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Common Office Medical Problems

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Title: Common Office Medical Problems


1
Common Office Medical Problems
  • Christian Wagner, MD
  • Clinical Assistant Professor
  • Department of Family Medicine
  • University of Illinois College of Medicine
  • at Urbana-Champaign
  • June 2010

2
  • Hyperlipidemia
  • Hypertension
  • Diabetes
  • Congestive Heart Failure

3
Hyperlipidemia
4
  • Types
  • heterozygous form - associated with total
    cholesterol level gt 300 mg/dL (7.7 mmol/L), high
    risk of coronary artery disease by 30-40, 50
    reduction in LDL receptor activity
  • homozygous form - associated with total
    cholesterol of 600-1000 mg/dL (15.5-26 mmol/L),
    rare, myocardial infarction by age 10 and death
    by age 20 is common, total deficiency of LDL
    receptor activity
  • familial hypercholesterolemia
  • Fredrickson Type IIa hyperlipoproteinemia
  • hyperbetalipoproteinemia
  • group A hyperlipidemia
  • LDL hyperlipoproteinemia

5
  • Incidence/Prevalence
  • hypercholesterolemia is eleventh most common
    diagnosis made during family physician visits
    analysis of patient visits to family physicians
    in United States 1995-1998 in National Ambulatory
    Medical Care Survey hypercholesterolemia
    diagnosis coded in 2.8 of visits (Ann Fam Med
    2004 Sep-Oct2(5)411 full-text)
  • estimated risk for developing dyslipidemia by age
    50 years
  • gt 80 for "borderline-high" LDL cholesterol (
    130 mg/dL 3.4 mmol/L)
  • 50 for "high" LDL cholesterol ( 160 mg/dL 4.1
    mmol/L)
  • 25 women and 65 men for "low" HDL cholesterol
    (lt 40 mg/dL 1 mmol/L)
  • Reference - based on 4,701 Framingham Offspring
    study participants (Am J Med 2007 Jul120(7)623)
  • prevalence of elevated cholesterol in children
    and adolescents
  • based on cohort of 9,868 children aged 6-17 years
    from National Health and Nutrition Examination
    Survey 1999-2006
  • prevalence of elevated total cholesterol (cut
    point 200 mg/dL or 5.2 mmol/L) 10.7
  • mean total cholesterol 163 mg/dL (4.2 mmol/L)
  • prevalence of elevated LDL cholesterol in 2,724
    adolescents aged 12-17 years (cut point 130 mg/dL
    or 3.4 mmol/L) 6.6
  • mean LDL cholesterol in adolescents 90.2 mg/dL
    (2.3 mmol/L)
  • estimated only 0.8 of adolescents exceed LDL
    threshold for considering for pharmacological
    treatment by current AAP guideline
  • Reference - Circulation 2009 Mar 3119(8)1108

6
  • Causes
  • autosomal dominant LDL receptor defect
    (heterozygous), inherited as autosomal codominant
    trait, else polygenic hyperlipidemia
  • Likely risk factors
  • diet
  • hypothyroidism
  • nephrotic syndrome
  • obstructive liver disease
  • hepatoma
  • Cushing's syndrome
  • anorexia nervosa
  • Werner's syndrome
  • acute intermittent porphyria

7
  • Complications
  • very high risk of CAD, premature atherosclerosis
  • elevated cholesterol clearly shown to be a risk
    factor for cardiovascular mortality in men 40-64
  • elevated cholesterol in younger men (35-39) shown
    to be associated with increased long-term risk
    for cardiovascular and total mortality study of
    64,205 men 35-39 followed 16 years plus 2 other
    studies of 12,283 men 18-39 followed 25-34 years
    increasing total cholesterol level associated
    with strong graded independent risk for total
    mortality and cardiovascular disease total
    cholesterol gt 240 mg/dL (6.2 mmol/L) compared
    with cholesterol lt 200 mg/dL (5.2 mmol/L)
    associated with significantly increased risk for
    total mortality, corresponding to reduce life
    expectancy of 3.8-8.7 years (JAMA 2000 Jul
    19284(3)311), editorial can be found in JAMA
    2000 Jul 19284(3)365
  • Associated conditions
  • association with subclinical hypothyroidism
    controversial
  • hypercholesterolemia associated with subclinical
    hypothyroidism, based on study of 1,191 patients
    40-60, 10.3 prevalence of subclinical
    hypothyroidism among patients with total
    cholesterol gt 309 mg/dL (8 mmol/L) (Clin
    Endocrinol (Oxf) 1999 Feb50(2)217 in QuickScan
    Reviews in Fam Pract 1999 Sep24(6)21)
  • subclinical hypothyroidism not associated with
    abnormal lipid levels after adjusting for
    confounding factors in US population-based study
    of 8,218 adults gt 40 years old (Ann Fam Med 2004
    Jul-Aug2(4)351 full-text)
  • smoking associated with elevated LDL cholesterol
    in study of 492 persons aged 26-66 with
    hypercholesterolemia (Clin Exp Med 2002
    Jul2(2)83)

8
  • Diagnosis Rule out
  • hypothyroidism
  • nephrotic syndrome
  • diabetes
  • obstructive liver disease
  • hypercholesterolemia secondary to diet
  • anorexia nervosa
  • Testing to consider
  • TSH, blood glucose, creatinine
  • fasting lipid profile
  • LDL total cholesterol - HDL - TG/5
  • not valid if TG gt 400
  • cardiovascular risk by lipid panel appears
    similar in patients fasting and non-fasting
  • based on data from 302,430 people without initial
    vascular disease
  • Reference - JAMA 2009 Nov 11302(18)1993

9
  • chemistry - cholesterol/triglyceride gt 1.5 (high
    TG if IIb)
  • high cholesterol - 300-600 mg/dL (800-1000
    homozygous)
  • electrophoresis - increased beta (increased
    pre-beta if IIb)
  • ultracentrifugation - high LDL, normal TG (high
    VLDL if IIb)
  • apolipoprotein B may help guide statin therapy in
    subgroup analysis of Collaborative Atorvastatin
    Diabetes Study (CARDS) (Clin Chem 2009
    Mar55(3)473), editorial can be found in Clin
    Chem 2009 Mar55(3)391)

10
  • Prognosis
  • homozygous - myocardial infarction in teens,
    heterozygous - MI in 40's
  • about 40 persons with familial
    hypercholesterolemia have normal lifespan, based
    on study of large family pedigree (BMJ 2001 Apr
    28322(7293)1019 full-text)

11
  • Treatment overview
  • diet low in cholesterol and total fat, increased
    polyunsaturated-to-saturated fat ratio
  • statins are drug of choice
  • target LDL cholesterol levels
  • "high risk" if coronary heart disease, diabetes,
    peripheral arterial disease, stroke, or 10-year
    cardiovascular risk gt 20
  • LDL goal lt 100 mg/dL (2.6 mmol/L)
  • optional goal lt 70 mg/dL (1.8 mmol/L) encouraged
    if very high risk
  • "moderately high risk" if 2 or more major risk
    factors
  • LDL goal lt 130 mg/dL (3.4 mmol/L)
  • optional goal lt 100 mg/dL (2.6 mmol/L) if 10-year
    risk of cardiovascular disease 10-20
  • "lower risk" if 0 or 1 major risk factor
  • LDL goal lt 160 mg/dL (4.1 mmol/L)
  • Reference - 2004 update to NCEP/ATP III
    guidelines (Circulation 2004 Jul 13110(2)227
    full-text)
  • see Cholesterol screening and management for
    cardiovascular disease prevention for details

12
  • Diet
  • diet low in cholesterol and total fat, increased
    polyunsaturated-to-saturated fat ratio
  • adherence to diet may result in 10-15 reduction
    in cholesterol level
  • insufficient evidence to evaluate
    cholesterol-lowering diet or other dietary
    interventions for familial hypercholesterolemia
  • based on Cochrane review
  • systematic review of 11 short-term randomized and
    quasi-randomized trials evaluating
    cholesterol-lowering diet in 331 children and
    adults with familial hypercholesterolemia
  • all trials of short duration and no primary
    outcomes evaluated ischemic heart disease, number
    of deaths and age at death)
  • no significant differences in most secondary
    outcomes
  • Reference - Cochrane Database Syst Rev 2010 Jan
    20(1)CD001918

13
  • Activity
  • moderate intensity walking may reduce total
    cholesterol/HDL ratio in men with
    hypercholesterolemia (level 3 lacking direct
    evidence)
  • based on randomized trial without clinical
    outcomes
  • 67 men (mean age 55.1 years) with
    hypercholesterolemia randomized to brisk walking
    (burning 300 kcal/walk) vs. control for 12
    weeks
  • walking group had significant reduction in total
    cholesterol/HDL and weight and borderline
    reduction in triglycerides
  • Reference - Prev Med 2008 Jun46(6)545

14
  • use of medications depend on patient's risk
    factors for atherosclerotic disease
  • secondary prevention (treatment for patients with
    atherosclerotic disease) typically targeted at
    LDL cholesterol level lt 100 mg/dL (2.6 mmol/L)
  • for help in determining need for medications in
    primary prevention of atherosclerotic disease,
    see Revised Sheffield table for determining risk
    of coronary artery disease
  • evidence-based assessment finds that
    lipid-lowering therapy generally indicated for
    patients with diabetes or diagnosis of coronary
    artery disease (JAMA 1999 Dec 1282(21)2051),
    summary can be found in Am Fam Physician 2000 May
    1561(10)3133
  • statins would be agents of first choice

15
  • bile acid sequestrants - cholestyramine
    (Questran), colestipol (Colestid), colesevelam
    (Cholestagel)
  • decreases LDL (and cholesterol) up to 25
  • second line drugs, large doses three times daily,
    start at low dose
  • side effects - constipation, fullness,
    discomfort, increases TGs if type IIb, interferes
    with drug absorption

16
  • nicotinic acid
  • side effects often occur gt 1 year after
    initiating drug therapy follow-up of 110
    individuals taking nicotinic acid (133 drug
    exposures), 63 took regular nicotinic acid
    (target dose 3,000 mg/day), 65 took SR nicotinic
    acid (1500 mg/day) 42-43 of each group
    discontinued the drug due to side effects, most
    commonly abnormal liver function tests (11 reg, 9
    SR), flushing (7 reg, 5 SR), abdominal pain (6
    reg, 7 SR), nausea/emesis (6 reg, 4 SR), rash (4
    reg, 4 SR), hyperuricemia (6 reg, 1 SR), and
    hyperglycemia (4 reg, 2 SR) other side effects
    included fatigue, ankle swelling, headache,
    itching, and arrhythmias patients took nicotinic
    acid an average of 16.7 (reg) and 14.9 (SR)
    months prior to developing the symptoms resulting
    in drug cessation (Am J Med 1995 Oct99(4)378 in
    QuickScan Reviews in Fam Pract 1996 Mar14)

17
  • in children
  • review of dietary therapy in children can be
    found in Am Fam Physician 2000 Feb 161(3)675,
    editorial can be found in Am Fam Physician 2000
    Feb 161(3)633
  • if cholesterol remains lt 300 mg/dL (7.8 mmol/L),
    bile acid-binding resins (cholestyramine,
    colestipol) are safe and efficacious
  • little experience with other lipid-lowering drugs
    in children
  • homozygous form very resistant to treatment -
    consider repeated exchange transfusion,
    portocaval shunting, liver transplantation
  • cholesterol-lowering treatments not associated
    with increased risk for non-illness mortality no
    significant associations between
    cholesterol-lowering treatments (diet, drugs,
    partial ileal bypass) and non-illness mortality
    (suicide, accident, trauma) in meta-analysis of
    19 randomized controlled trials lasting at least
    1 year non-significant trend observed in trials
    of dietary interventions and non-statin drugs, no
    increase with statins (BMJ 2001 Jan
    6322(7277)11 full-text)

18
  • Screening
  • see updated NCEP guidelines
  • cardiac risk factors - male gt 45, female gt 55, FH
    premature CHD, smoking, hypertension, HDL lt 35
    negative risk factor if HDL gt 60

19
  • United States Preventive Services Task Force
    (USPSTF) screening recommendations
  • USPSTF guidelines for screening for lipid
    disorders in adults
  • strongly recommend routine screening in men 35
    years old and women 45 years old (USPSTF Grade
    A recommendation)
  • recommend screening men aged 20-35 years and
    women aged 20-45 years if at increased risk for
    coronary heart disease (USPSTF Grade B
    recommendation)
  • no recommendation for or against routine
    screening in men aged 20-35 or women 20 years
    old who are not at increased risk for coronary
    heart disease (USPSTF Grade C recommendation)
  • Reference - USPSTF 2008 Jun or at National
    Guideline Clearinghouse 2008 Jul 2812634,
    previous version can be found in Am J Prev Med
    2001 Apr20(3 Suppl)73
  • USPSTF concludes there is insufficient evidence
    to recommend for or against routine screening for
    lipid disorders in children (USPSTF Grade I
    recommendation) (Pediatrics 2007 Jul120(1)e215
    or at National Guideline Clearinghouse 2007 Oct
    1510865), supporting systematic review can be
    found in Pediatrics 2007 Jul120(1)e189
  • United States Preventive Services Task Force
    (USPSTF) grades of recommendation
  • grade A - USPSTF recommends the service with high
    certainty of substantial net benefit
  • grade B - USPSTF recommends the service with high
    certainty of moderate net benefit or moderate
    certainty of moderate to substantial net benefit
  • grade C - USPSTF recommends against routinely
    providing the service with at least moderate
    certainty that net benefit is small, but in
    individual patients considerations may support
    providing the service
  • grade D - USPSTF recommends against providing the
    service with moderate to high certainty of no net
    benefit or harms outweighing benefits
  • grade I - insufficient evidence to assess balance
    of benefits and harms
  • see USPSTF Grade Definitions for more detail

20
  • Reviews
  • review can be found in BMJ 2008 Aug 21337a993,
    commentary can be found in BMJ 2008 Sep
    3337a1493, BMJ 2008 Sep 16337a1681
  • review of treatment of cholesterol abnormalities
    can be found in Am Fam Physician 2005 Mar
    1571(6)1137, commentary can be found in Am Fam
    Physician 2006 Mar 1573(6)973
  • Applied Evidence review of treatment of
    hyperlipidemia can be found in J Fam Pract 2002
    Apr51(4)370
  • review of dyslipidemia can be found in Am Fam
    Physician 1998 May 157(9)2192
  • review of drug treatment of lipid disorders can
    be found in N Engl J Med 1999 Aug 12341(7)498
    (author may have conflict of interest N Engl J
    Med 2000 Feb 24342(8)586), commentary can be
    found in N Engl J Med 1999 Dec 23341(26)2020
  • review of lifestyle, diet, dietary supplements
    and botanicals in management of hyperlipidemia
    can be found in Altern Ther Health Med 2003
    May-Jun9(3)28

21
  • Guidelines
  • synthesis of 3 guidelines (UMHS 2009, USPSTF
    2008, VA/DoD 2006) on screening for lipid
    disorders in adults can be found at National
    Guideline Clearinghouse 2010 Mar 8LIPSCREEN7
  • United States Preventive Services Task Force
    (USPSTF) guidelines for screening for lipid
    disorders in adults can be found in USPSTF 2008
    Jun or at National Guideline Clearinghouse 2008
    Jul 2812634, previous version can be found in Am
    J Prev Med 2001 Apr20(3 Suppl)73
  • USPSTF guidelines for screening for lipid
    disorders in children can be found in Pediatrics
    2007 Jul120(1)e215 or at National Guideline
    Clearinghouse 2007 Oct 1510865, supporting
    systematic review can be found in Pediatrics 2007
    Jul120(1)e189
  • American Academy of Pediatrics (AAP) clinical
    report on lipid screening and cardiovascular
    health in childhood (grade C recommendation
    lacking direct evidence)
  • recommendations include
  • increased physical activity and dietary changes
    for children at risk of overweight or obesity
  • screening between age 2-10 years in children with
    family history of dyslipidemia or premature
    cardiovascular disease or dyslipidemia (or if
    unknown family history or those with other
    cardiovascular disease risk factors)
  • consider pharmacologic intervention in patients
    8 years old with LDL level 190 mg/dL (4.9
    mmol/L) ( 160 mg/dL 4.1 mmol/L with family
    history of early heart disease or 2 other risk
    factors present or 130 mg/dL 3.4 mmol/L if
    diabetes mellitus)
  • limitations of recommendations
  • no data to predict risk of cardiovascular disease
    as an adult based on cholesterol levels in
    children
  • insufficient data to support specific
    evidence-based recommendation for cholesterol
    screening in children
  • insufficient data to support specific
    evidence-based recommendation for specific age to
    implement pharmacologic treatment
  • Reference - Pediatrics 2008 Jul122(1)198 or at
    National Guideline Clearinghouse 2009 May
    1813438, commentary can be found in BMJ 2008 Jul
    23337a886
  • previous American Academy of Pediatrics statement
    on cholesterol levels in children can be found in
    Pediatrics 1998 Jan (Am Fam Physician 1998 May
    157(9)2266 full-text)
  • commentary stating that childhood cholesterol
    screening is not justified can be found in
    Pediatrics 2000 Mar105(3)637 and in Pediatrics
    2001 May107(5)1229
  • parent history screening criteria not much better
    than random population screening in cohort of
    2,475 Quebec youths ages 9-16 years parent
    history had 41 sensitivity, 75 specificity, 8
    positive predictive value and 96 negative
    predictive value for identifying high LDL
    cholesterol (Pediatrics 2004 Jun113(6)1723),
    commentary can be found in Pediatrics 2005
    Jan115(1)195, summary can be found in Am Fam
    Physician 2005 Mar 1571(6)1203

22
Hypertension
23
Hypertension
  • stage 1 hypertension if SBP 140-159 mm Hg or DBP
    90-99 mm Hg
  • stage 2 hypertension if SBP gt 160 mm Hg or DBP gt
    100 mm Hg
  • stages of hypertension in children and
    adolescents
  • stage 1 hypertension if blood pressure 95th
    percentile to 99th percentile plus 5 mm Hg, based
    on charts for gender, age and height
  • stage 2 hypertension if blood pressure gt 99th
    percentile plus 5 mm Hg, based on charts for
    gender, age and height
  • Reference - Pediatrics 2004 Aug114(2 Suppl 4th
    Report)555 full-text, commentary can be found in
    Pediatrics 2005 Mar115(3)826

24
Types of Hypertension
  • types of hypertension based on renin-angiotensin
    system
  • type 1 hypertension is vasoconstrictor, high
    renin
  • renin secretion inappropriately high for blood
    pressure, exaggerated renal elimination of sodium
  • common in young white people
  • responds better to ACE inhibitors, angiotensin
    receptor blockers and beta blockers
  • type 2 hypertensin is sodium dependent, low renin
  • renin secretion suppressed by kidney's detection
    of excessive sodium reabsorption
  • common in young black people
  • responds better to diuretics and calcium channel
    blockers
  • Reference - BMJ 2006 Apr 8332(7545)833,
    commentary can be found in BMJ 2006 Apr
    22332(7547)974

25
Causes
  • unknown
  • 90-95 hypertension is essential hypertension

26
Pathogenesis
  • volume expansion, vasoconstriction - increased
    total peripheral resistance
  • resistant hypertension associated with elevated
    aldosterone and natriuretic peptide levels
  • based on case-control study
  • 279 consecutive patients with resistant
    hypertension (nonresponsive to 3 antihypertensive
    drugs) were compared to 53 controls with normal
    pressure or controlled hypertension
  • resistant hypertension associated with higher
    levels of aldosterone, brain-type natriurietic
    peptide and atrial natriuretic peptide
  • Reference - Arch Intern Med 2008 Jun
    9168(11)1159
  • bosentan, endothelin receptor antagonist, shown
    to reduce blood pressure in 4-week randomized
    trial with effect similar to enalapril adverse
    effects included headache, flushing, leg edema
    and elevated transaminases (N Engl J Med 1998 Mar
    19338(12)784), commentary can be found in N
    Engl J Med 1998 Jul 30339(5)346
  • review of pathogenesis of hypertension can be
    found in BMJ 2001 Apr 14322(7291)912
  • review of pathogenesis of hypertension can be
    found in Ann Intern Med 2003 Nov 4139(9)761

27
  • review of role of aldosterone in pathogenesis of
    metabolic syndrome and resistant hypertension can
    be found in Ann Intern Med 2009 Jun 2150(11)776
  • review of role of endothelin in pathogenesis of
    hypertension can be found in Mayo Clin Proc 2005
    Jan80(1)84
  • review of sodium and potassium in pathogenesis of
    hypertension can be found in N Engl J Med 2007
    May 10356(19)1966, commentary can be found in N
    Engl J Med 2007 Aug 23357(8)827

28
  • patients with normal and high-normal blood
    pressure at significant risk for developing
    hypertension over 4 years
  • based on 9,845 men and women with blood pressure
    lt 140/90 mm Hg in Framingham Heart Study
  • 4-year risk for hypertension in persons lt 65
    years old
  • 5.3 for those with optimum blood pressure (lt
    120/80 mm Hg)
  • 17.6 with normal blood pressure (120-129/80-84
    mm Hg)
  • 37.3 with high-normal blood pressure
    (130-139/85-89 mm Hg)
  • 4-year risk for hypertension in persons gt 65
    years old
  • 16 for those with optimum blood pressure
  • 25.5 with normal blood pressure
  • 49.5 with high-normal blood pressure
  • Reference - Lancet 2001 Nov 17358(9294)1682,
    editorial can be found in Lancet 2001 Nov
    17358(9294)1659

29
  • light-to-moderate alcohol use associated with
    increased risk of hypertension in men but not
    women
  • based on 2 prospective cohort studies
  • 28,848 women from Women's Health Study followed
    for 10.9 years and 13,455 from Physicians' Health
    Study followed for 21.8 years
  • all were without hypertension at baseline
  • 8,680 women and 6,012 men developed hypertension
  • adjusted relative risks for developing
    hypertension in women (compared to rare/never
    drinkers)
  • 0.98 (95 CI 0.91-1.05) for 1-3 drinks monthly
  • 0.96 (95 CI 0.87-1.06) for 1 drink daily
  • 1.1 (95 CI 0.97-1.25) for 2-3 drinks daily
  • 1.84 (95 CI 1.36-2.48) for 4 drinks daily
  • adjusted relative risks for developing
    hypertension in men (compared to rare/never
    drinkers) (p lt 0.0001)
  • 1.11 (95 CI 1-1.23) for 1-3 drinks monthly
  • 1.26 (95 CI 1.15-1.37) for 1 drink daily
  • 1.29 (95 CI 1.08-1.53) for 4 drinks daily
  • in women, relative risks similar with specific
    alcohol types compare to total alcohol intake
  • relative risks remained similar after adjusting
    for baseline blood pressure in women and men
  • Reference - Hypertension 2008 Apr51(4)1080
  • alcohol intake gt 2 drinks/day associated with
    increased blood pressure in men but not women in
    cross-sectional study of 5,448 adults gt 20 years
    old (J Hypertens 2007 May25(5)965)

30
  • dyslipidemia modestly associated with subsequent
    hypertension in prospective study of 16,130 women
    gt 45 years old followed for 10.8 years (Arch
    Intern Med 2005 Nov 14165(20)2420)
  • time urgency/impatience and hostility
    significantly associated with developing
    hypertension in 15-year prospective follow-up of
    3,308 black and white United States adults aged
    18-30 years at baseline no consistent
    associations with depression, anxiety, or
    achievement striving/competitiveness (JAMA 2003
    Oct 22-29290(16)2138), editorial can be found
    in JAMA 2003 Oct 22-29290(16)2190, commentary
    can be found in JAMA 2004 Feb 11291(6)692
  • smaller retinal arteriolar diameters associated
    with development of hypertension
  • in cohort of 2,451 normotensive persons aged
    43-84 years followed for 10 years (BMJ 2004 Jul
    10329(7457)79), correction can be found in BMJ
    2004 Aug 14329(7462)384, commentary can be
    found in BMJ 2004 Aug 28329(7464)514 and reply

31
Factors increasing risk of Hypertension
  • higher salt intake may be associated with
    increased risk for hypertension
  • urinary sodium levels strongly associated with
    systolic blood pressure in 10,074 men and women
    ages 20-59 years in 32 countries (BMJ 1996 May
    18312(7041)1249 full-text), editorial can be
    found in BMJ 1996 May 18312(7041)1241,
    commentary can be found in BMJ 1996 Jun
    29312(7047)1659 and BMJ 1997 Aug
    23315(7106)484
  • some evidence supports international consensus of
    lower risk of hypertension when salt intake is
    lower 24-hour urinary sodium excretion
    associated with systolic blood pressure,
    diastolic blood pressure and hypertension over
    range of sodium excretion rates from 70-400
    mmol/day (Arch Intern Med 1997 Jan 27157(2)234)

32
  • red meat intake may be associated with risk of
    hypertension in women 45 years old
  • based on prospective cohort study
  • 28,766 women 45 years old followed for 10 years
  • frequency of red meat intake assessed by food
    surveys and diagnosis of hypertension identified
    in annual follow-up questionnaires
  • incidence of hypertension in women who consumed
    (p 0.008 for trend)
  • no red meat 21.7
  • lt 0.5 servings daily 29.2 (relative risk RR
    1.24)
  • 0.5-1 servings daily 29.8 (RR 1.25)
  • 1-1.5 servings daily 33.1 (RR 1.32)
  • 1.5 servings daily 35.6 (RR 1.35)
  • Reference - J Hypertens 2008 Feb26(2)215

33
  • association of caffeine intake with hypertension
    may depend on beverage type
  • coffee intake over years associated with small
    increase in blood pressure
  • 1,017 white male former medical students (mean
    age 26) followed for median 33 years
  • consumption of 1 cup of coffee a day raised
    adjusted systolic blood pressure by 0.19 mm Hg
    (95 CI 0.02-0.35) and diastolic pressure by 0.27
    mm Hg (95 CI 0.15-0.39)
  • coffee drinkers had increased risk for
    hypertension compared with nondrinkers at
    baseline (28.3 vs. 18.8, p 0.03), drinking 5
    or more cups/day associated with 1.35-1.6x
    relative risk for hypertension none of these
    associations were statistically significant after
    adjusting for other variables
  • Reference - Arch Intern Med 2002 Mar
    25162(6)657, commentary can be found in Arch
    Intern Med 2003 Feb 10163(3)370

34
  • oral contraceptives may increase risk of
    hypertension
  • based on prospective cohort study of 68,297
    healthy female nurses aged 25-42 years followed
    for 4 years
  • 1,567 developed hypertension
  • 1.5 times relative risk of hypertension with
    current use of oral contraceptives, increased to
    1.8 times when adjusted for other factors
  • no increased risk from past use of oral
    contraceptives
  • absolute risk of hypertension due to oral
    contraceptives was only 41.5 cases/10,000
    person-years
  • Reference - Circulation 1996 Aug 194(3)483

35
  • some prospective cohorts find increased risk of
    hypertension with frequent analgesic use
  • higher daily doses of acetaminophen and NSAIDs
    associated with hypertension in 2 prospective
    cohort studies of women ages 51-77 years and
    women ages 34-53 years (Hypertension 2005
    Sep46(3)500)
  • frequent analgesic use, based on Nurses Health
    Study with 80,020 women ages 31-50 years followed
    for 2 years (Arch Intern Med 2002 Oct
    28162(19)2204), commentary can be found in Arch
    Intern Med 2003 May 12163(9)1113
  • aspirin, acetaminophen and ibuprofen use each
    associated with increased risk of incident
    hypertension in Nurses' Health Study
    (Hypertension 2002 Nov40(5)604 in CMAJ 2003 May
    27168(11)1445)

36
  • Short sleep duration
  • sleep duration lt 5 hours/night associated with
    2.1 times risk of hypertension in cohort of 4,810
    United States persons aged 32-59 years followed
    for 8-10 years of whom 647 were diagnosed with
    hypertension (Hypertension 2006 May47(5)833)
  • sleep duration 5 hours/night associated with
    about 2 times risk of hypertension for women (but
    not in men) in cross-sectional analysis of 5,766
    British persons aged 35-55 years, but results not
    statistically significant in longitudinal
    analysis (3,691 participants normotensive at
    baseline and followed mean 5 years) after
    adjusting for cardiovascular risk factors and
    psychiatric comorbidities (Hypertension 2007
    Oct50(4)693)
  • shorter sleep duration associated with increasing
    risk of hypertension
  • based on prospective cohort of 535 participants
    aged 33-45 years who had objective sleep duration
    and maintenance measurements and followed for 5
    years
  • incident hypertension in 14 over 5-year
    follow-up
  • 37 increase in odds of incident hypertension
    associated with each hour of reduction in sleep
    duration
  • Reference - Arch Intern Med 2009 Jun
    8169(11)1055

37
  • elevated C-reactive protein levels associated
    with increased risk of developing hypertension
  • based on 2 cohort studies
  • elevated C-reactive protein levels associated
    with increased risk of developing hypertension in
    dose-dependent fashion in prospective cohort
    study of 20,525 United States nurses gt 45 years
    old followed median 7.8 years (JAMA 2003 Dec
    10290(22)2945), editorial can be found in JAMA
    2003 Dec 10290(22)3000, commentary can be found
    in Am Fam Physician 2004 Jun 1569(12)2924
  • elevated C-reactive protein levels associated
    with incident hypertension in 7-year follow-up of
    3,919 young adults ages 25-37 years, but no
    significant association after adjusting for body
    mass index (Arch Intern Med 2006 Feb
    13166(3)345), commentary can be found in Arch
    Intern Med 2006 Jul 24166(14)1526

38
  • various single nucleotide polymorphisms in
    CYP19A1 gene associated with essential
    hypertension
  • based on case-control study with 218 patients
    with essential hypertension and 225 matched
    controls
  • Reference - Int J Med Sci 2008 Feb 75(1)29
    full-text
  • low ghrelin levels associated with type 2
    diabetes and hypertension
  • based on case-control study with 1,045 subjects
  • Reference - Diabetes 2003 Oct52(10)2546
  • high levels of trait anger associated with
    increased risk for hypertension in men but not in
    women
  • based on cohort of 2,334 men and women aged 45-64
    years with prehypertension but without heart
    disease or stroke at baseline and followed for
    4-8 years
  • risk of progression to hypertension
  • 59.9 with low trait anger
  • 55.6 with medium trait anger
  • 66.7 with high trait anger
  • association significant in men but not in women

39
Factors not associated with increased risk
  • modifiable low-risk factors associated with
    decreased risk in healthy women
  • based on prospective cohort study
  • 83,882 women aged 27-44 years in second Nurses
    Health Study without hypertension, cardiovascular
    disease, diabetes, or cancer, and with normal
    reported blood pressure were followed for 14
    years
  • incident hypertension in 14.7
  • modifiable low-risk factors independently
    associated with risk of hypertension
  • body mass index (BMI) lt 25 kg/m2
  • daily vigorous exercise (mean 30 minutes)
  • high score on Dietary Approaches to Stop
    Hypertension (DASH) diet based on responses to
    food frequency questionnaire
  • modest alcohol intake ( 10 g/day)
  • use of nonnarcotic analgesics lt 1/week
  • intake of supplemental folic acid 400 mcg/day

40
  • high job stress not associated with developing
    hypertension in 5-year follow-up of 292 healthy
    adults (mean age 38 years) (Hypertension 2003
    Dec42(6)1112)
  • job strain associated with modest increases in
    systolic blood pressure in prospective study of
    8,395 white-collar workers followed 7.5 years (Am
    J Public Health 2006 Aug96(8)1436)
  • vitamin D intake not associated with risk of
    hypertension in 3 cohorts with 209,313 nurses and
    physicians followed for at least 8 years
    (Hypertension 2005 Oct46(4)676)
  • high levels of anxiety and depression appear
    associated with lower systolic blood pressure 11
    years later
  • based on cohort study in Norway
  • 36,530 persons aged 20-78 years followed for 11
    years
  • Reference - Br J Psychiatry 2008 Aug193(2)108

41
  • birth weight does not appear to significantly
    affect adult blood pressure
  • systematic review found that birth weight has
    little effect on blood pressure later in life
  • 55 studies that reported regression coefficients
    found weaker associations with larger studies
  • studies with gt 3,000 participants found inverse
    association of birth weight and blood pressure of
    only 0.6 mm Hg/kg
  • only 25 of 48 studies that did not report
    regression coefficients found inverse association
  • Reference - Lancet 2002 Aug 31360(9334)659,
    commentary can be found in Lancet 2002 Dec
    21-28360(9350)2072
  • low birth weight has been suggested as risk
    factor for hypertension, but likely a confounding
    factor as maternal hypertension associated with
    low birth weight and parental hypertension
    increases risk of hypertension (BMJ 1998 Mar
    14316(7134)834), commentary can be found in BMJ
    1998 Sep 5317(7159)680 and in BMJ 1999 Apr
    3318(7188)943

42
Complications of Hypertension
  • Hypertension is a risk factor for
  • Coronary artery disease (CAD)
  • Heart failure
  • Chronic kidney disease
  • Stroke
  • Intracerebral hemorrhage
  • Transient ischemic attack (TIA)
  • Peripheral arterial disease (PAD)
  • Aortic regurgitation
  • Atrial flutter

43
Mortality associated with Hypertension
  • usual blood pressure directly related to vascular
    mortality at all pressures above 115/75 mm Hg and
    at all ages above 40 years
  • based on meta-analysis of individual patient data
    from 1 million adults in 61 prospective studies
  • Reference - Lancet 2002 Dec 14360(9349)1903,
    correction can be found in Lancet 2003 Mar
    22361(9362), commentary can be found in Lancet
    2003 Apr 19361(9366)1389, Evidence-Based
    Medicine 2003 Jul-Aug8(4)122
  • increased blood pressure associated with
    increased all-cause and cardiovascular mortality
  • based on prospective cohort study in China
  • 169,871 Chinese adults 40 years old examined in
    1991 and followed up 1999-2000
  • hypertension and prehypertension associated with
    increased all-cause and cardiovascular mortality
    (p lt 0.0001)
  • estimated deaths attributable to increased blood
    pressure in China in 2005
  • 2.33 million cardiovascular deaths
  • 1.27 million premature (lt 72 years old in men and
    lt 75 years in women) cardiovascular deaths
  • 1.86 million blood pressure-related deaths
    attributed to cerebrovascular diseases
  • Reference - Lancet 2009 Nov 21374(9703)1765,
    editorial can be found in Lancet 2009 Nov
    21374(9703)1728

44
  • elevated blood pressure associated with increased
    long-term mortality in young men
  • study of 10,874 men aged 18-39 years followed for
    25 years
  • blood pressure above normal associated with
    increased long-term mortality due to coronary
    heart disease, cerebrovascular disease, and all
    causes
  • Reference - Arch Intern Med 2001 Jun
    25161(12)1501, commentary can be found in Arch
    Intern Med 2002 Mar 11162(5)610
  • systolic (but not diastolic) blood pressure is a
    strong, positive, continuous and independent
    indicator of mortality risk in the elderly
    10-year follow-up of 3,858 outpatients gt 65, 74
    patients (1.9) were lost to follow-up and 1,561
    (41.3) died, 709 (45.4 all deaths) died from
    cardiovascular causes positive continuous,
    graded, strong and independent association
    observed with both total (P lt 0.001) and
    cardiovascular (P lt 0.001) mortality for systolic
    blood pressure (SBP) but not for diastolic blood
    pressure (DBP), no J-shaped mortality curve in
    subjects with lowest SBP and DBP (Arch Intern Med
    1999 Jun 14159(11)1205)
  • Stroke

45
Stroke
  • hypertension and type 2 diabetes increase risk of
    stroke independently based on 19-year prospective
    follow-up of 49,582 Finnish persons ages 25-74
    years (Stroke 2005 Dec36(12)2538)
  • stroke risk correlates with diastolic blood
    pressure (Lancet 1995 Dec 23-30346(8991-8992)164
    7 in J Watch 1996 Jan 1516(2)14)
  • midlife blood pressure associated with late-life
    stroke risk (Arch Intern Med 2001 Oct
    22161(19)2343), summary can be found in Am Fam
    Physician 2002 Mar 165(5)963
  • blood pressure important determinant of stroke
    risk in eastern Asian populations, whereas
    cholesterol concentration less important
    association between blood pressure and stroke
    seems stronger than in western populations
    population-wide reduction of 3 mm Hg in diastolic
    blood pressure should eventually decrease number
    of strokes by about 1/3 (Lancet 1998 Dec
    5352(9143)1801)

46
  • Cognitive decline
  • midlife hypertension associated with late-life
    cognitive dysfunction (JAMA 1995 Dec 202741846
    in J Watch 1996 Jan 1516(2)14)
  • hypertension associated with cognitive decline in
    20-year follow-up of 529 persons aged 18-83 years
    (Hypertension 2004 Nov44(5)631 in BMJ 2004 Nov
    20329(7476)1246)
  • End-stage regnal disease
  • elevated blood pressure is a strong risk factor
    for the development of end-stage renal disease (N
    Engl J Med 1996 Jan 4334(1)13 in QuickScan
    Reviews in Fam Pract 1996 Aug21(5)9, Arch
    Intern Med 2005 Apr 25165(8)923)

47
  • Perinatal mortality
  • maternal chronic hypertension associated with
    increased perinatal mortality in male infants
  • based on prospective cohort study of 866,188
    women with singleton pregnancies
  • 4,749 (0.55) were diagnosed with chronic
    hypertension
  • chronic hypertension in mothers associated with
  • intrauterine death odds ratio 3.07 for males
  • neonatal death odds ratio 2.99 for males
  • intrauterine death odds ratio 0.98 for females
    (not significant)
  • neonatal death odds ratio 1.88 for females (not
    significant)
  • Reference - BJOG 2008 Oct115(11)1436

48
Associated Conditions
  • obstructive sleep apnea
  • sleep disordered breathing and sleep apnea
    syndrome associated with hypertension
  • based on cross-sectional study of 6,132 middle
    aged or older individuals
  • association weak after adjustment for obesity
  • Reference - JAMA 2000 Apr 12283(14)1829,
    correction can be found in JAMA 2002 Oct
    23/30288(16)1985
  • editorial states that hypertension alone does not
    warrant testing for sleep apnea (JAMA 2000 Apr
    12283(14)1880
  • strong association between hypertension and
    obstructive sleep apnea
  • based on cohort of 2,677 adults ages 20-85 years
    referred to sleep clinic for suspected sleep
    apnea
  • Reference - BMJ 2000 Feb 19320(7233)479
    full-text, commentary can be found in BMJ 2000
    Jul 22321(7255)237 full-text
  • sleep-disordered breathing associated with
    hypertension
  • based on study of 1,741 persons ages 20-100 years
    selected as those with higher risk for
    sleep-disordered breathing from interviews of
    16,583 persons
  • Reference - Arch Intern Med 2000 Aug
    14/28160(15)2289, commentary can be found in
    Arch Intern Med 2001 Nov 26161(21)2634
  • sleep-disordered breathing associated with
    increased risk for hypertension
  • based on prospective study of 709 persons who had
    polysomnography and were followed 4 years
  • dose-response relationship found even after
    adjustment for known confounding factors
  • Reference - N Engl J Med 2000 May
    11342(19)1378, commentary can be found in N
    Engl J Med 2000 Sep 28343(13)966
  • drug-resistant hypertension may be associated
    with high rate of sleep apnea
  • based on case series of 41 patients on 3 or more
    antihypertensive medications
  • 83 found to have AHI gt 10/hour on overnight
    polysomnography

49
  • higher blood pressure associated with higher rate
    of bone loss in 3,676 elderly white women
    followed mean 3.5 years, even among women not
    taking antihypertensive agents (Lancet 1999 Sep
    18354(9183)971)
  • increased prevalence of panic attacks and panic
    disorder among hypertensive patients 351
    hypertensive patients compared with normotensive
    controls, 17-19 vs. 11 had panic attacks within
    6 months, 33-39 vs. 22 had history of panic
    attacks, 13 vs. 8 had panic disorder (Am J Med
    1999 Oct107(4)310 in JAMA 2000 Jan 5283(1)29)

50
  • hypertension is a risk factor for type 2 diabetes
  • prospective study of 12,550 persons 45-64 in
    Atherosclerosis Risk in Communities (ARIC) study
    who did not have diabetes at baseline and were
    evaluated at 3 years and 6 years
  • diabetes defined at all time points as fasting
    glucose gt 125 mg/dL (7 mmol/L), nonfasting
    glucose gt 200 mg/dL (11 mmol/L), use of insulin
    or oral hypoglycemic agent, or physician's
    diagnosis of diabetes
  • overall incidence of diabetes was 16.6 cases per
    1,000 person-years
  • hypertension increased risk by relative risk of
    2.43 (95 CI 2.16-2.73)
  • incidence of diabetes was 12 per 1,000
    person-years in 8,746 subjects with normal blood
    pressure
  • incidence of diabetes was 29.1 per 1,000
    person-years in 3,804 subjects with hypertension
  • among 3,804 subjects with hypertension
  • subgroup analysis performed to examine risk
    differences between different classes of
    antihypertensives and no treatment
  • classification of use of medications based on
    asking patient whether the medication had been
    prescribed to treat high blood pressure
  • thiazide diuretics, ACE inhibitors and calcium
    channel blockers were not shown to increase risk
    of diabetes significance of this finding is that
    "risk" of diabetes is not a valid reason to
    withhold thiazide diuretics
  • no significant differences upon comparing drug
    classes
  • beta blockers associated with statistically
    significant increased risk for diabetes compared
    to no treatment for hypertension with relative
    risk of 1.28 (95 CI 1.04-1.57, number needed to
    harm NNH with use of beta blockers if this
    association is true is 122 patients per year)
  • Reference - N Engl J Med 2000 Mar 30342(13)905,
    editorial can be found in N Engl J Med 2000 Mar
    30342(13)969,

51
  • hypothyroidism thyroid replacement in 30
    patients with hypothyroidism and hypertension led
    to reduction in aortic stenosis in all and
    normalization of blood pressure in 15 (Am Heart J
    2002 Apr143(4)718 in Am Fam Physician 2002 Sep
    166(5)851)
  • heart failure found in 2-3 patients with
    hypertension study of 388 patients with
    hypertension, 1.8 had left ventricular systolic
    ejection fraction lt 40, 2.8 had heart failure
    defined as dyspnea plus objective evidence of
    cardiac dysfunction (systolic dysfunction, atrial
    fibrillation or clinically significant valve
    disease) (BMJ 2002 Nov 16325(7373)1156full-text)
  • erectile dysfunction common in men with
    hypertension questionnaires sent to 467 men aged
    18-75 years with hypertension, 104 (22) returned
    questionnaires (mean age 62) 85 were sexually
    active, of whom 68 reported some degree of
    erectile dysfunction, 45 reported severe
    erectile dysfunction (J Urol 2000
    Oct164(4)1188)
  • systemic hypertension more common in glaucoma
    patients (odds ratio 1.29) based on case-control
    study with 27,080 glaucoma patients (Br J
    Ophthalmol 2005 Aug89(8)960)
  • hypermetropia (farsightedness) associated with
    hypertension in study of 321 patients with
    essential hypertension and 188 matched controls
    (Am J Ophthalmol 2005 Sep140(3)446)
  • review of retinal vascular disease associated
    with hypertension can be found in Postgrad Med
    2005 Jun117(6)33, commentary can be found in
    Postgrad Med 2005 Sep118(3)1

52
  • Family History (FH)
  • 75 FH hypertension and cardiovascular disease
  • parental hypertension associated with blood
    pressure change and hypertension
  • based on cohort study
  • 1,160 male persons followed for 54 years (29,867
    blood pressure measurements)
  • 264 (23) reported a parent with hypertension and
    583 new cases of parental hypertension occurred
    during follow-up
  • mean systolic and diastolic blood pressure
    significantly higher at baseline with parental
    hypertension
  • rate of annual blood pressure increase slightly
    higher (0.03 mm Hg) with parental hypertension
    for systolic blood pressure (p 0.04), but not
    diastolic blood pressure
  • risk of hypertension development in men (after
    adjustment for body mass index, alcohol
    consumption, coffee drinking, physical activity,
    and cigarette smoking) compared to men with
    parents without hypertension
  • hazard ratio 1.5 (95 CI 1.2-2) with maternal
    hypertension only
  • hazard ratio 1.8 (95 CI 1.4-2.4) with paternal
    hypertension only
  • hazard ratio 2.4 (95 CI 1.8-3.2) with
    hypertension in both parents
  • early-onset hypertension (age 55 years) in both
    parents associated with
  • 6.2-fold higher adjusted risk (95 CI 3.6-10.7)
    for hypertension at any point in adult life
  • 20-fold higher adjusted risk (95 CI 8.4-47.9) at
    age 35 years
  • Reference - Johns Hopkins Precursors Study (Arch
    Intern Med 2008 Mar 24168(6)643)

53
Physical Findings
  • General Physical
  • see Blood pressure measurement
  • check pulse - decreased if increased ICP,
    increased if hyperthyroidism (also a fib)
  • BP 2 times at visit, both arms, lying and
    standing (orthostatic hypotension with diabetic
    autonomic neuropathy, pheo, drugs)
  • suggestion to use standing BP for management
    decisions in elderly, to avoid risk of
    orthostatic hypotension (letter in Am Fam
    Physician 1996 May 1553(7)2282)
  • If BP difference between arms, use arm with
    consistently higher BP readings for monitoring
    (letter in JAMA 1995 Nov 1274(17)1345)
  • height and weight important for determining
    hypertension in children

54
  • HEENT
  • retinopathy
  • Stage I and II arterial narrowing, AV
    compression, silver/copper wiring (dilated vein
    over narrowed artery)
  • Stage III soft exudates (cotton-wool spots,
    micro-infarctions), flame hemorrhage
  • Stage IV papilledema
  • picture of hypertensive retinopathy can be found
    in Lancet 2004 Feb 7363(9407)456
  • review of hypertensive retinopathy can be found
    in N Engl J Med 2004 Nov 25351(22)2310
  • review of hypertensive retinopathy can be found
    in Lancet 2007 Feb 3369(9559)425, correction
    can be found in Lancet 2007 Jun 23369(9579)2078
  • routine funduscopy not supported by current
    evidence systematic review of studies assessing
    hypertensive retinopathy in adults large
    variation between observers in assessment of
    microvascular retinal changes hypertensive
    retinopathy did not predict hypertension well
    with 3 to 21 sensitivity, 88 to 98
    specificity, positive predictive values from 47
    to 72 and negative predictive values from 32 to
    67 inconsistent associations between retinal
    microvascular changes and cardiovascular risk
    except for retinopathy and stroke (increased risk
    of stroke also present in normotensive people
    with retinopathy) (BMJ 2005 Jul 9331(7508)73
    full-text)
  • check visual fields (tumor)

55
  • Neck
  • JVD, carotid bruits
  • Cardiac
  • PMI, S3 (from high LA pressure, suggests CHF,
    volume overload, need for treatment), S4 (usually
    stiff ventricle, diastolic heart failure), RV
    heave and murmur in back with coarctation of
    aorta, murmurs (TR and MR from dilation, rub in
    hyperthyroidism, murmurs with increased pulse and
    anemia)
  • Abdomen
  • AAA (palpate), abdominal bruits (press until
    scope pulsates), hepatomegaly (pulsatile if
    tricuspid regurgitation), renal mass, striae
  • Extremities
  • edema, decreased extremity pulses, listen for
    femoral bruits
  • decreased, absent and/or delayed femoral pulses
    in coarctation of the aorta
  • Neuro
  • look neurologic deficit as sign of stroke

56
Diagnosis of Hypertension
  • in pediatric patients
  • hypertension defined as average systolic and/or
    diastolic blood pressure 95th percentile for
    gender, age, and height on 3 or more occasions
  • see blood pressure charts for boys and girls
  • Reference - Pediatrics 2004 Aug114(2 Suppl 4th
    Report)555 full-text, commentary can be found in
    Pediatrics 2005 Mar115(3)826
  • new normative BP data in children and adolescents
    can be found in NHLBI Update on 1987 Task Force
    Report (Pediatrics 199698649 in Am Fam
    Physician 1997 May 155(6)2340)
  • study suggests that recommendations on BP cuff
    selection in children need to be reviewed,
    further study may be necessary to establish
    accuracy of published nomogram on normal BP in
    children (Pediatrics 1999 Sep104(3)e30
    full-text)

57
  • JNC 7 report recommends blood pressure cutoff
    when using ambulatory monitoring should be 135/85
    while awake and 120/75 while asleep
  • until relationship between self-recorded pressure
    and incidence of cardiovascular morbidity and
    mortality is further clarified by prospective
    studies, mean self-recorded blood pressure gt 135
    mm Hg systolic or 85 mm Hg diastolic may be
    considered hypertensive based on meta-analysis
    of summary data from 17 studies comparing
    self-recorded and standard blood pressures, 9 of
    which only included normotensive subjects (Arch
    Intern Med 1998 Mar 9158(5)481), commentary can
    be found in Arch Intern Med 1999 May
    10159(9)1007 and in Arch Intern Med 1999 Oct
    25159(19)2365
  • evidence-based review of diagnosis of essential
    and secondary hypertension can be found in
    Applied Evidence in J Fam Pract 2001
    Aug50(8)707
  • review of diagnosing secondary hypertension can
    be found in Am Fam Physician 2003 Jan 167(1)67,
    commentary noting excess licorice as possible
    cause can be found in Am Fam Physician 2003 Jul
    168(1)42

58
Recommended Testing
  • diagnostic workup of hypertension recommended by
    JNC 7
  • electrocardiogram (ECG)
  • urinalysis
  • blood glucose
  • serum potassium, creatinine, and calcium
  • hematocrit
  • lipid profile - HDL cholesterol, LDL cholesterol,
    triglycerides
  • optional - urinary albumin/creatinine ratio or
    urinary albumin excretion

59
  • assess for other major cardiovascular disease
    risk factors - obesity (BMI gt 30 kg/m2),
    dyslipidemia, diabetes mellitus, cigarette
    smoking, physical inactivity, microalbuminuria
    (estimated glomerular filtration lt 60 mL/minute),
    age (men gt 55 years, women gt 65 years), family
    history of premature cardiovascular disease (men
    lt 55 years, women lt 65 years)
  • assess for identifiable causes - sleep apnea,
    drugs (including steroids), chronic kidney
    disease, primary aldosteronism, renovascular
    disease, Cushing's syndrome, pheochromocytoma,
    coarctation of aorta, thyroid disease,
    parathyroid disease

60
  • recommendations from expert panels
  • 4 expert panels summarized are Joint National
    Committee (JNC 7), 2003 European Society of
    Cardiology, 2004 Canadian Hypertension Education
    Program and Institute for Clinical Systems
    Improvement (ICSI)
  • all 4 expert panels recommend
  • serum potassium and creatinine
  • fasting blood glucose
  • fasting lipid panel
  • hematocrit
  • urinalysis
  • ECG

61
  • in children and adolescents (workup of juvenile
    hypertension)
  • testing recommended in all children with
    persistent blood pressure 95th percentile or
    higher
  • BUN, creatinine, electrolytes, urinalysis, urine
    culture
  • CBC
  • renal ultrasound
  • fasting lipid panel, fasting glucose
  • echocardiogram
  • retinal exam

62
  • drug screen if history suggestive
  • polysomnography if history of loud, frequent
    snoring
  • ambulatory blood pressure monitoring if
    white-coat hypertension suspected and when other
    information on blood pressure pattern needed

63
  • additional testing in young children with stage 1
    hypertension and any child or adolescent with
    stage 2 hypertension
  • plasma renin (also if positive family history of
    severe hypertension)
  • renovascular imaging
  • isotopic scintigraphy (renal scan)
  • magnetic resonance angiography
  • duplex doppler flow studies
  • 3-dimensional CT
  • arteriography (DSA or classic)
  • plasma and urine steroid levels
  • plasma and urine catecholamines
  • Reference - Pediatrics 2004 Aug114(2 Suppl 4th
    Report)555 full-text, commentary can be found in
    Pediatrics 2005 Mar115(3)826

64
Blood Tests
  • persistent hypokalemia and metabolic alkalosis in
    Conn's syndrome
  • fasting glucose abnormalities in diabetes
    mellitus, Cushing's syndrome or acromegaly
  • microangiopathic hemolytic anemia
  • renal damage if creatinine gt 1.5
  • no association between serum ionized calcium
    levels and blood pressure in 3,834 patients 65-89
    from NHANES III study (J Am Geriatr Soc 1998
    Sep46(9)S87,P281)
  • genetic testing may eventually guide selection of
    antihypertensives case-control study among HMO
    patients taking drugs for hypertension with 206
    patients with first myocardial infarction, 177
    patients with first stroke and 715 controls
    among 653 with wild-type adducin genotype, use of
    diuretics (compared to other antihypertensives)
    was not associated with increased risk for
    myocardial infarction and stroke among 385
    carriers of variant adducin allele, use of
    diuretics was associated with decreased risk
    (about 50 relative risk) for myocardial
    infarction and stroke (JAMA 2002 Apr
    3287(13)1680)

65
Urine Tests
  • microalbuminuria associated with increased risk
    for cardiovascular events
  • increasing urine albumin-creatinine ratio
    associated with increasing cardiovascular risk in
    cohort of 8,206 patients without diabetes with
    stage II-III hypertension and left ventricular
    hypertrophy, with increased risk starting at
    urine albumin-creatinine ratio gt 1.16 mg/mmol
    (Ann Intern Med 2003 Dec 2139(11)901),
    commentary can be found in Ann Intern Med 2004
    Aug 3141(3)244 PDF
  • microalbuminuria common in hypertension and
    associated with increased risk for cardiovascular
    events in series of 319 patients with newly
    diagnosed mild-to-moderate essential
    hypertension, 40 had microalbuminuria (Am J
    Kidney Dis 1999 Dec34(6)996) follow-up of 54
    patients with microalbuminuria and 87 patients
    with normal urinary albumin excretion for 7 years
    found 12 (21) vs. 2 (2) with cardiovascular
    events (p lt 0.0002) (Am J Kidney Dis 1999
    Dec34(6)973), editorial can be found in Am J
    Kidney Dis 1999 Dec34(6)1139 (QuickScan Reviews
    in Fam Pract 2000 Jul25(4)3) no evidence that
    microalbuminuria screening in hypertension
    affects patient-oriented outcomes (DynaMed
    commentary)
  • no studies to evaluate benefit of screening for
    microalbuminuria in patients already taking ACE
    inhibitors or angiotensin II receptor blockers
    for other indications (J Fam Pract 2003
    Mar52(3)229)

66
Imaging
  • CXR (cardiomegaly, rule out CHF)
  • echocardiography for LVH
  • ACC/AHA/ASE 2003 guideline for clinical
    application of echocardiography can be found in J
    Am Coll Cardiol 2003 Sep 342(5)954, J Am Soc
    Echocardiogr 2003 Oct16(10)1091, Circulation
    2003 Sep 2108(9)1146
  • American College of Radiology (ACR)
    Appropriateness Criteria for routine chest
    radiographs in uncomplicated hypertension can be
    foun
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