michigan hypertension core curriculum - State of Michigan

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Objectives: 96 Hypertension Core Curriculum Polycystic Ovary Syndrome (PCOS) Susan Steigerwalt, MD • Understand/ Describe the prevalence of PCOS • Understand/Explain the pathophysiology of hypertension in PCO • Understand/List the Cardiovascular risk factors associated with PCO/ post test questions Polycystic Ovary Syndrome [PCOS] (characterized by elevated free testosterone and insulin resistance) should be considered in all young women presenting with hypertension with irregular menses (oligomenorrhea-less than 9 menstrual periods /year), particularly those with primary infertility. PCOS occurs in 7 % of women in industrialized countries. It is, however, more common in African Americans, Hispanics and obese women (28%in one study). Forty three percent of women with PCOS have metabolic syndrome; 50%in the US are obese, most commonly centripetal, with preferential location in the visceral fat depot. Accordingly, PCOS is an increasing problem in the U.S. PCOS is also under-diagnosed, and because of its associated features presents an excellent opportunity to prevent future disease. A majority of women with PCOS have sleep disordered breathing, even those who were not obese. 1 This relationship appears to correlate directly with insulin levels and presence of impaired glucose tolerance, independent of BMI, although average BMI in a recent study was 31. 2 Ninety two percent of women in one study had a high risk of OSA based on Epworth sleepiness scale or the PSQI. 3 Ambulatory blood pressure monitoring may be needed to diagnose hypertension in many women with PCOS. Interestingly, in one study 62% of obese and 2% of lean PCOS women had a lack of nocturnal fall in BP. In non-obese Taiwanese PCOS patients, higher androgen levels correlated with HTN while pharmacological blockade of the renin angiotensin system lowered both BP and androgens. 4 The mechanism of hypertension in PCOS is likely multifactoral: increased adrenergic drive, depressed adiponectin, insulin resistance, inflammation, OSA, and activation of the renin angiotensin system as manifested by elevations in plasma renin activity (PRa )and prorenin levels.. There is also an association between raised endothelin (ET)-1 levels (a potent vasoconstrictor) and androgens in
PCOS, independent of BMI that decrease with metformin treatment. 5 The pathophysiology of PCOS has been elegantly reviewed. 3 PCOS has not been specifically linked to adverse cardiovascular outcomes, per se. Nevertheless, women with PCOS manifest several high risk markers for future cardiovascular disease including: 1) an atherogenic lipid profile, 2) elevated c-reactive protein, 3) leucocytosis, 4) levels, 5) increased endothelin, 6) raised insulin levels, 7) left ventricular hypertrophy, 8) diastolic dysfunction, 9) increased coronary calcification and endothelial dysfunction, and 10) elevated plasminogen activator inhibitor (PA-I) levels. In summary, PCOS is common and under-diagnosed; once diagnosed, the patient must be screened for hyperlipidemia, obstructive sleep apnea and masked hypertension preferably with 24 hour ambulatory blood pressure monitoring. Additional features of PCOS such as infertility and increased risk of endometrial cancer must be co-managed with the patients’ gynecologist. Treatment consists of weight loss, exercise and insulin sensitizing agents such as metformin, which may also restore fertility, and comprehensive CVD risk factor management including control of BP. References: 1. Tasali E, Van Cauter E, Ehrmann DA. Relationships between sleep disordered breathing and glucose metabolism in polycystic ovary syndrome. J Clin Endocrinol Metab 2006;91:36-42. 2. Tasali E, Van Cauter E, Hoffman L, Ehrmann DA. Impact of obstructive sleep apnea on insulin resistance and glucose tolerance in women with polycystic ovary syndrome. J Clin Endocrinol Metab 2008;93:3878-84. 3. Ehrmann DA. Polycystic ovary syndrome. N Engl J Med 2005;352:1223-36. 4. Chen MJ, Yang WS, Yang JH, Chen CL, Ho HN, Yang YS. Relationship between androgen levels and blood pressure in young women with polycystic ovary syndrome. Hypertension 2007;49:1442-7. 5. Fogel RB, Malhotra A, Pillar G, Pittman SD, Dunaif A, White DP. Increased prevalence of obstructive sleep apnea syndrome in obese women with polycystic ovary syndrome. J Clin Endocrinol Metab 2001;86:1175-80. NKFM & MDCH 97
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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
Page 46 and 47: Table 2 Table 3 Screening Test for
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Page 52 and 53: side effects particularly well. A h
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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
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Page 72 and 73: Incidence and Prevalence The overal
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Page 80 and 81: References: 1. Lewington S, Clarke
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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
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Page 92 and 93: ANY patient, who develops paroxysma
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Page 98 and 99: Definition Prevalence Clinical Feat
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Page 104 and 105: Figure 3; Endocrine Society See tex
Page 106 and 107: INTRODUCTION 106 Hypertension Core
Page 108 and 109: Renal manifestations. Renal ischemi
Page 110 and 111: to assess renal dimensions and dupl
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Page 122 and 123: disease of the abdominal aorta and
Page 124 and 125: Table 1. Contemporary evaluation of
Page 126 and 127: 2. Screening tests for RAS RDU, MRA
Page 128 and 129: Manifestations of vital organ injur
Page 130 and 131: Table 6. Clinical evaluation of ren
Page 132 and 133: Table 9. Assessment of worsening re
Page 134 and 135: Table 11. New terminology for renal
Page 136 and 137: References: 1. Murphy TP, Soares G,
Page 138 and 139: 2001;12(6):1235-1241. 40. Subramani
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Page 144 and 145: 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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