FMcase 8

Case 8
54-year-old male with elevated blood pressure - Mr.

Martin
Author: Pablo Joo, M.D, Albert Einstein College of Medicine
Learning Objectives:
Define the nationally accepted guidelines for screening, diagnosing, and
staging the severity of hypertension (i.e., pre-hypertension, essential
hypertension, and resistant hypertension).
1.
Name appropriate elements of the hypertensive patient history to identify
lifestyle and other cardiovascular risk factors, and assess concomitant
disorders that affect prognosis and guide treatment.
2.
Identify appropriate elements of a comprehensive physical examination in
hypertensive patients, including proper techniques in blood pressure
measurement.
3.
Order recommended laboratory studies on an uncomplicated new
hypertensive patient on initial visits.
4.
Formulate basic management plans for the longitudinal care of patients with
hypertension.
5.
Describe elements of lifestyle modification (including health education and
behavioral change strategies) for hypertensive patients.
6.
Reflect on the importance of providing socio-culturally sensitive and
responsive education, counseling, and care to patients and their families.
7.
Demonstrate awareness of improved patient care outcomes through
effective communication with all members of the primary care team,
including nutritionists, social workers, and nurses.
8.
9. Develop awareness of practicing cost-effective health care and resource
allocation that does not compromise quality of care.
9.
Summary of Clinical Scenario: Mr. Jose Martin is a 54-year-old man from the
Dominican Republic who presents for a routine physical exam after not engaging
in routine health care for over a decade. He is uninsured and overweight. His
blood pressure is elevated. Over subsequent visits, Mr. Martin continues to
demonstrate elevated blood pressure. He is evaluated for the presence of
end-organ disease and identifiable causes of hypertension, and is eventually
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diagnosed with stage 1 essential hypertension. He is counseled about lifestyle
modification and given a prescription for hydrochlorothiazide. When these
measures do not adequately control his hypertension, lisinopril is added to his
regimen. Upon receiving results of a second fasting lipid profile, Mr. Martin is
advised to undertake lifestyle modifications to reduce his low-density lipoprotein
cholesterol (LDL) level.
Key Findings from History
Feels well
No health care for 10 years
No major illnesses or surgeries
Family history of diabetes and high
cholesterol (mother, living, age
73), fatal myocardial infarction
(father at age 64)
Uninsured with financial constraints
Work stress (12-hour days, 6 days
per week
20 lb weight gain over past 5 years
Key Findings from Physical
Exam
Overweight BMI = 27.4 kg/m2
Blood pressure: 145/85 mm Hg
No physical signs of end-organ
damage from high blood pressure
Differential Diagnosis:
Essential hypertension
Secondary hypertension.
Key findings from Testing:
Electrocardiogram: unremarkable
Blood work: Fasting glucose,
hematocrit, and basic metabolic
panel normal
Urinalysis: no evidence of protein,
glucose, or microalbumin
Fasting cholesterol panel: LDL
>130 mg/dL
Final Diagnosis: Hypertension
Case Highlights: This case explores socio-cultural aspects of care. Over the
course of the case, the student takes the patients uninsured status into account
2 of 12 10/26/11 7:53 AM
by considering the financial ramifications of different treatment plans. The
student also recognizes appropriate consultation resources and refers the patient
to pharmacy and social work students to obtain medication free of charge and
enroll the patient in other programs. The student demonstrates responsiveness to
the patients bilingual Latino status by providing culturally appropriate resources
in Spanish. Establishing a patient-centered medical plan includes integrating a
patients explanatory model of illness into the treatment decision.
Key Teaching Points
Knowledge:
Hypertension:
Definition: High blood pressure in an adult is systolic pressure > 140 mm Hg or
diastolic pressure > 90 mm Hg.
Diagnosis: According to Joint National Committee on Prevention, Detection,
Evaluation, and Treatment of High Blood Pressure (JNC 7) standards, there must
be at least two elevated measurementsat least five minutes apart, one in each
arm, on two or more visitsin order to accurately diagnose a patient with
hypertension. A patient cannot be diagnosed with hypertension if the patient is
acutely ill or in acute pain.
Epidemiology: Hypertension affects approximately 50 million people in the U.S.,
and one billion around the globe.
Etiology: 9598% of the hypertension in the U.S. is essential hypertension; that
is, chronically elevated blood pressure readings with no underlying identifiable
cause. Identifiable causes of hypertension are far less common and are known as
secondary hypertension. Causes of secondary hypertension include:
Sleep apnea
Chronic renal disease
Renovascular causes
Drug-induced causes
Pheochromocytoma
Primary aldosteronism
Chronic steroid use
Cushings syndrome
Thyroid or parathyroid disease
Coarctation of the aorta
Screening: The U.S. Preventive Services Task Force (USPSTF) recommends
screening for high blood pressure in patients without known hypertension starting
at age 18.White coat hypertension is defined as elevated blood pressure
readings occurring only at the doctors office or clinical setting, with normal blood
3 of 12 10/26/11 7:53 AM
pressures measured in the home environment. People with white coat
hypertension should still receive ongoing surveillance for the development of
essential hypertension.
Classification: Blood pressure (BP) is classified by the higher elevation of either
the systolic or diastolic pressure:
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Skills:
History:
According to JNC 7 guidelines, the evaluation of a patient with a possible new
diagnosis of hypertension has three goals:
To assess the presence or absence of target end-organ disease: 1.
Heart (history of congestive heart failure or cardiovascular disease)
Brain
Kidneys
Blood vessels (peripheral vascular disease)
Eyes (retinopathy)
The incidence of end-organ disease correlates with degree of hypertension. A
patient with > 10 years of hypertension may already have end-stage organ
disease.
To assess lifestyle and identify other cardiovascular risk factors or
concomitant disorders that may affect prognosis and guide treatment:
2.
Metabolic syndrome: History of diabetes, cholesterol, and/or obesity
Family history of premature cardiovascular disease or death (men < 55
years, women < 65 years)
Tobacco smoking elevates blood pressure, contributes to increased
morbidity and mortality, and interferes with the efficacy of blood pressure
medications.
Alcohol intake should be limited to no more than 1 oz. (30 mL) of ethanol
(the equivalent of two drinks per day in most men) and no more than 0.5 oz
of ethanol (one drink) per day in women and lighter-weight persons.
4 of 12 10/26/11 7:53 AM
Cocaine and ketamine use and narcotic withdrawal can elevate blood
pressure.
Age (> 55 years for men, > 65 years for women)
Physical inactivity
Microalbuminuria, or estimated glomerular filtration rate (GFR) < 60
mL/minute
To reveal identifiable causes of high blood pressure: 3.
Sleep apnea, chronic kidney disease, primary hyperaldosteronism,
renovascular disease, pheochromocytoma, coarctation of the aorta, and
thyroid or parathyroid disease
Prescription medications (e.g., birth control pills, amphetamines, thyroid
medications, steroids, and certain anti-depressants)
Over-the-counter medications (e.g., pseudoephedrine, appetite
suppressants, or non-steroidal anti-inflammatory drugs)
Herbal remedies (e.g., ma huang, bitter orange, ginkgo, ginseng, licorice,
and St. John's wort)
Cocaine and ketamine use, narcotic withdrawal, excessive alcohol intake,
and smoking
Other appropriate questions to ask include:
Whether there is a family history of diabetes and/or hypercholesterolemia
Patient's diet history
A review of psychosocial stressors: Stress directly causes the release of
angiotensin II and norepinephrine in the body (flight or fight syndrome),
and stressors can also make prioritizing adherence to blood pressure
medicines difficult.
Patients explanatory model of disease:Taking time to assess a patient's
understanding of his/her illness can improve clinical diagnosis and
management, promote culturally responsive health education, avoid
unnecessary medical testing, and lead to better understanding between
physicians and patients. This approach improves patient adherence to
medical regimens and enhances patient satisfaction. Questions that aid in
exploring a patients understanding of illness include:
What do you think caused your problem? What do you call it?
Why do you think it started when it did?
How does it affect your life?
How severe is it? What worries you the most?
What kind of treatment do you think would work?
How can the doctor be most helpful to you?
What is most important for you?
Have you seen anyone else about this problem? Other physicians?
Anyone else besides a physician?
Have you used non-medical remedies or treatments for your problem?
Who advises you about your health?
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Physical Exam:
Proper blood pressure measurement technique:
Patient should be seated quietly for at least five minutes in a chair with their
back supported, rather than on an examination table.
The arm should be supported at heart level.
Auscultate the blood pressure using a properly calibrated pressure gauge.
To ensure accuracy, it is essential to use an appropriately sized cuff. The
length of the cuff bladder should be at least 80% of the arm circumference,
and cuff width must be at least 40% of the arm circumference. A cuff that is
too small will yield an erroneously high blood pressure reading. (With
increasing prevalence of obesity, many adults may no longer fit into an
"adult" cuff, but may require an "extra large" or "thigh-sized cuff.")
When screening for hypertension, a measurement in each arm (five minutes
apart) is recommended to screen for aortic anomalies. For ongoing
monitoring, measurement is needed only on one arm.
Body mass index (BMI): Being overweight or obese is a risk factor for
hypertension, cholesterol, diabetes, and many other diseases.
Funduscopic eye examination: Assess for arteriovenous nicking, cotton-wool
spots, flame hemorrhages, exudates, and other changes associated with
hypertensive retinopathy or papilledema associated with hypertensive
emergencies.
Vascular examination: Auscultate for carotid, abdominal, and femoral bruits.
Assess lower extremities for pulses and edema, Assess for the presence of
peripheral vascular and cardiovascular disease, which can occur as a result of
hypertension.
Thyroid gland: Assess for nodules, tenderness, or thyromegaly, which might
indicate hyperthyroidism, one of the causes of secondary hypertension.
Lung examination: Assess for signs of congestive heart failure, such as crackles
or diminished breath sounds. Congestive heart failure can occur with
long-standing hypertension.
Heart examination: Assess heart rate, rhythm, presence of murmurs, or an
enlarged point of maximal impulse which may indicate cardiovascular disease,
valvular disease, or cardiomegaly.
Abdominal examination: Look for abdominal aortic pulsation or masses, or
enlarged kidneys as hypertension can contribute to peripheral vascular disease
and chronic kidney disease.
Neurologic examination: Assess for neurologic changes from ischemic or
hypertensive brain disease. It is important to get a baseline neurologic exam even
6 of 12 10/26/11 7:53 AM
if the findings are normal because subtle changes can happen over time.
Studies:
Several studies are recommended for a new diagnosis of hypertension:
Electrocardiogram: To assess rate and rhythm issues such as bradycardia,
tachycardia, or an underlying heart block. Beta blockers or calcium channel
blockers may be contraindicated for people with abnormal rates or rhythms. Look
for evidence of ischemic disease, previously undiagnosed myocardial infarctions,
or cardiac hypertrophy. Left ventricular hypertrophy (LVH) is the second best
prognostic factor for death in all people with or without hypertension. LVH is
reversible with proper attention and medical management.
Urinalysis: Proteinuria can indicate hypertensive nephropathy (target-organ
damage). Glucosuria may indicate undiagnosed diabetes or poorly controlled
diabetes (a potential co-morbid illness and sign of metabolic syndrome).
Blood glucose: An elevated random or fasting blood glucose may be evidence of
undiagnosed diabetes or poorly controlled diabetes (a potential co-morbid illness
and sign of metabolic syndrome). This may affect the choice of the first-line agent
used in managing hypertension.
Hematocrit: Low hematocrit may reveal anemic states in hypertensive patients.
Anemia makes the likelihood of a major cardiovascular event (e.g., stroke, heart
attack) more likely. If a hypertensive patient is found to be anemic, the
underlying cause (e.g., colon cancer or uterine fibroids) must be found and
addressed, and the anemia corrected. Anemia may also be the product of
target-organ damage in moderate to severe end-stage renal disease.
Serum potassium (K): Several blood pressure medications can cause potassium
derangements (angiotensin converting enzyme [ACE] inhibitors, angiotensin
receptor blockers [ARBs], and potassium- sparing diuretics, all of which may
cause or exacerbate hyperkalemia). A baseline potassium level is necessary for
determining any potential changes from antihypertensive therapy. Furthermore,
potassium disturbances can occur in Cushings syndrome or primary
hyperaldosteronism.
Serum creatinine or the corresponding estimated GFR: An elevated serum
creatinine (or the corresponding low estimated GFR) may indicate end- organ
damage (hypertensive nephropathy) from long-term uncontrolled hypertension.
Some blood pressure medicationssuch as ACE inhibitors, ARBs, and
diureticsalso elevate creatinine.
Fasting serum cholesterol panel (total cholesterol, LDL, HDL,
triglyceride): Obtained after a 9 to 12-hour fast, a lipid profile that includes
measurement of high-density lipoprotein (HDL), low-density lipoprotein (LDL),
and triglycerides is indicated to assess lipid co-morbidities. Hypertensive patients
have periodic fasting lipid panels as surveillance for cholesterol problems, and not
7 of 12 10/26/11 7:53 AM
as a general screening tool.
Urinary albumin excretion or albumin/creatinine ratio: The JNC 7 considers
the measurement of urinary albumin excretion or albumin/creatinine ratio (ACR)
optional, except for those with diabetes or kidney disease, in whom annual
measurements should be made. This may become a recommended test for all
hypertensive patients in the future JNC 8 report because microalbuminuria does
appear to have prognostic implications.
Serum calcium (Ca): JNC 7 also recommends serum calcium (Ca) level.
One-third of patients with hyperparathyroidism and hypertension may have illness
attributable to renal parenchymal damage due to nephrolithiasis. Increased
calcium levels can also have a direct vasoconstrictive effect. It is unclear why the
increased serum calcium level in hyperparathyroidism raises blood pressure, as
epidemiologic studies suggest that a high calcium intake lowers blood pressure. It
is also not clear why calcium channel blockers are effective antihypertensive
agents.
Management:
Target goal blood pressure:
Hypertensive patients <140/90 mmHg.
Hypertensive patients with diabetes or chronic renal disease <130/80
mmHg.
Stepwise approach to the treatment of hypertension (as per JNC7):
BP
Classification
Initial Drug Therapy
Without Compelling Indications With Compelling Indications
Normal
Pre-
hypertension
No antihypertensive drug
indicated
(See chart below)
Stage 1
Hypertension
Thiazide- type diuretics for
most. May consider ACEI, ARB,
BB, CCB, or combination.
(See chart below)
Stage 2
Hypertension
Two-drug combination for most
(usually thiazide- type diuretic
and ACE, ARB, beta blocker or
calcium channel blocker)
Other antihypertensive
drug (diuretic, ACE, ARB,
beta blocker, calcium
channel blocker) as needed
Compelling indication Initial therapy options
Heart Failure
Thiazides, beta blockers, ACE inhibitors,
ARBs, aldosterone antagonists
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Compelling indication Initial therapy options
Post-myocardial
infarction
Beta blockers, ACE inhibitors, aldosterone
antagonists
High coronary artery
disease risk
calcium channel blockers
Diabetes
ARBs, calcium channel blockers
Chronic kidney disease ACE inhibitors, ARBs
Recurrent stroke
prevention
Thiazides, ACE inhibitors
Step 1: Encourage lifestyle modifications.
Lifestyle modifications reduce blood pressure, enhance antihypertensive
medication efficacy, and decrease cardiovascular risks.
Lifestyle Modification
Approximate systolic BP
reduction range
Weight reduction 5-20 mmHg/10kg weight loss
DASH eating plan 8-14 mmHg
Dietary sodium reduction 2-8 mmHg
Physical activity 4-9 mmHg
Moderation of alcohol
consumption
2-4 mmHg
Step 2: Initiate antihypertensive drug therapy
For Stage 1 hypertensive patients, initiate one medicationfor most
patients a thiazide-type diuretic. (Other drug classes may also be
considered, such as an ACE inhibitor, ARB, beta blocker, or calcium channel
blocker.)
Stage 2 hypertensive patients without compelling indications are rarely
controlled on one drug alone. They usually require a thiazide-type diuretic
plus an ACE inhibitor, ARB, beta blocker, or calcium channel blocker. A
combination drug pill may reduce pill burden for patients and improve
compliance.
Special caution must be exercised in initial combined therapy in those at risk
for orthostatic hypotension such as the elderly, diabetic patients, and
patients with autonomic dysfunction (e.g., paraplegic patients).
Thiazide diuretics:
Hydrochlorothiazide is the most cost-effective antihypertensive drug on the
market (one-month supply costs ~$4.30)
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In use for over 70 years and extensively studied.
May cause hyponatremia (monitor blood electrolytes).
Avoid in patients with history of gout (may precipitate flares).
May be problematic for urine-incontinent patients.
Marked reduction in morbidity and mortality from hypertension compared to
newer, more expensive antihypertensive medications.
Doses of hydrochlorothiazide > 25 mg do not decrease blood pressure
further or further reduce morbidity and mortality rates.
Should be started at lower doses in elderly patients such as 6.25 mg or 12.5
mg a day (this population may experience hypotensive episodes). Although
elderly patients start at lower doses, they may require the same amount of
medication as younger persons to control their blood pressure.
Most other adults can start at 25 mg per day.
Doses of hydrochlorothiazide above 25 mg do not decrease blood pressure
further or further reduce morbidity and mortality rates.
Step 3: Titrate dose and/or add second agent
If blood pressure is still not at goal, continue to titrate dose in upward increments
until blood pressure control is achieved or maximum effective dose of the drug
has been reached. If blood pressure control has not been achieved at a maximum
effective dose of the initial drug, add another agent from another class. The
recommended second medication may be from the following classes: ACE
inhibitors, ARBs, beta blockers, or calcium channel blockers.
Step 4: Increase dose of second agent
If at subsequent visits, blood pressure in not adequately controlled after starting
the second agent, then titrate dose of second agent in upward increments until
blood pressure is optimal. If at maximum doses of the double combination of
medications blood pressure is still not at goal, continue adding agents from other
classes. Most hypertensive patients will require two or more medications to
optimize their blood pressure.
Socio-cultural considerations of hypertension treatment:
Lifestyle issues and socioeconomic factors may be critical barriers to blood
pressure control.
Blood pressure control rates are lowest in Mexican Americans and Native
Americans.
Prevalence, severity, and impact of hypertension are increased in African
Americans.
African Americans demonstrate somewhat reduced blood pressure
responses to monotherapy with beta blockers, ACE inhibitors, or ARBs
compared to diuretics or calcium channel blockers. These differences are
usually eliminated by adding adequate doses of a diuretic.
African Americans are two to four times more likely to develop angioedema
from ACE inhibitors than other groups.
Resistant hypertension and referral to specialist:
10 of 12 10/26/11 7:53 AM
Resistant hypertension is defined as the failure to achieve goal blood pressure in
patients who are adhering to full doses of an appropriate three-drug regimen that
includes a diuretic. Causes of resistant hypertension include:
Improper blood pressure measurement
Excess sodium intake
Inadequate diuretic therapy
Medication issues such as inadequate doses, drug actions and interactions
(e.g., non-steroidal anti-inflammatory drugs (NSAIDs), illicit drugs,
sympathomimetics, oral contraceptives), or over-the-counter (OTC) drugs
and herbal supplements
Excess alcohol intake
Underlying identifiable causes of hypertension (secondary hypertension)
Adult Treatment Plan III (ATP III) dyslipidemia therapy
recommendations:
ATP III recommends that people with CHD and CHD equivalents
simultaneously start lifestyle modifications and an LDL-lowering drug. LDL
goal is 70100 mg/dl.CHD risk equivalents include:
1.
Clinical CHD
Symptomatic carotid artery disease
Peripheral arterial disease
Abdominal aortic aneurysm
Diabetes is considered a CHD risk equivalent in ATP III
Determine the presence of major risk factors (other than LDL) that may
modify the LDL goal:
2.
Cigarette smoking
Hypertension (BP > 140/90 mmHg or on antihypertensive medication)
Low HDL cholesterol (< 40 mg/dL)
Family history of premature CHD (CHD in male first degree relative < 55
years; CHD in female first degree relative < 65 years)
Age (men > 45 years; women > 55 years)
If two or more risk factors (other than LDL) are present without CHD or CHD
risk equivalent, assess the 10-year (short-term) CHD risk (Framingham).
ATP III recommends that individuals with two or more risk factors (10-year
risk 1020%) take an LDL-lowering drug after three months of lifestyle
modifications if the LDL is still ! 130 mg/dL.
3.
Almost all people with 01 risk factor have a 10-year risk < 10%, thus
10-year risk assessment in people with 01 risk factor is usually not
necessary.
4.

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54-year-old male with elevated blood pressure - Mr.

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