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304
J. Nalamati and D. Damania
15. Redline S, Yenokyan G, Gottlieb DJ, Shahar E, O’Connor GT,
Resnick HE, etal. Obstructive sleep apnea-hypopnea and incident stroke: the sleep heart health study. Am J Respir Crit Care
Med. 2010;182(2):269–77.
16. Ren R, Li Y, Zhang J, Zhou J, Sun Y, Tan L, etal. Obstructive
sleep apnea with objective daytime sleepiness is associated with
hypertension. Hypertension. 2016;68(5):1264–70.
1 7. Calik MW. Treatments for obstructive sleep apnea. J Clin
Outcomes Manag. 2016;23(4):181–92.
18. Dieltjens M, Vanderveken OM, Heyning PH, Braem MJ.Current
opinions and clinical practice in the titration of oral appliances
in the treatment of sleep-disordered breathing. Sleep Med Rev.
2012;16(2):177–85.
19. Strollo PJ Jr, Soose RJ, Maurer JT, de Vries N, Cornelius J,
Froymovich O, et al. Upper-airway stimulation for obstructive
sleep apnea. N Engl J Med. 2014;370(2):139–49.
20. Sukhal S, Khalid M, Tulaimat A.Effect of wakefulness- promoting
agents on sleepiness in patients with sleep apnea treated with
CPAP: a meta-analysis. J Clin Sleep Med. 2015;11(10):1179–86.
21. Lee JJ, Sahu N, Rogers R, Soose RJ. Severe obstructive sleep
apnea treated with combination hypoglossal nerve stimulation
and oral appliance therapy. J Dental Sleep Med. 2015;2(4):185–6.
22. Tefft BC.Prevalence of motor vehicle crashes involving drowsy
drivers, United States, 2009–2013. Washington, DC: AAA
Foundation for Traffic Safety; 2014.
23. Eckert DJ, Jordan AS, Merchia P, Malhotra A.Central sleep apnea:
pathophysiology and treatment. Chest. 2007;131(2):595–607.
24. Javaheri S. Sleep disorders in systolic heart failure: a prospective study of 100 male patients. The final report. Int J Cardiol.
2006;106(1):21–8.
25. Grimm W, Koehler U. Cardiac arrhythmias and sleepdisordered breathing in patients with heart failure. Int J Mol Sci.
2014;15(10):18693–705.
26. Pepin JL, Borel JC, Janssens JP. Obesity hypoventilation syndrome: an underdiagnosed and undertreated condition. Am J
Respir Crit Care Med. 2012;186(12):1205–7.
2 7. Van Ryswyk E, Antic NA.Opioids and sleep-disordered breath-
ing. Chest. 2016;150(4):934–44.
Chapter 15. Sleep Apnea
28. Barateau L, Lopez R, Dauvilliers Y.Management of narcolepsy.
Curr Treat Options Neurol. 2016;18(10):43.
29. Liira J, Verbeek JH, Costa G, Driscoll TR, Sallinen M, Isotalo
LK, etal. Pharmacological interventions for sleepiness and sleep
disturbances caused by shift work. Cochrane Database Syst Rev.
2014;(8):CD009776.
30. Wijemanne S, Jankovic J.Restless legs syndrome: clinical presentation diagnosis and treatment. Sleep Med. 2015;16(6):678–90.
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Part IV
Cardiac
Chapter 16
Hypertension
JitendraBarmecha
Brief Introduction
Hypertension is the most common condition seen in primary
care practice. Not only is hypertension a major preventable
cause of cardio-cerebrovascular morbidity and mortality, but
it is also an independent risk factor for resulting end organ
damage including myocardial infraction, stroke, heart failure,
retinopathy, peripheral vascular disease, and end-stage renal
disease aka hypertension-mediated organ damage (HMOD).
Social determinants coupled with behavioral and genetic factors play an important role in the development of hypertension and its related complications.
Scope oftheProblem
Annually, over 10 million deaths worldwide can be attributed
to hypertension [1]. Approximately 80 million, or one in three
American adults, have high blood pressure. About one in
J. Barmecha (*)
Department of Internal Medicine, SBH Health System,
Bronx, NY, USA
e-mail: jbarmecha@sbhny.org
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2022
E. Sydney et al. (eds.), Handbook of Outpatient Medicine,
https://doi.org/10.1007/978-3-031-15353-2_16
309
310
J. Barmecha
three American adults also have prehypertension, blood
pressure numbers that are higher than normal but not yet in
the high blood pressure range. Seventy-seven percent of individuals diagnosed with hypertension are using antihypertensive medications, but only 54% have their condition controlled.
The prevalence of hypertension is projected to increase about
8% between 2013 and 2030. High blood pressure costs the
nation over $50 billion each year. This total includes the cost
of health care services, medications to treat high blood pressure, and missed days of work [2].
Based on the data provided by the American Heart
Association [2], there is widespread racial and gender disparity in the prevalence of high blood pressure in the US population. In recent years, the incidence and prevalence of
hypertension have increased, while rates of BP control have
decreased. Rates in African-Americans are among the highest of any population in the world.
• 46% of African-American women have high blood
pressure.
• 45% of African-American men have high blood pressure.
• 33% of white men have high blood pressure.
• 30% of white women have high blood pressure.
• 30% of Hispanic men have high blood pressure.
• 30% of Hispanic women have high blood pressure.
A recent analysis of the National Health and Nutrition
Examination Survey (NHANES) from 1999 to 2018 found
large increases in hypertension awareness, treatment, and
control (≈10%) within each race/ethnicity and sex subgroup
except for Black females. Among Black females, levels of
hypertension awareness, treatment, and control increased
between 1999–2002 and 2007–2010 but decreased between
2007–2010 and 2015–2018 [1].
History andReview ofSystems
Contributing factors to elevated blood pressure need to be
assessed during an initial visit and for all ongoing encounters.
Every clinical encounter requires a review of system and fam-
Chapter 16. Hypertension
ily history of symptoms of cardio-cerebrovascular diseases,
renal disease, diabetes, dyslipidemia, and gout. History of
symptoms suggestive of secondary hypertension should be
explored, e.g., weight gain, sedentary lifestyle, physical activity, and tobacco use [3]. Psychosocial and environmental factors that may elevate blood pressure like social determinants,
family situation, employment status, working conditions, and
education level need to be addressed. Sodium intake, alcohol
use, intake of saturated fat, and cholesterol should be
assessed. Medication history should include results and side
effects of previous antihypertensive therapy, use of commonly prescribed over-the-counter medications, herbals, and
illicit medications or recreational drugs that may raise blood
pressure or interfere with the effectiveness of antihypertensive medications.
311
Decision-Making/Differential Diagnoses
The early stages of hypertension may have no clinical manifestations except elevated blood pressures. Primary or essential hypertension should be considered when there are
consecutive elevated blood pressures, bilateral temporal
throbbing headaches, and unexplained lower extremity
edema.
Similar to primary hypertension, secondary hypertension
usually does not have specific signs and symptoms even with
elevated pressures. However, blood pressures not responding
to usual medications, early onset (before age 30) or late onset
(after age 55), normal BMI, no family history, and with end
organ damage and/or dysfunction should be evaluated for
refractory and or secondary hypertension.
Physical Examination
Physical examination either establishes the diagnosis or
depicts the severity of disease. The following examination can
be undertaken:
312
J. Barmecha
• Blood pressure measurements to detect and confirm the
presence of high blood pressure
• Examination of the eyes including the fundus
– Arteriolar narrowing
– Arteriovenous nicking
– Exudates, hemorrhages, and papilledema
• Examination of the neck
– Carotid bruits
– Distended veins
– Enlarged thyroid gland
• Examination of the heart
– Increased rate and size
– Precordial heave
– Clicks and murmurs
– Arrhythmias
– Third (S3) and fourth (S4) heart sounds
• Examination of the abdomen
– Bruits and abnormal aortic pulsation
– Enlarged kidneys
– Masses
• Examination of the extremities
– Diminished, delayed, or absent peripheral arterial
pulsations
– Bruits
– Edema
• Body habitus, looking for changes associated with secondary hypertension
• Peripheral and central nervous system for ischemic changes
Measuring Blood Pressure
The accurate measurement of blood pressure remains the
most important technique for evaluating hypertension [3].
The following steps are recommended when measuring blood
pressure to avoid inaccuracies.
Chapter 16. Hypertension
• No caffeine, exercise, or smoking for 30min prior.
• Seated quietly for 5min in a high back chair.
• Upper arms free of constrictive clothing.
• Both feet on floor, legs should not be crossed, and arm
supported at the level of the heart.
• Cuff bladder should encircle at least 80% of the arm
circumference.
• At least two blood pressure measurements per arm to
obtain an average reading.
• Inflate the cuff to 20–30mmHg above pulse extinction.
• Deflate at a rate of 2–3mmHg/s.
• Systolic BP=onset of first Korotkoff sound.
• Diastolic BP=disappearance of Korotkoff sounds.
• Neither the patient nor the observer should talk during the
measurement.
313
Diagnostic Studies
Baseline blood tests are recommended to identify those individuals at risk for hypertension or to obtain clues to diagnose
secondary hypertension
• Electrocardiogram
• Urinalysis
• Urine for drug screen (based on the history)
• Fasting blood glucose
• Complete blood count
• Serum sodium, potassium, calcium, creatinine or eGFR
(estimated glomerular filtration rate)
• Fasting lipid profile
• Thyroid-stimulating hormone (TSH)
• Optional tests: uric acid, measurement of urinary albumin
excretion or albumin/creatinine ratio
Echocardiography, renal artery evaluation, or brain imag-
ing are not routinely recommended.
As per recent guidelines from the American College of
Cardiology (ACC)/American Heart Association (AHA),
314
J. Barmecha
2020 [4], the blood pressure is categorized as normal, elevated, or stage 1 or 2 hypertension to prevent and treat high
BP (Table16.1).
The International Society of Hypertension (ISH) [5] pro-
vides the criteria for hypertension based on ambulatory and
home BP values to define hypertension; these definitions
apply to all adults above 18years old. These BP categories are
designed to align therapeutic approaches with BP levels
(Table16.2).
T . Categories of blood pressure in adults
a
Blood pressure Systolic (mmHg) Diastolic (mmHg)
Normal Less than 120 And less than 80
Elevated 120–129 And less than 80
Stage 1 hypertension 130–139 Or 80–89
Stage 2 hypertension 140 or higher Or 90 or higher
a
Based on AHA/ACC 2017 guidelines
T . International society of hypertension diagnostic blood
pressure criteria
a
Location and time Systolic BP/diastolic BP (mmHg)
Office blood pressure
≥140 and/or≥90
Ambulatory blood pressure monitoring
24-hour average ≥130 and/or≥80
Daytime average ≥135 and/or≥85
Nighttime average ≥120 and/or≥70
Home
a
Adapted from Unger T et al., 2020, International Society of
≥135 and/or≥85
Hypertension Global Hypertension Practice Guidelines.
Hypertension. 2020;75:1334–1357
Chapter 16. Hypertension
315
Clinical Quality Measure
Controlling blood pressure is part of a condition specific
clinical quality measure. The Healthcare Effectiveness Data
and Information Set (HEDIS) measures the percentage of
adults aged 18–85 with a diagnosis of hypertension, whose
most recent blood pressure reading was controlled based on
the following criteria:
Age 18–59 whose BP was <140/90
Age 60–85 with a diagnosis of diabetes whose BP was <140/90
Age 60–85 without a diagnosis of diabetes whose BP was
<150/90
Exclusions: Patients with end-stage renal disease (ESRD)
or kidney transplant and pregnant status during the measurement year and admission to a non-acute inpatient setting
during the measurement year.
Assessment
Once hypertension is diagnosed, further assessment is recommended to identify cardiovascular risk factors, and signs of
hypertension-mediated organ damage.
Cardiovascular risk can be estimated using a calculator
such as Framingham risk score (https://www.mdcalc.com/
framingham- risk- score- hard- coronary- heart- disease) [6].
Based on new guidance on low ASCVD risk (atherosclerotic
cardiovascular disease risk or 10-year CVD risk <10%)
adults with stage 1 hypertension (BP 130–139/80–89), management can start with non-pharmacologic therapy. If BP
remains uncontrolled at 3–6months, pharmacologic therapy
should be considered [7].