HTN Group Discussion

Question 1

1. What are pertinent physical exam components to assess a patient for an elevated blood pressure/new diagnosis of hypertension.

Answer 1

check BP in both arms
obtain orthostatic blood pressures
palpate and auscultate the heart
check vascular pulses
check for abdominal masses and aortic pulsation
lower extremity edema
palpate thyroid
examine optic fund (retinopathy and papillary edema- long term damage)
S4 gallop (due to having to contract against high pressure systemic pressure)
check lungs for heart failure
auscultate for renal artery stenosis or adrenal masses
BMI to help target therapy, and assess for hyperlipidemia or diabetic risk

Question 2

2. What are the recommended initial lab tests and indications for the test to assess a patient for elevated blood pressure.

Answer 2

urinalysis- DM, kidney disease
blood glucose 
hematocrit
serum K (Kohn syndrome- aldosterone due to tumor)
Ca
Creatine (kidney disease)
GFR
12 lead EKG
TSH levels
fasting lipids (HDL, LDL and triglycerides-- risk of atherosclerosis, quantify CV risk)

Question 3

3. What lifestyle changes might be suggested to a patient with b.p.

Answer 3

weight reduction (5-20mmHg)
DASH (8-14 mmHg)
dietary sodium (2-8 mmHg)
physical activity (4-9 mmHg)
moderation of alcohol consumption (2-4 mmHg)
smoking cessation (3.5 mmHg)

Question 4

4. Do you prescribe medication after first visit with HTN?

Answer 4

see if lifestyle modifications, could this be caused by white coat HTN, next steps could be multiple measurements or home monitoring, unless there is clear end organ damage

Question 5

5. What is the goal of HTN pressure?

Answer 5

goal to get the patient under 140/90, important to reduce cerebral vessels, protect kidney, protect coronary vessels; education on the side effects and consequences of HTN

Question 6

6. What are the pros and cons by single or multiple drug therapy.

Answer 6

more drugs, can effect more interacting systems; clinically managing, paying for or picking up drugs can also be a problem

Question 7

7. List the classes of antihypertensive drugs for treatment of HTN.

Answer 7

diuretics
ACE-I (side effects of cough but cheap)
ARB
CCB

B-blockers (for heart failure patients)

Question 8

8. What are the special conditions under situation of african american or asthmatics?

Answer 8

AA: increased risk of angioedema or slow acetylation due to ACE-I; B-blocker (B2) cause blocking of dilation of airways, (B1) specific can be sued but not at high doses; Asthma: ACE-I can cause bronchoconstriction (chose ARB)

Question 9

9. What is the preference of HTN meds for diabetics?

Answer 9

for diabetics: ACEi or ARB then CCB and diuretics;

use blockers of RAS and check for increased hyperkalema
ARB can dilate efferent vessels to limit glomerular pressure and proteinuria and prevent end organ damage (although will show increased creatinine)

Question 10

10. How do you decide to up an dose or add another med.

Answer 10

depends on how close you are to the goal, what is the cost to the patient? what is most likely to be biologically effective? (don’t usually use ACEi and ARB together)

Question 11

11. What are some concerns with persistent hypertension?

Answer 11

what is Mr. Jones doing (or not doing) to lower his BP- lifestyle changes, taking meds

Question 12

12. In hypertensive emergency what is the course of action

Answer 12

needs to be admitted for IV drugs including nitroprusside (most power vasodilator) and has short half-life which makes it easier to manipulate response; remember withdrawal of meds esp. B-blockers and central sympathalytics can cause rebound of the pressure

goal is to decrease mean arterial blood pressure by no more than 25% within 2 hours or to decrease the range of 160/100 mmHg

Question 13

13. What are the potential consequences if BP is or isn’t treated quickly.

Answer 13

end organ damage (pailledema, encephylopathy), stroke risk

too aggressive of treatment can cause low perfusion to organs, stroke or syncope

Question 14

14. What can be done to encourage compliance?

Answer 14

address patient concerns including side effects and cost, as well as other reasons about discontinuing meds as well as the significance of silent damage of the disease or importance of taking meds

Question 15

15. What are the recommendations for HTN with additional cardiac event like MI?

Answer 15

MI is compelling indication for B-blocker especially if there is reduced systolic performance and it can help to reduce cardiovascular events in the future (although it takes 2 mo to titrate the drug dosage)

ARB and ACEi can cause fibrosis in the ventricle