michigan hypertension core curriculum - State of Michigan

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18 Hypertension Core Curriculum Essential Hypertension Primary Hypertension Steven Yarows, MD Learning objectives • Understand the correct method of taking BP and then correctly interpret and categorize the results. • Since 1/3 of the US adult population has primary hypertension, understanding the important health and financial costs of this disease. • Understand the three predominant hypertension phenotypes - isolated systolic, mixed systolic/ diastolic and isolated diastolic hypertension. Pre-test Questions A 35 year old obese male comes to the office for a rash and has his routine BP measured with a standard cuff of 170/104 mmHg. He has a grandfather who died of a stroke at 83 years old, but he thinks his parents are in good health and only take ‘a few’ pills. You assess the rash and indicate it is tinea crura and advise an anti-fungal cream. You then address his BP by: A. Have him return in the morning for another BP reading B. Recheck his BP with a large cuff after sitting for 5 minutes C. Start a diuretic and have him return for a physical D. Advise him to lose weight and see him back in a year The likelihood of isolated systolic hypertension (ISH) is higher in: A. Over 70 years old B. Under 50 years old Which of the following is true? A. Inadequate control of systolic BP is usually the reason for uncontrolled hypertension B. Inadequate control of diastolic BP is usually the reason for uncontrolled hypertension C. Inadequate control of systolic and diastolic BP are equally likely in individuals with uncontrolled hypertension A 40 year old Black healthy male has been to your office twice in the past 2 months for upper respiratory infections and his average BP over these two visits was 160/102 mmHg; both BP readings were higher than150/96 mm Hg. His parents are both hypertensive on medication and he used their home BP monitor with a large cuff and it was 150/96 and 164/104 mmHg. What would be your starting therapy? A. Hydrochlorothiazide (diuretic) 25mg qd B. Valsartan (angiotensin receptor blocker) 320mg qd C. Metoprolol XL (extended release beta blocker) 50mg qd D. Amlodipine (dihydropyridine calcium channel blocker) 5mg qd E. Amlodipine/lotensin (dihydropyridine calcium channel blocker + ACE inhibitor) 5/20mg qd
Essential (Primary) Hypertension: Diagnosis of Hypertension Essential hypertension is a misnomer. There is nothing ‘essential’ about hypertension; perhaps “essential BP”, but not hypertension. This section will describe ‘primary hypertension’. Blood pressure (BP) is inherently variable within a reasonably predictable range. Hypertension is defined as elevated average BP over time, preferably with a minimum of 3 properly performed readings on different days and is never based on a single measurement. Your BP at rest is lower than your BP during activities. There is a natural diurnal variation for people with usual work-sleep cycles resulting in increased BP just prior to awakening continuing to be elevated in the morning while decreasing in the evening. BP also decreases in the early afternoon, which is why post-lunch lectures are difficult, and the nadir in BP occurs at 2-3AM, during sleep. This data is routinely obtained by 24-hour ambulatory blood pressure monitors. The decrease in BP during sleep is known as the ‘dip’ and is absent in some conditions and when absent results in increased cardiovascular (i.e., strokes, myocardial infarctions, death) events. Several selected conditions known to attenuate or eliminate the normal nocturnal decline in BP include: 1) chronic kidney disease (CKD), 2) obesity, 3) high sodium and/or low potassium diets, and 4) sleep disordered breathing. Too much pressure is potentially deleterious for any system. For example, an overinflated car tire allows you to drive to the store without any difficulty; however the increased pressure prematurely wears out the tire. The human circulatory system is similar. Prolonged BP elevation results in accelerated atherosclerosis and vascular remodeling that heighten the risk of stroke (brain), myocardial infarction (heart), myocardial hypertrophy (heart), kidney failure (kidney), and abdominal aneurysms (general circulatory). Contrary to pervasive myths, there is no specific BP reading that prognosticates without fail a cardiovascular catastrophe. When marked BP pressures are detected, repeated measurements and careful short-term follow-up are critical. Hypertension Phenotypes (Isolated Systolic, Isolated Diastolic, Isolated Systolic/Diastolic) BP is represented by two numbers (i.e., 120/50 mmHg). The highest number is the systolic BP and the lower is the diastolic BP. The BP is typically measured by either the auscultatory or oscillometric methods. The following is a discussion of hypertension phenotypes. Hypertension is classified into distinctive phenotypes. Mixed systolic/diastolic hypertension is most common in middle aged patients when both the diastolic and systolic BP are elevated above 140/90 mmHg in the office. Isolated systolic hypertension (ISH) is most common after 50 years old, although there is an unusual, benign form in the youth. 1,2 ISH is also the most risky hypertension phenotype despite the fact that the diastolic BP is not elevated. Isolated diastolic hypertension is least prevalent (and also least risky) hypertension phenotype. The different categories of hypertension have different pathological mechanisms which will be discussed in the Pathophysiology Section. Pre-hypertension is present when BP readings are between 120-139/80-89 mmHg. 3 These individuals are at risk for the development of hypertension. Thus, lifestyle modification (i.e., exercise, weight loss, salt and alcohol restriction) is recommended. Borderline or high normal BP is when the office readings are consistently between 135-140/85-90 mmHg in patients without CKD, diabetes, or ischemic heart disease. White Coat Hypertension (office hypertension) is present when the office BP is >140/90 mmHg, yet the outside the office the BP is
Page 1: MICHIGAN HYPERTENSION CORE CURRICUL
Page 4 and 5: April 2010 Dear Colleague: In 2005,
Page 6 and 7: Kevin L. Piggott, MD, MPH, FAAFP Pr
Page 8 and 9: Blood Pressure Measurement........
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Page 12 and 13: of the wrist. Additionally, there i
Page 14 and 15: asis. National guidelines recommend
Page 16 and 17: Post-Test Questions: 1. High BP is
Page 20 and 21: Masked Hypertension is when the off
Page 22 and 23: TABLE 1. Prevalence of Awareness, T
Page 24 and 25: Blood Pressure, Circulatory Physiol
Page 26 and 27: side of the vascular tree. Arterial
Page 28 and 29: upon the other co-morbidities prese
Page 30 and 31: Table 3. Clinically Available Clues
Page 32 and 33: In the setting of chronic hypertens
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Page 36 and 37: cause greater disruption of CBF aut
Page 38 and 39: References/Suggested Reading Agabit
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Page 42 and 43: development of essential HTN can se
Page 44 and 45: Figures: Figure 1. Pie-chart with m
Page 46 and 47: Table 2 Table 3 Screening Test for
Page 48 and 49: References: 1. U.S. Renal Data Syst
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Page 52 and 53: side effects particularly well. A h
Page 54 and 55: 14. Gaede P, Vedel P, Larsen N, Jen
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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
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INTRODUCTION 106 Hypertension Core
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Renal manifestations. Renal ischemi
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to assess renal dimensions and dupl
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stenosis severity. Patients with no
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ARAS, ischemic nephropathy, and imp
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the goals of minimizing injury to t
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hemodynamically impaired renal arte
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e classified as having “renovascu
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disease of the abdominal aorta and
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Table 1. Contemporary evaluation of
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2. Screening tests for RAS RDU, MRA
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Manifestations of vital organ injur
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Table 6. Clinical evaluation of ren
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Table 9. Assessment of worsening re
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Table 11. New terminology for renal
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References: 1. Murphy TP, Soares G,
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2001;12(6):1235-1241. 40. Subramani
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78. Tami LF, McElderry MW, al-Adli
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142 Hypertension Core Curriculum Pr
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monitored hypertension screening an
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Policy Development: Public health p
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Med Clin North Am. Jan 2004;88(1):2
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mind they will have no problem iden
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Role of Race in the Selection of An
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individuals of any race or ethnicit
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Older Patients Need Elevated Systol
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sister, mother and father. A family
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ecause pressure-related retinopathy
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pulses (lower in the left arm). 4 C
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Vital signs suggestive of OSAHS. 20
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may shed light on underlying medica
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References: patients. 8 However, th
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Objectives: 170 Hypertension Core C
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and evidence that anti-hypertensive
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When subjects are given instruction
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interestingly found only a 6.0/4.6
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pressure: a meta-analysis of random
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isolated systolic hypertension have
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Compelling Indications for Specific
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3.) Beta-blockers, ACE inhibitors,
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treatment levels - albeit though at
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Preparations and Dosage: Oral antih
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Preparations and Dosages: The Oral
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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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