Setting: office
CC: “I’m here for screening for a new job.”
VS: BP:148/94 mm Hg; P: 78 beats/minute
HPI: A 49-year-old man has come to your office for screening for his new job. He has some forms that need to be filled out. He is asymptomatic. He has never been told he had high BP before.
Only half of people with hypertension know it.
PMHX:
Appendectomy 2 years ago
Hernia repair 10 years ago
Medications: none
PE:
HEENT, Heart, Lungs, Abdomen, Neurologic: normal
Initial Orders:
Return in 1 to 2 weeks to recheck BP
The patient returns in 1 week. Interval History is unremarkable.
Preventive medications!
Check patients’ BP at every visit after age 18 years!
Orders:
Vital signs
Cholesterol, LDL
Influenza vaccination (if office visit occurs in the fall or winter)
Influenza vaccination should be given to every adult yearly.
Only half of people who know they have hypertension have well-controlled BP!
On CCS, is it hard to remember to do preventive medicine on all patients? It is easy for BP, lipid, and cancer screening to be lost in the “drama” of the acute problem, but you must do it.
Report:
VS: BP 148/92 mm Hg; P: 72 beats/minute
Twenty to thirty percent of mild elevations in BP are artifactual (not real).
Repeat three to six times if the patient has no symptoms.
Cardiac Output × Peripheral Resistance = Blood Pressure
The amount of time between return visits in hypertension evaluation is not precise. You are safe at having the patient come back in 1 to 2 weeks.
Report:
BP 146/94 mm Hg
Cholesterol and LDL: normal
Besides screening for hyperlipidemia, what other screening tests are routine for this person at age 49?
a. ECG
b. Colonoscopy
c. Prostate specific antigen (PSA)
d. Chest x-ray
e. None
Answer e. None
Colonoscopy starts at age 50 in a person at average risk with no family history of colon cancer. PSA testing is not recommended: It does not lower mortality and only increases the morbidity of unnecessary procedures. A screening chest x-ray is neither sensitive nor specific for anyone, including smokers.
“Screening” means testing an asymptomatic population.
Which form of secondary hypertension should you test the patient for?
a. Pheochromocytoma
b. Hyperaldosteronism (Conn syndrome)
c. Renal artery stenosis
d. None
Answer d. None
In the absence of specific symptoms, physical findings, or laboratory abnormalities, you should not be routinely tested for any of these.
Advise, educate, and counsel the patient on weight loss, exercise, sodium restriction, and diet. Have him return at 1 month intervals to assess compliance. Nutrition evaluation should occur for every patient with hypertension, diabetes, or hyperlipidemia. The Step 3 examination will want you to vigorously pursue lifestyle modifications and not pursue unnecessary laboratory evaluation.
For hypertension, no laboratory test is “essential” in an asymptomatic person with hypertension. Do not forget to “Educate,” “Advise,” and “Counsel” every patient.
Weight loss and exercise decrease BP by decreasing peripheral resistance.
Move the clock forward at 1-month intervals for 3 to 6 months to assess the efficacy of lifestyle modifications.
VS: BP 152/95 mm Hg
Orders:
Hydrochlorothiazide (HCTZ)
HCTZ
• Blocks sodium reabsorption at the distal tubule
• Can block only 6% to 7% of sodium
• Increases calcium reabsorption
Advance the clock only 1 week after introducing new medications. This is to check for both efficacy and adverse effects.
Repeat BP: 150/92 mm Hg
Only 60% to 70% of patients with hypertension have their BP level controlled with one BP medication.
Without sufficient control, it is not clear which BP medication should be added as a second agent.
Orders:
Add an ACE inhibitor, beta-blocker, or calcium channel blocker.
Angiotensin normally
• Increases aldosterone
• Increases ADH
• Increases thirst
• Increases sodium absorption at the proximal tubule
• Vasoconstricts peripheral vessels
Move the clock forward 1 week. If a BP medication works, it will be evident in 24 to 48 hours and the dose can be increased. If there is a “compelling indication” such as another disease, for example, diabetes (ACE, angiotensin receptor blocker [ARB]), myocardial infarction (MI) (beta-blocker), or osteoporosis (HCTZ), always start with the therapy that will also benefit the other compelling indication.
Beta stimulation normally
• Increases heart rate
• Increases stroke volume
• Increases renin release
ACE Inhibitor Cough
• From bradykinin increase
You do not have to investigate secondary hypertension unless BP is uncontrolled with the use of two to three medications. Once BP is brought under 140/90 mm Hg, do not add further medications unless the patient is diabetic or has end-organ damage. In those cases, continue to add medication until the BP is <130/80 mm Hg.
Calcium Channel Blocker Adverse Effect
• Constipation
• Edema