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USMLE – Hypertension

Pathophysiology
1. Increased systolic and/or diastolic blood pressure (in adults, diastolic > 85 mm Hg and sytolic > 140 mm Hg)
2. Classified as essential (idiopathic) or secondary
3. “Surgically correctable” – coarctation of aorta, renal artery stenosis, pheochromocytoma, Conn’s disease, Cushing’s syndrome
4. Environmental – salt intake, alcohol intake, obesity, occupation

Signs and Symptoms
1. Most cases are asymptomatic until severe, end-stage disease
2. Headache (unilateral and on awakening)
3. Palpitations
4. Easy fatigability
5. Impotence
6. Vascular sequelae – blurred vision, epistaxis, hematuria, transient cerebral ischemia
7. Bruits in renal arteries

Characteristic Test Findings
EKG – left ventricular hypertrophy

Associated Conditions
1. Renal failure
2. Stroke
3. Aortic aneurysms
4. Cardiac failure
5. Retinal changes – papilledema, hemorrhages, exudates
6. Oral contraceptives

Biochemistry
1. 20% of essential hypertension classified as low renin (salt sensitive with expanded extracellular fluid and increased sensitivity to angiotensin II)
2. 25% of essential hypertension is nonmodulating (salt has no effect)
3. 15% of essential hypertension is high renin
4. Increased levels of cytosolic calcium may play a role
5. Hyperinsulinemia/insulin resistance may play a role

Inheritance/Epidemiology
1. Premenopause – less common in women than men of same age; postmenopause – more common in women
2. Strong familial (multifactorial) genetic predisposition

Treatment
1. Diuretics (thiazides, furosemide)
2. Alpha-adrenergic receptor blockers (phentolamine, prazosin)
3. Beta-adrenergic receptor blockers (propranolol, atenolol)
4. Calcium channel blockers (nifedipine)
5. ACE inhibitors (captopril, enalapril)
6. Vasodilators (hydralazine)
7. Smoking cessation
8. Exercise
9. Salt restriction

Tips for USMLE
1. If diastolic pressure increases when patient moves from supine to standing, it is more likely essential hypertension
2. If diastolic pressure decreases when patient moves form supine to standing, it is more likely secondary hypertension
3. Hypertension causes renal failure, and renal failure causes hypertension

Lillian Thompson By Lillian Thompson

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