michigan hypertension core curriculum - State of Michigan

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Older Patients Need Elevated Systolic Blood Pressure to Perfuse Their Stiff Vessels 156 Hypertension Core Curriculum John Flack, MD, MPH It is absolutely true that as we age our arterial vasculature becomes less pliable and compliant. Vessel stiffening, while linked to the aging process, does not mean that elevated systolic pressures are need to adequately perfuse vital organs such as the brain in older persons. Numerous pharmacological treatment trials in older persons have established the benefits of treating isolated systolic hypertension - the prototype hypertension phenotype for stiff arterial blood vessels. The old adage that a normal SBP is “100 plus your age” has been repeatedly disproven as having any merit. It is, however, true that rapid reductions in BP in persons with stiff arterial blood vessels can precipitate acute target-organ ischemia. Thus, the goal for BP lowering in persons with stiff arterial vessels is to gradually lower BP over many weeks to months toward goal levels. How does the clinician know which patient has stiff arterial blood vessels? Well, for one, a reasonably crude indicator is advancing age. The diastolic BP begins to fall while the systolic BP continues to rise around the middle of the 6th decade of life. Generally speaking, the wider the pulse pressure the stiffer the arterial blood vessels. Persons with diabetes manifest premature aging of the vasculature and will therefore prematurely show the wide pulse pressure hypertension phenotype. Older persons with stiff arterial vessels are also more prone to orthostatic drops in their BP, in part because of reduced sensitivity of the baroreceptors. Accordingly, the BP in older persons should always be checked in the seated and standing position. If BP falls upon standing then the standing BP should be used as the target. Eliminate or reduce the doses of antihypertensive drugs known to cause/contribute to orthostatic hypotension - alpha blockers, central adrenergic inhibitors, and diuretics. The myth regarding stiff BP needing high arterial BP to perfuse them has, unfortunately, been a cover for those who believe that they are harming older persons by pharmacologically lowering the BP. The clinical evidence strongly proves just the opposite. Nevertheless, it does not hurt to start with lower drug doses and titrate a bit less frequently in an effort to more gradually lower BP in older persons with stiff vessels.
Initial Evaluation Initial Evaluation of the Hypertensive Patient B. Diaczok, MD and A. Badshah, MD Purpose Evaluation of hypertensive patients has multiple objectives: 1,2,3 a. To assess lifestyle and identify other cardiovascular risk factors and/or coexisting disorders that may affect prognosis and guide treatment b. To determine the duration of elevated BP, treatment history including compliance, and possible pressure-related symptoms (e.g., nervousness, headache, sleep disturbance) c. To identify possible causes of high BP d. To assess the presence or absence of target organ damage and clinical cardiovascular disease Patient Evaluation Evaluation of patient consists of: e. Medical History i. Hypertension history – date of onset, usual BP level, treatment history, compliance, etc. ii. Target organ damage iii. Identifiable causes of hypertension iv. Cardiovascular risk factors f. Physical examination g. “Routine” laboratory tests and other diagnostic testing History Medical history should include any previous diagnosis, treatment and complications of hypertension. 4,5 The patient with new onset hypertension should be assessed for their adherence to appropriate diet and lifestyles as well as to exposures that might have contributed/caused the BP elevation. 6,7 Patient should be screened for identifiable causes of hypertension, if indicated. 8,9 All non-BP cardiovascular risk factors also should be identified. 9 Major Lifestyle Emerging Coronary Heart Disease Risk CVD Risk Factors Risk Factors Risk Equivalent_______ -LDL cholesterol -Sedentary life style -CRP -Diabetes -Low HDL -Obesity -Lp(a) -Abdominal Aortic Aneurysm -Smoking -Atherogenic, diet -Subclinical -Peripheral Vascular Disease -Age Atherosclerosis -Symptomatic Carotid -Family history -Calcium score Disease -microalbuminuria -CKD HDL: Less than 40mg/dl is considered low Age: Males over 45 and females over 55 years old. Current smoker: Smoking one or more cigarettes in the past month. (The amount of cigarettes smoked correlate with increased risk). Family history: Premature atherosclerosis in a first degree relatives—son, daughter, brother, NKFM & MDCH 157
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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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Figure 1: 94 Hypertension Core Curr
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Objectives: 96 Hypertension Core Cu
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Definition Prevalence Clinical Feat
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intake. 4 Figure 1; Ion transport i
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loading with 200 mmoles (4.6 grams)
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Figure 3; Endocrine Society See tex
Page 106 and 107: INTRODUCTION 106 Hypertension Core
Page 108 and 109: Renal manifestations. Renal ischemi
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Page 124 and 125: Table 1. Contemporary evaluation of
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Page 138 and 139: 2001;12(6):1235-1241. 40. Subramani
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Page 150 and 151: mind they will have no problem iden
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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
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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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