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- Classify HTN according to JNC VII guidelines
- Perform the initial evaluation of a hypertensive patient and know common signs and symptoms of secondary HTN
- Recommend healthy lifestyle modifications for patients with hypertension or prehypertension
- Understand commonly used antihypertensive medications and some of their common side effects
- Understand compelling indications for specific antihypertensive medications
Initial Presentation
 |
Monte Burns, a 46-year old white man comes to your office for a physical exam before taking up a new exercise program he heard about on TV. You know that he has no significant past medical history and is generally in good health. He works as a busy executive at Hershey Foods, and his wife thinks that he could stand to lose a few pounds. He is 6 feet tall and weighs 214 pounds. Before you enter the room, your nurse points out that his blood pressure was 156/94 when she took it. |
1. Does this patient have hypertension? What are the classifications of hypertension?
He may or may not have HTN. Right now, all you know is that his present BP is elevated above what is considered normal. According to the JNC VII guidelines, HTN is classified as seen in table 1; based on the average of two or more properly measured, seated BP readings on each of at least two different office visits.
Table 1. Classification of blood pressure for adults**
NORMAL: <120 SBPmm Hg and <80 DBPmm Hg
PREHYPERTENSION: 120-139 SBPmm Hg or 80-89 DBPmm Hg
STAGE 1 HTN: 140-159 SBPmm Hg or 90-99 DBPmm Hg
STAGE 2 HTN: >159 SBPmm Hg or >99 DBPmm Hg
Before you can diagnose him with hypertension, you will need to know and do a few more things.
**Classification of Blood Pressure for Adults Aged 18 Years and Older, from JNC VII Guidelines, May 2003. (
http://www.nhlbi.nih.gov/guidelines/hypertension/)
2. What else would you like to know about Mr. Burns before you can advise if he can safely start his exercise program?
More history is needed. You need to know more about:
- Current level of fitness and what his new exercise program would entail.
- Cardiovascular disease (CVD) risk factors and any target organ damage, as these may affect prognosis and guide treatment. You need to do a careful review of his cardio-pulmonary systems. Since chronic hypertension is characteristically asymptomatic, you should be searching for historical and clinical evidence of target organ effects (e.g. angina or congestive heart failure symptoms).
- Pertinent family history (especially of heart disease)
- Previous BP measurements through the years
- Substance use including caffeine
- Current medications, including any over-the-counter (OTC) medications (especially herbals/supplements he might be on to try to 'burn' off the weight).
In addition to the CVD risk factors in this table, the JNC VII adds obesity, h/o microalbuminuria <60 mL/min, and age >55 for men or >65 for women.
Although probably more than 95% of hypertension is essential HTN, you should also ask questions to evaluate for rare causes of hypertension, so-called “secondary HTN” (e.g. pheochromocytoma etc.)
The following site has a good background about screening for secondary hypertension (clinical features that may suggest secondary HTN are shown in table 1 at this site):
http://www.uptodateonline.com/application/topic.asp?file=hyperten/4350
Medical History
Mr. Burns explains that he has not been making time for exercise in his busy schedule. He is interested in trying to walk at lunchtime 3-4 days a week for about a half hour. After more questioning, Mr. Burns tells you that the only daily medication he takes is a multivitamin. He drinks 2 cups of coffee in the morning daily. He does not smoke, and he drinks a glass of wine 2 nights a week with dinner. His parents are both still living, although his father just had a triple bypass operation a year ago at age 72. He knows of no other history of heart disease or hypertension. ROS were negative for shortness of breath, palpitations, chest pain, transient weakness or numbness, orthopnea, paroxysmal nocturnal dyspnea, headaches, loss of visual acuity, sweats, polyuria, polydipsia, daytime sleepiness, loud snoring, heat or cold intolerance, claudication or lower extremity edema.
You have known Mr. Burns for several years, and a quick review of your notes from previous visits reveals that his BPs have been running in the 130s-140s over 80s-90s (prehypertension range) and he has no significant past medical history.
3. What are the proper steps to measure blood pressure?
Proper BP measurement is the key to detection of HTN. Mr. Burns’ BP should be repeated with attention to the five basics steps:
- He is seated comfortably for about 5 minutes, arm bare and at heart level
- Cuff size is appropriate (the bladder within the cuff should encircle at least 80% of the arm)
- Ausculatory method with a properly calibrated sphygmomanometer
- Record the BP accurately (systolic blood pressure is the first appearance of 2 or more sounds, diastolic blood pressure is the point of the disappearance of sounds)
- At least two measurements, verify on contralateral arm
It is a good idea to provide your patient with their BP measurements verbally and in writing as well as their goal BPs.
4. What should you look for in the exam?
During the physical exam, direct special attention to the heart, lungs, and vascular system. You will need to pay close attention for any signs of target organ disease. This will include assessing for neurological deficits, the optic fundi, the thyroid and the heart. Check for any bruits especially in the neck, abdomen, and femoral regions. Check the kidneys and the abdomen for pulsations or masses, the lower extremities for edema. Check pulses in all extremities.
You should also look for signs of diseases that cause secondary HTN (ie. sleep apnea, drug use, kidney disease, etc).
The exam should also include a calculation of the Patient's body mass index (BMI) to assess for obesity. Overweight is defined as a BMI of 25 to 29.9 kg/m2; obesity as a BMI of >30 kg/m2. Severe or morbid obesity is defined as a BMI >40 kg/m2 (or 35 kg/m2 in the presence of comorbidities).
Physical Exam
You retake his BP. It is now 154/92 (L arm, sitting), 156/94 (R arm, sitting). P 82, R 12, T 98.3, Ht. 6’, Wt 210 lbs (BMI = 28.5)
Gen: The patient is a middle-aged, well-appearing male, slightly overweight, resting comfortably in a chair.
Eyes: No retinopathy, no AV nicking, no papilledema. No exophthalmos.
Neck: No thyromegaly, no carotid bruits, no JVD
Heart: Regular rate and rhythm without an S3 or S4. No murmurs, rubs or clicks. PMI in the MCL, non-sustained, about the size of a quarter. No sternal heave.
Lungs: Chest is symmetric with equal breath sounds. No wheezes, rales or rhonchi. No changes to percussion.
Abdomen: BS normoactive, no renal or aortic bruits. Soft, nondistended, nontender, no striae. No hepatosplenomegaly or masses.
Extremities: Upper: radial pulses 2+ bilateral. Lower: No edema, erythema. DP and femoral pulses 2+ bilateral. No clubbing or cyanosis.
Neuro: Mental Status: Alert and oriented x 3.
Cranial Nerves: II - XII intact
Motor strength: 5/5 bilateral upper and lower extremities.
Sensory: Pinprick and vibratory intact throughout.
Reflex: DTRs 2+ bilateral biceps, brachiorad., triceps, knees, and ankles without clonus.
Cerebellar: Finger to nose intact b/l.
Gait: Normal
Assessment
You explain to Mr. Burns that his BP is elevated today and that you would like him to come back in 6 weeks for a re-check. He asks you why you are worried about his BP.
5. Does Mr. Burns have HTN now?
Your suspicion is raised that Mr. Burns may have HTN and that the elevation was not just a transient event caused by racing to the office. But the JNC VII definition of HTN requires that the SBP is greater than or equal to 140 or the DSP is greater than or equal to 90, "based on the average of two or more properly measured, seated BP readings on each of two or more office visits." That means that you need at least 2 separate visits with Mr. Burns before you can diagnose him with HTN.
6. What does HTN put Mr. Burns at risk for?
The short answer is target organ damage and early death. Untreated HTN has been associated with a shortening of life by 10 to 20 years! Deleterious effects on the body are numerous despite the largely asymptomatic nature of the disease (i.e. the "silent killer"). Particularly affected organs include the heart (enlargement, MI, CHF, angina), eyes (scotomata, blurred vision, even blindness), kidneys (impaired renal function and eventual failure), peripheral vessels (AAA, PVD, claudication), and the brain (stroke or TIA). Beginning at BP of 115/75mm Hg, the risk of CVD doubles with each increment of 20/10mm Hg increase.
Management Plan
7. Mr. Burns' physical exam is essentially normal except for being moderately overweight (BMI = 29). What, if any, modifications can he make before his next visit?
Recommendations to patients for general lifestyle modification would include the following (see JNC VII “Lifestyle Modification” section):
- Stop smoking
- Weight reduction (average SBP reduction of 5–20 mmHg for every 10 kg of weight loss)
- Limit alcohol intake to no more than 1 ounce per day for men, ½ ounce for most women and lighter weight persons (average SBP reduction of 2–4 mmHg)
· increase aerobic physical activity: 30-45 minutes most days of the week (average SBP reduction of 4–9 mmHg)
- Reduce sodium intake to less than 2.4 grams per day (average SBP reduction of 2–8 mmHg)
- Maintain adequate dietary intake of potassium, calcium, and magnesium
- Reduce intake of dietary saturated fat and cholesterol for overall health
- Adoption of the Dietary Approaches to Stop Hypertension (DASH) eating plan (average SBP reduction of 8–14 mmHg)
See:
http://www.nhlbi.nih.gov/health/public/heart/hbp/dash/new_dash.pdf
The recommendations that you can make for Mr. Burns would be all of the above with the exception of the smoking (since he's a non-smoker).
Follow-up
Mr. Burns returns 6 weeks later and reports that he has been dieting and trying to fit exercise into his busy schedule. He has lost 6 pounds, but his BP is 152/94 on 2 measurements. You praise him for his efforts and encourage him to continue with his new lifestyle
8. Do you want to begin treatment or give him more time with his lifestyle modification program?
According to JNC VII guidelines, Mr. Burns now can be diagnosed with Stage 1 HTN without compelling indication for any specific drug (no clinical cardiovascular disease, target organ damage, DM etc.). The JNC VII guidelines state that initial drug therapy, as well as lifestyle modification is indicated at diagnosis of stage 1 or stage 2 HTN (see table 2 below). Monte Burns should begin on a single drug for now.
Table 2. Classification and Management of blood pressure for adults**
NORMAL: <120 SBPmm Hg and <80 DBPmm Hg
Lifestyle Modification: Encouraged
Initial Drug Therapy Without Compelling Indication: None indicated
Initial Drug Therapy With Compelling Indications: No antihypertensive indicated
PREHYPERTENSION: 120-139 SBPmm Hg or 80-89 DBPmm Hg
Lifestyle Modification:Yes
Initial Drug Therapy Without Compelling Indication: None indicated
Initial Drug Therapy With Compelling Indications: Drug(s) for compelling indications
STAGE 1 HTN: 140-159 SBPmm Hg or 90-99 DBPmm Hg
Lifestyle Modification: Yes
Initial Drug Therapy Without Compelling Indication: Thiazide diuretic for most. May consider ACEI, ARB, BB, CCB or combo.
Initial Drug Therapy With Compelling Indications: Drug(s) for compelling indications. Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed)
STAGE 2 HTN: >159 SBPmm Hg or >99 DBPmm Hg
Lifestyle Modification: Yes
Initial Drug Therapy Without Compelling Indication: Two drug combination for most. (usually thiazide plus ACEI, ARB, BB or CCB)
Initial Drug Therapy With Compelling Indications: Drug(s) for compelling indications. Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed
Key: ACEI= angiotensin converting enzyme inhibitor, ARB = angiotensin receptor blocker, BB = beta blocker, CCB = calcium channel blocker
**Classification of Blood Pressure for Adults Aged 18 Years and Older, from JNC VII Guidelines, May 2003. (http://www.nhlbi.nih.gov/guidelines/hypertension/)
9. What medication do you want to begin his therapy?
Mr. Burns does not have any significant co-morbidities that would be a compelling indication for any specific drug (see table 3 below).
He should probably be started on a thiazide diuretic. The ALLHAT trial is the largest controlled antihypertensive trial ever performed. It compared the treatment of HTN with four different drug classes including: a calcium channel blocker, an ACE inhibitor, an alpha-blocker and a thiazide diuretic. The thiazide diuretic treatment was found to be equal or superior in all cardiovascular outcomes and mortality. In addition, the thiazide was the least expensive of the drugs studied. Thiazides are usually well tolerated. A few side effects to watch out for include: orthostatic hypotension, photosensitivity, hypokalemia, and gout.
Table 3. Compelling indications for Individual Drug Classes
| Compelling Indication |
Initial Therapy Options |
Heart failure |
THIAZ, BB, ACEI, ARB, ALDO ANT |
Post myocardial infarction |
BB, ACEI, ALDO ANT |
High CVD risk |
THIAZ, BB, ACEI, CCB |
Diabetes |
THIAZ, BB, ACEI, ARB, CCB |
Chronic kidney disease |
ACEI, ARB |
Recurrent stroke prevention |
THIAZ, ACEI |
Key: THIAZ = thiazide diuretic, ACEI= angiotensin converting enzyme inhibitor, ARB = angiotensin receptor blocker, BB = beta blocker, CCB = calcium channel blocker, ALDO ANT = aldosterone antagonist
10. What, if any, lab work would you like to do before initiating treatment?
Lab tests are utilized to determine the suggestion of any end-organ damage or secondary hypertension and to determine the status of atherosclerotic vascular disease. The following initial labs are recommended: urinalysis, hematocrit, electrolytes (including Calcium), renals, glucose, fasting lipid profile, and 12 lead ECG. Cholesterol and glucose measurements are used to determine whether or not other risk factors for atherosclerotic vascular disease exist. Proteinuria and elevated creatinine may be suggestive of the renal effects of long-standing hypertension or renal disease causing secondary HTN. Left ventricular hypertrophy on ECG would also be suggestive of long-standing hypertension. Optional tests include a measurement of the urinary albumin excretion or Alb/Cr ratio. More extensive lab testing for causes of secondary HTN usually are not indicated unless suspicion is high or BP control is not achieved after treatment.
Diagnostic Testing
Mr. Burns' lab results for U/A, CBC, lytes, renals, glucose, cholesterol, and ECG are within normal limits.
You give Mr. Burns a prescription for Hydrochlorothiazide 25 mg to take one pill in the morning. You explain to him that he may urinate more frequently initially, but it should get better over time.
11. What potential side effects of hydrochlorothiazide (HCTZ) will you warn Mr. Burns about?
He should be aware of the following potential side effects of HCTZ:
- He could get sunburned more easily. He should avoid too much sun, sunlamps, and tanning beds. He should use sunscreen; wear protective clothing and eyewear.
- He should watch for gout attacks.
- He could develop a low potassium level. Signs include feeling tired, weak, numbness, or tingling, muscle cramps, constipation, vomiting, or fast heartbeat. He should be advised that if he notices any of these signs, he should call the doctor's office.
- He could feel lightheaded, sleepy, have blurred vision, or a change in thinking clearly.
- He could feel dizzy at times. He should rise slowly over several minutes from sitting or lying position.
- He could develop nausea or vomiting. Small frequent meals may help.
- He could develop a dry mouth. Frequent mouth care, sucking hard candy, or chewing gum may help.
12. Is there any utility to home BP monitoring?
Self-measurement of BP can provide valuable information to the physician. It has 3 distinct advantages:
- Distinguishing sustained HTN from "white-coat HTN" (a condition found in some patients whose blood pressure is consistently elevated in the physician’s office or clinic but normal at other times, thought to be due to transient stress)
- Assessing response to anti-hypertensive medication
- Improving patient adherence to treatment
The BP of people with HTN does tend to be higher in the office than outside, so this technique can be valuable for you in learning what Mr. Burns’ BP usually runs at home. If the patient has a blood pressure monitoring device at home, it is a good idea to have them bring it to the office to correlate their measurements to your sphygmomanometer.
2nd Follow-up
Mr. Burns returns in 6 weeks and his BP is now 138/88. His weight is down to 198 pounds (total of 16 pounds lost). You encourage him to continue with his healthy lifestyle and the medication. He will follow up with you every 2 months now, until his BP is shown to be stable at a goal of less than 140/90. If Mr. Burns does well with achieving a sustained and significant BP reduction with significant lifestyle changes, it would be reasonable to try to reduce or eliminate his medication in the future.
The BP goal for a patient without DM or renal disease is less than 140/90; however it is still considered prehypertensive at ranges 120-140/80-89. The prehypertensive patient should be treated with lifestyle modification. If DM or renal disease coexists, the goal BP is less than 130/80.
Initial Presentation
Dena Miles is a 56-year old African-American woman who is well known to your practice. Eight years ago you diagnosed her with type II diabetes mellitus. She is in your office today for a regular check-up (including her feet) and to go over her most recent lab results.
She is currently taking metformin and rosiglitazone to control her blood sugar. She checks herself about once a day, sometimes forgetting, and usually runs around 130s to 160s. She is post-menopausal and overweight. She has no other significant past medical history. She last visited her ophthalmologist 6 months ago and does not have any retinopathy. She does not smoke or drink alcohol.
Her father died at age 70 from renal failure from diabetes, but her mother is alive and well, having just had triple heart bypass surgery at age 81.
She denies any headaches, dizziness, loss of visual acuity, stroke, sudden weakness or numbness, shortness of breath, palpitations, chest pain, orthopnea, paroxysmal nocturnal dyspnea, claudication, lower extremity edema, sweats, polyuria, polydipsia, daytime sleepiness, loud snoring, or heat or cold intolerance.
Her blood pressure has been around 148/94 the past couple visits. Today it is 149/94. Besides being overweight and slightly decreased sensation on both her feet, her exam is normal.
Her HbA1c is 8.1%, and she has some microalbuminuria (60 mg/d). Her BUN and Cr are 35 and 1.3 respectively. A fasting lipid profile revealed: Total cholesterol 262, LDL 174, HDL 50, Triglycerides 162.
1: What should be the BP goal for this patient?
The goal BP for a patient with diabetes should be less than 130/80. Early treatment of HTN is important to prevent cardiovascular disease and to minimize progression of nephropathy and retinopathy.
2: Would you like to begin treatment of her HTN with a trial of lifestyle modification alone?
NO! Diabetics with BPs > 130/80 are at very high risk of developing cardiovascular complications such that antihypertensive drug therapy is warranted now. Besides, Ms. Miles' labs already demonstrate evidence of renal damage with elevated microalbumin. Nonpharmacologic modifications are also in order for Ms. Miles, but these cannot substitute for pharmacologic measures, especially with the evidence of early nephropathy and poor glycemic control. Lifestyle modifications including diet, exercise, sodium restriction, avoidance of smoking and alcohol should be encouraged. Strategies for weight reduction and glycemic control should be discussed with Ms. Miles.
3: You decide that Ms. Miles needs pharmacologic management of her HTN at this point. Which antihypertensive will you choose? What advantages would an ACEI or ARB have for Ms. Miles?
Combinations of two or more drugs are usually needed to achieve target goal of less than 130/80 in diabetic hypertensive patients. Either angiotensin-converting enzyme inhibitors (ACEI) or angiotensin II receptor blockers (ARBs) are preferred in patients with diabetes and nephropathy. Thiazide diuretics, beta-blockers, ACE inhibitors, ARBs, and calcium channel blockers have all been shown to be beneficial in reducing CVD and stroke in diabetics.
Advantages of ACEI or ARB:
- Lower BP
- Usually well-tolerated (except for the dry cough w/ ACEI - The exact etiology of the ACEI dry cough is not totally clear. It is suspected that the increase in bradykinin caused by the inhibition of the converting enzyme is the mechanism behind the cough)
- No adverse effects on lipid metabolism (as compared with beta-blockers)
- May lower plasma glucose by increasing responsiveness to insulin
- Protection against development and/or progression of diabetic nephropathy and reduce albuminuria
- Lower incidence of adverse cardiovascular outcomes among diabetics (who are at increased risk for cardiovascular disease)
- ARBs have been shown to reduce progression to macroalbuminuria
Management Plan
You decide to start Ms. Miles on lisinopril 10 mg daily, an ACEI that has a long track record of success and safety in diabetics. One major concern regarding ACEIs is their potential to cause acute renal failure in patients with bilateral renal artery stenosis. Other concerns to be alert for are hyperkalemia and avoidance in patients with renal failure. They are contraindicated in patients with renal failure and used with caution in patients with renal insufficiency.
A good link about ACEI: http://www.healthyhearts.com/acei.htm
You explain to her the benefits this medication will have for her, emphasizing its importance in decreasing the progression of renal disease. You also reiterate the importance of controlling her blood glucose levels. She seems to comprehend your advice and agrees to begin taking the lisinopril as well as to pay closer attention to her glucose checks.
4: What antihypertensive medication would you use if lisinopril fails?
If ACEIs are not well tolerated, angiotensin II receptor blockers (ARBs) should be considered. They have been proven efficacious in decreasing the progression of nephropathy, and they have a similar effect as an ACEI. The most common nuisance side effect of the ACEIs is a dry cough, which usually does not occur with ARBs. Also, if adequate BP control is not achieved on one drug, a thiazide diuretic may be added to the regimen. A number of combination drugs now exist that combine an ACEI with a thiazide or an ARB with a thiazide into one pill.
Follow-Up
Dena Miles returns after 4 weeks on lisinopril alone and reports diligently following her diet and medication regimen. Her BP in the office today is 142/90 (slightly decreased); you praise her for her efforts and explain that a notable BP reduction may take some time to achieve. You also add HCTZ 25 mg once a day. She proceeds to tell you about her bowling partner who takes propranolol, a beta-blocker, for his HTN. Her friend's BP is supposedly very well controlled. Ms. Miles asks you why you did not start her on a beta-blocker as well.
5: What are reasons commonly cited for avoiding beta-blockers in diabetics?
The common concerns about beta-blockers in diabetics is that they might have adverse effects on peripheral blood flow (thereby exacerbating peripheral vascular disease), prolong hypoglycemia, and mask hypoglycemic symptoms (by blunting the body's usual sympathetic response to hypoglycemia). Also, in one study, diabetic patients on beta-blockers gained more weight and required the addition of new glucose lowering agents more frequently than those on ACEIs. Despite these concerns, beta-blockers with diuretics have been proven effective in the treatment of HTN in diabetics, although diuretics can also aggravate glycemic control.
2nd Follow-up
Dena Miles comes back again 4 weeks later. It has now been 2 months since you started the lisinopril and 1 month since beginning the HCTZ. She had some labs checked before coming to your office. Her HbA1c is 7.5%, and urine microalbumin is 40 mg/d. BUN and Cr are 29 and 1.2, K+ is 4.3. Her BP is 135/86 by the nurse and 134/85 on your check. You and Ms. Miles are both very encouraged. You decide she would benefit from a further increase in her lisinopril dose to 10 mg bid, with follow-up BP and renal function labs in six weeks.
Discussion:
Hypertension (HTN) and diabetes are independent risk factors for vascular complications including CVD, atherosclerosis, stroke, peripheral vascular disease, retinopathy, and nephropathy. In type I DM, there is a close relationship between hypertension and diabetic renal disease. Blood pressure typically begins to rise about three years after onset of microalbuminuria. In type I DM, the overall incidence of HTN is approximately 15 to 25 percent in all patients with microalbuminuria and 75 to 85 percent in those with overt diabetic nephropathy.
The findings are somewhat different in type 2 diabetic patients. One study of over 3500 newly diagnosed patients found that 39 percent were already hypertensive. In approximately one-half of these patients, the elevation in BP occurred before the onset of microalbuminuria. HTN was strongly associated with obesity, and hypertensive patients were at increased risk for cardiovascular morbidity and mortality.
Early treatment of HTN is very important in DM patients both to prevent cardiovascular disease and to minimize progression of renal disease and diabetic retinopathy. One study found significant differences in hypertensive type 2 DM patients given either the standard treatment or intensified multifactorial intervention to control their BP. The intensive group had significantly lower rates of progression to nephropathy, progression of retinopathy, and progression of autonomic neuropathy than those in the standard group. (see reference by Gaede et al.)
Initial Presentation
Bob Brown is a 74-year old patient of yours for the past 20 years. He is a retired construction worker who now lives at home alone after his wife’s recent death. He has long-standing HTN, which has never been well controlled. He also has COPD from years of smoking, but quit 12 years ago. He had an appendectomy as a child and 3 inguinal hernia repairs during his working life. He can’t remember what his parents died from, but thinks it was “old age.” You recall that you have tried him on clonidine, methyldopa, and prazosin back when those were the choice drugs. You recently switched him to hydrochlorothiazide (25 mg) from clonidine to see if you couldn't make an impact on his BP.
Today in the office his BP reads 176/104.
You ask Mr. Brown how he is doing with this water pill, and he good-naturedly responds that he hasn't been able to keep track of it real well now that his wife isn't there to remind him all the time.
1: What are some common causes for inadequate response to antihypertensive therapy?
pseudoresistance:
white coat HTN
pseudohypertension in older patients
nonadherence to medication:
side effects
lack of education/understanding
unwilling
too expensive
volume overload:
excess salt intake
progressive renal damage
inadequate diuretic therapy
drug-related:
dose too low
inappropriate combinations
drug actions/interactions (nasal decongestants, caffeine, oral contraceptives, antidepressants, NSAIDs, cocaine, amphetamines)
associated conditions:
smoking
obesity
sleep apnea
ethanol intake > 1 ounce per day
chronic pain
identifiable:
secondary causes of HTN
2: What is the cause of pseudohypertension in older patients?
Pseudohypertension is a false elevation in BP readings due to excessive arterial stiffness and calcification. Therefore, compression of the brachial artery requires higher pressures than that actually found within the artery; thus systolic BP readings are falsely elevated. Additionally, the thickened vessel will stop vibrating more quickly during diastole, which will cause the sounds to disappear more quickly. This, in turn, will cause an elevated recording of the diastolic BP. Pseudohypertension should be suspected in the following settings:
- Marked HTN in the absence of end-organ damage
- Antihypertensive therapy causes symptoms of hypoperfusion without decreasing BP measurements
- “Pipestem” calcifications of the arteries seen on X-rays. Diagnosis of pseudohypertension can only be made via direct intra-arterial measurement of the BP.
3: Would you want to screen him for secondary causes of HTN?
No. Identifiable diseases causing HTN account for <5 % of all cases of HTN, so screening all hypertensive patients for these conditions is inappropriate. Though, one should always be looking for signs and symptoms suggestive of these causes when conducting the history and physical exam.
A useful mnemonic for remembering and assessing for secondary causes of hypertension is ABCDE:
A ~ Accuracy, Apnea (OSA), Aldosteronism
B ~ Bruits (renovascular disease), Bad kidneys
C ~ Catecholamines (pheo. etc.), Coarctation, Cushing’s syndrome
D ~ Drugs, Diet
E ~ Erythropoietin, Endocrine disorders
With Mr. Brown’s long history of HTN and probable history of marginal compliance, evaluation for a secondary cause of HTN would not be indicated at this time. A good link to further information on evaluation of secondary hypertension is: http://www.uptodateonline.com/application/topic.asp?file=hyperten/4350
Below is a table showing signs, symptoms and clues of secondary HTN:
Clinical Signs/Symptoms/Clues of Secondary HTN Causes:
General: Age onset before puberty or after age 50 and no family history of HTN
A
Aldosteronism: Hypokalemia and potassium wasting
Sleep Apnea: Obese men, loud snoring, daytime sleepiness, and morning confusion
B
Renovascular Disease: Refractory HTN. Acute elevation of serum Creatinine after giving ACEI or ARB. Abdominal bruit. HTN in Pt. with atherosclerotic disease or one smaller kidney. Repeated flash pulmonary edema
Primary kidney disease: Abnormal U/A, elevated creatinine
C
Pheochromocytoma: Paroxysmal HTN, triad (headache, palpitations, and sweating)
Cushing’s syndrome: Cushingoid facies, proximal muscle weakness, central obesity, buffalo hump, and ecchymosis
Coarctation of aorta: May have unequal BP in two arms, HTN in both arms with diminished femoral pulses, and/or low BP in legs.
D
Oral contraceptives: New HTN after start of OCP
E
Hypothyroid: Elevated TSH, weakness, cold intolerance, weight gain, fatigue myxedema
Hyperthyroid: Low or rarely high TSH, high T3/T4, heat intolerance, palpitations, weight loss, fatigue
Hyperparathyroid: High serum calcium, (classic hypercalcemia signs and symptoms: “ stones, bones, groans, and psychiatric overtones)
Management Plan
You tell Mr. Brown that it is important for him to take his medication. He cuts you off in mid-sentence, "Hey, doc, come on, I'm 74 already and haven't had any health problems! What's the big deal anyways?"
You patiently explain all this to Mr. Brown who begins to see your point. He agrees to try harder to stay on schedule with his HCTZ. "It'll be just like punchin' the clock, doc; no problem," he says.
You schedule Mr. Brown to return in 4-weeks.
4: Does the treatment of HTN in older persons have any real benefit?
YES!! Treatment of HTN in older persons (>60) has demonstrated major benefits in multiple large trials. Antihypertensive drug therapy has been shown to reduce strokes, coronary heart disease, cardiovascular disease, heart failure, progression of dementia and mortality. The benefits of treatment in older patients are real! In one 5-year double-blind randomized trial that assessed the ability of antihypertensive drug treatment to reduce risk of nonfatal plus fatal stroke in elderly men and women, the five-year incidence of total stroke was 5.2/100 for active treatment and 8.2/100 for placebo, which represents a substantial reduction in morbidity and mortality. The results were similar across age and race-sex subgroups. For the trial's secondary end points, rates were again lower for active treatment than placebo, e.g., nonfatal myocardial infarction plus coronary death relative risk was 0.73 (95% confidence interval 0.57 - 0.94); combined major cardiovascular events, relative risk is 0.68 (95% confidence interval 0.58 - 0.79); deaths from all causes, relative risk 0.87 (95% confidence interval 0.73 -1.05). See the Systolic Hypertension in the Elderly Program (SHEP) trial for more information.
Follow-up
You have Mr. Brown come back at 4-week intervals to check how he is doing, but after 2 months, you haven't made any progress with lowering his BP. He assures you that he never misses a pill now that he is "on the clock."
5: What do you want to do next?
Add another medication. One could add an ACEI, ARB, long acting calcium channel blocker or a beta-blocker. However, ACEIs were shown to decrease cardiovascular morbidity and mortality in elderly hypertensive patients in the Second Australian National Blood Pressure (ANBP2) trial.
Follow-up Plan
You decide to add an ACEI to his regimen. To make his regimen easiest, you both decide to go with a combination captopril/HCTZ (25mg/25mg) pill. You decide to give this a 2-month trial.
6: When is Mr. Brown's HTN considered resistant?
Resistance is usually defined as a BP over 140/90 mmHg in patients below age 60 and above 160/90 mmHg in those over age 60, despite intake of three or more and appropriate antihypertensive medications adequately dosed.
Discussion:
Hypertension is a common problem in the elderly with an incidence higher than 60% by age 70. The benefits of treatment of HTN in the elderly have been well studied and documented in numerous trials. As discussed earlier, antihypertensive drug therapy has been shown to reduce strokes, coronary heart disease, cardiovascular disease, heart failure, progression of dementia and mortality.
A 5-year double-blind randomized trial that assessed the ability of antihypertensive drug treatment to reduce stroke risk in elderly hypertensive patients, the five-year incidence of total stroke was 5.2/100 for active treatment and 8.2/100 for placebo (p = 0.0003). The results were similar across age and race-sex subgroups.
Multiple trials including the SHEP trial, the ALLHAT trial, and the ANBP2 trial all have shown that treatment of HTN in the elderly decreases the incidence of CVD, stroke, heart failure, dementia and mortality. For more info, see the references at the end of the case.
“JNC 7 Express: The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.” May 2003. http://www.nhlbi.nih.gov/guidelines/hypertension/.
“The Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure”. Arch Intern Med. 157, 1997.
“ALLHAT: The Antihypertensive and Lipid-Lowering Treatments to Prevent Heart Attack Trial.” http://allhat.sph.uth.tmc.edu/ Revised 1/8/2003.
Carretero and Oparil. “Essential hypertension: part 1: definition and etiology.” Circulation. 101, 2000. p 329.
Carretero and Oparil. “Essential hypertension: part 2: treatment.” Circulation. 101, 2000. p 446.
Chobanian, Bakris, Black, et al. “The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. The JNC 7 Report.” JAMA. 289:19. May 2003. pp. 2560-2572.
Deedwania. “Hypertension and diabetes: new therapeutic options.” Arch Intern Med. 160, 2000. pp 1585-1594.
Gaede P, Vedel P, Parving HH, Pedersen O. "Intensified multifactorial intervention in patients with type 2 diabetes mellitus and microalbuminuria: the Steno type 2 randomised study." Lancet. 1999 Feb 20;353(9153):617-22.)
Graves. “Management of difficult to control hypertension.” Mayo Clin Proc. 75, 2000. pp 278-284.
“JNC 7 Express: The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.” May 2003. http://www.nhlbi.nih.gov/guidelines/hypertension/.
“The Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure”. Arch Intern Med. 157, 1997.
“ALLHAT: The Antihypertensive and Lipid-Lowering Treatments to Prevent Heart Attack Trial.” http://allhat.sph.uth.tmc.edu/ Revised 1/8/2003.
Carretero and Oparil. “Essential hypertension: part 1: definition and etiology.” Circulation. 101, 2000. p 329.
Carretero and Oparil. “Essential hypertension: part 2: treatment.” Circulation. 101, 2000. p 446.
Chobanian, Bakris, Black, et al. “The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. The JNC 7 Report.” JAMA. 289:19. May 2003. pp. 2560-2572.
Deedwania. “Hypertension and diabetes: new therapeutic options.” Arch Intern Med. 160, 2000. pp 1585-1594.
Gaede P, Vedel P, Parving HH, Pedersen O. "Intensified multifactorial intervention in patients with type 2 diabetes mellitus and microalbuminuria: the Steno type 2 randomised study." Lancet. 1999 Feb 20;353(9153):617-22.)
Graves. “Management of difficult to control hypertension.” Mayo Clin Proc. 75, 2000. pp 278-284.
Kaplan and Rose. “Ambulatory Blood Pressure Monitoring and White Coat Hypertension.” UpToDate Online. 2004.
Messerli and Goldbourt. “High blood pressure and diabetes mellitus: are all anti-hypertensive drugs created equal?.” Arch Intern Med. 160, 2000. pp 2447-2452.
Onusko, E. “Diagnosing Secondary Hypertension.” American Family Physician. 67:1 pp.67-74. 2003.
Perry, Davis, Price et al. “Effect of Treating Isolated Systolic Hypertension on the Risk of Developing Various Types and Subtypes of Stroke: The Systolic Hypertension in the Elderly Program (SHEP).” JAMA. 284 (4), 2000. pp 465-471.
Perry, Davis, Price, et al. "Effect of Treating Isolated Systolic Hypertension on the Risk of Developing Various Types and Subtypes of Stroke: The Systolic Hypertension in the Elderly Program (SHEP)." JAMA 284 (4), July 26, 2000. pp 465-471.
Vijan, S, Haywood, R. “Treatment of Hypertension in Type 2 Diabetes Mellitus: Blood Pressure Goals, Choice of Agents, and Setting Priorities in Diabetes Care.” Ann Intern Med. 138:593-602. 2003
White, Prisant, and Wright. “Management of patients with hypertension and diabetes mellitus: advances in the evidence for intensive treatment.” Am J Med. 108, 2000. pp 238-245.