michigan hypertension core curriculum - State of Michigan

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etween adult socioeconomic position and pregnancy induced hypertension have found contradictory results. 4. BMI and maternal weight gain: There are few modifiable risk factors for pregnancy-related hypertensive disorders, but body mass index (BMI) and maternal weight gain may be important factors. A recent prospective cohort study 7 found that preconception BMI> 30 was a risk factor for preeclampsia (OR 3.3) and severe transient hypertension (OR 8.8 in Caucasian women and 4.9 in Black women). High gestational weight gain was also a risk factor or, alternatively, was associated with risk factors for pregnancy induced hypertension 8 and preeclampsia. 9 There is no single effective screening test that predicts preeclampsia. Management Evaluation and counseling of women with chronic hypertension should begin before conception and should include screening for target organ damage (including baseline measurement of renal function and proteinuria), and evaluation for secondary causes of hypertension. It is essential before conception that the patient’s antihypertensive medications be reviewed and that those drugs harmful to the developing fetus (angiotensin-converting enzyme [ACE] inhibitors, angiotensin II receptor blockers) be discontinued and replaced with medications considered safe for use during pregnancy (methyldopa, labetalol). It has to be recognized from the outset that the selection of a particular drugs to treat hypertension during pregnancy is all opinion based except for the avoidance of a small number of drugs known to be harmful to the fetus (e.g., ACEIs and ARBs as noted above). Only a few antihypertensive medications are recognized as being safe for use in pregnancy. No antihypertensive medication has specifically been proven safe for use during the first trimester It is exceeding difficult for ethical reasons to conduct randomized controlled trials during pregnancy. A recent Cochrane review 10 was only able to conclude “Until better evidence is available, the choice of antihypertensive should depend on the clinician’s experience and familiarity with a particular drug, and on what is known about adverse effects. Exceptions are diazoxide, ketanserin, nimodipine and magnesium sulphate, which are probably best avoided.” The reader is also referred to recent comprehensive reviews on the management of hypertensive disorders during pregnancy 11-13 Gestational vasodilation frequently allows the discontinuation of most or all antihypertensive medications early in pregnancy, although some may need to be restarted closer to delivery. Although bed rest is recommended for women with hypertension and preeclampsia, there is no evidence to show that it improves outcomes of pregnancy. There is no evidence from controlled trials that antihypertensive drugs improve maternal or fetal outcome in mild to moderate hypertension (BP< 160/110), whether pregnancy-induced or chronic. Not surprisingly, guidelines vary as to recommended thresholds for initiating antihypertensive medications. The most recent US guidelines advise treatment at ≥ 160/105 3 . Severe hypertension (≥ 160/110 requires prompt treatment to reduce the risk of maternal intracerebral hemorrhage or death. It is important that the obstetrical service or obstetrician be involved in women with a gestational age beyond 24 weeks to assist in antihypertensive management decisions that may affect the fetal status, as well as decide if or when emergent delivery is indicated. 262 Hypertension Core Curriculum
Degree of Hypertension Management Mild Rest, No medication Moderate Single agent therapy Severe Combination of Multiple agents Pharmacologic Therapy: Drugs for Gestational or Chronic Hypertension in Pregnancy DRUG DOSE POTENTIAL SIDE EFFECTS Methyldopa 0.5 to 3.0 g/d in 2 divided doses Beta blockers Labetalol Hydralazine Nifedipine Diuretics Hydrochlorothiazide: Furosemide ACE inhibitors and ARBs 200 to 1200 mg/d in 2 to 3 divided doses 50 to 300 mg/d in 2 to 4 divided doses 30 to 120 mg/d of a slow-release preparation 12.5 to 25.0 mg/d 40 to 80 mg daily Contraindicated orthostatic hypotension ,hepatitis and hemolytic anemia decrease uteroplacental blood flow; risk of growth restriction when started in first or second trimester (atenolol); fetal growth restriction neonatal thrombocytopenia volume contraction and electrolyte disorders cardiac defects, fetopathy, oligohydramnios, growth restriction, renal agenesis and neonatal anuric renal failure Methydopa is the most commonly used oral antihypertensive agent in pregnancy. It is a centrally acting α-2 receptor agonist, is usually well tolerated by pregnant women with a broad safety margin. Treatment with methyldopa has been reported to prevent subsequent progression to severe hypertension in pregnancy and does not seem to have adverse effects on uteroplacental or fetal hemodynamics or on fetal well being. 14 Children born to hypertensive women who received methyldopa treatment during pregnancy were followed from birth until age of 7 1/2 years. The frequency of problems with health, physical or mental handicap, sight, hearing, and behaviour was the same in children of treated and untreated women. 15 Methyldopa has also been shown recently to ameliorate the abnormal vascular stiffness characteristic of hypertensive disorders during pregnancy. 16 Methydopainduced hepatitis and hemolytic anemia are rare side effects with short term treatment. β-blockers are also widely used in pregnancy. None of the β-blockers have been associated with teratogenicity. A well designed prospective study from Glasgow reported that babies born to NKFM & MDCH 263
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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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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
Page 212 and 213: ecently published RCT investigated
Page 214 and 215: Post-test question: 35y/o male w/ h
Page 216 and 217: Orthostatic Hypotension Pretest que
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Page 222 and 223: References: 1. Hiitola P, Enlund H,
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Page 230 and 231: Treatment of Secondary Causes of Hy
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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 250 and 251: y sodium restriction or the use of
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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 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
Page 272 and 273: 272 Hypertension Core Curriculum Ca
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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