EXAM- HTN Cases Flashcards
Tom is a 55 year old male, no previous medical history, that you see in office. His blood pressure is 159/ 91. You start to think about diagnosing, managing, and prescribing for HTN. What resources will you use?
RxFiles
-p. 2 for general CVD risk assessments/ targets (including a section specific to BP and healthy behaviours)
-p. 5-8 BP meds
-p. 9 oral antihypertensives summary/ guideline comparison chart (all the info on one page)
-p. 10 has approaches to therapy based on htn canada guidelines
2020 HTN Canada Highlights
-how to measure bp/ algorithm for dx of HTN (p.8)
-bp thresholds for initiation of tx and treatment targets (p. 12)
-health behaviour recommendations (p. 13)
-pharmacological approach to 1st line tx
-considerations for individualized therapy
BC Guidelines.ca- Hypertension- Diagnosis and Management
-Management of HTN algorithm (p. 6)
-Contraindications for antihypertensives (p. 8)
-Pharm tx by comorbidity (p. 9)
-Basically all the info that’s in the HTN Canada highlights, but in a slightly different layout.
Back to Tom and his BP of 159/ 91. What will you prescribe him?
Slow your roll! No drugs yet. Tom needs more blood pressure measurements to definitively diagnose him with HTN (BCGuidelines, p. 4). You should schedule a dedicated office visit to assess BP, fam hx, physical exam, assess CVD risk, and do lab tests.
During your visit to assess BP, you take a medical history, assess Tom’s risk factors for HTN, do a physical exam, assess for target organ damage, and order labs. What labs do you order? What tool do you use to assess CVD risk?
UA- ACr, hematuria
Serum lytes, Cr, eGFR
Fasting BG, HbA1C
Blood lipids (non HDL cholesterol and triglycerides)
ECG
CVD risk- Framingham or other
BCGuidelines, p. 5
How will you measure Tom’s BP to confirm HTN?
Mean office BP >/= 180/110? Automatic dx of HTN
If has diabetes and AOBP/ non AOBP (see p. 3, 4 HTN Canada guidelines) is >/= 130/80, automatic dx of HTN
If no diabetes and AOBP .>/= 135/85 OR non AOBP >/= 140/90, send for out of office measurements (ABPM or HBPM, see p. 6, 7 of HTN Canada guidelines) to determine if truly has HTN vs WCH.
Tom’s AOBP is 140/ 87.
1) How did you take this BP?
2) What will you do next?
1) See p. 3 HTN Canada guidelines
2) Send him for out of office measurements- ABPM preferred.
Tom’s ABPM 24 hour mean is 144/ 87. What now?
Dx of HTN!
Discuss health behaviours (diet, sodium intake, physical activity, health weight, reducing alcohol intake and smoking cessation)
Prescribing an antihypertensive will be based on BP threshold for initiation of antihypertensive therapy and the patients specific risk factors (see p. 12, HTN Canada 2020 guidelines).
Tom is designated as moderated to high risk due to his multiple CV risk factors and FRS > 10%. His blood pressure is 144/ 87. You have discussed lifestyle modifications. What now?
I would probably prescribe Tom something based off his risk category and the BP threshold for initiation of antihypertensive therapy (p. 12 HTN Canada 2020 guidelines)
Using the chart on p. 14 (HTN Canada) or p. 6 (BC Guidelines), I would prescribe him a thiazide, ACE-I, ARB, or long acting CCB.
He has no comorbid medical conditions to consider that we know of, and we do not need to consider child bearing potential. He is on no other meds.
I would suggest Ramipril 1.25mg oral once daily (RxFiles p. 9) and schedule follow up in 4 weeks.
Teaching:
-May cause dry cough, loss of taste, rash, headache, dizziness, fatigue, pancreatitis, hyperkalemia (monitoring SCr and K+ at initiation of therapy and periodically)
-May cause angioedema- teach pts s&s (i.e., swelling in lips/ tongue/ eyes) and to seek medical help urgently
-May interact with other medications, make sure anyone prescribing for you knows you are on this medication. NSAIDS may reduce effects.
Other options could be:
Thiazides:
-Hydrochlorothiazide 12.5mg po once daily (low dose= less AEs, ineffective if poor renal function, DI with dig, lithium, nsaid, steroids, AE include rash, allergic reaction, photosensitivity…., CI in gout, supha allergy, anuria, hyponatriemia. Caution in glucose interolerance)
-Chorthalidone 12.5mg po once daily (longer t1/2 than hctz, may be more effective, preferred by HTN Canada guidelines)
ARBs
- Irbesartan 75mg po daily
CCB
-Amlodipine 2.5mg po daily (long acting DHPs) (do not take with grapefruit juice, DI with cyclosporin and fluconazole, may cause dizziness, headache, constipation ,facial flushing, ha, ankle edema, and more. CI in SBP <90, recent MI or pulm edema, sick sinus/ 2nd or 3rd degree AVD, HF. Reduce dose in hepatic impairment. Caution with BB, dig.
Its been 1 month and Tom comes back into office. His BP is unchanged at 144/ 87. What do you do?
Re talk about life style changes
Assess compliance
Increase dose (Rx files starts at very low initial dose)
or consider adding additional drug from list of first line treatments. (p. 6, BC Guidelines)
Tom is currently on Ramipril 5mg po daily. Discuss how high you would increase his dose before considering another agent?
I don’t know what the answer to this is. Vague per the guidelines. I think if you were getting some effect, I would probably go to 10mg/ day before starting him on another agent? The max dose of ramipril is 20mg/ day, but if we do 2 meds we can decrease AEs from both?
Susans notes say that for many pts with mild HTN, tx with a single drug is often sufficient. Mod to severe HTN may require multiple agents with different sites of action.
Tom is on Ramipril 10mg po daily. What other drug could you add to his therapy?
Ramipril= ACEI
Could add thiazide or CCB. Do not combine with ARB.
Altace is a ramipril hctz single pill combination that comes in multiple dosages (i.e., ramipril 10mg/ HCTZ 12.5mg). This would be ideal.
Tom forgot to mention- he has gout and a 2nd degree AV block. What medications should he not be given?
Thiazides (CI- gout)
CCBs (CI- AVB)
BB (CI- AVB)
(RxFiles, BCGuidelines (chart on p. 8)
New case! Jon is a 49 yo, non- smoker, T2DM with HTN. He is on metformin 2000mg daily, ramipril 5mg daily. His BP in office today is 160/97. What to do?
Lifestyle
Assess compliance
Ramipril is an ACEI- Add DHP- CCB- i.e., Amlodipine 2.5mg po once daily (Rx files p. 10, HTN Canada p. 16- in DM, if combination of ACEI is being considered, a DHP CCB is preferable to thiazide)
Teaching: interactions with grapefruit guide, other drugs. May cause dizziness, headache, rash, flushing, constipation, ankle swelling, and more. CI in SBP <90, MI or pulm edema, sick sinus, 2nd or 3rd degree AVB. Reduce dose in hepatic impairment.
Alternatively, you could consider combining with thiazide diuretic- it is not wrong (but do consider cautious use of thiazides in glucose intolerance). i.e. hctz 12.5mg po once daily
New case! Lisa is a 32 yo woman you dx with HTN. You have counselled her on lifestyle, ruled out secondary causes of HTN, done all the things. What will you prescribe for her?
I would recommend a thiazide (chlorthalidone or hctz) or long acting CCB (i.e. nifedipine 5mg po tid). Point is ACEI/ ARBs (RAAS inhibitors) are contraindicated in pregnancy and caution is required in prescribing to women of child bearing potential.
New case (from shared drive- CVS case study #1)!
Sam is a 67 year old Asian man who comes in to your office to “check up” on his health. You notice he has blood pressure of 150/95 averaged over three readings. His other past medical history includes previous NSTEMI, coronary artery bypass surgery over 20 years ago. His BMI is 31 and his waist circumference is 39 inches. What to do?
1) Review medical history, risk factors, lifestyle.
2) Physical exam- weight, heigh, waist circumference, dilated fundoscopy, CVS exam, abdo exam
3) Labs (UC, CBC, lytes, Cr, eGFR, FBG and A1C, blood lipids, ECG)
4) Assess CV risk (i.e., Framingham)
5) Talk about lifestyle changes (physical activity, diet/ sodium, weight reduction, decreased etoh/ smoking, relaxation, etc.)
I think that I would tend to wait for his labs before starting him on an antihypertensive (I want to see his renal function, and also determine his cardiovascular risk score). However, I don’t think it would be wrong to start him on something based on his BP and likely CV risk factors (i.e., hx nstemi and cabg)
Sam’s labs come back. Recall, he is 67 yo M, BP 150/95. FBG and HbA1C indicated impaired fasting glucose, but not in diabetes range. LFTs normal. Cholesterol 6.2 (normal 2- 5.19), HDL is 1.27 (normal >1.19). What now?
I started by scoring his CV risk using Framingham. I got a score of 17 which indicated 29.4% 10 year risk. Needs a statin, and also needs a HTN med (SBP > 130, high risk pt due to 10 year CVD risk >15%)(p.12 HTN Canada).
