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How should follow up be conducted after starting a patient on antihypertensives?
- Initially see every 1-2 weeks until BP is stabilized.
- Then Q 3 months for 1 year
- Then Q 6-12 months
What is the first line drug for uncomplicated HTN?
thiazide diuretics (low doses are sufficient-no more than 25mg HCTZ qd)
How does alcohol effect HTN?
- it is a vasopressor!
- Men: <1oz ethanol qday (<24oz beer, 10 oz wine, 3 oz 80 proof wiskey)
- Women: <0.5 oz ethanol q day (half the amount of men)
What is the DASH diet?
- "Dietary Approaches to Stop Hypertension"
- It is an eating plan rich in potassium, magnesium, and calcium obtained from fruits, veggies, and low fat dairy.
What steps should be taken to implement a weight loss plan to control HTN?
- 1. Specify a target weight
- 2. coordinate a dietary intervention (such as 1500 calorie diet)
- 3. give an exercise prescription program
- 4. Use frequent follow-up visits such as every 4-6 weeks.
- 5. Local community groups (Weight Watchers)
- Pts do not need to attain ideal body weight to benefit.
Mnemonic for secondary causes of HTN: ABCDE
- A: accuracy, alcohol, apnea(OSA), aldosteronism(hyokalemia, hyperaldosteronism)
- B: bruits(renovascular HTN), bad kidneys(renal parenchymal dz)
- C: Catecholamines(pheo), coarctation(rib notching on CXR), cushings(wt gain, hirsutism, amenorrhea, striae, moon facies)
- D: Drugs(sympathomimetics, corticosteroids, NSAIDS, OCPs, MAOIs), diet(excess sodium or obesity)
- E: endocrine (thyroid or hyperparathyroidism), erythropoietin (COPD can increase EPO)
Criteria for LVH on EKG
Deepest S wave in lead V1 or V2 plus tallest R wave in lead V5 or V6 > 35mm and/or R wave in lead aVL > 12mm
Age > 35
Left ventricular strain pattern(assymetric ST segment depression and T-wave inversion, usually in leads I, aVL, V4-V6
What are target BP goals with treatment?
- Most patients: <140/90
- Diabetics, renal dz or known CV disease: <130/80
How can one screen for hyperaldosteronism in a HTN workup?
Get a CMP: check potassium and sodium levels!
Labs in HTN workup
- UA: proteinuria and hematuria. If no protein, consider urine microalbumin to screen for early nephropathy.
- Kidneys: BUN and Cr
- ECG: LVH, arrhythmia, and baseline ST segment changes or signs of previous MI
- An echo may be indicated if LVH is supsected on ECG.
- Full Cholesterol panel
Physical exam in HTN
- CV exam: cardiac size, rhythm, third heart sound (S3), peripheral edema, decreased pulses, carotid bruits.
- Neuro: focal weakness, abnormal gait or other neuro abnormalities suggest prior CVA.
- Opthalmoscopic exam for hypertensive retinopathy
- Cushingoid features: moon face
- Renal: diastolic abdominal bruit, suggestive of renovascular HTN
- Coarctation: diminished femoral pulses with HTN in arms
What symptoms suggest end-organ damage in a patient with HTN?
Chest pain, orthopnea, PND, lower extremity edema, claudication.
What are the most common secondary causes of HTN in primary care?
- 1. Alcohol use
- 2. chronic renal dz
- 3. drugs (OTC such as decongestants and illicit drugs)
- Also consider: renovascular HTN, hyperaldosteronism, pheochromocytoma, OSA.
- Specific symptoms that suggest secondary causes: sweating, palpitations, flusing.
Stages of HTN?
- Stage 1:
- SBP 140-149
- DBP 90-99
What is the criteria for diagnosing HTN in most cases?
SBP>140 and/or DBP>90, an average of 3 readings over at least 6 weeks.
How high must BP be to make the diagnosis of HTN in a single office visit?
- -In the absence of a recognized cause of sencondary elevation.
How can an auscultatory gap be avoided when measuring BP?
- Palpate the ipsilateral radial pulse while inflating the cuff, the pulse will disappear when the cuff is adequately pressurized.
- *Take BP in both arms on first BP measurement!!
What is the USPSTF recommendation on screening for HTN
Screen adults 18 years and older, but no mention of an interval for screening.
Reducing systolic BP below 150 mm Hg decreases what?
- Decreased incidence of all types of strokes
- Lowering DBP by 10mm reduces number of strokes by up to 56% and incidence of CAD by 37%.