michigan hypertension core curriculum - State of Michigan

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4-Direct vasodilators (e.g.minoxidil) may be necessary in some cases – typically in men (causes fine vellus hair growth and is thus usually avoided in women). The use of minoxidil will necessitate concomitant beta-blockerade or the use of nonDHP calcium channel blockers to slow the pulse rate down and loop diuretics such as furosemide to counterbalance the minoxidil-induced fluid retention. . 5-Dual calcium-channel blockers (a dihydropyridine, such as amlodipine, plus a nonDHP calcium antagonist such as verapamil. 37 Summary and Recommendations White coat HTN and therapeutic noncompliance should be considered in persons suspected of having resistant HTN. Resistant HTN is typically multi factorial. Obesity and excessive alcohol and salt might exacerbate HTN resistance. Suboptimal dosing, the use of too few drugs, and inadequate use of diuretics are the most common causes of RH in primary care. Secondary causes (including exogenous substances) must also be considered. Post test RR is 48 year old man with history of uncontrolled HTN and a myocardial infarction ~ 6 months ago. His BP readings at his last three clinic visits were 179/95, 164/89 and 183/72 mm Hg while his pulse ranged from s 87 to 96 beats/min. His weight has been stable at 207 lbs. BUN and creatinine were 25 and 1.5, respectively. He continues to smoke but he does not exercise. His medication list includes metoprolol 25 mg BID, HCTZ 25 mg daily, and lisinopril 10 mg daily. He states that he has been compliant with medication for the last three months. Which one of the following choices represents the best approach to improve his BP control: 1) intensify life style modification, including smoking cessation and weight loss, 2) noncompliance is very likely and no medication adjustment is needed at this time, 3) screen for pheochromocytoma, 4) increase lisinopril to 20 mg/d, or 5) increase metoprolol to 50 mg BID and add amlodipine 5 mg/d. (Correct answer) References 1. Hyman DJ, Pavlik VN. Characteristics of patients with uncontrolled hypertension in the United States. N Engl J Med. Aug 16 2001;345(7):479-486. 2. Calhoun DA, Jones D, Textor S, et al. Resistant hypertension: diagnosis, evaluation, and treatment: a scientific statement from the American Heart Association Professional Education Committee of the Council for High Blood Pressure Research. Circulation. Jun 24 2008;117(25): e510-526. 232 Hypertension Core Curriculum
3. Singer GM, Izhar M, Black HR. Goal-oriented hypertension management: translating clinical trials to practice. Hypertension. Oct 2002;40(4):464-469. 4. Mancia G, De Backer G, Dominiczak A, et al. 2007 Guidelines for the Management of Arterial Hypertension: The Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). J Hypertens. Jun 2007;25(6):1105-1187. 5. Bramlage P, Pittrow D, Wittchen HU, et al. Hypertension in overweight and obese primary care patients is highly prevalent and poorly controlled. Am J Hypertens. Oct 2004;17(10):904-910. 6. Weinberger MH. Salt sensitivity of blood pressure in humans. Hypertension. Mar 1996;27(3 Pt 2):481-490. 7. Wildman RP, Gu D, Muntner P, et al. Alcohol intake and hypertension subtypes in Chinese men. J Hypertens. Apr 2005;23(4):737-743. 8. Xin X, He J, Frontini MG, Ogden LG, Motsamai OI, Whelton PK. Effects of alcohol reduction on blood pressure: a meta-analysis of randomized controlled trials. Hypertension. Nov 2001;38(5):1112-1117. 9. Garg JP, Elliott WJ, Folker A, Izhar M, Black HR. Resistant hypertension revisited: a comparison of two university-based cohorts. Am J Hypertens. May 2005;18(5 Pt 1):619-626. 10. Carter BL, Lund BC, Hayase N, Chrischilles E. A longitudinal analysis of antihypertensive drug interactions in a Medicaid population. Am J Hypertens. May 2004;17(5 Pt 1):421-427. 11. Fugh-Berman A. Herb-drug interactions. Lancet. Jan 8 2000;355(9198):134-138. 12. Sowers JR, White WB, Pitt B, et al. The Effects of cyclooxygenase-2 inhibitors and nonsteroidal anti-inflammatory therapy on 24-hour blood pressure in patients with hypertension, osteoarthritis, and type 2 diabetes mellitus. Arch Intern Med. Jan 24 2005;165(2):161-168. 13. Johnson AG, Nguyen TV, Day RO. Do nonsteroidal anti-inflammatory drugs affect blood pressure? A meta-analysis. Ann Intern Med. Aug 15 1994;121(4):289-300. 14. Pavlicevic I, Kuzmanic M, Rumboldt M, Rumboldt Z. Interaction between antihypertensives and NSAIDs in primary care: a controlled trial. Can J Clin Pharmacol. Fall 2008;15(3):e372-382. 15. Wofford MR, King DS, Wyatt SB, Jones DW. Secondary Hypertension: Detection and Management for the Primary Care Provider. J Clin Hypertens (Greenwich). Mar 2000;2(2):124- 131. 16. Yakovlevitch M, Black HR. Resistant hypertension in a tertiary care clinic. Arch Intern Med. Sep 1991;151(9):1786-1792. 17. Saelen MG, Prosch LK, Gudmundsdottir H, et al. Controlling systolic blood pressure is difficult in patients with diabetic kidney disease exhibiting moderate-to-severe reductions in renal function. Blood Press. 2005;14(3):170-176. 18. Moser M, Setaro JF. Clinical practice. Resistant or difficult-to-control hypertension. N Engl J Med. Jul 27 2006;355(4):385-392. 19. Safian RD, Textor SC. Renal-artery stenosis. N Engl J Med. Feb 8 2001;344(6):431-442. 20. Gordon RD, Stowasser M, Tunny TJ, Klemm SA, Rutherford JC. High incidence of primary aldosteronism in 199 patients referred with hypertension. Clin Exp Pharmacol Physiol. Apr 1994;21(4):315-318. 21. Douma S, Petidis K, Doumas M, et al. Prevalence of primary hyperaldosteronism in resistant hypertension: a retrospective observational study. Lancet. Jun 7 2008;371(9628):1921-1926. 22. Calhoun DA, Nishizaka MK, Zaman MA, Thakkar RB, Weissmann P. Hyperaldosteronism among black and white subjects with resistant hypertension. Hypertension. Dec 2002;40(6):892- 896. 23. Gaddam KK, Nishizaka MK, Pratt-Ubunama MN, et al. Characterization of resistant hypertension: association between resistant hypertension, aldosterone, and persistent intravascular volume expansion. Arch Intern Med. Jun 9 2008;168(11):1159-1164. 24. Mosso L, Carvajal C, Gonzalez A, et al. Primary aldosteronism and hypertensive disease. NKFM & MDCH 233
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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
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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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Page 184 and 185: 3.) Beta-blockers, ACE inhibitors,
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Page 188 and 189: Preparations and Dosage: Oral antih
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Page 208 and 209: Table 2: (JNC VII, 2004) 208 Hypert
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Page 216 and 217: Orthostatic Hypotension Pretest que
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Page 234 and 235: Hypertension. Aug 2003;42(2):161-16
Page 236 and 237: emergency by virtue of the associat
Page 238 and 239: PATHOPHYSIOLOGY The underlying mech
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Page 244 and 245: ACUTE KIDNEY INJURY (AKI) In additi
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Page 256 and 257: GISEN Group (Gruppo Italiano di Stu
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Page 260 and 261: DEFINITION AND CLASSIFICATION Hyper
Page 262 and 263: etween adult socioeconomic position
Page 264 and 265: women treated with atenolol in earl
Page 266 and 267: Obstet Gynecol. Dec 12 2008. 5. Vol
Page 268 and 269: able to dissipate the pressure rise
Page 270 and 271: Use of Dihydropyridine Calcium Anta
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Page 274 and 275: Case 4 Hypertensive patient with CK
Page 276 and 277: Case 6 276 Hypertension Core Curric
Page 278 and 279: year. Sodium restriction and weight
Page 280: What may be causing these new sympt
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