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FM34 Family Medicine
Common Presenting Problems Toronto Notes 2019
• significantrecentincreaseinBPoverprevioushypertensivelevelsassociatedwithevidenceofvascular damage on fundoscopy, but without papilledema
■ malignant HTN
• sufficientelevationinBPtocausepapilledemaandothermanifestationsofvasculardamage(retinal
hemorrhages, bulging discs, mental status changes, increasing creatinine)
• whitecoathypertension
■ high clinic BP with normal home BP and 24 ambulatory BP, caused by anxiety in clinic
• maskedhypertension
■ normal clinic BP with high BP in home and/or ambulatory setting, often provoked by anxiety, job stress, exercise
Etiology
• essentialhypertension(90%,undeterminedcause) • secondaryhypertension(10%,knowncause)
Suspect Hyperaldosteronism when
• HTN refractory to treatment with ≥3 drugs
• Spontaneous hypokalemia
• Profound diuretic-induced hypokalemia
(<3.0 mmol/L)
• Incidental adrenal adenomas
Hypertensive Emergencies
• Malignant HTN
• Cerebrovascular
Hypertensive encephalopathy Stroke
Intracerebral hemorrhage SAH
• Cardiac
Acute aortic dissection
Acute refractory LV failure Myocardial infarction/ischemia Acute pulmonary edema
• Renal failure
Predisposing Factors
• familyhistory
• obesity(especiallyabdominal) • alcoholconsumption
• stress
• sedentarylifestyle
• smoking
Table 20. Causes of Secondary HTN
• male
• age>30
• excessivesaltintake/fattydiet • AfricanAmericanancestry
• dyslipidemia
Renal Endocrine
Vascular Drug-Induced
Investigations
Common Cause
Renovascular HTN
Renal parenchymal disease, glomerulonephritis, pyelonephritis, polycystic kidney
1o hyperaldosteronism Pheochromocytoma
Cushing’s syndrome Hyperthyroidism/hyperparathyroidism Hypercalcemia of any cause
Coarctation of the aorta Renal artery stenosis
Estrogens/OCP Steroids MAOIs Lithium Cocaine Amphetamines
NSAIDs Decongestants Alcohol
• forallpatientswithHTN:
■ electrolytes, Cr, fasting glucose and/or HbA1c, lipid profile, 12-lead ECG, urinalysis
■ self-measurement of BP at home is encouraged (recommended devices listed at www.hypertension.
ca)
• forspecificpatientetiology:
■ DM or chronic kidney disease: urinary protein excretion
■ if suspected renovascular HTN: renal ultrasound, captopril renal scan (if GFR >60 mL/min), MRA/
CTA (if normal renal function)
■ if suspected endocrine cause: plasma aldosterone, plasma renin (aldosterone-to-renin ratio)
• measuredfrommorningsamplestakenfrompatientsinsittingpositionafterresting15min • discontinuealdosteroneantagonists,ARBs,β-blockers,andclonidinepriortotesting
■ if suspected pheochromocytoma: 24 h urine for metanephrines and creatinine • ifsuspectedLVdysfunction:echocardiogram
Diagnosis
• allCanadianadultsshouldhaveBPassessedatallappropriateclinicalvisits,oscillometricpreferredto manual