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8. 54-year-old male with elevated blood pressure- Mr. Martin

Terms in this set (39)

When to Screen for High Blood Pressure

The United States Preventive Service Task Force (USPSTF) makes evidence-based recommendations about screening for disease with poor outcomes that could be prevented through early detection and treatment.

The USPSTF recommends screening for high blood pressure in patients without known hypertension starting at age 18. (USPSTF Grade A recommendation: a high certainty that the net benefit is substantial).

Evidence-Based Recommendations
The Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC) periodically releases reports on the diagnosis and treatment of high blood pressure. The current JNC8 report only updated the evidence-based recommendations for the management of high blood pressure based on large-scale clinical trials. JNC8 did not update the recommendations for the diagnosis and prevention of high blood pressure, and mostly defaulted these recommendations to the earlier JNC7 report.
Mr. Martin's blood pressure is 150/85 mmHg in his right arm, and the pulse is 80 beats per minute.

A. Hypertension
1. Hypertension affects approximately 50 million people (US) and as many as one billion people (worldwide)

2. In adults 60 years and older, a systolic blood pressure > 150 or a diastolic blood pressure > 90 is defined as hypertension.

3. In adults younger than 60 years old, a systolic blood pressure > 140 or a diastolic blood pressure > 90 is defined as hypertension.

4. Prehypertension
This designation is intended to identify individuals in whom early intervention by adoption of healthy lifestyles could reduce blood pressure, decrease the rate of progression of blood pressure to hypertensive levels with age, or prevent hypertension entirely. Prehypertension is technically a higher subset of normal blood pressure.
Recommended History for Possible New Diagnosis of Hypertension

Evaluation of a patient with a possible new diagnosis of hypertension has three goals:
1. Assess the presence or absence of target end organ disease
2. Assess lifestyle and identify other cardiovascular risk factors or concomitant disorders that may affect prognosis and guide treatment
3. Reveal identifiable causes of hypertension
Assess the presence or absence of target end organ disease. Untreated or poorly treated hypertension leads to serious complications in several organ systems including the:
1. Heart: LVH, angina or prior myocardial infarction, prior coronary revascularization, heart failure.
2. Brain: Stroke or TIA
3. Kidneys: Chronic renal failure.
4. Blood vessels: Peripheral artery disease.
5. Eyes: Retinopathy.

1. Thus, it is important to ask about signs or symptoms of end organ disease in these areas, such as any history of:
A. CHF, CVD or symptoms, renal disease, peripheral vascular disease, or retinopathy.

2. It is also appropriate to ask about history of known hypertension and duration. A patient with more than 10 years of hypertension may already have end-stage organ disease.
Assess lifestyle and identify other cardiovascular risk factors or concomitant disorders that may affect prognosis and guide treatment.
3. Assess lifestyle and identify other cardiovascular risk factors or concomitant disorders that may affect prognosis and guide treatment. Major cardiovascular risk factors include:
A. A patient with a history of diabetes and/or cholesterol, and/or obesity may also have hypertension as part of metabolic syndrome.
B. A patient with a family history of premature cardiovascular disease or death
(men under age 55, women under age 65) increases the risk of cardiovascular disease or death up to eight times higher than that of the rest of the population.
C. Tobacco smoking elevates blood pressure, contributes to increased morbidity and mortality, and interferes with the efficacy of blood pressure medications.
D. Alcohol intake should be limited to no more than 1 oz (30 mL) of ethanol, the equivalent of two drinks per day in most men and no more than 0.5 oz of ethanol (one drink) per day in women and lighter weight persons.
E Cocaine and ketamine use and narcotic withdrawal can elevate blood pressure.
F. Other major risk factors include: age (older than 55 for men, 65 for women), physical inactivity, microalbuminuria or estimated GFR 60 mL/minute.
Reveal identifiable causes of high blood pressure
G. Reveal identifiable causes of high blood pressure such as: sleep apnea, chronic kidney disease, primary aldosteronism, renovascular disease, pheochromocytoma, coarctation of the aorta, and thyroid or parathyroid disease.
H. A review of all medications, including OTC and complementary medications is crucial. Some common prescription medications like:
1. birth control pills, amphetamines, thyroid medications, steroids, and certain anti-depressants may elevate blood pressure.
Some common OTC meds can also elevate blood pressure, such as:
2. pseudoephedrine, appetite suppressants, or NSAIDS. Some herbal remedies may elevate blood pressure such as:
3. ma huang, bitter orange, ginkgo, ginseng, licorice, and St. John's wort.

As noted above, cocaine and ketamine use, narcotic withdrawal, excessive alcohol intake and smoking can also elevate blood pressure.

Other appropriate questions include:
1. Family history of diabetes and / or hypercholesterolemia
2. Patient's diet history
3. A review of psychosocial stressors.
- Stress directly causes the release of angiotensin II and norepinephrine in the body (flight or fight syndrome), and stressors can also make prioritizing adherence to blood pressure medicines difficult.

Answers B (personal history of cancer), F (personal history of glaucoma), and H (family history of colon cancer) are not essential elements of an initial focused history for a patient with a possible new diagnosis of hypertension. These questions are appropriate however for a more general medical history.
Dx HTN + Causes of HTN
Which of the following accurately describes the best way to measure blood pressure according to the JNC7 recommendations?

A . The patient should be seated quietly for thirty minutes before a blood pressure measurement is taken.
B. The patient should be seated on an examination table when taking their blood pressure measurement.
C. The arm should be supported at heart level.
D. The length of the bladder of the cuff must be at least 80% of the arm circumference.
E. The width of the cuff must be at least 40% of the arm circumference.
F. An adult-sized cuff should be used for most adults.
The patient should be seated quietly for at least five minutes in a chair with their back supported.

The arm should be supported at heart level. You want to auscultate the blood pressure with your stethoscope using a properly calibrated and validated instrument.

The most important point is using an appropriately sized cuff to ensure accuracy. The length of the bladder of the cuff should be at least 80% of the arm circumference, and the width of the cuff must be at least 40% of the arm circumference.
A cuff that is too small will give you an erroneously high blood pressure reading.
With increasing prevalence of obesity, most adults no longer will fit into an "adult" cuff, but may require an "extra large" or "thigh-sized cuff."


C,D,E have been selected by the expert.
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Based on what you know about the patient so far, write a one- to three- sentence summary statement to communicate your understanding of the patient to other providers.
- tell Mr. Martin about the importance of the next visit to confirm the diagnosis of hypertension.
- A lot of people have a hard time making lifestyle changes in order to improve their blood pressure because you do not see the effects of high blood pressure until you've had it for many years.
- important to remember that the higher your blood pressure is, the greater your chances of heart attack, heart failure, stroke, and kidney disease.
- The good news is that there is a lot you can do to lower your blood pressure.
1. good for not smoking tobacco as that eliminates an important potential risk factor.
2. increasing the amount of exercise he does each week.
3. cutting down the amount of salt and fried foods in his meals and to increase his intake of fresh vegetables and fruits.
4. You invite him to bring along his wife, who is the main food preparer in the home, for further discussion, and Mr. Martin tells you he will talk with her about this.
5. Behavioral Counseling
What treatment approaches would you recommend for someone with hypertension?

A Lifestyle modifications
B No antihypertensive medication is indicated at this time
C Initiate thiazide diuretic
D Initiate a beta-blocker
E Initiate an alpha blocker
A + C
Management of Hypertension
1. Lifestyle modifications per JNC 8:
All adults aged >18 with hypertension should be encouraged to implement lifestyle interventions that should be continued throughout management.

Initial pharmaceutical management for patients >18 years old as per JNC 8:
The table below outlines the first antihypertensive medications of choice for various demographics and comorbid conditions:
Which of the following statements are true about thiazide diuretics?

A Hydrochlorothiazide is the most cost-effective antihypertensive drug.
B A 50 mg dose of hydrochlorothiazide reduces blood pressure, and decreases morbidity and mortality, more than a 25 mg dose of hydrochlorothiazide.
C Thiazides may affect electrolyte levels.
D Thiazide diuretics should be avoided in patients with a history of gout.
E Thiazide diuretics should be started at 25mg in elderly patients.
F Thiazide diuretics may cause elderly patients to become incontinent of urine.
A,C,D,F have been selected by the expert.
Thiazide diuretics may cause elderly patients to become incontinent of urine
- Aging decreases bladder capacity, decreases time of awareness of need to void, increased detrusor instability decreased pelvic floor muscles, incomplete emptying, and atrophic urethral changes.
- Thiazide diuretics may exacerbate problems for those on the threshold or already incontinent of urine.

Thiazides have demonstrated marked reduction in morbidity and mortality from hypertension
- low-dose (12.5 to 25 mg/d chlorthalidone or hydrochlorothiazide) and high-dose (50 mg/d or more of both drugs) diuretic therapy lowered blood pressure to a similar degree and exerted a similar benefit in reducing stroke, congestive heart failure, cardiovascular, and total mortality
- only low-dose diuretic therapy significantly reduced coronary heart disease incidence. Chlorthalidone is a thiazide-like diuretic.
- A 2009 Cochrane review reinforced that no other drug class improved health outcomes better than low-dose thiazides, and beta-blockers and high-dose thiazides were inferior.
- In addition, low-dose inexpensive thiazides should be the first choice drug in most patients with elevated blood pressure.

- Thiazide diuretics should be started at lower doses in elderly patients such as 6.25mg or 12.5mg (NOT 25 mg) a day, because this population may be more sensitive to this drug class and may experience hypotensive episodes.
- Most other adults can start at 25mg per day. Although elderly patients start at lower doses, they may require the same amount of medication as younger persons to control their blood pressure.

Remember that JNC 8 does not single out thiazide diuretics as the first choice anti-hypertensive for most patients. Instead, the JNC 8 includes thiazide diuretics as a recommended option for all patients except those with chronic kidney disease (ACE/ARBs)
What initial laboratory testing would you order in the office as per JNC 7 standards for Mr. Martin, now that he has a new diagnosis of essential hypertension?

Initial Laboratory Testing for New Diagnosis of Essential Hypertension:
Lab tests:
1. Electrocardigram,
2. urinalysis,
3. blood glucose,
4. blood hematocrit,
5. serum potassium (K),
6. serum creatinine estimate GFR,
7. fasting serum cholesterol panel, 8. measurement of urinary albumin excretion or albumin/creatinine ration (ACR),
9. serum Calcium
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Lifestyle modifications reduce blood pressure, enhance antihypertensive medication efficacy, and decrease cardiovascular risks.

Which lifestyle change will decrease blood pressure the most?
A Weight reduction
B DASH eating plan
C Dietary sodium reduction
D Physical activity
E Moderation of alcohol consumption
A
You recognize that Mr. Martin has several major risk factors for atherosclerotic cardiovascular disease (ASCVD). According to the Pooled Cohort Equations risk calculator, Mr. Martin's estimated ten-year risk of an ASCVD event is:
Multiple Choice Answer:
A <5%
B <7.5%
C <10%
D <20%
E 20% or greater
An estimated 10-year risk of ASCVD >7.5 is considered elevated.

The Pooled Cohort Equations produces a patient's 10-year risk of incident ASCVD based upon their major risk factors
1. age,
2. gender
3. smoking status
4. hypertension
5. systolic blood pressure
6. diabetes
7. total and HDL cholesterol
aspirin prophylaxis
Regarding his high blood pressure measurement today, what does JNC 8 recommend as the next step in his drug management?

A Discontinue lifestyle modifications
B Continue lifestyle modifications
C Continue the hydrochlorothiazide at the current dose (25mg/day)
D Discontinue the hydrochlorothiazide
E Increase the hydrochlorothiazide to 50mg/day
F Initiate an alpha blocker drug
G Initiate an angiotensin converting enzyme inhibitor (ACEI) drug
Alpha-blockers have no proven decrease in morbidity and mortality demonstrated in research studies and are not for treatment of essential hypertension.
They are only utilized as an adjunct in hard-to-control blood pressure.
Alpha-blockers are often prescribed in prostatism but should not be used as a first line anti-hypertensive in patients with benign prostatic hypertrophy (BPH).
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When to refer to a specialist
In formulating your choice for the second agent, let's discuss how demographics, lifestyle issues, and socioeconomic factors may impact blood pressure control. Which of the following is true?

A Overall, treatment for all demographic groups is similar, but lifestyle issues and socioeconomic factors may be critical barriers to blood pressure control.

B The rates of blood pressure control are highest in Mexican Americans and Native Americans.

C Prevalence, severity, and impact of hypertension are increased in African Americans.

D African Americans demonstrate somewhat reduced BP responses to monotherapy with BBs, ACE inhibitors, or ARBs compared to diuretics or CCBs.
All doctors must take time to assess their patient's understanding of their illness. This...

A Allows you to offer medical plans that resonate with the patient's priorities.
B Encourages partnership with the patient in their care.
C Reduces inappropriate clinical diagnosis and management.
D Has no effect on patient adherence to medical regimens.
E Reduces risk of misunderstanding between physicians and their patients.
F Reduces patient satisfaction with their physician.
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A 65-year-old female presents to your office for a routine visit. She is found to have a blood pressure of 146/96. You repeat the blood pressure in her other arm and get 148/92. Her pulse is 70 and regular. Her last BP reading was one year ago and was 120/76. She has no other medical problems. Her BMI is 28. She states that she likes to walk 30 minutes every other day with her husband and has been doing that for years now. At this time, the most appropriate diagnosis is...
Single Choice Answer:
A white coat hypertension
B elevated blood pressure
C benign essential hypertension stage 1
D secondary hypertension
A 68-year-old male was diagnosed with benign essential hypertension a few months ago and has been working on diet and lifestyle modifications. He has a BMI of 28, mild knee arthritis but no other medical diagnoses. He has been a patient of yours for several years, and returns today as planned. Today his blood pressure is 156/94. The remainder of his cardiovascular exam is within normal limits. After counseling the patient, he agrees to start an antihypertensive medication. His creatinine is 0.9, urinalysis is normal, and electrolytes are within normal limits. which of the following is the most appropriate medication to begin in this patient?
Single Choice Answer:
A Beta blocker
B Thiazide diuretic
C Nitrate
D Loop diuretic
E Clonidine
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