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Hypertension, Hyperlipidemia: Are our children safe?

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Title: Hypertension, Hyperlipidemia: Are our children safe?


1
Hypertension, Hyperlipidemia Are our children
safe?
  • Patrick R

2
Hints and exam tips
  • HTN is a hot topic for exams particularly, what
    is really malignant HTN and who needs urgent
    treatment.
  • Also be sure that you know how to recognize the
    secondary causes of HTN
  • Lipids are less beloved by examiners though they
    do like to ask about niacin and flushing

3
Cardiovascular risk in your clinic patients
  • Do not approach HTN, Hyperlipidemia as individual
    problems.
  • Look upon them as part of your patients
    cardiovascular risk profile once your patients
    understand that they are changing their lifestyle
    and taking meds to lower their risks of stroke,
    heart attack, kidney disease and peripheral
    vascular disease they will be more likely to
    follow your advice
  • Consider does your pt have the metabolic
    syndrome
  • Any 3 of
  • obesity, high TG, low HDL, HTN, impaired glucose
    tolerance

4
Who are my at risk patients who should I be
screening? (basically everyone!)
  • Obesity
  • Dyslipidemia all pts need fasting lipid profile
  • DM
  • Smoking
  • Lack of exercise
  • Age gt55 for men, gt65 for women
  • FHx of premature cardiovascular disease
  • Microalbuminuria in diabetics

5
Hypertension
  • Management should be based on the JNC-7
    guidelines
  • Treatment should be instituted at gt140/90 in most
    pts or gt130/80 in pts with DM or chronic kidney
    disease
  • Stage II HTN is gt160/100 and only important to
    distinguish because these patients usually need 2
    drugs to control.
  • Making 1st diagnosis needs 2 readings at least 5
    mins apart and in both arms. Many doctors will
    actually get two readings a week or two apart in
    a previously undiagnosed patient, and many
    patients will be resistant to start therapy
    without more than one reading
  • Ambulatory BP monitoring can be used to evaluate
    for white coat HTN, and also helpful in assessing
    response to therapy, or persuading a pt that he
    needs treatment

6
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8
New diagnosis of HTN
  • Assess other cardiovascular risk factors
  • Look for reversible causes of HTN
  • Look for evidence of end organ damage
  • Renal
  • Retinal
  • Cardiac check EKG, consider stress test if any
    history of angina type symptoms
  • CNS take full Hx and evaluate for previous TIA.
    Check for carotid bruits
  • Peripheral artery disease check for AAA and
    distal pulses
  • Lifestyle modification
  • Medication

9
A 56-year-old man undergoes a routine physical
examination. A funduscopic examination is
performed. What does the funduscopic photograph
show? ( A ) Arteriolar sclerosis and
hypertensive retinopathy ( B ) Diabetic
proliferative retinopathy ( C ) Papilledema ( D )
Malignant hypertensive retinopathy
10
  • Correct Answer A
  • Characteristic changes are noted in the retinas
    of patients with longstanding hypertension.
    Narrowing of the terminal branches of retinal
    arterioles may be seen, as well as general
    narrowing of vessels with severe local
    constriction (as shown in this photograph).
  • As the disease progresses, striate hemorrhages
    and soft exudates become visible. In a normal
    eye, retinal arterioles are transparent, so that
    blood flow is visible during ophthalmoscopy. A
    light streak from the ophthalmoscope will reflect
    from the convex wall of the healthy arteriole. In
    a sclerotic arteriole, thickening and fibrosis of
    the vessel wall develop as the sclerosis
    progresses. The central light reflex increases in
    width, and the walls of the vessel look like
    burnished copper, producing a "copper-wire"
    arteriole.
  • With further progression and additional
    fibrosis, the entire width of the arteriole
    reflects the white stripe, producing
    "silver-wire" arteries. This patient's
    funduscopic photograph shows both the "copper and
    silver wires" characteristic of arteriolar
    sclerosis and the characteristic changes of
    hypertensive retinopathy.

11
A 62-year-old hypertensive woman is evaluated
because of headaches and confusion. After her
vital signs are recorded, a funduscopic
examination is performed. Based on the
funduscopic examination, which of the following
conditions most likely present? ( A ) Optic
neuritis ( B ) Arteriolar sclerosis ( C ) Brain
tumor ( D ) Malignant hypertension
12
  • Correct Answer D
  • The retinal changes associated with malignant
    hypertension consist of arteriolar narrowing,
    severe local vasoconstriction, hemorrhages,
    exudates, and papilledema. The exudates are
    caused by fibroid necrosis of vessel walls.
    Papilledema associated with malignant
    hypertension can be differentiated from
    papilledema due to other causes by its clinical
    context.
  • Optic neuritis, generally monocular and another
    cause of a disk swelling, is not associated with
    hypertension and will have accompanying afferent
    pupillary defects and loss of vision. Both
    papilledema associated with malignant
    hypertension and optic neuritis can be
    accompanied by loss of vision. Arteriolar
    sclerosis is not accompanied by papilledema.
    Brain tumors can be associated with papilledema
    but not arteriolar narrowing, vasoconstriction,
    hemorrhages, or exudates.

13
Non-essential HTN
  • Although most cases of HTN are essential HTN,
    always consider whether it could be due to
    another process.
  • Sleep Apnea
  • Drug induced (esp cocaine, also drugs like
    NSAIDS, OCP)
  • Chronic renal disease
  • Renal artery stenosis
  • Cushings syndrome or treatment with steroids
  • Hyperaldosteronism
  • Pheochromocytoma
  • Coarctation of aorta
  • Thyroid and parathyroid disease

14
  • A 25-year-old man is evaluated because of
    several months of episodic sweating, headaches,
    and palpitations. His medical history includes
    surgical repair of ankle injuries sustained in a
    fall while rollerblading 6 months ago the
    anesthesiologist noted that the patient's blood
    pressure fluctuated significantly during the
    procedure and advised him to be evaluated for
    possible hypertension.
  • On physical examination, he is 180 cm (71 in)
    tall and weighs 72 kg (158 lb) his pulse rate is
    80/min, and his blood pressure is 135/80 mm Hg.
    He has no goiter, lid lag, or tremor. Plasma
    glucose was normal during an episode of
    palpitations. His thyroid function tests are
    normal.
  • Measurement of which of the following is the
    best next step in the evaluation of this patient?
  • ( A ) Serum insulin and insulin-like growth
    factor 1 ( B ) Repeat measurements of blood
    pressure ( C ) Catecholamines in a 24-hour urine
    sample ( D ) Thyroid stimulating hormone (TSH)

15
  • Correct Answer C
  • This patient has three classic symptoms that
    suggest pheochromocytoma headache, sweating, and
    palpitations, all of an episodic nature. The
    diagnosis is further suggested by the history of
    labile blood pressure during a recent surgical
    procedure.
  • The fact that he is not currently hypertensive
    does not argue against the diagnosis, because
    many patients with pheochromocytoma have
    hypertension only during their episodic
    paroxysms. Once suspected clinically, the
    diagnosis is established biochemically with the
    finding of elevated urinary secretion of
    catecholamines or their metabolites. Diagnostic
    yield is highest when the collection is initiated
    with the onset of an episode. Though rare,
    pheochromocytoma can be life threatening, and if
    it is considered in the differential diagnosis of
    a patients symptoms, testing should be ordered.
  • Although some of the patients symptoms are
    suggestive of acromegaly or stress, there are no
    other symptoms, historical features, or physical
    findings that support these diagnoses. Physical
    examination does not suggest hypothyroidism, and
    the normal results of thyroid function tests
    exclude this diagnosis. A normal plasma glucose
    concentration during a symptomatic episode
    excludes insulinoma.

16
  • A 41-year-old man is evaluated because of easy
    bruising. His medical history includes recent
    onset of borderline diabetes mellitus, which is
    being treated by diet. Review of systems shows a
    4.6-kg (10-lb) weight gain, fatigue, muscle
    weakness, decreased libido, and depression. He
    uses no drugs, quit smoking 1 year ago, and has
    been drinking one to two six-packs of beer
    nightly.
  • On physical examination, he is 183 cm (72 in)
    tall and weighs 91 kg (200 lb) his pulse rate is
    88/min, and his blood pressure is 150/95 mm Hg.
    He has a round face and supraclavicular and
    posterior cervical fullness. He has plethoric
    facies, tinea versicolor of the chest, no
    petechiae, and three or four ecchymoses on the
    extremities. Neurologic examination is normal,
    except for 3/5 strength in proximal leg muscles.
  • Which of the following is the most likely
    diagnosis?
  • ( A ) von Willebrands disease ( B ) Platelet
    dysfunction ( C ) Hemochromatosis ( D ) Cushings
    syndrome ( E ) Small vessel vasculitis

17
  • Correct Answer D
  • This patient presents with clinical features
    suggestive of Cushings syndrome. Urine-free
    cortisol is the best test to diagnose this
    disorder. However, because of his recent heavy
    alcohol use, he may have alcoholic
    pseudo-Cushings syndrome. This disorder can
    mimic endogenous Cushings syndrome and can only
    be distinguished from it by having the patient
    abstain from alcohol for an extended period of
    time. No evaluation for Cushings syndrome should
    be done until after a period of abstinence.
  • The patients easy bruising can be explained by
    excess circulating cortisol. Small vessel
    vasculitis would produce palpable purpura not
    found in this patient. von Willebrands disease
    could produce bruising but not his other
    symptoms. Platelet dysfunction would produce
    petechiae, not bruising. Hemochromatosis would be
    expected to produce liver function abnormalities,
    heart failure, diabetes, decreased libido, and a
    bronze discoloration of the skin but not the
    hypertension, round face, and abnormal fat
    deposition of Cushings syndrome.

18
  • A healthy 52-year-old woman is evaluated for her
    routine annual physical examination. On physical
    examination, she is 162 cm (64 in) tall and
    weighs 60 kg (130 lb) her pulse rate is 80/min,
    and her blood pressure is 160/100 mm Hg. On two
    subsequent days, she has her blood pressure
    measured and the results are in the same range.
  • Laboratory studies show the following
  • Serum sodium 140 meq/LSerum potassium 3.3
    meq/LSerum creatinine 0.8 mg/dLPlasma glucose 78
    mg/dL
  • Which of the following is the most likely
    diagnosis?
  • ( A ) Primary hyperaldosteronism ( B )
    Renovascular hypertension ( C )
    Pheochromocytoma ( D ) Bartters syndrome ( E )
    Cushings syndrome

19
  • Correct Answer A
  • This patient presents with the typical features
    of primary hyperaldosteronism (autonomous
    overproduction of aldosterone). Most patients
    with this disorder are asymptomatic, and it
    should be considered in all patients with
    hypertension and hypokalemia.
  • A paired plasma aldosterone concentration to
    plasma renin activity ratio of greater than 20 is
    suggestive of this disorder, and referral to a
    specialist is advisable because some patients can
    be cured with unilateral adrenalectomy. Although
    Cushings syndrome may cause hypertension and
    hypokalemia, there are no suggestive clinical
    features of this disorder on the patients
    history and physical examination. Renovascular
    hypertension and pheochromocytoma are not
    associated with hypokalemia. Bartters syndrome
    is associated with hypokalemia but not
    hypertension.

20
Lifestyle modifications
  • Should be prescribed to all patients including
    those in the pre-hypertension range ie.
    120-140 systolic 80-90 diastolic, and really all
    of your patients of a certain age with or without
    other cardiovascular risk factors
  • Weight reduction
  • aim for BMI 18.5-24.9
  • Loss of 10 Kg can reduce BP by up to 20mmHg
  • Diet
  • Reduce saturated fat
  • Increase fruit and vegetable content
  • Can reduce BP by 8-14 mmHg
  • Sodium restriction
  • Reduce to lt2.4g sodium per day can reduce BP by
    2-8mmHg
  • Exercise
  • Aerobic physical activity eg walking for 30 mins
    per day can reduce BP by 4-9mmHg
  • Limiting alcohol
  • lt1 drink per day in women, lt2 drinks per day in
    men can reduce BP by 2-4mmHg

21
Drug choices
  • Thiazides
  • First line in most patients, but risk of gout,
    impaired glucose tolerance, impotence and many
    pts dont like them due to urinary effect
  • ß blockers
  • Useful in pts with heart failure and post MI,
    generally not used in diabetic patients on
    sulfonylureas due to concerns that the ß blocker
    masks the symptoms of hypoglycemia. Also
    contraindicated in pts with bronchospasm
  • Watch for postural hypotension, can cause
    impotence, pts may complain of feeling tired
  • ACE inhibitors
  • Useful in cardiac pts, diabetics and certain pts
    with renal disease
  • Sometimes less helpful in african americans
  • Usually recommended that you check Chem 7 prior
    to starting and a couple of weeks into treatment
    as pts with renal artery stenosis can get rising
    creatinines and dangerously high K
  • Calcium channel blockers
  • Generally not first line now, but usually well
    tolerated.
  • Remember that many patients need two medications
    to adequately control BP.
  • Pt should be scheduled for follow up visit six
    weeks after starting med or changing dose and
    then dose titrated accordingly.

22
  • A 47-year-old man who has had type 1 diabetes
    mellitus for 23 years is found to have
    hypertension that has been unresponsive to
    dietary salt restriction. His physical
    examination shows a blood pressure of 144/94 mm
    Hg and background retinopathy.
  • His creatinine, blood urea nitrogen, and
    potassium are normal. A 24-h urine albumin
    excretion rate is 152 mg. A second urine sample
    is also positive for albumin, which measures 85
    mg/24 h.
  • Which one of the following medications should be
    used to treat this patients blood pressure?
  • ( A ) Thiazide diuretic ( B ) Central
    sympatholytic agent ( C ) Angiotensin-converting
    enzyme (ACE) inhibitor ( D ) Calcium-channel
    blocker

23
  • Correct Answer C
  • Several medications are effective in treating
    hypertension in patients with diabetes.
    Angiotensin-converting enzyme (ACE) inhibitors,
    however, have been shown to have selective
    benefit in this regard they not only lower blood
    pressure, but also can retard the rate of
    progression of any underlying nephropathy.
  • In this patient, the presence of
    microalbuminuria (albumin level greater than 40
    mg/24 h) indicates the presence of early
    nephropathy. Because ACE inhibitors can retard
    the progression of nephropathy even in
    normotensive individuals, these agents should be
    given even if nonpharmacologic therapy has been
    successful in lowering the blood pressure to
    normal levels. However, such use can cause
    hyperkalemia, and because patients with diabetes
    are prone to hyporeninemic hypoaldosteronism
    (type IV renal tubular acidosis), it is important
    to check potassium levels during therapy.
  • Other agents lack this selective benefit and are
    used as second-line treatment or if ACE
    inhibitors cannot be tolerated.

24
  • A 48-year-old woman was found to have primary
    hypertension 6 months ago. Despite a trial of
    lifestyle modifications, her blood pressure
    remained elevated at about 158/96 mm Hg. Therapy
    with amlodipine, 5 mg daily, was begun.
  • The patient returns for a follow-up visit 6
    weeks after beginning amlodipine. Several blood
    pressures readings in the office average 152/92
    mm Hg. She has also noted progressive ankle edema
    since therapy was begun.
  • Which of the following is most appropriate at
    this time?
  • ( A ) No change in therapy ( B ) Change to
    another antihypertensive agent ( C ) Increase the
    amlodipine to 10 mg daily ( D ) Recommend a
    low-salt diet and support hose

25
  • Correct Answer B
  • This patients blood pressure control while on
    amlodipine is inadequate (blood pressure has not
    been reduced to lt 140/90 mm Hg), and she has
    developed pedal edema attributable to the
    dihydropyridine calcium-channel blocker.
  • Her medication should be changed to another
    antihypertensive agent that is unlikely to induce
    edema and will optimize blood pressure control.
  • Adequate control of blood pressure to lt 140/90
    mm Hg is achieved in only 45 of patients treated
    with medication, which represents only 27 of all
    patients with hypertension. This has been labeled
    the great hypertension disconnect. Almost all
    physicians know the target blood pressure of lt
    140/90 mm Hg however, we are not very successful
    in achieving this target.
  • When target blood pressure is not attained there
    are three possible options 1) increase the dose
    of the initial agent, 2) add a second agent, or
    3) change to another drug or class of agent.
  • This patient requires a change to another
    antihypertensive agent to achieve a target blood
    pressure and reduce side effects. Increasing this
    patients dihydropyridine calcium-channel blocker
    is not indicated because this will likely
    increase her edema. A recent randomized,
    double-blind, clinical trail demonstrated that
    thiazide diuretics were superior to calcium
    channel blockers or angiotensin-converting enzyme
    inhibitors in lowering systolic blood pressure.
    The diuretic was superior to calcium channel
    blockers in preventing heart failure, and
    superior to angiotensin-converting enzyme
    inhibitors in reducing combined coronary vascular
    disease outcomes, stroke, and heart failure.
    Since diuretics are less expensive and more
    effective in preventing 1 or more major forms of
    coronary vascular disease, they should be
    preferred for first-step anti-hypertensive
    therapy in most patients. Finally, salt
    restriction and support hose are unlikely to
    resolve the medication-induced edema or improve
    the blood pressure.

26
  • A 56-year-old man is seen for routine follow-up
    of hypertension. He has no complaints. He denies
    any recent change in health status or drug use.
    His has been prescribed a four-drug regimen of
    diltiazem sustained-release (SR), captopril,
    atenolol, and hydrochlorothiazide. He is taking
    all his medications. At his last clinic visit 2
    months ago, his pulse rate was 68/min, and his
    blood pressure was 138/86 mm Hg. He has no other
    medical problems.
  • On physical examination, his pulse rate is
    86/min and his blood pressure is 194/116 mm Hg.
    The rest of his physical examination is
    unremarkable. A stat complete blood count,
    electrolytes, blood urea nitrogen, creatinine,
    glucose levels, and urinalysis are all normal.
  • Which of the following is the most reasonable,
    immediate office-treatment option?
  • ( A ) Captopril and hydrochlorothiazide,
    orally ( B ) Nifedipine, sublingually ( C )
    Lorazepam, orally ( D ) Nitroprusside,
    intravenously ( E ) No change in medications,
    follow-up in 2 weeks

27
  • Correct Answer A
  • The most common cause of accelerated or urgent
    hypertension is noncompliance with prescribed
    therapy, despite frequent patient claims to the
    contrary.
  • Reasonable blood pressure control at the
    previous visit suggests that the regimen was
    effective. The fact that the pulse rate is now
    86/min casts some doubt on whether the atenolol
    has been taken recently. Immediate administration
    of some or all of the patients medications will
    help re-establish that they are effective for
    this patient.
  • It is not necessary to lower the blood pressure
    to normal at this juncture. The use of sublingual
    nifedipine to lower blood pressure has been
    condemned by medical experts and the U.S. Food
    and Drug Administration. The precipitous and
    uncontrolled decrease in blood pressure
    frequently produced by sublingual nifedipine
    presents a risk of myocardial infarction, stroke,
    or death. Because the patient has no evidence of
    acute end-organ damage (papilledema, abnormal
    mental status or neurologic findings), admission
    to the intensive care unit for treatment of
    hypertensive crisis is not warranted. Anxiety is
    not evident, nor is it likely to produce this
    magnitude of blood pressure elevation thus,
    treatment with lorazepam is not indicated. Asking
    the patient to resume treatment with all
    medications (option E) is reasonable, but the
    follow-up period of 2 weeks is unreasonably long.
    It would be preferable to verify that the
    patients regimen is effective before sending him
    home.

28
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29
Lipids
  • Check fasting lipoprotein analysis after 9-12
    hour fast
  • Should be done at first visit to you and then
  • Ideal values
  • LDL lt 130
  • Total cholesterol lt200
  • TG lt200
  • HDL gt40
  • When instituting and following Tx, your first aim
    should be to control LDL. If once LDL is
    controlled the pt still has high TG then consider
    adding nicotinic acid or fibrate

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33
ATP III GUIDELINES
  • STEP 1 Determine lipid level after 9-12 hr. fast
  • STEP 2 Identify CHD risk equivalents
  • Clinical CHD
  • AAA
  • Symptomatic carotid artery disease
  • PAD

34
ATP III Guidelines
  • STEP 3 Determine major risk factors other than
    LDL
  • Cigarette smoking
  • BPgt140/90 or on anti-HTN Rx
  • Low HDL (lt40)
  • Family Hx CHD (lt65 females, lt 55 males)
  • Age (men gt45, women gt55)

35
ATP III Guidelines
  • STEP 4 If 2 risk factors (other than LDL)
    present without CHD/CHD risk equivalent, assess
    10-year CHD risk (Framingham)
  • gt20 CHD risk equivalent
  • 10-20
  • lt10

36
Framingham Risk Scores
  • Method for assessing how aggressive you should be
    at lowering lipids.
  • Based on risk factors identified in the
    Framingham study.
  • Includes age, smoking, BP and both total and HDL
    cholesterol and assigns a score for each result,
    then dependent on total score you can calculate
    10 year risk of having cardiovascular event

37
ATP III Guidelines
  • STEP 5 Determine risk category

38
ATP III Guidelines
  • STEP 6 Institute Lifestyle Changes

39
Very High Risk of CAD
  • Goal LDL should be lt70
  • -pt with established CAD
  • PLUS
  • -multiple risk factors (DM)
  • OR
  • -severe, poorly-controlled risk factors
  • OR
  • -multiple risk factors of the metabolic
    syndrome
  • OR
  • -acute coronary syndrome

40
ATP III Guidelines
  • STEP 7 Consider adding drug therapy
    (simultaneously with lifestyle changes if CHD/CHD
    equivalents)

41
The Drugs
42
ATP III Guidelines
  • STEP 8 Identify metabolic syndrome, and treat,
    if present 3 months after TLC

43
ATP III Guidelines
  • STEP 9 Treat elevated triglycerides
  • Therapeutic lifestyle modifications
  • Primary aim is to reach LDL goal
  • If still high after LDL goal is reached, set HDL
    goal 30 mg/dL higher than LDL goal ? intensify
    statin or add nicotinic acid or fibrate

44
Preguntas
  • 1. 65 yo male with BPH, actively smoking, 210
    lbs, comes for his first physical since 1978. BP
    148/92. Lipid panel T chol 208, LDL 135, HDL
    38, TG 130
  • What are his goals?
  • How do you get him there?

45
What can we do to help you stop smoking?
  • Ask every pt at every visit whether they are
    smoking and how much and document in the chart
  • Find out whether they want to quit
  • Ask what you can do to help them quit
  • Only 5-8 of smokers can quit on their own
  • Advice from a doctor can improve the smoking
    cessation rate by 2.5
  • Quitting smoking can decrease risk of death from
    CAD by 50 in the first year of cessation
  • Cancer risk decreases to risk of 30 to 50
    compared to people who continue to smoke after 10
    years

46
Hazards of Smoking Cessation
  • Withdrawal symptoms
  • Peak in 1-3 days after cessation
  • Cravings can last months
  • Depression
  • Mild, but may still require counseling,
    treatment, or return to smoking
  • Weight gain
  • Often 1-2 kg in first 2 weeks with additional 2-3
    kg over the next 4-5 months
  • Integrate dietary interventions with smoking
    cessation
  • Exacerbations of Ulcerative Colitis

47
Adjuncts in smoking cessation
48
Varenicline (Chantix)
  • Novel partial agonist of nicotinic acetylcholine
    receptors
  • Better than bupropron and placebo at 12 wks and
    52 wks
  • Side effects nausea, abnormal dreams

49
Questions?
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