Rotation Information |
Administration |
Rotation Information |
Administration |
Patient Education |
JNC 7 Full Report, 2003 |
AFP - Diagnosing Secondary Hypertension, 2003 |
NEJM - Resistant Hypertension, 2006 |
|
AFP - Hypertension in Children and Adolescents, 2006 |
NEJM - Systolic Hypertension in the Elderly, 2007 |
AFP - Hypertensive Disorders of Pregnancy, 2008 |
NEJM - Initial Treatment of Hypertension, 2003 |
AFP - Combination Therapy of Hypertension, 2008 |
NEJM - Hypertensive Retinopathy, 2004 |
AFP - Hypertension in Older Patients, 2005 |
JAMA - Systolic Hypertension in Older People, 2004 |
Below is a list of short cases or prompts to highlight a variety of common diagnostic and management dilemmas in the realm of hypertension. For each case, consider what you have done in practice and what you have seen other providers do. Following the case prompt is a brief summary of what our references would recommend in this situation. Like everything in medicine, these dilemmas need to be approached with both science and art as we take care of our patients.
A 45 yo male with a strong FH of CAD was admitted with an STEMI 4 days ago. After management of his acute symptoms, he was found to have new diagnoses of HTN, hyperlipidemia, and mild LV systolic dysfunction with an EF of 45%. You look back and a BP in the office 9 months ago was 162/90. What medication(s) would you choose to manage this patient’s HTN?
Literature Review:
This patient has probably stage 2 HTN. He has “compelling indications” for certain drugs due to his recent MI. Though HCTZ would have been an appropriate choice in the office 9 months ago, at this time I would start with BOTH a beta blocker and an ACE-I. Low doses of each should be started and titrated up as an outpatient to reach a goal of < 130/80.
Bottom Line: Beta blocker and ACE-I
A 56 yo obese female with type II DM and systolic heart failure (EF 30%) has persistent blood pressures at home and in the office of 148/92. She is prescribed HCTZ 25, Enalapril 40, and Metoprolol 200. What is your target blood pressure for this patient and what are your next steps?
Literature Review:
This patient has resistant HTN – defined as BP not at goal despite full doses of 3 anti-hypertensives including a diuretic. This patients BP goal is < 130/80 due to DM and CHF. With any patient is important to review compliance and understanding of medications and BP goals. The JNC reference card lists a differential to think about for resistant HTN and also suggests re-reviewing the possibility of secondary causes. In this patient with CHF a likely cause of resistant HTN is under-diuresis. The NEJM article states that more than 60% of patients with resistant hypertension have signs of volume overload and have improved HTN with improved diuresis. Particularly if she has CKD, a loop diuretic instead of HCTZ may be more effective.
Bottom Line: Review med & diet compliance, review secondary causes again. In this patient, consider more aggressive diuresis.
A 73 yo male has longstanding HTN which is only fairly well controlled. He takes HCTZ 25, Enalapril 20, and Atenolol 50. His BPs in the office and at home run 150s/90s. He is known to have CKD with a creatinine of 1.9 (GFR 37). How might you adjust his medications?
Literature Review:
Aggressive control of BP < 130/80 and use of ACE-I or ARBs have been shown to slow progression of diabetic and non-diabetic kidney disease. This patient is not yet at goal. His HCTZ might no longer be effective for him given his low GFR. I would consider stopping the HCTZ and increasing the ACE-I. An increase in the creatinine up to 35% above baseline is acceptable after increasing an ACE-I as long as it stabilizes over 2-3 months and is not associated with severe hyperkalemia. This patient should already be trying to follow a low potassium diet given his CKD. Also keep in mind in this elderly patient that following standing blood pressures will be helpful to prevent orthostasis and too aggressive BP management.
Bottom Line: Stop HCTZ (not effective). Try to increase ACE-I to get to BP < 130/80.
A 62 yo female with schizophrenia and poor med compliance presents to the FMI after a 15 month absence. She has known HTN and is prescribed HCTZ 25 and Atenolol 25. She was sent over from the Crisis Unit for evaluation because blood pressures there were 190 / 100. She has a headache and is anxious but denies any other complaints. How should you manage her blood pressure? Does she need to be admitted?
Literature Review:
This patient needs to be assessed for signs and symptoms of end-organ damage – including mental status change, pulmonary edema, unstable angina, acute renal failure, (pre-eclampsia if pregnant). This requires a careful physical exam - including fundoscopic exam – and lab evaluation. If all this is reassuring, then you can make the diagnosis of hypertensive urgency – high BP, no symptoms. In that situation, the goal is to lower blood pressure over next 24-48 hours. Consider leaving patient in a quiet room to relax and re-check their BP. Then try to choose a med regimen they will be compliant with and bring back for re-check in 48 hours.
If there are signs of end-organ damage on exam or labs, then you have a diagnosis of hypertensive emergency which requires admission and usually IV medication to lower BP in a more controlled fashion.
Bottom Line: Assess for end-organ damage to determine disposition, then treat to lower BP.
A 45 yo female with FH of HTN and generalized anxiety disorder presents to your office. She is very anxious about taking medicines but also anxious about having a stroke like her mother. She has been told she has “mild” HTN in the past. Her BP today is 187/89. At past visits she generally runs systolics in the 160-180s with a HR in the 90s. She tells you her BP when she checks at Walmart is always normal. Is this white coat HTN? What should you do?
Literature Review:
This is a patient with whom building a therapeutic alliance will be very valuable. Clearly her anxiety is playing a role in her BP, but likely will also influence her ability to engage in her diagnosis and be compliant with treatment recommendations. Looking carefully for end-organ damage will be a great clue as to whether she has HTN that is of clinical significance. If she has end-organ damage, then she by definition has HTN and treatment should proceed accordingly.
If no end organ damage, some would advocate for home BP or ambulatory BP monitoring to get a more accurate set of readings. Indications for ambulatory monitoring are:
- Suspected white coat hypertension
- Suspected episodic hypertension (eg, pheochromocytoma)
- Hypertension resistant to increasing medication
- Hypotensive symptoms while taking antihypertensive medications
- Autonomic dysfunction
Even if ambulatory monitoring is normal, there is data to suggest that white coat HTN only is an independent risk factor for stroke and for developing regular HTN. This patient should be seen regularly in follow-up not only for BP but also for her anxiety.
Bottom Line: White coat hypertension means BP are normal out of the office. People with white coat HTN are at increased risk for HTN and should be seen in follow-up regularly.
You are on your surgery rotation and are seeing a patient for a quick H&P prior to their scheduled hemi-colectomy for a concerning colonic polyp that was non-resectable with colonoscopy. This 52 yo male has a PMH of HTN only and takes Atenolol and HCTZ daily. He believes his doctor told him not to take anything by mouth including medicines before the surgery. His pre-op blood pressure is 182/94. Did his doctor give him good advice? What should you do now?
Literature Review:
The patient could have and probably should have continued his beta-blocker the morning of surgery. His blood pressure at this time, however, is not a contraindication to surgery as uncontrolled HTN is considered only a “minor” surgical risk. In conjunction with anesthesia, I would probably give him some form of beta blocker IV or po prior to going to the OR. Caution should be taken in patients with multiple medications not to abruptly stop them with surgery – especially Clonidine and/or beta blockers – can see severe rebound HTN.
Bottom Line: Continue beta blockers prior to surgery.
A healthy 24 yo G2 P1 presents at 10 weeks for her first pre-natal visit. She is feeling fine and takes only PNV. Her previous pregnancy ended in an induction for pre-eclampsia at term, NSVD. Her BP at your visit is 152/92. You look back and see a similar BP at her post-partum visit two years ago. Is this a problem? What should you do?
Literature Review:
This patient meets criteria for the diagnosis of chronic HTN since she likely had HTN before becoming pregnant and has BP > 140/90 before 20 weeks gestation. She should be screened for end-organ damage with a UA and BMP. Treatment of HTN in pregnancy is reserved for BPs > 150/90 as treatment of mild HTN does not improve neonatal outcomes. Labetolol, Hydralazine, and Nifedipine are commonly used. ACE-I and Propranolol and Atenolol are not recommended due to teratogenicity (ACE-I) and IUGR. She should have ongoing blood pressure monitoring, serial measurements of proteinuria, observation for sxs of pre-eclampsia and antenatal testing for growth beginning around 28-32 weeks.
Bottom Line: This is chronic HTN in pregnancy and should be treated – Labetolol or Nifedipine. Check renal function, follow for proteinuria and sxs of pre-eclampsia. Begin antenatal testing at 28-32 weeks.
A 12 year old boy presents for a WCC. He is feeling fine and he and his mom have no concerns. He is doing well in school and mom states he eats a balanced diet. His height is 60 inches, weight is 130 lbs. BMI is 25. BP taken by the MA is 129/89. Exam is otherwise unremarkable. How would you counsel this child and parent? Does he have HTN? What are your next steps?
Literature Review:
This patient is considered overweight based on his BMI for age. His blood pressure is also in > 95% range based on his age, height, and gender, giving him the diagnosis of Stage 1 HTN. Technically he should have three different readings elevated like this one before making the diagnosis. He should have a physical exam just like we have discussed for adults looking for target organ damage, and signs of secondary causes. The most common cause of HTN in this age group is renal parenchymal disease, but essential HTN is second, and perhaps more likely in this patient given his obesity.
Children with a diagnosis of HTN should have a lab evaluation to include CV risk assessment (FLP, fasting glucose) but also to look for end-organ damage (Echo, retinal exam). Evaluation for secondary causes in children focuses first on the kidneys and should include a UA and a renal ultrasound as well as a CBC and BMP. First line therapy for Stage 1 HTN in children is diet and lifestyle changes.
Bottom Line: Make the diagnosis with careful review of BMI and blood pressure in all kids. Review diet, screen time and exercise in more detail. Confirm diagnosis after three readings, then get labs, Echo, and renal ultrasound. Begin medication only if intensive TLC is ineffective.