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• Individuals with BMI >50 have underlying Obesity
Hypoventilation syndrome and individuals with underly-
ing heart failure can have Central Sleep Apneas, when
Positive airway pressure therapy may need frequent fol-
low up and consider repeat titration.
• Hypoglossal Nerve stimulation and dental appliances are
effective in moderate to severe of Obstructive Sleep
apnea, however it has not been tested in individuals with
BMI >32.
Don’t Miss This!
• Obstructive sleep apnea, although the commonest cause, is
only one of the many causes of excessive daytime sleepi-
ness (EDS). Do not miss other coexisting conditions like
restless legs syndrome (frequent in pregnant individuals,
individuals with end-stage kidney disease, patients on
diuretics), narcolepsy, and the most common of all chronic
sleep deprivation.
• For circadian rhythm sleep disorders, the best shift that
causes least sleep disturbance is the 4PM–12MN shift.
References
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deprivation: an unmet public health problem. The National
Academies Collection: Reports funded by National Institutes of
Health. Washington, DC. 2006.
2. American Academy of Sleep Medicine. International classifica-
tion of sleep disorders. 3rd ed. Darien, IL: American Academy of
Sleep Medicine; 2014.
3. Young T, Palta M, Dempsey J, Skatrud J, Weber S, Badr S. The
occurrence of sleep-disordered breathing among middle-aged
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CPAP for prevention of cardiovascular events in obstructive
sleep apnea. N Engl J Med. 2016;375(10):919–31.
5. Senthilvel E, Auckley D, Dasarathy J. Evaluation of sleep dis-
orders in the primary care setting: history taking compared to
questionnaires. J Clin Sleep Med. 2011;7(1):41–8.
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247
6. Johns MW. Reliability and factor analysis of the Epworth sleepi-
ness scale. Sleep. 1992;15(4):376–81.
7. Neelapu BC, Kharbanda OP, Sardana HK, Balachandran R,
Sardana V, Kapoor P, et al. Craniofacial and upper airway mor-
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review and meta- analysis of cephalometric studies. Sleep Med
Rev. 2016;
8. Chai-Coetzer CL, Antic NA, McEvoy RD. Ambulatory models
of care for obstructive sleep apnoea: Diagnosis and manage-
ment. Respirology. 2013;18(4):605–15.
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T, Gannon M, et al. Identifying patients at risk for obstructive
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10. Redline S, Yenokyan G, Gottlieb DJ, Shahar E, O'Connor GT,
Resnick HE, et al. Obstructive sleep apnea-hypopnea and inci-
dent stroke: the sleep heart health study. Am J Respir Crit Care
Med. 2010;182(2):269–77.
11. Ren R, Li Y, Zhang J, Zhou J, Sun Y, Tan L, et al. Obstructive
sleep apnea with objective daytime sleepiness is associated with
hypertension. Hypertension. 2016;68(5):1264–70.
12. Calik MW. Treatments for obstructive sleep apnea. J Clin
Outcomes Manag. 2016;23(4):181–92.
13. 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.
14. 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.
15. Sukhal S, Khalid M, Tulaimat A. Effect of wakefulness-promot-
ing agents on sleepiness in patients with sleep apnea treated with
CPAP: a meta-analysis. J Clin Sleep Med. 2015;11(10):1179–86.
16. Lee JJ, Sahu N, Rogers R, Soose RJ. Severe obstructive sleep
apnea treated with combination hypoglossal nerve stimulation
and oral appliance therapy.. Journal of Dental. Sleep Med.
2015;2(4):185–6.
17. Tefft BC, Safety AFFT. Prevalence of motor vehicle crashes
involving drowsy drivers, United States, 2009—2013. Washington,
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tive study of 100 male patients. The final report. Int J Cardiol.
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drome: an underdiagnosed and undertreated condition. Am
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J. Nalamati and D. Damania
Part IV
Cardiac
251© Springer International Publishing AG 2018
E. Sydney et al. (eds.), Handbook of Outpatient Medicine,
https://doi.org/10.1007/978-3-319-68379-9_15
Introduction
Hypertension is the most common chronic condition seen in
primary care practice. Hypertension is not only a major pre-
ventable cause of cardio-cerebrovascular morbidity and mor-
tality; it is also an independent risk factor for end-organ
damage including myocardial infarction, stroke, heart failure,
retinopathy, and end-stage renal disease. Social determinants
coupled with behavioral and genetic factors play an impor-
tant role in the development of hypertension and its related
complications.
Scope of the Problem
Annually, over ten 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 three
Chapter 15
Hypertension
Jitendra Barmecha
J. Barmecha, MD, MPH, SFHM, FACP (*)
Department of Internal Medicine, SBH Health System,
4422 Third Avenue, Bronx, NY 10457, USA
e-mail: jbarmecha@sbhny.org
252
American adults also have prehypertension, blood pressure
values 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 $48.6 billion each
year. This total includes the cost of healthcare services, medica-
tions to treat high blood pressure, and missed days of work [2].
Based on the data provided by the American Heart
Association in 2015 [3], there is widespread racial and gender
disparity in the prevalence of high blood pressure in the US
population. Rates in African-Americans are among the high-
est 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.
Key History and Physical Exam
Contributing factors to elevated blood pressure need to be
assessed during an initial visit and all subsequent visits. Every
clinical encounter requires a review of systems and family
history of symptoms of cardio-cerebrovascular disease, renal
disease, diabetes, dyslipidemia, and gout. History of symp-
toms suggestive of secondary hypertension should be
explored, e.g., weight gain, sedentary lifestyle, physical activ-
ity, and tobacco use [4]. Psychosocial and environmental fac-
tors that may elevate blood pressure such as social
determinants, family situation, employment status, working
conditions, and education level need to be addressed. Sodium
intake, alcohol use, and intake of saturated fat and choles-
terol should be assessed. Medication history should include
effectiveness of prior therapy and/or intolerance to previous
J. Barmecha
253
antihypertensive therapy and use of commonly prescribed
over-the-counter medications, herbal and illicit medications,
or recreational drugs that may raise blood pressure or inter-
fere with the effectiveness of antihypertensive medications.
Decision-Making/Differential Diagnoses
The early stages of hypertension may have no clinical manifes-
tations except elevated blood pressures. Primary or essential
hypertension should be considered when there are consecu-
tive 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,
normal BMI, no family history, and presence of end-organ
damage and/or dysfunction should be evaluated for second-
ary hypertension (Tables 15.1 and 15.2).
Physical Examination
Physical examination establishes the diagnosis and may reveal
the severity of disease. The following examination should be
performed:
Table 15.1 Classification of blood pressure in adults
Blood pressure
Systolic
(mmHg)
Diastolic
(mmHg)
Normal <120 And <80
Prehypertension 120–139 Or 80–89
Stage 1 hypertension 140–159 Or 90–99
Stage 2 hypertension ≥160 ≥100
Stage 3 hypertension >180 >110
Isolated systolic hypertension >140 <90
15. Hypertension
254
Table 15.2 Categories of
secondary hypertension
in adults
Secondary
Renal
Parenchymal diseases
Vascular (renal artery
stenosis)
Tumors (renin producing)
Adrenal
Cushing’s disease
Primary aldosteronism
Pheochromocytoma
Endocrine
Hypothyroidism
Hyperthyroidism
Acromegaly
Carcinoid tumors
Vascular
Coarctation of the aorta
Aortic regurgitation
Medications
Oral contraceptives
Erythropoietin
NSAIDS
Corticosteroids
Cyclosporine
Miscellaneous
(continued)
J. Barmecha
255
• Blood pressure measurements bilaterally to detect and
confirm the presence of high blood pressure
• Examination of the eyes including 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
Secondary
Pregnancy
Perioperative period
Alcohol withdrawal
Obstructive sleep apnea
Caffeine
Nicotine
Table 15.2
(continued)
15. Hypertension
256
• Body habitus, looking for changes associated with second-
ary 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 [5].
The following steps are recommended when measuring blood
pressure to avoid inaccuracies:
• No caffeine, exercise, or smoking for 30 min prior.
• Seated quietly for 5 min in a high-back chair.
• Upper arms free of constrictive clothing.
• Both feet on the 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 20–30 mmHg above pulse extinction.
• Deflate at a rate of 2–3 mmHg/s.
• Systolic BP = onset of the first Korotkoff sound.
• Diastolic BP = disappearance of Korotkoff sounds.
• Neither the patient nor the observer should talk during the
measurement.
Laboratory Tests
Baseline tests are recommended to identify those individuals
at risk for hypertension or to obtain clues to diagnose second-
ary hypertension:
• Electrocardiogram
• Urinalysis
• Blood glucose measurement
• Complete blood count
J. Barmecha