1 00:00:00,120 --> 00:00:02,730 This lecture is gonna talk about the overview 2 00:00:02,730 --> 00:00:04,958 and presentation of hypertension 3 00:00:04,958 --> 00:00:07,504 and it's one of four mini lectures 4 00:00:07,504 --> 00:00:10,083 for you to review prior to class. 5 00:00:13,800 --> 00:00:17,528 The objectives for this particular mini lecture are 6 00:00:17,528 --> 00:00:22,528 in the first four bullets, but these are the objectives 7 00:00:23,700 --> 00:00:25,890 for all of the mini lectures 8 00:00:25,890 --> 00:00:30,820 for class to prepare for in class case studies. 9 00:00:33,240 --> 00:00:35,310 So we're gonna really just kind of review a little bit 10 00:00:35,310 --> 00:00:37,710 about hypertension, its implications 11 00:00:37,710 --> 00:00:39,633 for you as a primary care provider. 12 00:00:40,680 --> 00:00:45,210 Really very briefly talk about the pathophysiology 13 00:00:45,210 --> 00:00:47,310 from kind of that bird's eye view. 14 00:00:47,310 --> 00:00:50,878 So I would encourage you to go back to your patho notes 15 00:00:50,878 --> 00:00:55,462 or your textbook and review the patho that's associated 16 00:00:55,462 --> 00:00:58,170 with the onset of hypertension. 17 00:00:58,170 --> 00:01:01,680 And then we're gonna spend some time looking at risk factors 18 00:01:01,680 --> 00:01:03,693 and some pertinent history and 19 00:01:03,693 --> 00:01:08,693 physical exam assessments when you are faced 20 00:01:10,440 --> 00:01:12,599 with evaluating an individual that has 21 00:01:12,599 --> 00:01:17,283 either known hypertension or has an elevated blood pressure. 22 00:01:20,610 --> 00:01:21,660 So we'll talk a little bit about 23 00:01:21,660 --> 00:01:23,670 your hypertension and health, 24 00:01:23,670 --> 00:01:28,190 and here's a slide that I like that shows how complicated 25 00:01:28,190 --> 00:01:31,141 and how much different things play 26 00:01:31,141 --> 00:01:36,060 into the onset of hypertension. 27 00:01:36,060 --> 00:01:39,210 So clearly we see the effect of the social determinants 28 00:01:39,210 --> 00:01:43,800 of health combined with the built environment 29 00:01:43,800 --> 00:01:48,800 and then also the genetics and epigenetic effect. 30 00:01:48,990 --> 00:01:52,050 So we can see this real great overlap 31 00:01:52,050 --> 00:01:53,970 of all of those things. 32 00:01:53,970 --> 00:01:57,030 So what we try and do in the treatment 33 00:01:57,030 --> 00:02:00,810 of hypertension is really help mitigate areas 34 00:02:00,810 --> 00:02:04,920 that we have control over to assist people 35 00:02:04,920 --> 00:02:08,634 in minimizing their risk of developing hypertension 36 00:02:08,634 --> 00:02:12,510 or preventing the morbidity mortality associated 37 00:02:12,510 --> 00:02:13,533 with hypertension. 38 00:02:22,260 --> 00:02:25,470 A little bit about the epidemiology. 39 00:02:25,470 --> 00:02:27,990 Nearly half of all of adults in the US 40 00:02:27,990 --> 00:02:30,048 have a diagnosis of hypertension. 41 00:02:30,048 --> 00:02:32,430 I would imagine that's probably even a little bit 42 00:02:32,430 --> 00:02:35,100 higher post Covid, 43 00:02:35,100 --> 00:02:38,490 but yet only a quarter of them have it under control. 44 00:02:38,490 --> 00:02:40,890 So this is really what we call that bread and butter 45 00:02:40,890 --> 00:02:44,340 of primary care and where you can have a lot 46 00:02:44,340 --> 00:02:47,430 of impact on the future health of individuals 47 00:02:47,430 --> 00:02:52,413 by addressing their hypertension and getting it to goal. 48 00:02:53,550 --> 00:02:57,090 We still see a higher percentage of men than women 49 00:02:57,090 --> 00:03:02,090 however, excuse me, as older women, older adult 50 00:03:02,550 --> 00:03:04,320 that are identify as female 51 00:03:04,320 --> 00:03:09,320 or biologically as female, 44% premenopausal let's say, 52 00:03:10,800 --> 00:03:12,600 and it goes even higher. 53 00:03:12,600 --> 00:03:16,383 So that eventually it over time there it tends to equal out. 54 00:03:17,850 --> 00:03:21,240 We do see this more common in individuals 55 00:03:21,240 --> 00:03:24,900 that are not considered white Caucasian 56 00:03:24,900 --> 00:03:28,770 with non-Hispanic black adults being mostly affected. 57 00:03:28,770 --> 00:03:30,390 There's many reasons for that. 58 00:03:30,390 --> 00:03:33,180 There may be some genetic, but it's mostly has to do 59 00:03:33,180 --> 00:03:36,210 with some of the social determinants of health, diet, 60 00:03:36,210 --> 00:03:41,210 lifestyle and whatnot that poses them more risk factors 61 00:03:44,040 --> 00:03:46,173 for the development of hypertension. 62 00:03:47,550 --> 00:03:49,480 And unfortunately in 2019 63 00:03:50,520 --> 00:03:53,850 there were half a million individuals that died 64 00:03:53,850 --> 00:03:56,070 with hypertension listed as a primary 65 00:03:56,070 --> 00:03:57,480 or contributing cause of death. 66 00:03:57,480 --> 00:03:58,770 So that's pretty significant. 67 00:03:58,770 --> 00:04:03,770 So you can see how if we can really reduce one's risk 68 00:04:04,950 --> 00:04:09,950 of developing or risk of mortality morbidity associated 69 00:04:09,960 --> 00:04:14,760 with it, that's really pretty significant. 70 00:04:14,760 --> 00:04:18,330 It still is reportedly one of the most preventable deaths. 71 00:04:18,330 --> 00:04:21,150 This is kind of in the middle of the epidemic. 72 00:04:21,150 --> 00:04:25,380 So it may be that in the post Covid years 73 00:04:25,380 --> 00:04:30,330 that it drops down to in the lower top 10, 74 00:04:30,330 --> 00:04:32,370 but it does cost a significant amount of money. 75 00:04:32,370 --> 00:04:35,370 And we'll see that in the slide in the future. 76 00:04:35,370 --> 00:04:38,160 So this is just another visual way of looking 77 00:04:38,160 --> 00:04:42,900 at the prevalence of high blood or hypertension 78 00:04:42,900 --> 00:04:47,900 excuse me, and or individuals that are taking medications. 79 00:04:48,120 --> 00:04:50,910 So kind of combined and as I said before 80 00:04:50,910 --> 00:04:53,940 we can see here non-Hispanic black populations 81 00:04:53,940 --> 00:04:55,680 are most significantly affected. 82 00:04:55,680 --> 00:04:58,200 But then we also see the individuals 83 00:04:58,200 --> 00:04:59,670 from the federal poverty level 84 00:04:59,670 --> 00:05:03,480 of less than a hundred percent, 130% more affected. 85 00:05:03,480 --> 00:05:06,243 And we can also see the individuals greater than 30. 86 00:05:07,080 --> 00:05:08,867 Here is men, this is, 87 00:05:10,091 --> 00:05:13,447 and here is the total adjusted age adjusted. 88 00:05:15,780 --> 00:05:18,240 So when you kind of think about, hmm, 89 00:05:18,240 --> 00:05:22,974 I have a man who happens to be older than 60 and maybe 90 00:05:22,974 --> 00:05:27,974 has an ethnicity that's not considered Caucasian, 91 00:05:28,260 --> 00:05:33,260 white Caucasian and comes from a lower federal poverty level 92 00:05:33,570 --> 00:05:34,560 that they're gonna, you know, 93 00:05:34,560 --> 00:05:37,470 that you need to really assess them 94 00:05:37,470 --> 00:05:39,210 from a much more holistic standpoint. 95 00:05:39,210 --> 00:05:40,590 Not that you don't do that with everyone, 96 00:05:40,590 --> 00:05:42,360 but you really wanna take a deeper dive 97 00:05:42,360 --> 00:05:46,860 into things that you can help to mitigate their risk 98 00:05:46,860 --> 00:05:51,453 and their, and the progression to overt disease. 99 00:05:52,560 --> 00:05:55,080 When we talk about costs, we see that the percentage 100 00:05:55,080 --> 00:05:58,050 of costs are actually higher for hypertension than diabetes. 101 00:05:58,050 --> 00:06:00,150 And that's because there are more patients 102 00:06:00,150 --> 00:06:01,770 with hypertension than diabetes. 103 00:06:01,770 --> 00:06:05,940 So if you put it on as equal, you can see how 104 00:06:05,940 --> 00:06:09,090 much incredible cost that's associated with this. 105 00:06:09,090 --> 00:06:12,300 But here's the percentage of patients and cost per patients. 106 00:06:12,300 --> 00:06:14,110 So a cost per patient is higher 107 00:06:15,480 --> 00:06:16,560 than it is with hypertension. 108 00:06:16,560 --> 00:06:18,630 We just happen to have more patients 109 00:06:18,630 --> 00:06:21,030 that have hypertension than diabetes. 110 00:06:21,030 --> 00:06:24,570 Now this is, I think this slide is a couple years old now 111 00:06:24,570 --> 00:06:28,560 at this point, but as we see diabetes increase, 112 00:06:28,560 --> 00:06:30,810 we also see the fiscal ramifications. 113 00:06:30,810 --> 00:06:32,070 And these are just of individuals 114 00:06:32,070 --> 00:06:34,611 with diabetes and individuals with hypertension. 115 00:06:34,611 --> 00:06:37,890 You put an individual with hypertension and diabetes 116 00:06:37,890 --> 00:06:42,890 your cost is gonna be more than $6,000 per individual. 117 00:06:45,630 --> 00:06:48,927 So what we do know is that if we don't treat hypertension 118 00:06:48,927 --> 00:06:53,927 then it progresses to clinical disease 119 00:06:54,120 --> 00:06:56,970 and a cardiovascular event within 10 years. 120 00:06:56,970 --> 00:07:01,020 So that's, so what we see here is this percent risk. 121 00:07:01,020 --> 00:07:06,020 So if we can decrease a risk, you know here in the 5%-10%, 122 00:07:06,913 --> 00:07:11,913 then we can really change that 10 year risk here. 123 00:07:12,570 --> 00:07:15,360 So with adequate treatment 124 00:07:15,360 --> 00:07:18,510 we really are starting to reverse, well, we're not, 125 00:07:18,510 --> 00:07:23,370 depending on where they are, we can reverse up to 25%. 126 00:07:23,370 --> 00:07:26,070 So if we're treating here at clinical disease 127 00:07:26,070 --> 00:07:31,070 if we can get them treated, then we're gonna prevent them 128 00:07:31,530 --> 00:07:33,987 from going on to a cardiovascular event 129 00:07:33,987 --> 00:07:38,987 with an overall risk reduction of 25%, if that makes sense. 130 00:07:39,060 --> 00:07:41,640 The big take home, what I want you to get of this slide 131 00:07:41,640 --> 00:07:45,990 is that this is essentially a 10 year trajectory and 132 00:07:45,990 --> 00:07:48,638 at any point if we can treat them adequately 133 00:07:48,638 --> 00:07:51,600 we may be reducing their overall risk 134 00:07:51,600 --> 00:07:55,560 of 25% regardless of what that treatment might be. 135 00:07:55,560 --> 00:07:58,350 So this is really, hypertension is really a cardiorenal 136 00:07:58,350 --> 00:07:59,490 continuum because we know 137 00:07:59,490 --> 00:08:03,030 that hypertension is probably the leading cause 138 00:08:03,030 --> 00:08:06,120 along with diabetes for chronic kidney disease 139 00:08:06,120 --> 00:08:10,407 which is outpacing the ability for nephrology 140 00:08:12,600 --> 00:08:14,910 to actually care for the volume of patients 141 00:08:14,910 --> 00:08:16,560 that are affected. 142 00:08:16,560 --> 00:08:20,940 So here, this is the primary hallmark of what we do as NPs 143 00:08:20,940 --> 00:08:25,170 in terms of prevention, but really here is the far majority 144 00:08:25,170 --> 00:08:27,486 of what you're gonna be doing in clinical practice, 145 00:08:27,486 --> 00:08:31,740 is treating or assessing target organ damage, 146 00:08:31,740 --> 00:08:33,960 hopefully when it's not significant. 147 00:08:33,960 --> 00:08:38,910 So here on this continuum, identifying any risk factors 148 00:08:38,910 --> 00:08:41,191 new risk factors for chronic kidney disease 149 00:08:41,191 --> 00:08:44,790 and really mitigating their atherosclerotic risk. 150 00:08:44,790 --> 00:08:49,790 So we see lipids here and lipid treatment here 151 00:08:49,830 --> 00:08:53,280 is really kind of, we do this through our diagnostic testing 152 00:08:53,280 --> 00:08:55,800 and this can be through diagnostic testing 153 00:08:55,800 --> 00:08:58,890 but also some history taken in a physical exam. 154 00:08:58,890 --> 00:09:02,073 But we really wanna stop this from happening. 155 00:09:05,790 --> 00:09:07,500 Again, this is a bird's eye view 156 00:09:07,500 --> 00:09:10,680 of all of the physiologic mechanisms involved 157 00:09:10,680 --> 00:09:14,190 in hypertension and certainly stress and age. 158 00:09:14,190 --> 00:09:18,633 And we'll see that in the next slide, specifically age, 159 00:09:21,480 --> 00:09:25,950 kind of augments or you see much more of an effect 160 00:09:25,950 --> 00:09:30,093 of the pathophysiology on an individual of an older age, 161 00:09:31,380 --> 00:09:35,580 and age and sex also determine what your vessels look like. 162 00:09:35,580 --> 00:09:40,580 And, but on top of that, we also see stress and environment. 163 00:09:41,580 --> 00:09:42,990 So again, the social determinants 164 00:09:42,990 --> 00:09:45,555 of health kind of come into play here. 165 00:09:45,555 --> 00:09:47,790 But what you also see is even 166 00:09:47,790 --> 00:09:50,250 though there's genetic aspects 167 00:09:50,250 --> 00:09:54,900 central CNS aspects, cardiac, renal, GI and endocrine 168 00:09:54,900 --> 00:09:59,280 the medications that we use actually affect 169 00:09:59,280 --> 00:10:04,020 kind into these organs here, for example 170 00:10:04,020 --> 00:10:08,370 like when we talk about decreasing sympathetic activation 171 00:10:08,370 --> 00:10:10,290 well we have medications that can do that. 172 00:10:10,290 --> 00:10:13,410 Now that only affects one piece 173 00:10:13,410 --> 00:10:17,940 of this really complicated patho, but certainly 174 00:10:17,940 --> 00:10:21,990 if sympathetic activation we can use beta blockers, right? 175 00:10:21,990 --> 00:10:24,270 So we hear is the genetics 176 00:10:24,270 --> 00:10:28,170 behind angiotensinogen and whatnot. 177 00:10:28,170 --> 00:10:30,930 We can actually use ACE inhibitors 178 00:10:30,930 --> 00:10:34,110 and angiotensin receptor blockers to kind of help 179 00:10:34,110 --> 00:10:35,970 with this aspect. 180 00:10:35,970 --> 00:10:38,584 Sodium retention, we can use diuretics, 181 00:10:38,584 --> 00:10:42,210 endocrine, with insulin resistance increasing 182 00:10:42,210 --> 00:10:46,620 or aldosterone dysregulation we can use by spirolactam. 183 00:10:46,620 --> 00:10:50,040 So those are examples of how knowing the physiology 184 00:10:50,040 --> 00:10:53,850 and knowing the drugs and knowing how those drugs 185 00:10:53,850 --> 00:10:56,610 affect different aspects will be helpful 186 00:10:56,610 --> 00:10:58,263 in treating individuals. 187 00:11:00,000 --> 00:11:01,830 This is just a nice little snapshot, 188 00:11:01,830 --> 00:11:03,957 I think, about hypertension and aging. 189 00:11:03,957 --> 00:11:06,900 So we have all of these things 190 00:11:06,900 --> 00:11:10,030 that kind of affect our ability to care 191 00:11:13,320 --> 00:11:18,320 for older adults but also affect risk associated with it. 192 00:11:19,980 --> 00:11:22,380 So we have this classic like of course 193 00:11:22,380 --> 00:11:24,450 we all are biologically aging 194 00:11:24,450 --> 00:11:26,290 every second of every day 195 00:11:28,290 --> 00:11:31,829 and then we use medications to kind 196 00:11:31,829 --> 00:11:34,860 of combat this inflammatory processes 197 00:11:34,860 --> 00:11:38,400 the endothelial dysfunction and the oxidative stress 198 00:11:38,400 --> 00:11:42,810 all of which lead to functional decline, fractures, 199 00:11:42,810 --> 00:11:46,410 cognitive decline, cardiovascular events, 200 00:11:46,410 --> 00:11:48,990 which then lead to morbidity mortality. 201 00:11:48,990 --> 00:11:50,943 So it kind of goes inward. 202 00:11:51,780 --> 00:11:54,880 So these are the things that we can intervene on 203 00:11:56,430 --> 00:12:01,430 that if we don't, create this, which then creates this 204 00:12:01,680 --> 00:12:03,393 which then leads to this. 205 00:12:07,350 --> 00:12:11,130 As you probably know in your clinical experiences, 206 00:12:11,130 --> 00:12:12,630 as limited as they may be, 207 00:12:12,630 --> 00:12:16,230 that there is a significant overlap 208 00:12:16,230 --> 00:12:17,910 with other chronic health conditions. 209 00:12:17,910 --> 00:12:20,504 And here we see this piece right here 210 00:12:20,504 --> 00:12:25,020 of the individuals that have heart disease 211 00:12:25,020 --> 00:12:28,590 and high blood pressure and dementia and Alzheimer's. 212 00:12:28,590 --> 00:12:33,590 And so we see that the big chunk here is hypertension. 213 00:12:33,660 --> 00:12:36,060 So if we can do something about that, 214 00:12:36,060 --> 00:12:39,810 we're gonna actually affect all of this right here, 215 00:12:39,810 --> 00:12:42,624 which is kind of exciting if you think about it that way. 216 00:12:42,624 --> 00:12:44,160 So let's move on to talking 217 00:12:44,160 --> 00:12:46,290 about how we evaluate an individual. 218 00:12:46,290 --> 00:12:47,967 And this should be straightforward. 219 00:12:47,967 --> 00:12:51,990 This is a recap of physical assessment 220 00:12:51,990 --> 00:12:55,263 advanced health assessment and your history taking. 221 00:12:56,100 --> 00:12:59,850 So these are key areas that are very specific 222 00:12:59,850 --> 00:13:02,460 but overlap a lot with other things that we're doing. 223 00:13:02,460 --> 00:13:06,360 So we wanna know if anybody has a personal history 224 00:13:06,360 --> 00:13:08,610 of hypertension at one point in their life because 225 00:13:08,610 --> 00:13:12,125 if they do and for some reason they were able to control it 226 00:13:12,125 --> 00:13:17,125 with diet and healthy interventions 227 00:13:19,950 --> 00:13:22,200 and it comes back that, you know, 228 00:13:22,200 --> 00:13:24,090 we don't have to kind of really start that workup 229 00:13:24,090 --> 00:13:26,670 from the very beginning of do they have hypertension 230 00:13:26,670 --> 00:13:27,543 or do they not. 231 00:13:28,410 --> 00:13:31,500 If they have any symptoms suggesting coronary artery disease 232 00:13:31,500 --> 00:13:32,820 or any other comorbidity. 233 00:13:32,820 --> 00:13:33,660 So we see a lot 234 00:13:33,660 --> 00:13:36,570 of overlap as I had just mentioned, between hypertension 235 00:13:36,570 --> 00:13:40,530 and diabetes, heart failure, dyslipidemia, renal disease 236 00:13:40,530 --> 00:13:42,540 and peripheral vascular disease. 237 00:13:42,540 --> 00:13:44,190 So we're really actually 238 00:13:44,190 --> 00:13:46,830 when we're evaluating somebody with hypertension, 239 00:13:46,830 --> 00:13:49,290 we also wanna know do they have any of these 240 00:13:49,290 --> 00:13:51,360 or are they at risk for any of these because then 241 00:13:51,360 --> 00:13:52,530 that will actually 242 00:13:52,530 --> 00:13:55,620 affect your treatment plan for these individuals. 243 00:13:55,620 --> 00:13:58,620 Family history, again, it's that genetic profile 244 00:13:58,620 --> 00:14:01,410 if they use any modifiable risks, right? 245 00:14:01,410 --> 00:14:05,939 So family history of premature disease is non-modifiable, 246 00:14:05,939 --> 00:14:08,280 but use of tobacco, alcohol 247 00:14:08,280 --> 00:14:11,100 or any other type of drug is definitely modifiable 248 00:14:11,100 --> 00:14:13,590 and something that we can encourage them to think 249 00:14:13,590 --> 00:14:18,590 about and hopefully decrease or eliminate as a risk factor. 250 00:14:19,890 --> 00:14:22,900 Again, the same thing with dietary intake 251 00:14:23,940 --> 00:14:25,410 and then medications, 252 00:14:25,410 --> 00:14:27,780 because if we find that somebody's taking a medication, 253 00:14:27,780 --> 00:14:31,800 for example pseudoephedrine or herbal medications 254 00:14:31,800 --> 00:14:33,630 and that's causing their blood pressure to be high 255 00:14:33,630 --> 00:14:35,400 we can find alternatives for them. 256 00:14:35,400 --> 00:14:36,938 And we don't wanna treat somebody with hypertension 257 00:14:36,938 --> 00:14:39,125 if they're using medications that elevate 258 00:14:39,125 --> 00:14:40,773 their blood pressure. 259 00:14:42,660 --> 00:14:44,303 So those are just some of the risk factors 260 00:14:44,303 --> 00:14:45,870 that in the previous slide. 261 00:14:45,870 --> 00:14:49,080 But we do know more and more about 262 00:14:49,080 --> 00:14:50,700 how the social determinants 263 00:14:50,700 --> 00:14:54,454 of health play on an individual's risk of hypertension. 264 00:14:54,454 --> 00:14:59,454 So trauma as a child where you grew up, 265 00:14:59,820 --> 00:15:02,640 you know what environment you grew up, 266 00:15:02,640 --> 00:15:04,890 what your occupation is, is it high stress? 267 00:15:04,890 --> 00:15:08,400 So these are some long lasting stressors, 268 00:15:08,400 --> 00:15:11,280 could be subclinical stressors but are stressors 269 00:15:11,280 --> 00:15:14,130 to the body that alter that HPA access 270 00:15:14,130 --> 00:15:19,130 which then over term, over time, excuse me, increase risk. 271 00:15:19,230 --> 00:15:21,120 And then there's your classic ones, you know, 272 00:15:21,120 --> 00:15:24,603 if somebody has like reduced amount of nephrons 273 00:15:24,603 --> 00:15:27,420 from some sort of kidney injury, 274 00:15:27,420 --> 00:15:30,480 if they have diabetes or high lipids, 275 00:15:30,480 --> 00:15:35,480 if their lifestyle is high in salt, low in exercise, 276 00:15:36,840 --> 00:15:39,570 sleep has been paid a little bit more attention 277 00:15:39,570 --> 00:15:41,250 to than it ever has been 'cause we know 278 00:15:41,250 --> 00:15:45,180 that sleep affects pretty much every aspect 279 00:15:45,180 --> 00:15:47,520 of our life but has been actually implicated 280 00:15:47,520 --> 00:15:50,850 in clinical disease and clinical disease management. 281 00:15:50,850 --> 00:15:53,040 And we know that because of obstructive sleep apnea 282 00:15:53,040 --> 00:15:56,310 and the role of obstructive sleep apnea with hypertension 283 00:15:56,310 --> 00:15:58,773 and then the classic ones that we think about. 284 00:16:01,260 --> 00:16:02,700 So things that you wanna think about 285 00:16:02,700 --> 00:16:04,639 if for some reason your patient has a very 286 00:16:04,639 --> 00:16:07,504 high blood pressure, and you wanna make sure 287 00:16:07,504 --> 00:16:09,748 that this isn't something that is kind of been high 288 00:16:09,748 --> 00:16:13,470 for a very long time, we call that malignant hypertension 289 00:16:13,470 --> 00:16:18,470 or in danger of actually causing immediate harm. 290 00:16:19,260 --> 00:16:24,260 And that's, you know, mentation, weakness, visual changes, 291 00:16:25,140 --> 00:16:26,940 chest pain, cough and shortness of breath. 292 00:16:26,940 --> 00:16:28,950 Obviously, those are classic ones. 293 00:16:28,950 --> 00:16:32,640 Nausea, vomiting, fatigue is a little bit of 294 00:16:32,640 --> 00:16:35,250 a difficult one because I think everybody is tired 295 00:16:35,250 --> 00:16:38,943 these days but certainly if they're more lethargic. 296 00:16:41,490 --> 00:16:46,490 So these are considered more the commonly 297 00:16:47,070 --> 00:16:51,630 uncommon forms of secondary hypertension "CHAPS," 298 00:16:51,630 --> 00:16:54,150 a pneumonic that I kind of found when 299 00:16:54,150 --> 00:16:57,090 I was updating this lecture. 300 00:16:57,090 --> 00:17:01,170 So it's easy to remember, this is not inclusive, 301 00:17:01,170 --> 00:17:03,540 but it's just some of the more common ones that you see. 302 00:17:03,540 --> 00:17:06,360 And I say common meaning they're really not very common, 303 00:17:06,360 --> 00:17:09,090 they're very uncommon, but they're classically attributed 304 00:17:09,090 --> 00:17:12,510 to secondary hypertension and that's Cushing's syndrome, 305 00:17:12,510 --> 00:17:15,993 hyperaldosteronism, aortic coarctation, 306 00:17:17,250 --> 00:17:20,520 stenosis of the arteries and a pheochromocytoma. 307 00:17:20,520 --> 00:17:22,650 And there will be history taking elements 308 00:17:22,650 --> 00:17:25,230 and physical exam findings of each of these 309 00:17:25,230 --> 00:17:26,820 that will kind of point you away 310 00:17:26,820 --> 00:17:29,040 from primary hypertension and more 311 00:17:29,040 --> 00:17:32,580 towards the secondary hypertension, for example, 312 00:17:32,580 --> 00:17:35,767 history taking that suggests that they're having a lot 313 00:17:35,767 --> 00:17:40,633 of palpitations, flushing, headache, exertional headache, 314 00:17:43,200 --> 00:17:46,140 you know, you might think more about a pheochromocytoma 315 00:17:46,140 --> 00:17:48,330 which is incredibly rare. 316 00:17:48,330 --> 00:17:53,160 Cushing's syndrome is much more likely to be exogenous 317 00:17:53,160 --> 00:17:57,510 than endogenous with steroid use, chronic steroid use. 318 00:17:57,510 --> 00:17:59,280 But you know, there are certain things that we see 319 00:17:59,280 --> 00:18:03,840 in that such as, you know, weight gain, 320 00:18:03,840 --> 00:18:06,510 central adiposity, increased striae, 321 00:18:06,510 --> 00:18:09,450 so those aren't physical exam, facial, 322 00:18:09,450 --> 00:18:12,210 the facies that they have they call it, 323 00:18:12,210 --> 00:18:15,603 which is a horrible description of moon facies. 324 00:18:16,560 --> 00:18:19,200 Sometimes with renal artery stenosis you don't know that 325 00:18:19,200 --> 00:18:22,920 until you find that their hypertension is treated 326 00:18:22,920 --> 00:18:25,440 and you're trying to treat it and it's refractory. 327 00:18:25,440 --> 00:18:27,051 So those are some caveats 328 00:18:27,051 --> 00:18:30,480 as you move forward in your clinical experiences, 329 00:18:30,480 --> 00:18:33,003 you can kind of put in your back pocket. 330 00:18:34,590 --> 00:18:38,073 So when we talk about assessing somebody for the first time, 331 00:18:39,720 --> 00:18:43,410 or even actually somebody who's coming in for a follow up 332 00:18:43,410 --> 00:18:46,710 or maybe has not had a kind of that diagnostic workup 333 00:18:46,710 --> 00:18:48,990 or has not had a really well thought through 334 00:18:48,990 --> 00:18:52,523 physical history and physical is really looking 335 00:18:52,523 --> 00:18:55,230 at a good solid risk and assessment. 336 00:18:55,230 --> 00:18:57,839 And this is the hallmark of this entire course 337 00:18:57,839 --> 00:19:01,890 is assessing them for risk because if they are a high risk, 338 00:19:01,890 --> 00:19:05,400 you are gonna be more aggressive than if they're low risk. 339 00:19:05,400 --> 00:19:08,939 And then the next step is assessing the presence of any type 340 00:19:08,939 --> 00:19:13,350 of target organ disease or damage that we'll talk about. 341 00:19:13,350 --> 00:19:14,790 And then we'll bring that out a lot 342 00:19:14,790 --> 00:19:16,350 in the case-based scenario. 343 00:19:16,350 --> 00:19:18,390 And then do you wanna evaluate them 344 00:19:18,390 --> 00:19:20,970 for any secondary causes of hypertension? 345 00:19:20,970 --> 00:19:22,980 And generally the answer is no, 346 00:19:22,980 --> 00:19:25,950 because they don't happen very often. 347 00:19:25,950 --> 00:19:27,510 So always think horses, 348 00:19:27,510 --> 00:19:30,090 sometimes you'll see a zebra here and there 349 00:19:30,090 --> 00:19:34,440 but it is good to have that CHAPS in the back of your mind 350 00:19:34,440 --> 00:19:36,150 pneumonic in the back of your mind 351 00:19:36,150 --> 00:19:38,745 back pocket to kind of think, "Oh this just doesn't sound 352 00:19:38,745 --> 00:19:42,930 like regular primary or essential hypertension." 353 00:19:42,930 --> 00:19:44,280 So when we talk about the organs 354 00:19:44,280 --> 00:19:46,324 that we're gonna specifically assess 355 00:19:46,324 --> 00:19:49,341 that are associated with hypertension 356 00:19:49,341 --> 00:19:52,800 is the brain, eyes, blood vessels, 357 00:19:52,800 --> 00:19:55,440 heart and kidneys, and also making sure 358 00:19:55,440 --> 00:19:57,960 that that blood pressure is actually accurate 359 00:19:57,960 --> 00:20:00,180 which a lot of the times it is not. 360 00:20:00,180 --> 00:20:04,200 And there are different ways that we can assess these organs 361 00:20:04,200 --> 00:20:06,390 on physical through history taking, 362 00:20:06,390 --> 00:20:09,093 physical exam and diagnostic testing. 363 00:20:10,860 --> 00:20:12,600 This is just a nice little slide. 364 00:20:12,600 --> 00:20:14,910 This should be a very much a recap 365 00:20:14,910 --> 00:20:18,390 of your advanced physical assessment 366 00:20:18,390 --> 00:20:19,890 but it kind of talks you through 367 00:20:19,890 --> 00:20:21,741 and I'm not gonna spend a lot of time on this, 368 00:20:21,741 --> 00:20:24,744 what you're supposed to be looking for 369 00:20:24,744 --> 00:20:29,520 on a physical exam that might lead you to an assessment 370 00:20:29,520 --> 00:20:34,207 of hypertension and help you gauge how aggressive 371 00:20:34,207 --> 00:20:38,073 that you're going to be in terms of treatment. 372 00:20:40,410 --> 00:20:43,200 And again, this is a slide that you can refer back to 373 00:20:43,200 --> 00:20:45,390 but if you don't have a blood pressure that is 374 00:20:45,390 --> 00:20:47,822 assessed correctly, then you can't interpret 375 00:20:47,822 --> 00:20:50,400 that blood pressure for what it means. 376 00:20:50,400 --> 00:20:53,520 And that includes home measuring, but it includes in office. 377 00:20:53,520 --> 00:20:56,280 So a lot of times you'll see that patient rushed 378 00:20:56,280 --> 00:21:00,300 into the room that hopefully it's not you 379 00:21:00,300 --> 00:21:03,060 as the nurse practitioner and hopefully it's not the nurse 380 00:21:03,060 --> 00:21:04,380 and hopefully it's not the MA, 381 00:21:04,380 --> 00:21:05,970 but they're taking the blood pressure 382 00:21:05,970 --> 00:21:09,270 over clothing and using that 383 00:21:09,270 --> 00:21:14,270 as a valid blood pressure when it is actually not. 384 00:21:16,590 --> 00:21:21,590 So up next in a future mini-lecture is the evaluation 385 00:21:21,810 --> 00:21:23,640 and management of hypertension. 386 00:21:23,640 --> 00:21:25,710 So if you have any questions, please post those 387 00:21:25,710 --> 00:21:29,223 to the discussion board or better yet, bring them to class.