276.1 🎓 醫學生版

276.1.0.1 📌 一頁重點

276.1.0.1.1 Definition + Classification (2017 ACC/AHA vs 2023 ESC)

276.1.0.1.1.1 2017 ACC/AHA

Category	SBP	DBP
Normal	< 120	AND < 80
Elevated	120-129	AND < 80
Stage 1 HTN	130-139	OR 80-89
Stage 2 HTN	≥ 140	OR ≥ 90
Hypertensive crisis	> 180	OR > 120

276.1.0.1.1.2 2023 ESC (Maintaining Higher Threshold)

Category	SBP	DBP
Optimal	< 120	< 80
Normal	120-129	80-84
High-normal	130-139	85-89
Grade 1 HTN	140-159	90-99
Grade 2 HTN	160-179	100-109
Grade 3 HTN	≥ 180	≥ 110
Isolated systolic	≥ 140	< 90

276.1.0.1.1.3 Taiwan 2022 Guidelines

• Aligned with 2017 ACC/AHA: ≥ 130/80 mmHg
• Goal < 130/80 for most
• Home BP-based (HBPM) recommended

276.1.0.1.2 Epidemiology

• Global: ~ 1.4 billion adults with HTN; only ~ 50% diagnosed, < 25% controlled
• Taiwan (2017-2020 NAHSIT): 25% adults; > 40% in age ≥ 60
• #1 modifiable risk factor for stroke, IHD, HF, CKD
• PURE study: 11% of global CV deaths attributable to HTN

276.1.0.1.3 Pathophysiology

276.1.0.1.3.1 Primary (Essential) HTN — 90-95%

• Multifactorial: genes × environment × age
• Mechanisms:
  • ↑ Sympathetic tone
  • RAAS activation (renin → angiotensin II → aldosterone)
  • Sodium / volume retention (kidney + aldosterone)
  • Endothelial dysfunction (↓ NO, ↑ ET-1)
  • Vascular remodeling / stiffness (arterial stiffening with age)
  • Inflammation, oxidative stress

276.1.0.1.3.2 Secondary HTN — 5-10%

• Identifiable cause
• See below for workup
• Higher prevalence in young, resistant, severe, abrupt onset, low K+ HTN

276.1.0.1.4 Sequelae of Uncontrolled HTN

276.1.0.1.4.1 Cardiac

• LVH (concentric, then eccentric)
• HF (HFpEF, then HFrEF)
• CAD / MI
• AF (atrial remodeling)

276.1.0.1.4.2 Cerebral

• Ischemic stroke (3-4x risk)
• Hemorrhagic stroke (8x risk)
• Vascular dementia
• Lacunar infarcts (microvascular)

276.1.0.1.4.3 Renal

• Hypertensive nephrosclerosis (CKD progression)
• Albuminuria (often first sign)
• ESRD (especially in African Americans, DM)

276.1.0.1.4.4 Vascular

• Aortic aneurysm + dissection
• PAD
• Atherosclerosis acceleration

276.1.0.1.4.5 Ocular

• Hypertensive retinopathy (Keith-Wagener-Barker grading)
• AV nicking
• Cotton wool spots, hemorrhages
• Papilledema (malignant HTN)

276.1.0.1.5 Diagnosis + Confirmation

276.1.0.1.5.1 Office BP Measurement

• Patient seated, back supported, feet on floor, 5 min rest
• No caffeine, exercise, smoking within 30 min
• Cuff sized appropriately
• Both arms first visit
• Average of 2-3 readings
• Auscultatory or oscillometric
• 2 separate visits required

276.1.0.1.5.2 Out-of-Office BP (CRITICAL — recommended for all)

• Ambulatory BP Monitoring (ABPM):
  • 24-hour automated measurement
  • Day (awake): ≥ 135/85
  • Night (sleep): ≥ 120/70
  • 24-h average: ≥ 130/80
• Home BP Monitoring (HBPM):
  • Twice daily (AM + PM), 7 days
  • Discard day 1
  • ≥ 135/85 = hypertension
• Indications: confirm diagnosis, white coat / masked HTN, treatment response, nocturnal HTN, resistant HTN

276.1.0.1.5.3 White Coat vs Masked HTN

• White coat HTN: office HTN, normal out-of-office (15-30%)
• Masked HTN: normal office, high out-of-office (10-20%) — same CV risk as sustained HTN
• Sustained HTN: high office + high out-of-office

276.1.0.1.5.4 Nocturnal HTN & Dipping

• Normal dipper: night BP ↓ 10-20% from day
• Non-dipper: < 10% drop — ↑ CV risk
• Reverse dipper: night > day — worst prognosis
• Extreme dipper: > 20% drop — ↑ stroke risk in some

276.1.0.1.6 Workup of Hypertension

276.1.0.1.6.1 Initial Evaluation

• History: family hx, duration, lifestyle (Na, alcohol, exercise), meds (NSAIDs, OCPs, decongestants, steroids), OSA symptoms, sleep
• Physical: BP both arms, weight, BMI, waist; auscultate for carotid + renal bruits; fundoscopy; signs of secondary HTN (Cushing, hyperthyroid, pheo)
• Labs:
  • CBC, BUN/Cr, eGFR
  • Electrolytes (K, Na, Ca)
  • UA + urine albumin/Cr ratio
  • Fasting glucose, HbA1c
  • Lipid panel
  • TSH
• ECG: LVH, prior MI, ischemia

276.1.0.1.6.2 Cardiovascular Risk Assessment

• ASCVD risk (10-year): age, sex, race, BP, cholesterol, DM, smoking
• PCE (Pooled Cohort Equation) for ACC/AHA
• SCORE2 for ESC

276.1.0.1.7 Secondary HTN — When to Suspect

276.1.0.1.7.1 Red Flags

• Age < 30 or > 60 at onset
• Severe / resistant HTN (≥ 3 drugs at max dose, including diuretic)
• Sudden onset / rapid progression
• Hypokalemia (esp without diuretic)
• Discordant target organ damage
• Episodic / paroxysmal
• Family history

276.1.0.1.7.2 Common Causes

Renovascular: - Atherosclerotic RAS (elderly, multiple vascular risks) - Fibromuscular dysplasia (young women) - Workup: renal Doppler / CTA / MRA / captopril renogram - Treatment: revascularize if FMD, OMT if ARAS (CORAL trial)

Primary Aldosteronism (PA): - 5-10% of HTN (most common secondary cause!) - Aldosterone-producing adenoma (Conn’s) or bilateral hyperplasia - Hypokalemia + alkalosis (40% normokalemic) - Workup: aldosterone/renin ratio (ARR) → confirmatory (saline infusion, captopril) → adrenal CT → adrenal vein sampling - Treatment: surgery (adenoma) or MRA (hyperplasia)

Pheochromocytoma: - < 1% of HTN - Episodic HTN with HA, palpitations, diaphoresis (“5 Ps”) - 24h urine metanephrines / plasma free metanephrines - CT / MRI for tumor localization (adrenal); MIBG for extra-adrenal - Treatment: α-blockade (phenoxybenzamine) BEFORE β-blockade, then surgery - Genetic testing for syndromes (MEN2, VHL, NF1, SDHx)

Cushing’s Syndrome: - Adrenal cortisol excess - Central obesity, moon facies, striae, hirsutism, glucose intolerance - Workup: 24h urine cortisol, dexamethasone suppression, midnight salivary cortisol - ACTH for differentiation - Treatment: surgery, medical (ketoconazole, mifepristone), radiation

Coarctation of Aorta: - Young, BP higher in arms than legs - Reduced femoral pulses, “rib notching” on CXR - Echo / CT / MRI confirms - Treatment: surgical or balloon angioplasty

Obstructive Sleep Apnea (OSA): - ~ 30-40% of HTN - Snoring, witnessed apnea, daytime sleepiness - STOP-BANG, Epworth - Polysomnography - Treatment: CPAP, weight loss, MAD

Drug-Induced: - NSAIDs, glucocorticoids, OCPs, sympathomimetics, EPO, calcineurin inhibitors, cocaine, alcohol - Yohimbine, MAOIs + tyramine

Other: - Hyperthyroidism - Hyperparathyroidism (Ca-mediated) - Acromegaly - CKD (most common) - Renal parenchymal disease

276.1.0.1.8 Special Forms of HTN

276.1.0.1.8.1 Resistant HTN

• BP > target on 3 antihypertensives (including a diuretic) at optimal doses
• Confirm with ABPM (rule out white coat)
• Workup: adherence, white coat, secondary causes, lifestyle, OSA, drugs
• Treatment: spironolactone is most effective add-on (PATHWAY-2 2015)

276.1.0.1.8.2 Pseudoresistant

• White coat HTN
• Non-adherence (~ 50%)
• Suboptimal regimen / dosing
• Measurement error

276.1.0.1.8.3 Hypertensive Emergency vs Urgency

• Emergency: BP > 180/120 + acute end-organ damage (encephalopathy, IS/HS, MI, pulmonary edema, dissection, eclampsia, AKI) → IV agents, ICU
• Urgency: BP > 180/120 without acute end-organ damage → oral, gradual

276.1.0.2 🩺 床邊速查

• ACC/AHA HTN: ≥ 130/80 (Stage 1 130-139, Stage 2 ≥ 140)
• ESC HTN: ≥ 140/90
• ABPM: 24h ≥ 130/80, day ≥ 135/85, night ≥ 120/70
• HBPM: ≥ 135/85
• Resistant HTN: 3 drugs incl diuretic; add spironolactone first (PATHWAY-2)
• Most common secondary HTN: primary aldosteronism (5-10%)

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