Medicina

• Essential (primary) hypertension


  Most common type, about 90% of cases
• If they start seizing then you know they have what's called eclampsia that's the only really difference between preeclampsia and eclampsia seizures
• Vasoactive chemicals


  Chemicals released by the placental vessels that cause vasoconstriction to try to increase blood pressure and perfuse the placenta and baby
• Vasoactive chemicals are released


  This increases maternal blood pressure and can lead to complications
• Drugs that amp up the sympathetic nervous system (sympathomimetics)

  • Cocaine
  • Amphetamines
  • PCP
• Sleep apnea


  Periods of apnea during sleep cause low oxygen levels, which activates the sympathetic nervous system and leads to high refractory blood pressure
• Essential hypertension


  • Patient is 25-55 years old, has a family history, and is refractory to 3 or more antihypertensives
• Normal blood pressure


  Systolic <120, Diastolic <80
• Stage 1 hypertension


  Systolic >130 but <140, Diastolic >80 but <90
• Stage 2 hypertension


  Systolic >140, Diastolic >90
• Hypertensive urgency


  High blood pressure with no target organ damage
• Hypertensive emergency


  High blood pressure with target organ damage
• Target organ damage from hypertension

  • Cardiovascular disease
  • Neurological disease
  • Renal disease
  • Retinal disease
• High afterload from hypertension

  Causes left ventricular hypertrophy, inhibits ventricular filling, and can lead to diastolic heart failure
• Hypertension


  Triggers atherosclerosis, which can lead to coronary artery disease, myocardial infarction, and peripheral artery disease
• High shearing forces from hypertension

  Can cause aortic dissection or aortic aneurysm
• Hypertension


  Can cause carotid stenosis, transient ischemic attacks, and cerebrovascular accidents due to atherosclerosis of cerebral vessels
• Severe hypertension


  Can cause intracerebral or subarachnoid hemorrhage from vessel rupture
• Hypertension


  Causes sclerosis of the afferent arterioles, leading to glomerular ischemia, renal injury, acute kidney injury, and chronic kidney disease
• Severe hypertension can cause hematuria (blood in the urine) due to rupture of glomerular capillaries
• Renal injury can potentially progress to acute kidney injury or chronic kidney disease, which are common causes of chronic kidney disease
• Diabetes and hypertension are the two big causes of chronic kidney disease
• Progression of renal injury

  1. Increasing sclerosis

  2. Stimulates ischemia

  3. Stimulates renal injury

  4. Can lead to acute kidney injury or chronic kidney disease
• Very high blood pressure


  Can blow open renal arteries and glomeruli, causing blood to leak into the glomerulus and urine (hematuria)
• Acute kidney injury


  Abrupt increase in creatinine
• Chronic kidney disease


  Drop off in GFR over time
• Hypertensive retinopathy


  • Grade 1: Retinal vessel sclerosis
  • Grade 2: Small hemorrhages
  • Grade 3: Edema and aneurysms
  • Grade 4: Papilledema (optic disc swelling)
• Blood pressure >180/120 with target organ damage is a hypertensive emergency, without target organ damage is a hypertensive urgency
• Diagnostic approach to hypertension

  1. Check BP in both arms

  2. Recheck in 1-4 weeks if elevated

  3. Rule out white coat hypertension with home monitoring
• Lifestyle modifications for hypertension

  • Lose weight
  • DASH diet
  • Exercise
  • Reduce sodium
  • Reduce alcohol
• Stage 1 hypertension


  BP 130-139/80-89, start antihypertensives if ASCVD risk ≥10%
• Stage 2 hypertension


  BP ≥140/90, start antihypertensives immediately
• Antihypertensive drug classes


  • ACE inhibitors
  • ARBs
  • Thiazide diuretics
  • Calcium channel blockers
• Considerations for antihypertensive choice

  • African American ethnicity: Calcium channel blockers or thiazides preferred over ACE/ARBs
  • Comorbidities: Select drug based on patient's other conditions
• Antihypertensives for specific conditions

  • Post-MI: Beta blockers, ACE/ARBs
  • Heart failure: Beta blockers, ACE/ARBs, aldosterone antagonists
  • Coronary artery disease: Beta blockers, ACE/ARBs, calcium channel blockers, nitrates
  • Atrial fibrillation: Beta blockers, calcium channel blockers
  • Diabetes/CKD: ACE/ARBs
  • Pregnancy: Hydralazine, methyldopa, labetalol, nifedipine
  • Osteoporosis: Hydrochlorothiazide
  • BPH: Alpha-1 blockers
• Avoid beta blockers in reactive airway disease, acute decompensated heart failure; avoid calcium channel blockers in acute decompensated heart failure; avoid ACE/ARBs and aldosterone antagonists in acute kidney injury or hyperkalemia; avoid thiazides in gout
• Treatment of hypertensive emergency


  1. Assess for target organ damage

  2. If no target organ damage, aim to lower BP to <160/100 in 1-2 days with oral meds

  3. If target organ damage, lower BP by 25% in 1-2 hours with IV meds, then to <160/100 in next 2-6 hours, then normalize over 1-2 days
• IV antihypertensives for hypertensive emergency

  • Nicardipine
  • Esmolol
  • Nitroprusside
  • Hydralazine
  • Labetalol
• cuales son las proteinas de mayor importancia en los músculos cardiacos?

  • Miosina y actina.
• Menciona los Organelos de esta imagen

  1. Nucleolo
  2. njcleo
  3. rer
  4. lisosoma