic nervous system and increase your blood pressure the last one here is sleep apnea believe it or not this happens to be a big one uh this is really becoming a very prominent one and what happens is patients who have a sleep apnea they have periods of apnea and during those periods of apnea they don't properly oxygenate so they develop very low oxygen levels during their sleep process when you develop low oxygen levels what it does is is it activates your sympathetic nervous system and whenever you increase your sympathetic nervous systems hopefully trying to get more blood flow to the lungs and get better perfusion to the lungs but unfortunately what it does is is it clamps down on your systemic vessels and these patients develop pretty high refractory blood pressure so you want to think about this usually as a potential cause if you have a patient who is obese if you have a patient who has maybe a lot of somnolence they snore a lot at night maybe witnessed by their partner and they have high blood pressure think about sleep apnea related secondary hypertension all right that covers secondary hypertension right so now what I need us to do is we have a patient who has either essential or secondary secondary refractory to three or more anti-pretensives essential usually these are the features and they're usually 25 55 years of age and they have a family history when these patients come in you have to think about okay we've talked a lot about high blood pressure here is the cause of this disease what is truly High well when you look at this normal blood pressure should be adequately less than 120 systolic and less than 80 diastolic as they start getting their BP a little bit higher maybe it's in between it's greater than 120 but it's at least less than 130. now we're at pre-hypertensive then we get to the patient who's stage one their blood pressure is still a little bit High we don't really like this it's greater than 130 but it's at least less than 140 and in this particular situation it's greater than 80 but it's at least less than 90. then we get to the stage two this is a patient who's usually not very good we don't like this they are greater than 140. and well they are greater than 90. this is usually where we get a little bit concerned when we see this for at least two or more readings if we see this number for two or more readings this is truly what we would consider to be hey this patient needs antihypertensives stage one if you're at that point and you have other comorbidities and a lot of risk factors you could start medications but what we really get concerned is when patients get their blood pressure up to greater than 180 systolic or greater than 120 diastolic but there's two terminologies that we have to understand and we'll go into more detail next hypertensive urgency is when this has a high blood pressure hypertensive emergency has this high blood pressure so what differentiates them do they have Target organ damage I'm going to say that again hypertensive urgency is no target organ damage hypertensive emergency is Target organ damage but they both can have this high blood pressure that is super important all right we've covered the pathophys of all of this now what I want to do is I want to say why is hypertension bad what are the complications all right my friend so now we're going to talk about the target organ damage so the patient has a hypertensive urgency versus emergency just dollar greater than 180 or die solid greater than 120 and if they have Target organ damage it's an emergency if they do not have Target organ damage it's an urgency now patients who have Target organ damage as usually going to come in a couple different flavors one is cardiovascular disease neurological disease renal disease and retinal disease these are the common features of injury and complications from high blood pressure one of these is when patients have chronically high blood pressure what happens is is your afterload right so the pressure inside of the aorta is going to be super super high right so when you have this like super high afterload what does this do right so the pressure here is going to be crazy high when you got this High afterload what it'll do is it'll make the left ventricle have to work a ton harder so now this left ventricle is going to have to get all kinds of thick so it's going to trigger something called left ventricular hypertrophy and that left ventricular hypertrophy will then make it almost impossible for the ventricles to be able to fill well right so now imagine this small this like space here there's a very little space for blood to be able to come in and so now this is going to be inhibited and whenever you reduce filling what can that lead to heart failure right because it's going to drop the cardiac output so these patients usually develop something called diastolic heart failure this is super calm and very very very common cause of patients developing heart failure what's another terminology for diastolic heart failure that I want you guys to become a very con you know aware of it's also called half half heart rate with a preserved ejection fraction EF less than I mean greater than 40 percent that's one thing now in acute scenarios where the afterload is super high I'm talking really really high blood pressure it can make it really hard for blood to get out of the heart and they can develop what's called acute pulmonary edema or Flash pulmonary edema that's something else to consider all right next thing that I want you guys to remember is whenever patients have hypertension what this does is is this triggers atherosclerosis hypertension is definitely a trigger you guys remember that mnemonic I told you sad CHF and the H was for hypertension this will cause atherosclerosis these plaques that develop within the vessel walls if it develops within the coronary arteries this will do what reduce the oxygen perfusion to The myocardium of the heart that can then progress to what's called ischemia now ischemia of the actual myocardium can look a couple different ways right so we can have this Bland term called coronary artery disease which could be stable or it could completely progress to an MI so sometimes if you have like a plaque rupture this could potentially almost occlude the entire vascular Lumen and that could really really reduce the oxygen supply or completely occlude the oxygen supply so that's one example of why hypertension can lead to atherosclerosis of the coronary vessels and leave the coronary artery disease or potentially MI the other one is if it includes the peripheral vessels in your extremities now your peripheral arteries are plaqued up and now all of this tissue of the leg starts becoming ischemic and this is going to cause a lot of pain to the muscles it's going to start causing skin lesions what's that called peripheral artery disease so these patients can develop peripheral artery disease and sometimes they can have significant ischemia to the lymph where it's almost critical in ischemia so sometimes this is another thing to potentially remember as well so atherosclerosis of the coronary or peripheral vessels is a big thing here the last one for cardiovascular disease is when patients have hypertension when that blood is just shooting so imagine this it's just plowing right here out of the left ventricle into the aorta it's causing a lot of shearing forces within the aorta if it shears up that aorta what can that do what is that going to do so imagine here I have a lot of shearing forces you know shearing forces is kind of like a lot of pressure against the actual blood vessel wall when that happens it's going to cause a tear and now blood can start tracking in this look at this it can start tracking inside of this Lumen this false Lumen if you will so it's usually kind of this area between the Tunica um intima and the Tunica Media and the blood can start tracking through here what is this called This is called a aortic dissection so these high shearing forces can lead to an aortic dissection that is another big big thing that can happen and scary in patients who have super high blood pressure all right another one is that whenever you have these high shearing forces the other thing is that this is going to cause the it causes like damage to the vessels of the Tunica externa that Supply like the they call them the vase of a storm they come become damaged and they don't get enough blood supply to the abdominal aorta and sometimes this thing gets super weak and it starts ballooning and so another thing that you can get here is you can also get what's called an aortic aneurysm so an aortic aneurysm can occur because of the shearing forces but it also can occur from like microvascular disease so sometimes the tiny little vessels that supply the actual blood vessel itself that's it seems weird right blood vessels Supply blood vessels yes it does sometimes this can also cause an aortic aneurysm and usually it's more common for it to be the abdominal aortic aneurysms these are definitely going to be the most common in comparison to the thoracic aortic aneurysms all right so these are some of the big complications that we can see with patients having hypertension pretty terrifying right and then things blow you know it's going to be a bad day for the patient or another one neurological disease so blood vessels that are supplying the actual central nervous system or the spinal brain and the spinal cord is another particular problem again atherosclerosis is a very very problematic thing so if you start getting a lot of atherosclerosis that's occurring particularly on the blood vessels that supply the brain this is also going to cause a lot of problems so now this plaque is narrowing the actual vessel Lumen what it can do is it can actually really hit the carotids really hard right around that bifurcation point and this can lead to what's called carotid stenosis and sometimes this may present as a TIA so some patients May develop what's called a transient ischemic attack where they have a very little blood flow that gets up in the brain and this can actually lead to ischemia to the brain and they can start exhibiting symptoms of neurological deficits of a stroke but usually it resolves sometimes what also can happen is you can plaque up really big arteries like the middle cerebral artery other vessels like the vertebral basilar artery and you can literally block off blood flow to the tissues here all right and if that happens you can literally cause death of the tissue and this is called a cerebrovascular accident so you can also cause a cerebrovascular accident because of these plaques narrowing the actual Lumen of the vessels and limiting the oxygen supply to the tissues another terrifying complication the other thing is what if the pressure is so high that it's enough to rupture these blood vessels look at this it just pops open or it forms an aneurysm and that aneurysm then bursts so other things that you could potentially see here is you could see rupturing of the actual vessels which can lead to things like an intra cerebral hemorrhage or things like a subarachnoid hemorrhage so these are all things that you want to be aware of whenever the patient has super high blood pressure you rupture the vessels or you plaque up the vessels simple as that all right let's come back we're going to come to a retinal disease in a second we're going to go over to renal disease all right this one's interesting you kind of plaque up the vessels but it's in a little bit of a different way so whenever the patient has super high blood pressure what happens is a lot of blood will be flowing through this thing called the affair and arterial into the glomerulus filtering and filtering and filtering tons of this filtrate into the glomerular area what happens is that your GFR is just too high and your kidneys don't like it when the GFR is way too high so then what it does is is it causes thickening or sclerosis of the afferent arterial so you're going to get what's called sclerosis of the afferent arterial or the renal vessels we're going to put afferent arterial which is this guy here what that does is that reduces the blood flow into the actual glomerulus and multiple areas of the glomerulus this can lead to ischemia and this eventually over time will cause renal injury so renal injury so you'll start damaging and destroying a lot of your renal cells and what happens is when you cause this renal injury this can potentially progress to like something like an acute kidney injury if it's really really bad or a chronic kidney disease which is actually going to be one of the more common causes of chronic kidney diseases right so there's two big causes diabetes and hypertension so this is a really really high risk factor for that so you have increasing sclerosis of this which then stimulates ischemia which then stimulates renal injury and can lead to these factors here so this is another problematic issue and that can arise one way that you could tell is that sometimes this blood pressure is really really high that it can just blow open these renal arteries these actual glomerulite and sometimes blood can actually leak into the glomerulus and into the urine and this is another feature that can sometimes be Associated more with akis so you also want to watch out for look for I'm going to write it here in red hematuria so blood in the urine this also is a common finding here that if a patient has an increase because how do we Define a acute kidney injury it's an Abrupt increase in the creatinine right CKD is there's a drop off in the GFR over time so these are going to be big things to remember here all right the next one and the last one is retinal disease so this one's interesting so in patients who have retinal disease we have different grades of hypertensive retinopathy right so we call this retinopathy there's grade one grade two grade three grade four obviously as you go towards this four it gets worse the concept is the same though usually what happens is these retinal vessels that I'm zooming in on you get sclerosis first so they get kind of hard and they reduce some of the oxygen supply to the tissue the retinal tissue over time it progresses and the pressure continues to remain elevated that it causes small hemorrhaging that's the second part and then lastly potentially it can progress where it starts causing a lot of Edema tons of Edema and the way that this can look if you take this pathophysiologically you look at the eye they may have these like tight little like what's called AV nicking that you may notice on grade one as you go into grade two you may also notice again a lot of kind of like these constricted vessels as you go into grade three you may notice a lot of these like tiny little aneurysms and what's called cotton wool spots then as we progress to grade four which is usually the one that they ask in your exams especially during hypertensive emergencies is is there kind of like blurring of the optic disc is there a lot of swelling there on that area and that's characteristic of what's called papilledema so this is a big finding that you want to watch out for more of the chronic stages you may see again these cotton wool spots these micro aneurysms these hemorrhages AV nicking these are some of the things that you might notice in The Chronic stages but acutely you'll want to watch out for that one all right so this is the complications that you see with hypertension usually again Target organ damage so if a patient has a blood pressure that's greater than 180 or 120 and they have any of these features we can call that a hypertensive emergency urgency that just have a high blood pressure they don't have any of these features over time with hypertension it does cause a lot of chronic damage and you want to watch out for that let's talk about the diagnostic approach all right how do we diagnostically approach high blood pressure when a patient comes in you want to get a BP in both arms reason why is you don't want to miss a patient who maybe has a high blood pressure and it's maybe they have an aortic dissection or they have some type of like weird subclavian stenosis or something that's altering the blood pressure within both extremities so just make sure you check both arms in the office do they have hypertensive readings in other words is it stage one stage two or is in the crisis stages if it's high I would have them come back to the office and anywhere between one to four weeks earlier the better though recheck it again if I recheck it again and it's still elevated the patient has hypertension so you need at least two or more readings that are at least spaced out between maybe two office visits and it's confirmed that in those two office visits the patient has elevated blood pressure in both arms they have hypertension the one thing that you don't want to miss is something called white coat hypertension so sometimes patients can have blood pressure because they're getting nervous and anxious coming into the hospital or coming into the clinic to get their blood pressure checked but when they're at home their blood pressure is normal and these patients make sure that you rule that out and have them check their blood pressure at home we call this ambulatory blood pressure monitoring and just make sure that their blood pressure is actually either elevated if you think that they have hypertension at home or is it normal at home and only elevated in the office that might make you think about white coat hypertension the last thing is if a patient has a blood pressure of greater than 180 over 120 you have to then suspect do they have a hypertensive crisis is there no target organ damage oh then that's a hypersensitive urgency is it positive Target organ damage then it's a hypertensive emergency and that's how we would go about through determining a patient's diagnosis of hypertension ruling out y code hypertension and determining if they have a hypertensive crisis and which type of that crisis it is all right now we come into the bread and butter here of hypertension how do we treat it so we have a patient who comes in they have normal BP in less than 120 less than 80. everybody in every aspect of life should be getting lifestyle modifications you should always be trying to lose weight eat better the DASH diet has been one of the diets that's been shown to provide benefit exercise reduce the sodium intake reduce alcohol same thing for pre-hypertensive patients when you get to stage one again less than 140 less than 90 but greater than 130 greater than 80. in these scenarios it's still lifestyle modifications here's what's different if a patient has an atherosclerotic cardiovascular disease risk of greater than or equal to 10 percent you need to start an antihypertensive the reason why is because they have other factors that are making their potential risk of stroke or Mi or peripheral artery disease much higher and in that scenario controlling their blood pressure is super super important so that's when we'll start them on a drug usually the most common drugs for essential hypertension is ACE inhibitors or arbs thiazide erratics or a calcium channel blocker usually amlodipine or nifedipine are super common drugs to use if we go to the next one stage two this is when they are greater than 140 or greater than 90. in these scenarios you have to again Institute lifestyle modifications but right away start anti-pretensives you don't even care about their risk greater than a degree to 10 if it's been consistently greater than 140 over 90 lifestyle modifications have not worked you got to start on anti-hypertensive right away again use Ace inhibitor arbs thiazides or calcium channel blockers how do you know which one to pick generally for most of these you can pick any of them but one of the things that they may try to test you on on the exam is if they're African-American calcium channel blockers such as amlodipine and the phetipine and thiazides have been shown to be significantly more beneficial in patients who are African-American type of ethnicity as compared to ACE inhibitors and arbs because they have what's called Low renin hypertension and so I would actually consider that on the exam all right but oftentimes what the exam will try to do is test you as to what agent you'll use based upon the comorbidity that they have do they have another disease that would actually make you pick this drug over another one so for example that they just have a myocardial infarction if they did we all know that beta blockers are great ACE inhibitors and arbs are great because they reduce ventricular Remodeling and also beta blockers reduce the risk of v-tac or vfib arrhythmias in general do they have heart failure same thing beta blockers ACE inhibitors arbs but add-on aldosterone antagonists those are the other ones to consider do they have coronary artery disease same thing beta blockers ACE inhibitors or arbs but you can consider calcium channel blockers as well the tiazem Verapamil amlodipine the other thing that I would also consider here is when you're talking about coronary artery disease nitrates have been shown to be beneficial isosorbide dinitrate isosorbide mononitrate these are drugs that you could potentially be instituting in these patients the whole point of using these drugs and patients who have coronary artery disease is if they have Associated angina so angina ACE inhibitors and arbs will not be beneficial in angina but beta blockers reduce contractility reduce heart rate that reduces myocardial oxygen demand calcium channel blockers same thing reduce myocardial oxygen demand and nitrates reduce preload which reduces the amount of work that the heart has to do to generate a good stroke volume so these are the drugs that you'd want to give a patient has angina as a result of their coronary artery disease and has hypertension atrial fibrillation it's usually beta blockers and calcium channel blockers that will be your go-to choice here and if they have diabetes and CKD there's usually particular drugs such as ACE inhibitors arbs that have been shown to reduce protein urea and reduce a lot of the actual destructive damage so they actually help with improving the patient's progression of kidney disease so they have renal protection but they also reduce albumin albuminaria so these would be the drugs that you'd want to give here pregnancy I want you to remember the mnemonic healthy moms love nifedipine and this is hydralazine methyl dopa labetalol and amphetapine these are the drugs that have no teratogenic effect and have been shown to be beneficial in patients who have pregnancy related hypertension and then the other kind of ones that maybe kind of be scattered in there is osteoporosis you want something that's going to conserve calcium so Hydrochlorothiazide is a really good one there and then BPH is your Alpha One receptor blocker so doxazos and tamsulosin these would be the things I want you guys to remember now things to quickly consider but we'll go over this more in Pharmacology as beta blockers should try to be avoid in any reactive airway disease like COPD and Asthma and acute decompensated heart failure because it can worsen cardiogenic shock calcium channel blockers don't give these an acute decompensated heart failure ACE inhibitors arbs avoid this in patients who have an acute kidney injury or the potassium is super high same thing with aldosterone antagonists because these can increase your potassium in your creatinine and then lastly thiazide should be avoided in gout because they can cause hyperuricemia all right so how do we treat a patient who comes in with a blood pressure of greater than 180 over 120. I got to know do they have Target organ damage do they have any neurological deficits any confusion encephalopathy any chest pain or any signs of EKG changes the pulmonary edema or any evidence of acute heart failure do they have an aortic dissection aortic aneurysm do they have an acute kidney injury if they do then we're going to go a different pathway but if they don't it's a hypertensive urgency aim to drop their blood pressure to less than 160 over 100 but use oral medications as needed okay there's no need to rush to drop the blood pressure quickly get them down to at least the normal BP in one to two days again just to avoid any kind of like abrupt drop in the blood pressure um because you don't want to cause ischemia and we'll talk about that in a second if they do have Target organ damage they have neurological deficits encephalopathy chest pain acute heart failure presentations like pulmonary edema aortic dissections or aneurysms or Aki they have a hypertensive emergency and you want to be really careful you want to get the blood pressure down but you don't want to get it down too quickly so you want to drop the map by approximately 25 within the first one to two hours use IV agents and we'll talk about those that can be utilized after that for the next two to six hours aim to get them to the same BP here less than or equal to 160 over 100 and then over the next one to two days then try to normalize the blood pressure the reason why this is super important that you don't want to drop their BP too quickly is if their blood pressure is super high and you drop it quickly and you reduce the perfusion to that organ and that can cause ischemia and then actually cause worsening organ malperfusion and Target organ damage even more so that's something to really really be careful of when patients come in super high blood pressures don't drop them too quickly because you can cause worsening encephalopath but the worsening cardiac ischemia worsening acute kidney injury all right so what are these IV anti-hypertensives that we can use the choices are usually depending upon if you want to get their blood pressure super titratable and super closely controlled so if I'm trying to actually titrate this to their blood pressure goal usually IV agents things like nicartipine or asthma law or nitroprocide would be the Agents of choice that are nicely titratable I'd say the cardiopian is going to be the most common esmelon is good if they have any cardiac disease like CAD Mi or aortic disease nitropresside is one that can also be given but I would really be careful because of the risk of lactic acidosis that can develop with this one if the blood pressure is not as needed to be closely titrated we can do IV pushes and so we can give things like hydralazine or labetalol so that would cover in this lecture hypertension I hope it made sense I hope that you guys enjoyed it and as always until next time [Music]