13. SMOKING CESSATION-----------------------------PG 96-103 Somerset Family Medicine Clinical Module
Bread & Butter of Family Medicine:
Hypertension Prevelance: Most common chronic condition. Over 60% of elderly have HTN, more common and more severe in African Americans.
Without treatment approximately many will die of CAD, CHF, CVA and renal failure.
Etiology: Majority caused by unknown reason or hereditary, Essential or Idiopathic HTN (90-95%), while 5-10% of cases are due to other causes
Secondary causes: Hyperthyroidism, hyperaldosteronism, pheochromocytoma (epin and norepinephrine, Cushing, sleep apnea and renal artery stenosis.
Meds that increase BP: pseudoephedrine, OCP, NSAIDS, opiates, cocaine and energy drinks.
Usually asymptomatic (silent killer) discovered during routine medical care, but severe HTN may present with headache, dizziness, SOB or blurred vision.
COMPLICATIONS OF CHRONIC HYPERTENSION:
1.Left Ventricular Dysfunction: Due to increased afterload, the left ventricle has to accommodate by increasing its diameters concentrically leading to Concentric left ventricular hypertrophy which can be detected on EKG, on the long run, the hypertrophied LV becomes stiff and Diastolic failure occurs which manifests as S4, eventually Systolic dysfunction ensues if HTN is not controlled.
2. Vascular disease: HTN accelerates atherosclerosis and is considered the most common risk factor for ischemic heart disease, and is a risk factor for both ischemic and hemorrhagic strokes.
3. Hypertensive Retinopathy & NephropathyLeading to eye problems and renal failure.
DIAGNOSTIC TESTS: UA, EKG, Metabolic panel, Lipid panel.
Routine tests for hypertension cases are:
Treatment: JNC guidelines vs standard of care, you may or may not follow guidelines but you must follow standard of care.
Erectile dysfunction: Beta blocker and Diuretics (although others may as well)
In the general population aged ≥60 years, initiate pharmacologic treatment to lower blood pressure (BP) at systolic blood pressure (SBP) ≥150 mm Hg or diastolic blood pressure (DBP) ≥90 mm Hg and treat to a goal SBP <150 mm Hg and goal DBP <90 mm Hg.
In the general population <60 years, initiate pharmacologic treatment to lower BP at DBP ≥90 mm Hg and treat to a goal DBP <90 mm Hg.
In the general population <60 years, initiate pharmacologic treatment to lower BP at SBP ≥140 mm Hg and treat to a goal SBP <140 mm Hg.
In the population aged ≥18 years with chronic kidney disease (CKD), initiate pharmacologic treatment to lower BP at SBP ≥140 mm Hg or DBP ≥90 mm Hg and treat to goal SBP <140 mm Hg and goal DBP <90 mm Hg.
In the population aged ≥18 years with diabetes, initiate pharmacologic treatment to lower BP at SBP ≥140 mm Hg or DBP ≥90 mm Hg and treat to a goal SBP <140 mm Hg and goal DBP <90 mm Hg.
In the general nonblack population, including those with diabetes, initial antihypertensive treatment should include a thiazide-type diuretic, calcium channel blocker (CCB), angiotensin-converting enzyme inhibitor (ACEI), or angiotensin receptor blocker (ARB).
In the general black population, including those with diabetes, initial antihypertensive treatment should include a thiazide-type diuretic or CCB.
In the population aged ≥18 years with CKD, initial (or add-on) antihypertensive treatment should include an ACEI or ARB to improve kidney outcomes. This applies to all CKD patients with hypertension regardless of race or diabetes status.
The main objective of hypertension treatment is to attain and maintain goal BP. If goal BP is not reached within a month of treatment, increase the dose of the initial drug or add a second drug from one of the classes in recommendation 6 (thiazide-type diuretic, CCB, ACEI, or ARB). The clinician should continue to assess BP and adjust the treatment regimen until goal BP is reached. If goal BP cannot be reached with 2 drugs, add and titrate a third drug from the list provided. Do not use an ACEI and an ARB together in the same patient. If goal BP cannot be reached using only the drugs in recommendation 6 because of a contraindication or the need to use more than 3 drugs to reach goal BP, antihypertensive drugs from other classes can be used. Referral to a hypertension specialist may be indicated for patients in whom goal BP cannot be attained using the above strategy or for the management of complicated patients for whom additional clinical consultation is needed.
Investigate for secondary hypertension if you see the following:
Young(< 30) or old(> 60) patient
Failure to control pressure with 2 medications.
≥180/120 mmHg without evidence of end organ damage
≥180/120 mmHg with symptoms or evidence of end organ damage (papilledema, chest pain, acute kidney injury, encephalopathy, focal neurological deficit). These patients should be immediately sent to the ER
# Drug of choice for hyertensive emergency in pregnancy - hydrazine (S/E : coronary steel syndrome)
# Eplerenone is a pottasium sparing diuretic but it does not cause gynecomastia.
# 1st choice of drugs in African American with HTN – CCB(amlodipine)
# ACE inhibitors and ARB’s are C/I in pregnant woman.
# Drug of choice for patients with HTN with asthma- amlodipine
# Drug of choice patients HTN with COPD/angina/supraventricular tachycardia with angina - verapamil.
# Hydrochlorothiazide increases calcium and parathyroid hormone.
#S/E of ACE Inhibitors mnemonic: CAPTOPRIL.
C : Cough
A : Angioedema
P : prodrug(All ACE inhibitors are prodrugs except Captopril and lisinopril)
T : taste alterans(Dysguesea)
O: Orthostatic hypotension.
P : Pregnancy C/I
R : Renal stenosis C/I
I : Increase potassium
L : Lowers angiotensin II production.
# Drug of choice for HTN with BPH – Tamsulosin. It does not cause orthostatic hypotention.
A 45 Yo male presented for routine physical exam, he has no complaints, his Vital signs are as follows: BP 155/90 , HR: 60, Temp: 98, Resp: 13
Which of the following is the best next step in management?
a. Initiate Lisinopril
b. Initiate a diuretic
c. Repeat in 2 wks
d. Doppler U/S of the kidneys
A 32 Y/O male presented for routine health care exam with mild weakness of lower extremities, polydipsia and polyuria, he denied any other complaints, his vital signs are BP: 135/95 , HR: 76, Temp 97.1 , Respiration: 12, His chemistry profile is as follows:
Blood Glucose: 76
Which of the following is the best next step in management?
a. Repeat the BP measurement in 2 weeks
b. Initiate HCTZ
c. Measure Aldosterone/ Renin Ratio
d. Initiate lifestyle changes.
3.A 55 YO male with type 2 DM presented with HTN on more 3 readings, he was initiated on Lisinopril 10 mg 1 wk. ago, his GFR had been decreased from 90 ml/min at that time to 81 ml/min , which of the following is the best next step in management?
Switch to Candesartan 4mg
Switch to a diuretic
Continue treatment with Lisinopril
4. You are seeing a 45-year-old diabetic woman who reports bilateral
and depression. Which of the following medications is the likely
cause of her edema?
5. A 52 YO male patient with HTN presents for complete physical examination, he is taking Amlodipine 10 mg/d, he eats a well balance healthy diet and exercises regularly, but he complains of leg swelling in the last 3 months, physical examination confirms bilateral pitting edema, His cardiac exam is unrevealing, his EKG is normal and His vital signs : BP 130/82, HR: 88, Temp : 97.2 , Respiration: 12
His blood work is as follows:
Anion Gap: 7
Bilirubin total: 0.6
Which of the following is the best explanation of these findings:
6 .A 58 YO male presented to the ER with acute chest pain, he was diagnosed with ST elevation myocardial infarction and was discharged 10 days later on medications.
Two years later he was found dead in his apartment without obvious reason.
The autopsy showed dilated ventricular chambers of the heart with increased cardiac diameters. Which of the following would prevent the subsequent complication if given before?
Atenolol 100 mg
Aspirin 81 mg
Captopril 50 mg
HCTZ 12.5 mg
Simvastatin 20 mg
7. A 1hr neonate born to a 33 YO female presented with respiratory distress immediately after birth, examination revealed a flattened nose, recessed chin, prominent epicanthal folds, and low-set abnormal ears, his mother has oligohydramnios during her pregnancy, which of the following scenario is likely during the pregnancy?
8. You have diagnosed a 35-year-old African American man with hypertension.
Lifestyle modifications helped reduce his blood pressure, but he was
still above goal. You chose to start hydrochlorothiazide, 25 mg daily. This
helped his blood pressure, but it is still 142/94 mm Hg. Which of the following
is the best approach to take in this situation?
a. Increase his hydrochlorothiazide to 50 mg/d
b. Change to a loop diuretic
c. Change to an ACE inhibitor
d. Change to a β-blocker
e. Add an ACE inhibitor.
9.A 58 YO male presented to the ER with headache and confusion for 3 hr, his past medical history is significant for HTN, his vital signs : BP 118/110, HR: 90, Temp 98, Respiration: 12, physical exams shows increased DTRs, which of the following is the best treatment ?