Hypertension, Hypertension, Hyperlipidemia: Are our Hyperlipidemia: Are our

children safe?children safe?

Patrick RPatrick R

Hints and exam tipsHints and exam tips

HTN is a hot topic for exams – particularly, HTN is a hot topic for exams – particularly, what is really malignant HTN and who what is really malignant HTN and who needs urgent treatment. needs urgent treatment.

Also be sure that you know how to Also be sure that you know how to recognize the secondary causes of HTNrecognize the secondary causes of HTN

Lipids are less beloved by examiners Lipids are less beloved by examiners though they do like to ask about niacin though they do like to ask about niacin and flushingand flushing

Cardiovascular risk in your Cardiovascular risk in your clinic patientsclinic patients

Do not approach HTN, Hyperlipidemia as Do not approach HTN, Hyperlipidemia as individual problems. individual problems.

Look upon them as part of your patients Look upon them as part of your patients cardiovascular risk profile – once your patients cardiovascular risk profile – once your patients understand that they are changing their lifestyle understand that they are changing their lifestyle and taking meds to lower their risks of stroke, and taking meds to lower their risks of stroke, heart attack, kidney disease and peripheral heart attack, kidney disease and peripheral vascular disease they will be more likely to vascular disease they will be more likely to follow your advicefollow your advice

Consider does your pt have the “metabolic Consider does your pt have the “metabolic syndrome”syndrome”

Any 3 of Any 3 of obesity, high TG, low HDL, HTN, impaired glucose toleranceobesity, high TG, low HDL, HTN, impaired glucose tolerance

Who are my at risk patients – Who are my at risk patients – who should I be screening? who should I be screening? (basically (basically

everyone!)everyone!)

ObesityObesity Dyslipidemia – all pts need fasting lipid profileDyslipidemia – all pts need fasting lipid profile DMDM SmokingSmoking Lack of exerciseLack of exercise Age >55 for men, >65 for womenAge >55 for men, >65 for women FHx of premature cardiovascular diseaseFHx of premature cardiovascular disease Microalbuminuria in diabetics Microalbuminuria in diabetics

HypertensionHypertension

Management should be based on the “JNC-7” guidelines Management should be based on the “JNC-7” guidelines Treatment should be instituted at >140/90 in most pts Treatment should be instituted at >140/90 in most pts

or >130/80 in pts with DM or chronic kidney diseaseor >130/80 in pts with DM or chronic kidney disease Stage II HTN is >160/100 and only important to Stage II HTN is >160/100 and only important to

distinguish because these patients usually need 2 drugs distinguish because these patients usually need 2 drugs to control. to control.

Making 1Making 1stst diagnosis needs 2 readings at least 5 mins diagnosis needs 2 readings at least 5 mins apart and in both arms. Many doctors will actually get apart and in both arms. Many doctors will actually get two readings a week or two apart in a previously two readings a week or two apart in a previously undiagnosed patient, and many patients will be resistant undiagnosed patient, and many patients will be resistant to start therapy without more than one readingto start therapy without more than one reading

Ambulatory BP monitoring can be used to evaluate for Ambulatory BP monitoring can be used to evaluate for white coat HTN, and also helpful in assessing response white coat HTN, and also helpful in assessing response to therapy, or persuading a pt that he needs treatmentto therapy, or persuading a pt that he needs treatment

New diagnosis of HTNNew diagnosis of HTN Assess other cardiovascular risk factorsAssess other cardiovascular risk factors Look for reversible causes of HTNLook for reversible causes of HTN Look for evidence of end organ damage Look for evidence of end organ damage

Renal Renal RetinalRetinal Cardiac – check EKG, consider stress test if any Cardiac – check EKG, consider stress test if any

history of angina type symptomshistory of angina type symptoms CNS – take full Hx and evaluate for previous TIA. CNS – take full Hx and evaluate for previous TIA.

Check for carotid bruitsCheck for carotid bruits Peripheral artery disease – check for AAA and Peripheral artery disease – check for AAA and

distal pulsesdistal pulses Lifestyle modificationLifestyle modification MedicationMedication

A 56-year-old man undergoes a routine physical examination. A A 56-year-old man undergoes a routine physical examination. A funduscopic examination is performed.funduscopic examination is performed.What does the funduscopic photograph show? What does the funduscopic photograph show? ( A ) Arteriolar sclerosis and hypertensive retinopathy( A ) Arteriolar sclerosis and hypertensive retinopathy( B ) Diabetic proliferative retinopathy( B ) Diabetic proliferative retinopathy( C ) Papilledema( C ) Papilledema( D ) Malignant hypertensive retinopathy( D ) Malignant hypertensive retinopathy

Correct Answer = Correct Answer = AA

Characteristic changes are noted in the retinas of patients with Characteristic changes are noted in the retinas of patients with longstanding hypertension. Narrowing of the terminal branches of longstanding hypertension. Narrowing of the terminal branches of retinal arterioles may be seen, as well as general narrowing of retinal arterioles may be seen, as well as general narrowing of vessels with severe local constriction (as shown in this vessels with severe local constriction (as shown in this photograph). photograph). As the disease progresses, striate hemorrhages and soft exudates As the disease progresses, striate hemorrhages and soft exudates become visible. In a normal eye, retinal arterioles are transparent, become visible. In a normal eye, retinal arterioles are transparent, so that blood flow is visible during ophthalmoscopy. A light streak so that blood flow is visible during ophthalmoscopy. A light streak from the ophthalmoscope will reflect from the convex wall of the from the ophthalmoscope will reflect from the convex wall of the healthy arteriole. In a sclerotic arteriole, thickening and fibrosis of healthy arteriole. In a sclerotic arteriole, thickening and fibrosis of the vessel wall develop as the sclerosis progresses. The central the vessel wall develop as the sclerosis progresses. The central light reflex increases in width, and the walls of the vessel look like light reflex increases in width, and the walls of the vessel look like burnished copper, producing a "copper-wire" arteriole.burnished copper, producing a "copper-wire" arteriole. With further progression and additional fibrosis, the entire width of With further progression and additional fibrosis, the entire width of the arteriole reflects the white stripe, producing "silver-wire" the arteriole reflects the white stripe, producing "silver-wire" arteries. This patient's funduscopic photograph shows both the arteries. This patient's funduscopic photograph shows both the "copper and silver wires" characteristic of arteriolar sclerosis and "copper and silver wires" characteristic of arteriolar sclerosis and the characteristic changes of hypertensive retinopathy. the characteristic changes of hypertensive retinopathy.

A 62-year-old hypertensive woman is evaluated because of A 62-year-old hypertensive woman is evaluated because of headaches and confusion. After her vital signs are recorded, a headaches and confusion. After her vital signs are recorded, a funduscopic examination is performed. funduscopic examination is performed. Based on the funduscopic examination, which of the Based on the funduscopic examination, which of the following conditions most likely present?following conditions most likely present?( A ) Optic neuritis( A ) Optic neuritis( B ) Arteriolar sclerosis( B ) Arteriolar sclerosis( C ) Brain tumor( C ) Brain tumor( D ) Malignant hypertension( D ) Malignant hypertension

Correct Answer = Correct Answer = DD

The retinal changes associated with malignant The retinal changes associated with malignant hypertension consist of arteriolar narrowing, severe hypertension consist of arteriolar narrowing, severe local vasoconstriction, hemorrhages, exudates, and local vasoconstriction, hemorrhages, exudates, and papilledema. The exudates are caused by fibroid papilledema. The exudates are caused by fibroid necrosis of vessel walls. Papilledema associated with necrosis of vessel walls. Papilledema associated with malignant hypertension can be differentiated from malignant hypertension can be differentiated from papilledema due to other causes by its clinical context. papilledema due to other causes by its clinical context. Optic neuritis, generally monocular and another cause Optic neuritis, generally monocular and another cause of a disk swelling, is not associated with hypertension of a disk swelling, is not associated with hypertension and will have accompanying afferent pupillary defects and will have accompanying afferent pupillary defects and loss of vision. Both papilledema associated with and loss of vision. Both papilledema associated with malignant hypertension and optic neuritis can be malignant hypertension and optic neuritis can be accompanied by loss of vision. Arteriolar sclerosis is not accompanied by loss of vision. Arteriolar sclerosis is not accompanied by papilledema. Brain tumors can be accompanied by papilledema. Brain tumors can be associated with papilledema but not arteriolar associated with papilledema but not arteriolar narrowing, vasoconstriction, hemorrhages, or exudates. narrowing, vasoconstriction, hemorrhages, or exudates.

Non-essential HTNNon-essential HTN

Although most cases of HTN are essential Although most cases of HTN are essential HTN, always consider whether it could be HTN, always consider whether it could be due to another process.due to another process.

Sleep ApneaSleep Apnea Drug induced (esp cocaine, also drugs like NSAIDS, OCP)Drug induced (esp cocaine, also drugs like NSAIDS, OCP) Chronic renal diseaseChronic renal disease Renal artery stenosisRenal artery stenosis Cushing’s syndrome or treatment with steroidsCushing’s syndrome or treatment with steroids HyperaldosteronismHyperaldosteronism PheochromocytomaPheochromocytoma Coarctation of aortaCoarctation of aorta Thyroid and parathyroid diseaseThyroid and parathyroid disease

A 25-year-old man is evaluated because of several A 25-year-old man is evaluated because of several months of episodic sweating, headaches, and months of episodic sweating, headaches, and palpitations. His medical history includes surgical repair palpitations. His medical history includes surgical repair of ankle injuries sustained in a fall while rollerblading 6 of ankle injuries sustained in a fall while rollerblading 6 months ago; the anesthesiologist noted that the patient's months ago; the anesthesiologist noted that the patient's blood pressure fluctuated significantly during the blood pressure fluctuated significantly during the procedure and advised him to be evaluated for possible procedure and advised him to be evaluated for possible hypertension. hypertension.

On physical examination, he is 180 cm (71 in) tall and On physical examination, he is 180 cm (71 in) tall and weighs 72 kg (158 lb); his pulse rate is 80/min, and his weighs 72 kg (158 lb); his pulse rate is 80/min, and his blood pressure is 135/80 mm Hg. He has no goiter, lid blood pressure is 135/80 mm Hg. He has no goiter, lid lag, or tremor. Plasma glucose was normal during an lag, or tremor. Plasma glucose was normal during an episode of palpitations. His thyroid function tests are episode of palpitations. His thyroid function tests are normal. normal.

Measurement of which of the following is the best Measurement of which of the following is the best next step in the evaluation of this patient?next step in the evaluation of this patient?( A ) Serum insulin and insulin-like growth factor 1( A ) Serum insulin and insulin-like growth factor 1( B ) Repeat measurements of blood pressure( B ) Repeat measurements of blood pressure( C ) Catecholamines in a 24-hour urine sample( C ) Catecholamines in a 24-hour urine sample( D ) Thyroid stimulating hormone (TSH)( D ) Thyroid stimulating hormone (TSH)

Correct Answer Correct Answer CC

This patient has three classic symptoms that suggest This patient has three classic symptoms that suggest pheochromocytoma: headache, sweating, and palpitations, all of pheochromocytoma: headache, sweating, and palpitations, all of an episodic nature. The diagnosis is further suggested by the an episodic nature. The diagnosis is further suggested by the history of labile blood pressure during a recent surgical procedure. history of labile blood pressure during a recent surgical procedure.

The fact that he is not currently hypertensive does not argue The fact that he is not currently hypertensive does not argue against the diagnosis, because many patients with against the diagnosis, because many patients with pheochromocytoma have hypertension only during their episodic pheochromocytoma have hypertension only during their episodic paroxysms. Once suspected clinically, the diagnosis is established paroxysms. Once suspected clinically, the diagnosis is established biochemically with the finding of elevated urinary secretion of biochemically with the finding of elevated urinary secretion of catecholamines or their metabolites. Diagnostic yield is highest catecholamines or their metabolites. Diagnostic yield is highest when the collection is initiated with the onset of an episode. when the collection is initiated with the onset of an episode. Though rare, pheochromocytoma can be life threatening, and if it Though rare, pheochromocytoma can be life threatening, and if it is considered in the differential diagnosis of a patient’s symptoms, is considered in the differential diagnosis of a patient’s symptoms, testing should be ordered. testing should be ordered.

Although some of the patient’s symptoms are suggestive of Although some of the patient’s symptoms are suggestive of acromegaly or stress, there are no other symptoms, historical acromegaly or stress, there are no other symptoms, historical features, or physical findings that support these diagnoses. features, or physical findings that support these diagnoses. Physical examination does not suggest hypothyroidism, and the Physical examination does not suggest hypothyroidism, and the normal results of thyroid function tests exclude this diagnosis. A normal results of thyroid function tests exclude this diagnosis. A normal plasma glucose concentration during a symptomatic normal plasma glucose concentration during a symptomatic episode excludes insulinoma. episode excludes insulinoma.

A 41-year-old man is evaluated because of easy bruising. His A 41-year-old man is evaluated because of easy bruising. His medical history includes recent onset of borderline diabetes medical history includes recent onset of borderline diabetes mellitus, which is being treated by diet. Review of systems shows a mellitus, which is being treated by diet. Review of systems shows a 4.6-kg (10-lb) weight gain, fatigue, muscle weakness, decreased 4.6-kg (10-lb) weight gain, fatigue, muscle weakness, decreased libido, and depression. He uses no drugs, quit smoking 1 year ago, libido, and depression. He uses no drugs, quit smoking 1 year ago, and has been drinking one to two six-packs of beer nightly. and has been drinking one to two six-packs of beer nightly.

On physical examination, he is 183 cm (72 in) tall and weighs 91 On physical examination, he is 183 cm (72 in) tall and weighs 91 kg (200 lb); his pulse rate is 88/min, and his blood pressure is kg (200 lb); his pulse rate is 88/min, and his blood pressure is 150/95 mm Hg. He has a round face and supraclavicular and 150/95 mm Hg. He has a round face and supraclavicular and posterior cervical fullness. He has plethoric facies, tinea versicolor posterior cervical fullness. He has plethoric facies, tinea versicolor of the chest, no petechiae, and three or four ecchymoses on the of the chest, no petechiae, and three or four ecchymoses on the extremities. Neurologic examination is normal, except for 3/5 extremities. Neurologic examination is normal, except for 3/5 strength in proximal leg muscles. strength in proximal leg muscles.

Which of the following is the most likely diagnosis?Which of the following is the most likely diagnosis?( A ) von Willebrand’s disease( A ) von Willebrand’s disease( B ) Platelet dysfunction( B ) Platelet dysfunction( C ) Hemochromatosis( C ) Hemochromatosis( D ) Cushing’s syndrome( D ) Cushing’s syndrome( E ) Small vessel vasculitis( E ) Small vessel vasculitis

Correct AnswerCorrect Answer DD

This patient presents with clinical features suggestive of Cushing’s This patient presents with clinical features suggestive of Cushing’s syndrome. Urine-free cortisol is the best test to diagnose this syndrome. Urine-free cortisol is the best test to diagnose this disorder. However, because of his recent heavy alcohol use, he disorder. However, because of his recent heavy alcohol use, he may have alcoholic pseudo-Cushing’s syndrome. This disorder can may have alcoholic pseudo-Cushing’s syndrome. This disorder can mimic endogenous Cushing’s syndrome and can only be mimic endogenous Cushing’s syndrome and can only be distinguished from it by having the patient abstain from alcohol for distinguished from it by having the patient abstain from alcohol for an extended period of time. No evaluation for Cushing’s syndrome an extended period of time. No evaluation for Cushing’s syndrome should be done until after a period of abstinence. should be done until after a period of abstinence.

The patient’s easy bruising can be explained by excess circulating The patient’s easy bruising can be explained by excess circulating cortisol. Small vessel vasculitis would produce “palpable purpura” cortisol. Small vessel vasculitis would produce “palpable purpura” not found in this patient. von Willebrand’s disease could produce not found in this patient. von Willebrand’s disease could produce bruising but not his other symptoms. Platelet dysfunction would bruising but not his other symptoms. Platelet dysfunction would produce petechiae, not bruising. Hemochromatosis would be produce petechiae, not bruising. Hemochromatosis would be expected to produce liver function abnormalities, heart failure, expected to produce liver function abnormalities, heart failure, diabetes, decreased libido, and a bronze discoloration of the skin diabetes, decreased libido, and a bronze discoloration of the skin but not the hypertension, round face, and abnormal fat deposition but not the hypertension, round face, and abnormal fat deposition of Cushing’s syndrome. of Cushing’s syndrome.

A healthy 52-year-old woman is evaluated for her routine A healthy 52-year-old woman is evaluated for her routine annual physical examination. On physical examination, annual physical examination. On physical examination, she is 162 cm (64 in) tall and weighs 60 kg (130 lb); her she is 162 cm (64 in) tall and weighs 60 kg (130 lb); her pulse rate is 80/min, and her blood pressure is 160/100 pulse rate is 80/min, and her blood pressure is 160/100 mm Hg. On two subsequent days, she has her blood mm Hg. On two subsequent days, she has her blood pressure measured and the results are in the same range. pressure measured and the results are in the same range.

Laboratory studies show the following:Laboratory studies show the following:

Serum sodium 140 meq/LSerum potassium 3.3 Serum sodium 140 meq/LSerum potassium 3.3 meq/LSerum creatinine 0.8 mg/dLPlasma glucose 78 meq/LSerum creatinine 0.8 mg/dLPlasma glucose 78 mg/dLmg/dL

Which of the following is the most likely diagnosis?Which of the following is the most likely diagnosis?

( A ) Primary hyperaldosteronism( A ) Primary hyperaldosteronism( B ) Renovascular hypertension( B ) Renovascular hypertension( C ) Pheochromocytoma( C ) Pheochromocytoma( D ) Bartter’s syndrome( D ) Bartter’s syndrome( E ) Cushing’s syndrome( E ) Cushing’s syndrome

Correct Answer = Correct Answer = AA

This patient presents with the typical features of This patient presents with the typical features of primary hyperaldosteronism (autonomous primary hyperaldosteronism (autonomous overproduction of aldosterone). Most patients with this overproduction of aldosterone). Most patients with this disorder are asymptomatic, and it should be considered disorder are asymptomatic, and it should be considered in all patients with hypertension and hypokalemia. in all patients with hypertension and hypokalemia. A paired plasma aldosterone concentration to plasma A paired plasma aldosterone concentration to plasma renin activity ratio of greater than 20 is suggestive of renin activity ratio of greater than 20 is suggestive of this disorder, and referral to a specialist is advisable this disorder, and referral to a specialist is advisable because some patients can be cured with unilateral because some patients can be cured with unilateral adrenalectomy. Although Cushing’s syndrome may adrenalectomy. Although Cushing’s syndrome may cause hypertension and hypokalemia, there are no cause hypertension and hypokalemia, there are no suggestive clinical features of this disorder on the suggestive clinical features of this disorder on the patient’s history and physical examination. patient’s history and physical examination. Renovascular hypertension and pheochromocytoma are Renovascular hypertension and pheochromocytoma are not associated with hypokalemia. Bartter’s syndrome is not associated with hypokalemia. Bartter’s syndrome is associated with hypokalemia but not hypertension. associated with hypokalemia but not hypertension.

Lifestyle modificationsLifestyle modifications Should be prescribed to all patients including those in the Should be prescribed to all patients including those in the

“pre-hypertension” range – ie. 120-140 systolic 80-90 “pre-hypertension” range – ie. 120-140 systolic 80-90 diastolic, and really all of your patients of a certain age with diastolic, and really all of your patients of a certain age with or without other cardiovascular risk factorsor without other cardiovascular risk factors

Weight reduction Weight reduction aim for BMI 18.5-24.9aim for BMI 18.5-24.9 Loss of 10 Kg can reduce BP by up to 20mmHgLoss of 10 Kg can reduce BP by up to 20mmHg

DietDiet Reduce saturated fatReduce saturated fat Increase fruit and vegetable contentIncrease fruit and vegetable content Can reduce BP by 8-14 mmHgCan reduce BP by 8-14 mmHg

Sodium restrictionSodium restriction Reduce to <2.4g sodium per day can reduce BP by 2-8mmHgReduce to <2.4g sodium per day can reduce BP by 2-8mmHg

ExerciseExercise Aerobic physical activity eg walking for 30 mins per day – can Aerobic physical activity eg walking for 30 mins per day – can

reduce BP by 4-9mmHgreduce BP by 4-9mmHg Limiting alcoholLimiting alcohol

<1 drink per day in women, <2 drinks per day in men can reduce <1 drink per day in women, <2 drinks per day in men can reduce BP by 2-4mmHgBP by 2-4mmHg

Drug choicesDrug choices ThiazidesThiazides

First line in most patients, but risk of gout, impaired glucose tolerance, First line in most patients, but risk of gout, impaired glucose tolerance, impotence and many pts don’t like them due to urinary effectimpotence and many pts don’t like them due to urinary effect

ββ blockers blockers Useful in pts with heart failure and post MI, generally not used in Useful in pts with heart failure and post MI, generally not used in

diabetic patients on sulfonylureas due to concerns that the diabetic patients on sulfonylureas due to concerns that the ββ blocker blocker masks the symptoms of hypoglycemia. Also contraindicated in pts masks the symptoms of hypoglycemia. Also contraindicated in pts with bronchospasmwith bronchospasm

Watch for postural hypotension, can cause impotence, pts may Watch for postural hypotension, can cause impotence, pts may complain of feeling “tired”complain of feeling “tired”

ACE inhibitorsACE inhibitors Useful in cardiac pts, diabetics and certain pts with renal diseaseUseful in cardiac pts, diabetics and certain pts with renal disease Sometimes less helpful in african americans Sometimes less helpful in african americans Usually recommended that you check Chem 7 prior to starting and a Usually recommended that you check Chem 7 prior to starting and a

couple of weeks into treatment as pts with renal artery stenosis can couple of weeks into treatment as pts with renal artery stenosis can get rising creatinines and dangerously high Kget rising creatinines and dangerously high K

Calcium channel blockersCalcium channel blockers Generally not first line now, but usually well toleratedGenerally not first line now, but usually well tolerated. .

Remember that many patients need two medications to adequately Remember that many patients need two medications to adequately control BP. control BP.

Pt should be scheduled for follow up visit six weeks after starting Pt should be scheduled for follow up visit six weeks after starting med or changing dose and then dose titrated accordingly. med or changing dose and then dose titrated accordingly.

A 47-year-old man who has had type 1 diabetes A 47-year-old man who has had type 1 diabetes mellitus for 23 years is found to have hypertension mellitus for 23 years is found to have hypertension that has been unresponsive to dietary salt that has been unresponsive to dietary salt restriction. His physical examination shows a restriction. His physical examination shows a blood pressure of 144/94 mm Hg and background blood pressure of 144/94 mm Hg and background retinopathy. retinopathy. His creatinine, blood urea nitrogen, and potassium His creatinine, blood urea nitrogen, and potassium are normal. A 24-h urine albumin excretion rate is are normal. A 24-h urine albumin excretion rate is 152 mg. A second urine sample is also positive for 152 mg. A second urine sample is also positive for albumin, which measures 85 mg/24 h. albumin, which measures 85 mg/24 h. Which one of the following medications Which one of the following medications should be used to treat this patient’s blood should be used to treat this patient’s blood pressure?pressure?( A ) Thiazide diuretic( A ) Thiazide diuretic( B ) Central sympatholytic agent( B ) Central sympatholytic agent( C ) Angiotensin-converting enzyme (ACE) ( C ) Angiotensin-converting enzyme (ACE) inhibitorinhibitor( D ) Calcium-channel blocker( D ) Calcium-channel blocker

Correct Answer = Correct Answer = CC

Several medications are effective in treating hypertension in Several medications are effective in treating hypertension in patients with diabetes. Angiotensin-converting enzyme (ACE) patients with diabetes. Angiotensin-converting enzyme (ACE) inhibitors, however, have been shown to have selective benefit in inhibitors, however, have been shown to have selective benefit in this regard: they not only lower blood pressure, but also can retard this regard: they not only lower blood pressure, but also can retard the rate of progression of any underlying nephropathy. the rate of progression of any underlying nephropathy. In this patient, the presence of microalbuminuria (albumin level In this patient, the presence of microalbuminuria (albumin level greater than 40 mg/24 h) indicates the presence of early greater than 40 mg/24 h) indicates the presence of early nephropathy. Because ACE inhibitors can retard the progression of nephropathy. Because ACE inhibitors can retard the progression of nephropathy even in normotensive individuals, these agents nephropathy even in normotensive individuals, these agents should be given even if nonpharmacologic therapy has been should be given even if nonpharmacologic therapy has been successful in lowering the blood pressure to normal levels. successful in lowering the blood pressure to normal levels. However, such use can cause hyperkalemia, and because patients However, such use can cause hyperkalemia, and because patients with diabetes are prone to hyporeninemic hypoaldosteronism (type with diabetes are prone to hyporeninemic hypoaldosteronism (type IV renal tubular acidosis), it is important to check potassium levels IV renal tubular acidosis), it is important to check potassium levels during therapy. during therapy. Other agents lack this selective benefit and are used as second-Other agents lack this selective benefit and are used as second-line treatment or if ACE inhibitors cannot be tolerated.line treatment or if ACE inhibitors cannot be tolerated.

A 48-year-old woman was found to have primary A 48-year-old woman was found to have primary hypertension 6 months ago. Despite a trial of lifestyle hypertension 6 months ago. Despite a trial of lifestyle modifications, her blood pressure remained elevated at modifications, her blood pressure remained elevated at about 158/96 mm Hg. Therapy with amlodipine, 5 mg about 158/96 mm Hg. Therapy with amlodipine, 5 mg daily, was begun. daily, was begun.

The patient returns for a follow-up visit 6 weeks after The patient returns for a follow-up visit 6 weeks after beginning amlodipine. Several blood pressures readings beginning amlodipine. Several blood pressures readings in the office average 152/92 mm Hg. She has also in the office average 152/92 mm Hg. She has also noted progressive ankle edema since therapy was noted progressive ankle edema since therapy was begun. begun.

Which of the following is most appropriate at this Which of the following is most appropriate at this time?time?

( A ) No change in therapy( A ) No change in therapy( B ) Change to another antihypertensive agent( B ) Change to another antihypertensive agent( C ) Increase the amlodipine to 10 mg daily( C ) Increase the amlodipine to 10 mg daily( D ) Recommend a low-salt diet and support hose( D ) Recommend a low-salt diet and support hose

Correct Answer = Correct Answer = BB

This patient’s blood pressure control while on amlodipine is inadequate This patient’s blood pressure control while on amlodipine is inadequate (blood pressure has not been reduced to < 140/90 mm Hg), and she has (blood pressure has not been reduced to < 140/90 mm Hg), and she has developed pedal edema attributable to the dihydropyridine calcium-channel developed pedal edema attributable to the dihydropyridine calcium-channel blocker. blocker. Her medication should be changed to another antihypertensive agent that is Her medication should be changed to another antihypertensive agent that is unlikely to induce edema and will optimize blood pressure control.unlikely to induce edema and will optimize blood pressure control.Adequate control of blood pressure to < 140/90 mm Hg is achieved in only Adequate control of blood pressure to < 140/90 mm Hg is achieved in only 45% of patients treated with medication, which represents only 27% of all 45% of patients treated with medication, which represents only 27% of all patients with hypertension. This has been labeled the “great hypertension patients with hypertension. This has been labeled the “great hypertension disconnect.” Almost all physicians know the target blood pressure of < disconnect.” Almost all physicians know the target blood pressure of < 140/90 mm Hg; however, we are not very successful in achieving this target. 140/90 mm Hg; however, we are not very successful in achieving this target. When target blood pressure is not attained there are three possible options: When target blood pressure is not attained there are three possible options: 1) increase the dose of the initial agent, 2) add a second agent, or 3) change 1) increase the dose of the initial agent, 2) add a second agent, or 3) change to another drug or class of agent. to another drug or class of agent. This patient requires a change to another antihypertensive agent to achieve This patient requires a change to another antihypertensive agent to achieve a target blood pressure and reduce side effects. Increasing this patient’s a target blood pressure and reduce side effects. Increasing this patient’s dihydropyridine calcium-channel blocker is not indicated because this will dihydropyridine calcium-channel blocker is not indicated because this will likely increase her edema. A recent randomized, double-blind, clinical trail likely increase her edema. A recent randomized, double-blind, clinical trail demonstrated that thiazide diuretics were superior to calcium channel demonstrated that thiazide diuretics were superior to calcium channel blockers or angiotensin-converting enzyme inhibitors in lowering systolic blockers or angiotensin-converting enzyme inhibitors in lowering systolic blood pressure. The diuretic was superior to calcium channel blockers in blood pressure. The diuretic was superior to calcium channel blockers in preventing heart failure, and superior to angiotensin-converting enzyme preventing heart failure, and superior to angiotensin-converting enzyme inhibitors in reducing combined coronary vascular disease outcomes, stroke, inhibitors in reducing combined coronary vascular disease outcomes, stroke, and heart failure. Since diuretics are less expensive and more effective in and heart failure. Since diuretics are less expensive and more effective in preventing 1 or more major forms of coronary vascular disease, they should preventing 1 or more major forms of coronary vascular disease, they should be preferred for first-step anti-hypertensive therapy in most patients. Finally, be preferred for first-step anti-hypertensive therapy in most patients. Finally, salt restriction and support hose are unlikely to resolve the medication-salt restriction and support hose are unlikely to resolve the medication-induced edema or improve the blood pressure. induced edema or improve the blood pressure.

A 56-year-old man is seen for routine follow-up of A 56-year-old man is seen for routine follow-up of hypertension. He has no complaints. He denies any hypertension. He has no complaints. He denies any recent change in health status or drug use. His has recent change in health status or drug use. His has been prescribed a four-drug regimen of diltiazem been prescribed a four-drug regimen of diltiazem sustained-release (SR), captopril, atenolol, and sustained-release (SR), captopril, atenolol, and hydrochlorothiazide. He is taking all his medications. At hydrochlorothiazide. He is taking all his medications. At his last clinic visit 2 months ago, his pulse rate was his last clinic visit 2 months ago, his pulse rate was 68/min, and his blood pressure was 138/86 mm Hg. He 68/min, and his blood pressure was 138/86 mm Hg. He has no other medical problems. has no other medical problems. On physical examination, his pulse rate is 86/min and On physical examination, his pulse rate is 86/min and his blood pressure is 194/116 mm Hg. The rest of his his blood pressure is 194/116 mm Hg. The rest of his physical examination is unremarkable. A stat complete physical examination is unremarkable. A stat complete blood count, electrolytes, blood urea nitrogen, blood count, electrolytes, blood urea nitrogen, creatinine, glucose levels, and urinalysis are all normal. creatinine, glucose levels, and urinalysis are all normal. Which of the following is the most reasonable, Which of the following is the most reasonable, immediate office-treatment option?immediate office-treatment option?( A ) Captopril and hydrochlorothiazide, orally( A ) Captopril and hydrochlorothiazide, orally( B ) Nifedipine, sublingually( B ) Nifedipine, sublingually( C ) Lorazepam, orally( C ) Lorazepam, orally( D ) Nitroprusside, intravenously( D ) Nitroprusside, intravenously( E ) No change in medications, follow-up in 2 weeks( E ) No change in medications, follow-up in 2 weeks

Correct Answer = Correct Answer = AA

The most common cause of accelerated or urgent hypertension is The most common cause of accelerated or urgent hypertension is noncompliance with prescribed therapy, despite frequent patient noncompliance with prescribed therapy, despite frequent patient claims to the contrary. claims to the contrary. Reasonable blood pressure control at the previous visit suggests that Reasonable blood pressure control at the previous visit suggests that the regimen was effective. The fact that the pulse rate is now 86/min the regimen was effective. The fact that the pulse rate is now 86/min casts some doubt on whether the atenolol has been taken recently. casts some doubt on whether the atenolol has been taken recently. Immediate administration of some or all of the patient’s medications Immediate administration of some or all of the patient’s medications will help re-establish that they are effective for this patient. will help re-establish that they are effective for this patient. It is not necessary to lower the blood pressure to normal at this It is not necessary to lower the blood pressure to normal at this juncture. The use of sublingual nifedipine to lower blood pressure juncture. The use of sublingual nifedipine to lower blood pressure has been condemned by medical experts and the U.S. Food and Drug has been condemned by medical experts and the U.S. Food and Drug Administration. The precipitous and uncontrolled decrease in blood Administration. The precipitous and uncontrolled decrease in blood pressure frequently produced by sublingual nifedipine presents a risk pressure frequently produced by sublingual nifedipine presents a risk of myocardial infarction, stroke, or death. Because the patient has no of myocardial infarction, stroke, or death. Because the patient has no evidence of acute end-organ damage (papilledema, abnormal mental evidence of acute end-organ damage (papilledema, abnormal mental status or neurologic findings), admission to the intensive care unit status or neurologic findings), admission to the intensive care unit for treatment of hypertensive crisis is not warranted. Anxiety is not for treatment of hypertensive crisis is not warranted. Anxiety is not evident, nor is it likely to produce this magnitude of blood pressure evident, nor is it likely to produce this magnitude of blood pressure elevation; thus, treatment with lorazepam is not indicated. Asking elevation; thus, treatment with lorazepam is not indicated. Asking the patient to resume treatment with all medications (option E) is the patient to resume treatment with all medications (option E) is reasonable, but the follow-up period of 2 weeks is unreasonably long. reasonable, but the follow-up period of 2 weeks is unreasonably long. It would be preferable to verify that the patient’s regimen is effective It would be preferable to verify that the patient’s regimen is effective before sending him home. before sending him home.

LipidsLipids Check fasting lipoprotein analysis after 9-12 Check fasting lipoprotein analysis after 9-12

hour fasthour fast Should be done at first visit to you and then Should be done at first visit to you and then Ideal values: Ideal values:

LDL < 130LDL < 130 Total cholesterol <200Total cholesterol <200 TG <200TG <200 HDL >40HDL >40

When instituting and following Tx, your first When instituting and following Tx, your first aim should be to control LDL. If once LDL is aim should be to control LDL. If once LDL is controlled the pt still has high TG then controlled the pt still has high TG then consider adding nicotinic acid or fibrateconsider adding nicotinic acid or fibrate

ATP III GUIDELINESATP III GUIDELINES

STEP 1: Determine lipid level after 9-STEP 1: Determine lipid level after 9-12 hr. fast 12 hr. fast

STEP 2: Identify CHD risk equivalentsSTEP 2: Identify CHD risk equivalents Clinical CHDClinical CHD AAAAAA Symptomatic carotid artery diseaseSymptomatic carotid artery disease PADPAD

ATP III GuidelinesATP III Guidelines

STEP 3: Determine major risk factors STEP 3: Determine major risk factors other than LDLother than LDL Cigarette smokingCigarette smoking BP>140/90 or on anti-HTN RxBP>140/90 or on anti-HTN Rx Low HDL (<40)Low HDL (<40) Family Hx CHD (<65 females, < 55 Family Hx CHD (<65 females, < 55

males)males) Age (men >45, women >55)Age (men >45, women >55)

ATP III GuidelinesATP III Guidelines

STEP 4: If 2+ risk factors (other than STEP 4: If 2+ risk factors (other than LDL) present without CHD/CHD risk LDL) present without CHD/CHD risk equivalent, assess 10-year CHD risk equivalent, assess 10-year CHD risk (Framingham)(Framingham) >20%: CHD risk equivalent>20%: CHD risk equivalent 10-20%10-20% <10%<10%

Framingham Risk ScoresFramingham Risk Scores Method for assessing how aggressive Method for assessing how aggressive

you should be at lowering lipids. you should be at lowering lipids. Based on risk factors identified in the Based on risk factors identified in the

Framingham study. Framingham study. Includes age, smoking, BP and both Includes age, smoking, BP and both

total and HDL cholesterol and total and HDL cholesterol and assigns a score for each result, then assigns a score for each result, then dependent on total score you can dependent on total score you can calculate 10 year risk of having calculate 10 year risk of having cardiovascular eventcardiovascular event

ATP III GuidelinesATP III Guidelines

STEP 5: Determine risk categorySTEP 5: Determine risk category

ATP III GuidelinesATP III Guidelines

STEP 6: Institute Lifestyle ChangesSTEP 6: Institute Lifestyle Changes

Very High Risk of CADVery High Risk of CAD Goal LDL should be <70:Goal LDL should be <70: -pt with established CAD-pt with established CAD PLUSPLUS -multiple risk factors (DM)-multiple risk factors (DM) OROR -severe, poorly-controlled risk factors-severe, poorly-controlled risk factors OROR -multiple risk factors of the metabolic -multiple risk factors of the metabolic

syndromesyndrome OROR -acute coronary syndrome-acute coronary syndrome

ATP III GuidelinesATP III Guidelines

STEP 7: Consider adding drug STEP 7: Consider adding drug therapy (simultaneously with lifestyle therapy (simultaneously with lifestyle changes if CHD/CHD equivalents)changes if CHD/CHD equivalents)

The DrugsThe DrugsDrugDrug ActionAction Side effectsSide effects

HMG CoA HMG CoA reductase reductase inhibitors inhibitors (STATINS)(STATINS)

Reduce LDL by 18-50%Reduce LDL by 18-50%

Increase HDL by 5-15%Increase HDL by 5-15%

Reduce TG by 7-30%Reduce TG by 7-30%

Myopathy – warn your Myopathy – warn your pts to come in for CK pts to come in for CK check if muscle paincheck if muscle pain

LFT abnormalities – LFT abnormalities – contraindicated in liver contraindicated in liver diseasedisease

Bile Acid Bile Acid Sequestrants (eg. Sequestrants (eg. Cholestyramine)Cholestyramine)

Reduce LDL by 15-30%Reduce LDL by 15-30%

Increase HDL by 3-5%Increase HDL by 3-5%

No effect on TGNo effect on TG

GI upsetGI upset

Affect absorption of Affect absorption of other drugsother drugs

Don’t use in high TG – Don’t use in high TG – other drugs are betterother drugs are better

Nicotinic AcidNicotinic Acid Reduce LDL by 5-25%Reduce LDL by 5-25%

Increase HDL by 15-35%Increase HDL by 15-35%

Reduce TG by 25-50%Reduce TG by 25-50%

Main SE is flushing – tell Main SE is flushing – tell them to take their them to take their aspirin right beforeaspirin right before

Can ppt gout, DM, Can ppt gout, DM, hepatic toxicityhepatic toxicity

Fibric acidsFibric acids Reduce LDL by 5-20%Reduce LDL by 5-20%

Increase HDL by 10-20%Increase HDL by 10-20%

Reduce TG by 20-50%Reduce TG by 20-50%

High risk of myopathy High risk of myopathy when combined with when combined with statins. statins.

CI in renal and liver CI in renal and liver diseasedisease

Can ppt gallstonesCan ppt gallstones

ATP III GuidelinesATP III Guidelines

STEP 8: Identify metabolic syndrome, STEP 8: Identify metabolic syndrome, and treat, if present 3 months after and treat, if present 3 months after TLCTLC

ATP III GuidelinesATP III Guidelines

STEP 9: Treat elevated triglyceridesSTEP 9: Treat elevated triglycerides Therapeutic lifestyle modificationsTherapeutic lifestyle modifications Primary aim is to reach LDL goalPrimary aim is to reach LDL goal If still high after LDL goal is reached, set If still high after LDL goal is reached, set

HDL goal 30 mg/dL higher than LDL goal HDL goal 30 mg/dL higher than LDL goal intensify statin or add nicotinic acid or intensify statin or add nicotinic acid or fibratefibrate

PreguntasPreguntas

1. 65 yo male with BPH, actively 1. 65 yo male with BPH, actively smoking, 210 lbs, comes for his first smoking, 210 lbs, comes for his first physical since 1978. BP: 148/92. physical since 1978. BP: 148/92. Lipid panel: T chol: 208, LDL: 135, Lipid panel: T chol: 208, LDL: 135, HDL 38, TG: 130HDL 38, TG: 130

What are his goals?What are his goals? How do you get him there?How do you get him there?

What can we do to help you What can we do to help you stop smoking?stop smoking?

Ask every pt at every visit whether they are smoking Ask every pt at every visit whether they are smoking and how much and document in the chartand how much and document in the chart

Find out whether they want to quitFind out whether they want to quit Ask what you can do to help them quitAsk what you can do to help them quit Only 5-8% of smokers can quit on their ownOnly 5-8% of smokers can quit on their own Advice from a doctor can improve the smoking Advice from a doctor can improve the smoking

cessation rate by 2.5%cessation rate by 2.5% Quitting smoking can decrease risk of death from Quitting smoking can decrease risk of death from

CAD by 50% in the first year of cessationCAD by 50% in the first year of cessation Cancer risk decreases to risk of 30 to 50% compared Cancer risk decreases to risk of 30 to 50% compared

to people who continue to smoke after 10 yearsto people who continue to smoke after 10 years

Hazards of Smoking Hazards of Smoking CessationCessation

Withdrawal symptomsWithdrawal symptoms Peak in 1-3 days after cessationPeak in 1-3 days after cessation Cravings can last monthsCravings can last months

DepressionDepression Mild, but may still require counseling, Mild, but may still require counseling,

treatment, or return to smokingtreatment, or return to smoking Weight gainWeight gain

Often 1-2 kg in first 2 weeks with additional 2-3 Often 1-2 kg in first 2 weeks with additional 2-3 kg over the next 4-5 monthskg over the next 4-5 months

Integrate dietary interventions with smoking cessation Integrate dietary interventions with smoking cessation Exacerbations of Ulcerative ColitisExacerbations of Ulcerative Colitis

Adjuncts in smoking cessationAdjuncts in smoking cessationDrugDrug IssuesIssues DosingDosing

Nicotine gumNicotine gum Main problem is compliance Main problem is compliance – they have to be using – they have to be using pretty much continuously. pretty much continuously.

<25 cigarettes per <25 cigarettes per day use 2mg, >25 day use 2mg, >25 cigarettes per day use cigarettes per day use 4mg4mg

Use 1-2 tabs per hour Use 1-2 tabs per hour for 4-6 weeksfor 4-6 weeks

Nicotine patchNicotine patch Main SE is insomnia – tell pt Main SE is insomnia – tell pt to remove the patch at nightto remove the patch at night

21mg/d for 6weeks 21mg/d for 6weeks then 14mg/d for 2 then 14mg/d for 2 weeks then 7mg/d for weeks then 7mg/d for 2 weeks2 weeks

WellbutrinWellbutrin Can be used in addtion to Can be used in addtion to the patch or gum and treats the patch or gum and treats the concomitant depression the concomitant depression associated with stopping associated with stopping smokingsmoking

Contraindicated in seizures, Contraindicated in seizures, alcohol abuse, anorexia, alcohol abuse, anorexia,

150mg bid – start 1-2 150mg bid – start 1-2 weeks prior to the weeks prior to the quit date and quit date and continue for 7-12 continue for 7-12 weeks. weeks.

Varenicline (Chantix)Varenicline (Chantix)

Novel partial agonist of nicotinic Novel partial agonist of nicotinic acetylcholine receptorsacetylcholine receptors

Better than bupropron and placebo Better than bupropron and placebo at 12 wks and 52 wksat 12 wks and 52 wks

Side effects: nausea, abnormal Side effects: nausea, abnormal dreamsdreams

Questions? Questions?