PANCE - Hypertension Pathophysiology

Here are key facts for PANCE (Physician Assistant National Certifying Examination) & PANRE from the Blood Pressure Regulation and Hypertension tutorial, as well as points of interest at the end of this document that are not directly addressed in this tutorial but should help you prepare for the boards. See the tutorial notes for further details and relevant links.

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1. Determinants of mean arterial pressure:

• Cardiac output (CO)
• Total peripheral resistance (TPR)
• Formula: MAP = CO × TPR

2. Components of cardiac output:

• Heart rate
• Stroke volume
• Formula: CO = HR × SV

3. Factors affecting stroke volume:

• Preload: affected by blood volume and venous return
• Contractility: intrinsic force of contraction
• Afterload: resistance against which heart pumps

4. Determinants of peripheral resistance:

• Vasoconstriction of small arteries and arterioles
• Anatomic changes in vessel walls (remodeling)
• Blood viscosity (minor component)

1. Renin-Angiotensin-Aldosterone System:

• Angiotensin II: potent vasoconstrictor
• Increases sodium and water retention
• Stimulates release of norepinephrine, ADH, and aldosterone
• Target for multiple antihypertensive medications

2. Posterior pituitary hormone:

• Antidiuretic hormone (vasopressin)
• Functions as vasoconstrictor
• Increases water reabsorption in collecting ducts

3. Adrenal cortex hormone:

• Aldosterone
• Increases sodium and water retention
• Effects similar to ADH on blood volume

4. Sympathetic mediators:

• Norepinephrine
• Increases heart rate and contractility
• Causes vasoconstriction

1. Classification:

• Hypertensive urgency: BP >180/120 mmHg without end-organ damage
• Hypertensive emergency: BP >180/120 mmHg with end-organ damage

2. Clinical presentation:

• Severe headache with confusion
• Impaired vision
• Chest pain, shortness of breath
• Nausea/vomiting
• Anxiety
• Seizures

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1. Vasoactive balance:

• Vasodilators: nitric oxide, prostaglandins, histamine, bradykinin
• Vasoconstrictors: angiotensin II, norepinephrine, endothelin
• Clinical relevance: medications target this balance

2. RAAS clinical significance:

• Angiotensin II breaks down bradykinin (vasodilator)
• ACE inhibitors both reduce angiotensin II and increase bradykinin
• Explains therapeutic effects and side effect profile

3. Vascular remodeling:

• Hypertension produces vessel damage and inflammation
• Results in elevated endothelin (vasoconstrictor)
• Reduces nitric oxide (vasodilator)
• Impact: chronic hypertension becomes more resistant to treatment

1. Volume-dependent hypertension:

• Salt-sensitive patients develop hypertension with high sodium intake
• Clinical clues: edema, response to diuretics
• Therapeutic approach: sodium restriction, diuretics

2. Secondary hypertension:

• Aldosterone-secreting tumors increase blood volume and preload
• Clinical clues: hypokalemia, metabolic alkalosis
• Diagnostic approach: aldosterone/renin ratio

3. Multifactorial contributions:

• Genetic and epigenetic factors
• Diet (especially sodium)
• Physical activity levels
• Environmental factors

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Below is information not explicitly contained within the tutorial but important for PANCE & PANRE. 1. BP measurement technique:

• Proper cuff size and positioning
• Patient positioning and preparation
• Multiple readings on separate occasions
• Ambulatory and home BP monitoring

2. Classification (ACC/AHA 2017):

• Normal: <120/<80 mmHg
• Elevated: 120-129/<80 mmHg
• Stage 1: 130-139/80-89 mmHg
• Stage 2: ≥140/≥90 mmHg
• Hypertensive crisis: >180/>120 mmHg

3. Secondary hypertension screening:

• Clinical clues suggesting secondary causes
• Initial diagnostic workup
• When to refer for specialist evaluation

1. Non-pharmacologic interventions:

• DASH diet
• Sodium restriction (<2.3g/day)
• Regular physical activity
• Weight loss
• Alcohol limitation
• Smoking cessation

2. Pharmacotherapy:

• First-line agents: thiazides, ACEIs, ARBs, CCBs
• Second-line agents: beta-blockers, alpha-blockers, aldosterone antagonists
• Combination therapy principles
• Monitoring parameters

3. Special populations:

• Elderly
• Pregnancy
• Diabetes
• CKD
• CVD
• African American patients

1. Target organ damage:

• Heart: LVH, heart failure, CAD
• Brain: stroke, TIA, vascular dementia
• Kidneys: CKD, proteinuria
• Vessels: aortic aneurysm, PAD
• Eyes: retinopathy

2. Patient education:

• Medication adherence strategies
• Self-monitoring guidance
• Warning signs requiring medical attention
• Lifestyle modification counseling

3. Follow-up schedule:

• Monitoring frequency based on control and risk
• Laboratory monitoring
• Reassessment of cardiovascular risk
• Medication adjustment approach