michigan hypertension core curriculum - State of Michigan

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monitored hypertension screening and control for over a decade. 10 Previous BRFS results showed that 95 % of the respondents have had their BP measured and the latest Michigan BRFS reported 29% having ever been told by a physician they had high BP. Of those who had been told they had high BP, 79.4% reported taking blood pressure medication. The BRFS also monitors and reports other behavioral risk factors such as weight, fruit and vegetable intake, physical activity and cigarette smoking. A summary of selected risk factors from the 2007 BRFS results compared to the U.S. average is shown below: Less Than 5 Fruits No Leisure Cigarette Overweight Vegetables/Day Physical Inactivity Smoking Michigan 64.6 % 78.7% 20.9% 21.1% U.S. 63% 75.7% 23% 19.7% In 2006 the BRFS reported only 4.8% of Michiganians were practicing four key healthy lifestyles - a healthy weight, eating 5 fruits and vegetables per day, engaging in regular physical activity and not smoking. 10 Evidence from studies show that these healthy lifestyles are efficacious in preventing and controlling essential hypertension. The following information describes the role of these behaviors in hypertension. The established modifiable risk factors for hypertension described in The Seventh Report of the Joint National Committee are as follows; 1) excess body weight, 2) excess dietary sodium intake, 3) inadequate intake of fruits, vegetables, and potassium, 4) physical inactivity, and 5) excess alcohol intake. 11 Family history of hypertension and African American ancestry are risk factors for hypertension and although not modifiable they can be identified and monitored. Identification of those who meet the criteria for prehypertension is also important to focus the public, patients, and physicians on the importance of this BP range. JNC VII makes it clear that prehypertension is not a disease category. Rather, its purpose is to be an alert to promote intervention by the adoption of healthy lifestyles in hopes of preventing or delaying the development of hypertension. Excess body weight increases hypertension and is an increasing problem in the U.S. According to NHANES data, obesity (defined as a BMI ≥ 30 kg/m 2 ) has increased from 22.9% in 1988-1994 to 32.2% in 2003-2004 time periods. 12,13 Overweight and obesity combined (defined as a BMI ≥ 25 kg/m 2 ) has increased from 55.9% in NHANES 1988-1994 to 66.3% in NHANES 2003-2004. In the Framingham Heart Study, a 5% weight gain over 4 years was associated with a 20 – 30% increased odds of hypertension. 14 A BMI of 25.0-29.9 is associated with a 2.4 times relative ten year risk of developing hypertension among men and 3.8 times and 4.2 times relative ten year risk for a BMI of 30-34.9 and ≥ 35 respectively. 15 A 4.5 kg (10 pounds) weight loss can reduce BP and/or prevent hypertension in a large proportion of overweight persons with an anticipated 5 – 20 mmHg systolic blood pressure reduction per 10 kg (22 pounds) loss. 11 Ideally, maintaining a healthy weight throughout one’s lifetime is preferred. Consuming a diet less than 2,300 mg of sodium per day (about 1 teaspoon of salt) is currently recommended for most Americans; except individuals with hypertension, blacks and middle-aged and older adults who should consume less than 1,500 mg. 16 The average American diet contains 3,375 mg per day. 17 Decades of research support a causal relationship between dietary sodium intake and elevated BP. 18 Multiple meta-analyses of randomized controlled studies have found significant reductions in BP associated with a reduction in sodium intake. 18 A reduction of 100 mmol/day of sodium intake resulted in a 0.75 – 3.57 mm Hg decrease in SBP and a 0.1 – 1.66 reduction in DBP. Importantly, lowering sodium intake by just 44 mmol/L demonstrated a 38% reduction in the incidence 144 Hypertension Core Curriculum
of hypertension. 19 Furthermore, there appears to be a graded response in BP to lower sodium consumption. 20 Further dietary approaches include eating a diet high in fruits, vegetables and low fat dairy products but low in saturated and total fat. 11 This is the foundation of the recommended Dietary Approaches to Stop Hypertension (DASH) eating plan. This plan is high in potassium from the fruits and vegetables as well as high in calcium from low-fat dairy products. Meats are limited. Implementing such a diet is believed to lower systolic blood pressure by 8 – 14 mm Hg. 11,20 A combination of DASH diet and sodium reduction has effects on blood pressure equivalent to single drug therapy. 20 In persons who are physically inactive, the risk for developing hypertension is 30-50% greater than for those physically fit. 18 Increasing aerobic exercise has been shown to reduce BP in both hypertensives and non-hypertensives. This inverse relationship has been noted at all ages, in both genders, and in racial subgroups. It is independent of body weight. As a result, exercising for at least 30 minutes per day the majority of the days of the week is recommended. In doing so, it may be reasonably anticipated to reduce SBP by 4 – 9 mm Hg. 11 Excess alcohol intake is associated with elevated BP. 21-23 In the ARIC study, it was found that drinking alcohol in amounts greater than 210 g per week (3 alcoholic beverages) was associated with a greater risk of developing hypertension in normotensive persons after 6 years of follow-up. The risk was greatest in African American men. 24 Reduced alcohol consumption in normotensive men has been shown in a meta-analysis to reduce SBP by almost 4 mm Hg and diastolic by approximately 2 mm Hg. 24 It is therefore recommended that men have no more than 2 alcoholic beverages per day and for women, no more than one. The classification of prehypertension (BP of 120-139/80-89) was introduced in JNC VII essentially replacing the prior category of “high normal” (BP of130-139/85-89) and a range that had been considered “normal” (BP of 120-129/80-84). The significance of this classification is to highlight the importance of the increased cardiovascular risk associated with this range of BP’s and to initiate appropriate lifestyle changes to prevent or delay the development of hypertension. Progression to hypertension from “normal” and “high normal” BP’s during a median of 10.9 years of follow-up was 37.3% and 58.1% respectively. 25 Prehypertension is associated with an increased risk of left ventricular hypertrophy, coronary artery disease, myocardial infarction, and renal arteriosclerosis. 26 It is also associated with an increased cardiovascular and all-cause mortality. 27 Utilizing the lifestyle measures of reduced sodium intake, DASH eating plan, physical activity, maintaining a healthy weight or losing weight if overweight or obese and limiting alcohol consumption can be effective to lower prehypertensive BPs but the impact on outcomes is largely unknown. 28 Pharmacotherapy for uncomplicated prehypertension is not currently recommended. 28,26,11 The PREMIER clinical trial 29 showed that a behavioral program of weight loss, sodium reduction, increased physical activity, limited alcohol intake and the behavioral program with the DASH eating plan can reduce systolic and diastolic BP. Furthermore, both interventions were superior to advice alone. Implementation of healthy lifestyle changes in the current healthcare system is challenging. The identification of hypertension risk factors is a preventive service and the United States Preventive Services Task Force (USPSTF) does recommend screening for high BP in adults. However, Yarnall et.al. have shown that 7.4 hours per day is needed for the provision of preventive services alone in the current model of healthcare delivery. 30 When hypertension is identified, receiving recommended care occurs only 64.7% of the time and when counseling or education is a recommended service, it is received only 18.3 % of the time. 31 There are movements to reform the current acute care model, such as the patient centered medical home, which may improve the ability to provide these services The complexities of our healthcare system that preclude the delivery of recommended services are beyond the scope of this chapter, but they need to be addressed and not ignored. Likewise, it is important to take seriously what is important to patients and incorporate their preferences in clinical decision making. 32 NKFM & MDCH 145
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MICHIGAN HYPERTENSION CORE CURRICUL
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April 2010 Dear Colleague: In 2005,
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Kevin L. Piggott, MD, MPH, FAAFP Pr
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Blood Pressure Measurement........
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10 Hypertension Core Curriculum Blo
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of the wrist. Additionally, there i
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asis. National guidelines recommend
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Post-Test Questions: 1. High BP is
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18 Hypertension Core Curriculum Ess
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Masked Hypertension is when the off
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TABLE 1. Prevalence of Awareness, T
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Blood Pressure, Circulatory Physiol
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side of the vascular tree. Arterial
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upon the other co-morbidities prese
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Table 3. Clinically Available Clues
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In the setting of chronic hypertens
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34 Hypertension Core Curriculum Tab
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cause greater disruption of CBF aut
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References/Suggested Reading Agabit
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40 Hypertension Core Curriculum Chr
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development of essential HTN can se
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Figures: Figure 1. Pie-chart with m
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Table 2 Table 3 Screening Test for
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References: 1. U.S. Renal Data Syst
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50 Hypertension Core Curriculum Spe
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side effects particularly well. A h
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14. Gaede P, Vedel P, Larsen N, Jen
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Learning Objectives: 56 Hypertensio
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glycemic risk factdors such as hype
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. Weight loss c. Weight gain d. A a
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References: 1. Association AD. All
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64 Hypertension Core Curriculum Spe
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foods and turn out of necessity to
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Figure 1: Table 1. Metabolic Syndro
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9. Singh GK, Kogan MD, Van Dyck PC,
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Incidence and Prevalence The overal
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access to healthy foods than their
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As a part of the approach to managi
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B Hypertensive Adults (rate, percen
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References: 1. Lewington S, Clarke
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82 Hypertension Core Curriculum
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appear to be related to access to c
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CDC MMWR Feb 24, 2006/55(07); 177-1
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Figure 1; Clinical presentation and
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90 Hypertension Core Curriculum Phe
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ANY patient, who develops paroxysma
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Page 98 and 99: Definition Prevalence Clinical Feat
Page 100 and 101: intake. 4 Figure 1; Ion transport i
Page 102 and 103: loading with 200 mmoles (4.6 grams)
Page 104 and 105: Figure 3; Endocrine Society See tex
Page 106 and 107: INTRODUCTION 106 Hypertension Core
Page 108 and 109: Renal manifestations. Renal ischemi
Page 110 and 111: to assess renal dimensions and dupl
Page 112 and 113: stenosis severity. Patients with no
Page 114 and 115: ARAS, ischemic nephropathy, and imp
Page 116 and 117: the goals of minimizing injury to t
Page 118 and 119: hemodynamically impaired renal arte
Page 120 and 121: e classified as having “renovascu
Page 122 and 123: disease of the abdominal aorta and
Page 124 and 125: Table 1. Contemporary evaluation of
Page 126 and 127: 2. Screening tests for RAS RDU, MRA
Page 128 and 129: Manifestations of vital organ injur
Page 130 and 131: Table 6. Clinical evaluation of ren
Page 132 and 133: Table 9. Assessment of worsening re
Page 134 and 135: Table 11. New terminology for renal
Page 136 and 137: References: 1. Murphy TP, Soares G,
Page 138 and 139: 2001;12(6):1235-1241. 40. Subramani
Page 140 and 141: 78. Tami LF, McElderry MW, al-Adli
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Page 146 and 147: Policy Development: Public health p
Page 148 and 149: Med Clin North Am. Jan 2004;88(1):2
Page 150 and 151: mind they will have no problem iden
Page 152 and 153: Role of Race in the Selection of An
Page 154 and 155: individuals of any race or ethnicit
Page 156 and 157: Older Patients Need Elevated Systol
Page 158 and 159: sister, mother and father. A family
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Page 162 and 163: pulses (lower in the left arm). 4 C
Page 164 and 165: Vital signs suggestive of OSAHS. 20
Page 166 and 167: may shed light on underlying medica
Page 168 and 169: References: patients. 8 However, th
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Page 172 and 173: and evidence that anti-hypertensive
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Page 176 and 177: interestingly found only a 6.0/4.6
Page 178 and 179: pressure: a meta-analysis of random
Page 180 and 181: isolated systolic hypertension have
Page 182 and 183: Compelling Indications for Specific
Page 184 and 185: 3.) Beta-blockers, ACE inhibitors,
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Page 188 and 189: Preparations and Dosage: Oral antih
Page 190 and 191: Preparations and Dosages: The Oral
Page 192 and 193: patients with tachy-brady syndrome
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significant proteinuria. Pharmacolo
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the effect found by the ACE inhibit
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and nominally statistically signifi
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sensitive K+-channels in vascular s
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clonidine (Catapres†) 0.1-0.8 mg
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Learning Objectives 204 Hypertensio
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general, the response to beta-block
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Table 2: (JNC VII, 2004) 208 Hypert
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Learning objectives: 210 Hypertensi
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ecently published RCT investigated
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Post-test question: 35y/o male w/ h
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Orthostatic Hypotension Pretest que
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BP. It is important to note that la
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1- Fludrocortisone : a mineralocort
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References: 1. Hiitola P, Enlund H,
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www.neuroanatomy.wisc.edu/.../Image
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Learning objectives: 226 Hypertensi
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controlled BP to have been victimiz
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Treatment of Secondary Causes of Hy
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4-Direct vasodilators (e.g.minoxidi
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Hypertension. Aug 2003;42(2):161-16
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emergency by virtue of the associat
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PATHOPHYSIOLOGY The underlying mech
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trials included a placebo arm. Seve
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an indication for careful and modes
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ACUTE KIDNEY INJURY (AKI) In additi
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Blood Pressure Research Council, an
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[ACE inhibitors (ACEIs), angiotensi
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y sodium restriction or the use of
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44 months 24 , and were also seen i
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• Hypertension in dialysis patien
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GISEN Group (Gruppo Italiano di Stu
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258 Hypertension Core Curriculum
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DEFINITION AND CLASSIFICATION Hyper
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etween adult socioeconomic position
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women treated with atenolol in earl
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Obstet Gynecol. Dec 12 2008. 5. Vol
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able to dissipate the pressure rise
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Use of Dihydropyridine Calcium Anta
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272 Hypertension Core Curriculum Ca
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Case 4 Hypertensive patient with CK
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Case 6 276 Hypertension Core Curric
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year. Sodium restriction and weight
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What may be causing these new sympt
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