michigan hypertension core curriculum - State of Michigan

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upon the other co-morbidities present. This is the diagnostic algorithm for hypertension that is used by the Joint National Committee on the Detection Evaluation and Treatment of High Blood Pressure 7 th Report (also known as the JNC 7). In persons with diabetes mellitus, chronic kidney disease (estimated glomerular filtration rates [EGFR] < 60 ml/min/1.73 m 2 and/or spot urine albumin:creatinine ratio of > 200 mg/g), BP is considered elevated and diagnostic of hypertension when the systolic BP is > 130 and/or the diastolic BP is > 80 mm Hg. In all other persons, the BP elevation that is diagnostic of hypertension is > 140/90 mm Hg. It should be noted that it takes more than one accurate BP measurement to diagnose hypertension in most instances. However, in the clinical setting some patients with and without the aforementioned co-morbidities will have BP levels below these diagnostic thresholds yet still be considered hypertensive because they are taking antihypertensive medications that have lowered their BP readings to below these thresholds. 4. Circadian Blood Pressure Variation Throughout the 24-hour time period, in normal persons BP levels typically follow a predictable pattern. BP has a circadian rhythm. Blood pressure is approximately 10 – 20 % lower at night (2400 - 0599h) than between (0600 - 2200h). The BP nadir occurs early in the morning, a few hours after midnight, and begins to increase from this low level several hours before awakening. The rise in BP during the early morning hours occurs in parallel with a rise in pulse rate, increase in blood viscosity, and increased platelet aggregation. Some individuals - persons with chronic kidney disease/low estimated glomerular filtration rates, overweight African American women consuming high sodium diets, persons with low dietary potassium intakes, those with sleep disordered breathing, hyperactive sympathetic nervous systems - have been shown to have a blunted BP circadian rhythm. That is, BP (either systolic, diastolic, or both) do not fall at least 10% below average daytime levels at night. These persons are called “non-dippers”. There are also persons who are hyper-dippers (nighttime BP is > 20 mm Hg lower than the daytime BP) such as some stroke survivors. Both non-dippers and hyper-dippers have higher risks for pressure-related cardiovascular injury (e.g., stroke, heart failure) than persons with normal nocturnal declines in BP of ~ 10 – 20%. Twenty four hour BP readings are easily obtained in the clinical setting. Ambulatory BP monitoring is accomplished with specialized portable BP measurement devices that provide typically 2 – 3 BP measurements per hour that are stored in the device and are available for retrieval and analysis when the ambulatory BP monitoring device is returned to the clinic. It is, however, important to note that in hypertensive individuals ambulatory BP levels are typically lower than office cuff BP determinations. Accordingly, the threshold for elevated or abnormal ambulatory BP levels is numerically lower than for cuff BPs (Table 1). Table 1. Suggested Values for the Upper Limit of Normal Ambulatory Blood Pressure 28 Hypertension Core Curriculum
4. Cardiovascular-Renal Complications of Hypertension Table 2 displays BP sensitive target organs. That is, these are the organs that clinically manifest dysfunction and/or anatomic changes that can be detected clinically. Yet, with prevention of hypertension or, once hypertension develops, control of BP, pressure-related dysfunction of these organs is either preventable or, alternatively, can be forestalled. Table 2. Blood Pressure Target Organs Elevated BP, particularly SBP, is associated with multiple microvascular (eg, retinopathy, nephropathy) and macrovascular (eg, myocardial infarction, atherothrombotic stroke) cardiovascular-renal complications. Target-organ dysfunction, such as left ventricular systolic dysfunction (systolic and/or diastolic heart failure), can occur because of micro- and macro-vascular disease/dysfunction resulting in chronic ischemia of the myocardium. In addition to these organ-specific complications, hypertension causes premature morbidity and mortality. Though persons without hypertension can experience these complications, on average, persons with hypertension experience them relatively prematurely; hypertensives also are at higher overall risk for these complications than normotensive persons. The risk for virtually all cardiovascular-renal complications can be reduced with effective antihypertensive treatment. It is, however, important to note that the risk for pressure-related cardiovascular-renal complications at BP levels well below hypertension diagnosis thresholds. Risk approximately doubles for each 20/10 mm Hg higher BP above the level of 115/75 mm Hg. 5. Clinical Detection of Pressure-Related Target Organ Injury It is not infrequent that clinicians encounter patients in whom they do not have prior medical records that document important historical trends in BP. Patients are also often unaware of their prior level of BP control. Nevertheless, there are relatively easily detectable clues to the prior level of BP control. Documentation of any or all of the findings in table 3 would suggest that BP control has been less than optimal. NKFM & MDCH 29
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........
Page 10 and 11: 10 Hypertension Core Curriculum Blo
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 18 and 19: 18 Hypertension Core Curriculum Ess
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 30 and 31: Table 3. Clinically Available Clues
Page 32 and 33: In the setting of chronic hypertens
Page 34 and 35: 34 Hypertension Core Curriculum Tab
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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Page 58 and 59: glycemic risk factdors such as hype
Page 60 and 61: . Weight loss c. Weight gain d. A a
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Page 66 and 67: foods and turn out of necessity to
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Page 72 and 73: Incidence and Prevalence The overal
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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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michigan hypertension core curriculum - State of Michigan

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