michigan hypertension core curriculum - State of Michigan

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side effects particularly well. A holistic and integrated approach to HTN management in this population is necessary for the best outcomes and should include coordination of management by what are often multiple care providers. A non-medical, but real concern is the cost of medication. 10, 11 Elderly individuals are less likely to be working and more likely to be on fixed incomes than their younger counterparts. In addition, as elderly patients may have co-morbid medical conditions, their out of pocket medical costs may be substantial prior to starting anti-hypertensive therapy. The financial issue also impacts access to health care and BP monitoring which must be considered. In assessing elderly individuals, a provider needs to be comfortable with having frank and open discussions about the financial realities of care and design a treatment plan that minimizes the economic burden to the treated individual. Such an approach must involve aggressive and deliberate use of generic medications, minimize polypharmacy and encourage consistent feedback from the treated individual to ensure that the HTN treatment is not placing an undue burden on the individual. Hypertension treatment is covered in a separate section of the book, but there are a few issues worth noting. The first is that several studies have demonstrated the effectiveness and utility of treating HTN in older and elderly individuals. 12-14 Cardiovascular events, most notable stroke and heart failure, can be reduced and treated individuals experience reduced morbidity and in many cases, reduced mortality. Secondly, the treatment goals for older and elderly individuals are no different from those in the general population. Specifically, using the JNC-7 recommendations as a guide, BP should be less than 140 mmHg over less than 90 mmHg in most individuals and less than 130 mmHg over less than 80 mmHg in individuals with DM or CKD. Third, an appreciation for cultural differences is necessary to achieve optimal results. 15 In regards to specific medications, the thiazide diuretics have shown great efficacy in the elderly population, as have ACE-I and calcium channel blockers. 13,16,17 Nevertheless, thiazide diuretics and calcium channel blockers will lower BP more as monotherapy than other antihypertensive drug classes; however, single drug therapy with any drug class is unlikely to control BP, especially SBP to below goal levels in most elderly antihypertensives. Thus, in most situations the practitioner will be using combination drug therapy, typically a diuretic or calcium channel blocker, in combination with a RAAS inhibitor in a slow, deliberate approach to BP lowering in the elder population. 52 Hypertension Core Curriculum
Figures: Figure 1. Graph showing prevalence of HTN with increasing age Tables: Table 1. Trials Involving Older Persons Essential points check: 1. Hypertension is extremely common in older individuals. 2. Elderly individuals often have multiple co-morbid medical conditions in addition to HTN. 3. Orthostatic hypotension is a significant issue in the treatment of HTN in elderly individuals. 4. The goals for HTN treatment do not change with age. Post-Test Questions: 1. Compared to young people the prevalence of HTN in the elderly is a. Increased (Correct answer) b. Decreased c. The same References: 1. Marchiando RJ, Elston MP. Automated ambulatory blood pressure monitoring: clinical utility in the family practice setting. Am Fam Physician 2003;67:2343-50. 2. Wang PS, Avorn J, Brookhart MA, et al. Effects of noncardiovascular comorbidities on antihypertensive use in elderly hypertensives. Hypertension 2005;46:273-9. 3. Vasan RS, Larson MG, Leip EP, et al. Impact of high-normal blood pressure on the risk of cardiovascular disease. N Engl J Med 2001;345:1291-7. 4. Casiglia E, Mazza A, Tikhonoff V, Scarpa R, Guglielmi F, Pessina AC. Arterial hypertension and mortality in the elderly. Am J Hypertens 2002;15:958-66. 5. Hyman DJ, Pavlik VN. Characteristics of patients with uncontrolled hypertension in the United States. N Engl J Med 2001;345:479-86. 6. Gupta V, Lipsitz LA. Orthostatic hypotension in the elderly: diagnosis and treatment. Am J Med 2007;120:841-7. 7. Mukai S, Lipsitz LA. Orthostatic hypotension. Clin Geriatr Med 2002;18:253-68. 8. Franklin SS, Jacobs MJ, Wong ND, L'Italien GJ, Lapuerta P. Predominance of isolated systolic hypertension among middle-aged and elderly US hypertensives: analysis based on National Health and Nutrition Examination Survey (NHANES) III. Hypertension 2001;37:869-74. 9. Wong ND, Lopez VA, L'Italien G, Chen R, Kline SE, Franklin SS. Inadequate control of hypertension in US adults with cardiovascular disease comorbidities in 2003-2004. Arch Intern Med 2007;167:2431-6. 10. Mojtabai R, Olfson M. Medication costs, adherence, and health outcomes among Medicare beneficiaries. Health Aff (Millwood) 2003;22:220-9. 11. Shulman NB, Martinez B, Brogan D, Carr AA, Miles CG. Financial cost as an obstacle to hypertension therapy. Am J Public Health 1986;76:1105-8. 12. Beckett NS, Peters R, Fletcher AE, et al. Treatment of hypertension in patients 80 years of age or older. N Engl J Med 2008;358:1887-98. 13. Jamerson K, Weber MA, Bakris GL, et al. Benazepril plus amlodipine or hydrochlorothiazide for hypertension in high-risk patients. N Engl J Med 2008;359:2417-28. NKFM & MDCH 53
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 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
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
Page 40 and 41: 40 Hypertension Core Curriculum Chr
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 54 and 55: 14. Gaede P, Vedel P, Larsen N, Jen
Page 56 and 57: Learning Objectives: 56 Hypertensio
Page 58 and 59: glycemic risk factdors such as hype
Page 60 and 61: . Weight loss c. Weight gain d. A a
Page 62 and 63: References: 1. Association AD. All
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Page 66 and 67: foods and turn out of necessity to
Page 68 and 69: Figure 1: Table 1. Metabolic Syndro
Page 70 and 71: 9. Singh GK, Kogan MD, Van Dyck PC,
Page 72 and 73: Incidence and Prevalence The overal
Page 74 and 75: access to healthy foods than their
Page 76 and 77: As a part of the approach to managi
Page 78 and 79: B Hypertensive Adults (rate, percen
Page 80 and 81: References: 1. Lewington S, Clarke
Page 82 and 83: 82 Hypertension Core Curriculum
Page 84 and 85: appear to be related to access to c
Page 86 and 87: CDC MMWR Feb 24, 2006/55(07); 177-1
Page 88 and 89: Figure 1; Clinical presentation and
Page 90 and 91: 90 Hypertension Core Curriculum Phe
Page 92 and 93: ANY patient, who develops paroxysma
Page 94 and 95: Figure 1: 94 Hypertension Core Curr
Page 96 and 97: Objectives: 96 Hypertension Core Cu
Page 98 and 99: Definition Prevalence Clinical Feat
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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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