Case 8 - 54 yo with elevated blood pressure

Question 1

HTN diagnosis

Answer 1

2 measurements of elevated blood pressure (>140/>90) at least five minutes apart, one in each arm on two or more visits

Question 2

HTN etiology

Answer 2

95-98% essential hypertension

the rest is secondary hypertension 2/2 renal dz, meds, chronic steroids, pheos, hyperaldosteronism

Question 3

Blood pressure classification

Answer 3

Normal: 160 / >100

Question 4

Proper blood pressure measurement

Answer 4

• pt should be sitting quietly for 5 minutes in chair
• arm should be at heart level
• length of cuff should be at least 80% circumference of arm
• width should be at least 40% arm circumferece

Question 5

HTN physical exam

Answer 5

BMI, fundoscopy, vascular exam, thyroid gland, lungs, heart, abd exam, neuro exam

Question 6

Studies recommended for a new diagnosis of hypertension

Answer 6

• EKG
• urinalysis to look for glucose in urine
• serum potassium - evaluate before put on diuretic
• serum creatinine/GFR
• fasting serum cholesterol
• urine albumin excretion
• serum calcium - r/o hyperparathyoidism

Question 7

Managing HTN

Answer 7

Step 1: encourage lifestyle recommendations - weight loss give you the greatest reduction in systolic BP followed by DASH, followed by physical activity

Step 2: Initiate hypertensive drug therapy
For stage 1 HTN, start thiazide, ACEI, ARB or CCB. For stage 2, start on a two drug combo. If african american, choose between HCTZ and CCB. For diabetes or CKD, start ACEI or ARB. For heart failure, start beta-blocker or ACEI
Step 3: titrate dose

Question 8

Hydrochlorothiazide

Answer 8

• most cost-effective antiHTN on the market
• can cause hyponatremia
• avoid in pts with hx of gout
• doses greater than 25 do not improve mortality

Question 9

sociocultural considerations in treating HTN

Answer 9

• blood pressure control is worst in mexican and native americans
• prevalence, severity and impact of HTN increased in african americans
• AA show decreased response to one drug
• AA 2-4x more likely to develop angioedema

Question 10

When to refer to specialist?

Answer 10

WHen patient has failed to achieve goal blood pressure while adhering to full doses of a three drug regimen

Question 11

ATP III recommendations for dyslipidemia therapy

Answer 11

• recommends LDL goal of 70-100 for people with CHD or CHD equivalents (CAD, PAD, AAA, diabetes)