Changes

=Essential Hypertension=

=Essential Hypertension=

*H&P:  

*H&P:  

*Dx: Primary/Essential Hypertension (95% of cases). Rule out secondary causes, BP > 130/90 on three separate occasions. DDx includes secondary HTN (5% of cases; suspect if patient very young, very old, very high BP, or refractory to treatment), secondary causes listed below:

*Dx: BP > 130/90 on three separate occasions or BP ≥ 180/1120 or with evidence of end organ damage. Primary/Essential Hypertension (95% of cases). Rule out secondary causes. DDx includes secondary HTN (5% of cases; suspect if patient very young, very old, very high BP, or refractory to treatment), secondary causes listed below:

** Endocrine: [[Conn syndrome]] (most common), [[Cushing's syndrome]], [[Pheochromocytoma]], [[Hyperthyroidism]], [[Hyperparathyroidism]]

** Endocrine: [[Conn syndrome]] (most common), [[Cushing's syndrome]], [[Pheochromocytoma]], [[Hyperthyroidism]], [[Hyperparathyroidism]]

** Renal: bilateral [[RAS]], [[PKD]], [[CKD]], '''glomerular disease (nephrotic and nephritic syndromes)'''

** Renal: bilateral [[RAS]], [[PKD]], [[CKD]], '''glomerular disease (nephrotic and nephritic syndromes)'''

** Other: [[Cocaine]], [[OSA]], [[OCPs]], [[Coarctation]]

** Other: [[Cocaine]], [[OSA]], [[OCPs]], [[Coarctation]]

* Tx: For SBP 121-130, start with 8-12 weeks lifestyle modifications and reassess. If SBP 131-139 or DBP 81-89, risk stratify based on 10-yr ASCVD risk, if > 10%, start medication, if < 10%, can do trial of lifestyle modifications. When starting medication, start with 1 or 2 agents depending on severity, reassess efficacy every month and up the dose or add another agent as needed. ACEI/ARB (good for kidney protection, don't do both), Dihydropyridine CCB (better for HTN) > non-dihydropyridine CCB (better for rate control), Beta Blockers (cardiac selective (MAN BABES) > non-selective), Thiazide-Like Diuretics > Thiazide-Type Diuretics. For most patients, the combination of ACEI/ARB + CCB is the best, so start with one of these two classes so that the second can be added later for synergy. Special population considerations: [[CHF]] (avoid CCBs, use beta blockers, ACEI/ARBs, spironolactone), [[CKD]] (use ACEI/ARB), Pregnancy (hydralazine, labetalol, nicardipine, methyldopa), post-MI (use beta blockers + ACEI/ARB), Blacks (CCB + thiazide-like diuretic), Cocaine (don't give beta blockers due to unopposed alpha).

* Tx: For SBP 121-130, start with 8-12 weeks lifestyle modifications and reassess. If SBP 131-139 or DBP 81-89, '''risk stratify based on 10-yr ASCVD risk, if > 10%, start medication, if < 10%, can do trial of lifestyle modifications'''. For stage 2 hypertension (>140/90), '''start treatment with 2 medications.''' When starting medication, start with 1 or 2 agents depending on severity, reassess efficacy every month and up the dose or add another agent as needed. ACEI/ARB (good for kidney protection, don't do both), Dihydropyridine CCB (better for HTN) > non-dihydropyridine CCB (better for rate control), Beta Blockers (cardiac selective (MAN BABES) > non-selective), Thiazide-Like Diuretics > Thiazide-Type Diuretics. For most patients, the combination of ACEI/ARB + CCB is the best, so start with one of these two classes so that the second can be added later for synergy. Special population considerations: [[CHF]] (avoid CCBs, use beta blockers, ACEI/ARBs, spironolactone), [[CKD]] (use ACEI/ARB), Pregnancy (hydralazine, labetalol, nicardipine, methyldopa), post-MI (use beta blockers + ACEI/ARB), Blacks (CCB + thiazide-like diuretic), Cocaine (don't give beta blockers due to unopposed alpha).

* Hypertensive Urgency BP > 180 + mild symptoms

* Hypertensive Urgency BP > 180 + mild symptoms

* Hypertensive Emergency BP > 180 + ominous symptoms

* Hypertensive Emergency BP > 180 + ominous symptoms