Family Medicine Hypertension Case File

Family Medicine Hypertension Case File

Eugene C. Toy MD, Donald Briscoe, MD, FA  AFP, Bruce Britton, MD, Joel J. Heidelbaugh, MD, FA  AFP, FACG

Case 30

A 47-year-old African-American man presents to your office for a follow-up visit. He was seen 3 weeks ago for an upper respiratory infection and noted incidentally to have a blood pressure of 164/98 mm Hg. He vaguely remembered being told in the past that his blood pressure was "borderline:' He feels fine, has no complaints, and his review of systems is entirely negative. He does not smoke cigarettes, drinks "a couple of beers on the weekends;' and does not exercise regularly. He has a sedentary job. His father died of a stroke at the age of 69. His mother is alive and in good health at the age of 72. He has two siblings and is not aware of any chronic medical issues that they have. In the office today, his blood pressure is 156/96 mm Hg in his left arm and 152/98 mm Hg in the right arm. He is afebrile, his pulse is 78 beats/min, respiratory rate 14 breaths/min, he is 70-in tall, and weighs 210 lb. A general physical examination is normal.

⯈ What diagnosis (or diagnoses) can you make today?

⯈ What further evaluation needs to be performed?

⯈ What nonpharmacologic intervention(s) may be beneficial?

⯈ What is the recommended initial medication management?

ANSWER TO CASE 30

Hypertension

Summary: A 47-year-old man is found to have an elevated blood pressure reading when seen for an unrelated problem visit. On follow-up, his blood pressure remains elevated. He is obese and leads a sedentary lifestyle, but does not have other high risks based on his personal or family history.

• Diagnoses: Hypertension and obesity
• Necessary further evaluation: Blood glucose; serum potassium, fasting cholesterol panel, estimated glomerular filtration rate (GFR), creatinine, and calcium levels; hematocrit; urinalysis; electrocardiogram (ECG)
• Nonpharmacologic interventions: Dietary Approaches to Stop Hypertension (DASH) diet; alcohol limitation to no more than two drinks per day; increased physical activity; weight reduction
• Recommended initial medication: Thiazide diuretic or calcium channel blocker

ANALYSIS

Objectives

1. Know the diagnostic criteria for hypertension.
2. Learn the recommended initial evaluation of persons found with an elevated blood pressure.
3. Know the medication and lifestyle modifications that can help to control blood pressure.
4. Learn the complications and risks of uncontrolled hypertension.

Considerations

The patient presented here is typical of one seen every day in primary care offices and represents the most common presentation of hypertension. Most hypertensive patients do not have any symptoms of their disease. They are typically seen for another reason and noted to have a high blood pressure reading. Untreated hypertension significantly raises an individual's risk of myocardial infarction, cerebrovascular accidents, and renal failure, among other conditions. The risk of cardiovascular disease doubles with each increase in blood pressure of 20/10 mm Hg above 115/75 mm Hg. Because of the high prevalence of the problem, the lack of symptoms, and the demonstrated efficacy of treatment in reducing the risk of complications, the United States Preventive Services Task Force (USPSTF) recommends screening every adult patient for hypertension by measuring their blood pressure. The appropriate screening interval is not clearly defined, but most practitioners will check the blood pressure of every adult patient at every office visit.

Approach To:

Hypertension

DEFINITIONS

JNC 8: The eighth report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure. A comprehensive, evidence-based review of the diagnosis, evaluation, and management of hypertension published in 2013.

CLINICAL APPROACH

Hypertension is the most common primary diagnosis at physician office visits in the United States each year. Approximately 50 million Americans have hypertension and approximately 30% are unaware of their problem. The prevalence is higher in African Americans and in older patients. National Health and Nutritional Examination Surveys (NHANES) data suggest that hypertension is responsible for approximately one-third of heart attacks, one-half of heart failure, and one-fourth of premature deaths. Most patients with end-stage kidney disease are hypertensive. Hypertensive nephrosclerosis is responsible for approximately one-fourth of endstage kidney disease. The risk of complications is directly related to the elevation of the blood pressure-the higher the blood pressure, the higher the risk.

Elevated systolic blood pressure is a greater risk for cardiovascular disease complications than elevated diastolic pressure. Control of systolic blood pressure tends to be more difficult to achieve, and when it is achieved, the diastolic blood pressure usually comes under control as well. The goal of treatment is to get the blood pressure to less than 140/90 in adults up to age 59 and 150/90 mm Hg in patients over age 60. For persons with diabetes or kidney disease, the goal is to achieve a blood pressure of less than 140/90 mm Hg.

Diagnosis and Workup

The diagnosis of hypertension relies on accurate measurement of blood pressure. The appropriate technique is to allow the patient to sit quietly in a chair (not on the examination table) with a supported back and feet on the floor for 5 minutes prior to making the measurement. The blood pressure should be measured at least twice, using a calibrated sphygmomanometer and an appropriately sized cuff for the patient. The blood pressure cuff should encircle at least 80% of the patient's arm; a cuff that is too small can result in a falsely elevated reading.

The diagnosis of hypertension is made based on the average of two properly taken blood pressure measurements at two or more office visits. The JNC 8 did away with the classification of prehypertension, stages 1 and 2 hypertension in order to focus in on when pharmacologic therapy should be started.

When hypertension is diagnosed, an evaluation consisting of a history, physical examination, and focused diagnostic studies should be performed, with the goals of assessing overall cardiovascular risks, identification of possibly secondary causes of hypertension, and determination of the presence of any end-organ damage.

Secondary causes that should be considered include coarctation of the aorta, renovascular and renal disease, Cushing disease, hyperthyroidism, hyperparathyroidism, hyperaldosteronism, pheochromocytoma, and obstructive sleep apnea. Historical information should include personal and family medical histories, an assessment of diet and activity levels, and specific questioning regarding tobacco, alcohol, recreational drug, and medication (both prescription and nonprescription) use. Patients should be questioned about cardiovascular, cerebrovascular, and peripheral arterial disease symptoms.

Along with blood pressure in both arms, examination should include all other vital signs and a measurement of body mass index. Other specific components of the examination should include a funduscopic examination for signs of retinopathy, oropharynx, and neck for signs of obstructive sleep apnea, palpation of the thyroid, auscultation for carotid, femoral, and renal bruits, palpation of peripheral pulses, abdominal palpation for signs of organomegaly or aortic aneurysm, and a complete cardiopulmonary examination.

Initial testing should include measurement of serum potassium, creatinine (with glomerular filtration rate calculation), and calcium, blood glucose, fasting lipids, and hematocrit. A urinalysis should be done to look for proteinuria or cellular components suggestive of renal disease. An ECG should be performed to evaluate for changes consistent with coronary artery disease and to screen for left ventricular hypertrophy (LVH).

Nonpharmacologic Management

Once the diagnosis of hypertension is made, patients should be advised of specific lifestyle modifications that can both reduce their blood pressure and reduce their overall cardiac risk factors. These should include efforts to lose weight if overweight or obese, increase physical activity, and reduce consumption of alcohol. Men should consume no more than two alcoholic beverages a day and women no more than one. Any smoker should be counseled to quit.

A high-potassium and high-calcium diet, the DASH diet plan, reduces blood pressure in an amount comparable to single-agent drug therapy. An informational brochure detailing the DASH diet is available from the National Heart, Lung, and Blood Institute. Combining the various lifestyle modifications provides additive benefits, and these efforts should continue even when the decision is made to start medications.

Pharmacologic Management

Lowering blood pressure reduces the risk of adverse outcomes such as strokes and heart attacks. In the primary treatment of hypertension in African-American patients, thiazide diuretics or calcium channel blockers are the recommended first-line therapy. In non-African-American patients, according to the JNC 8, the first-line pharmacologic treatment can be diuretics, calcium channel blocker, angiotensin-converting enzyme (ACE) inhibitor, or angiotensin receptor blocker (ARB) with a goal of less than 140/90 in those under 60 years and less than 150/90 if 60 years or older. Patients with hypertension who are inadequately controlled with nonpharmacologic interventions alone should be started the agents described earlier unless there

is a compelling reason to start another class of medication (Table 30-1). T he goal of therapy is to attain and maintain goal blood pressure. If goal blood pressure is not reached with one agent after 1 month, then the physician can either increase the dose of the initial agent or add a second drug.

CASE CORRELATION

• See Case 20 (Chest Pain).

COMPREHENSION QUESTIONS

30.1 A 62-year-old woman presents for a routine physical examination. She is asymptomatic and is not taking any medications. Her blood pressure is found to be 145/85 mm Hg on two readings and her body mass index (BMI) is 29. Review of her chart reveals that her blood pressure was 143/84 mm Hg on a visit 4 months ago for a urinary tract infection. Which of the following is the most accurate statement regarding her blood pressure?

A. Her blood pressure is normal and she is at average risk for developing hypertension.

B. She is at risk for needing pharmacologic treatment for hypertension.

C. She has hypertension and should be started on a thiazide diuretic.

D. She has hypertension and should be started on multidrug therapy

30. 2 A 66-year-old Caucasian woman has an average blood pressure of 155/70 mm Hg despite appropriate lifestyle modification efforts. Her only other medical problems are osteopenia, kidney stones, and mild depression. Her last lipid panel revealed a total cholesterol of 160 mg/dL, high-density lipoprotein (HDL) 40 mg/dL, and low-density lipoprotein (LDL) 90 mg/dL. Which of the following would be the most appropriate treatment at this time?

A. Lisinopril (Prinivil, Zestril)

B. Propranolol (Inderal)

C. Amlodipine (Norvasc)

D. Chlorthalidone

E. Losartan (Cozaar)

30.3 A 48-year-old type 2 Caucasian diabetic man has had persistent blood pressure readings of 150/95 mm Hg for the past 6 months. Current medications include glyburide and metformin. His last HbA1c was 7.9% and the patient has a BMI of 24. On physical examination, position sense is intact but a peripheral neuropathy is detected in a stocking and glove pattern. Vibratory sensation is decreased bilaterally on both lower extremities. Eye examination shows mild papilledema but no cotton wool spots. When questioned, he says that he still occasionally sneaks a cookie after dinner and drinks alcohol nightly. Which of the following is the most appropriate treatment for him?

A. DASH diet and recheck blood pressure in 3 months

B. Thiazide diuretic alone

C. Angiotensin-converting enzyme inhibitor alone

D. Combination of angiotensin-converting enzyme inhibitor and thiazide diuretic

30.4 At a routine checkup, a 6-year-old boy is found to have a blood pressure of 150/90 mm Hg. Repeated blood pressure readings are consistently elevated. The child was delivered at 36 weeks by normal spontaneous vaginal delivery with no complications. All major milestones were met on time and he currently is enrolled in first grade. The child has been healthy up until this point. Which of the following is the most appropriate diagnosis and therapeutic step?

A. The child has essential hypertension and should be started on the DASH diet.

B. The child most likely has hyperthyroidism and should be started on a β-blocker while thyroid studies are performed.

C. The child most likely has renal parenchymal disease and should have a urinalysis and renal ultrasound ordered.

D. The child most likely has "white coat" hypertension and the readings should be ignored if there is no family history of hypertension.

E. The child most likely has a pheochromocytoma and should start a 24-hour urine collection for metanephrines.

ANSWERS

30.1 B. This patient's blood pressure falls within the definition of hypertension but outside the need for immediate pharmacologic intervention. She would benefit from the institution of lifestyle modifications to try to reduce her risk of progression.

30.2 D. In the JNC 8 guidelines, calcium channel blockers, thiazides, ARBs, and ACE inhibitors are first line in nonblack patients over age 60. In this case, β-blockers may worsen the depression. Thiazide diuretics may improve osteoporosis, and reduce hypercalciuria which can reduce nephrolithiasis.

30.3 C. This patient's blood pressure goal is less than 140/90 mm Hg. He is above this goal, so an ACE inhibitor or ARB is first-line therapy regardless of BMI or HbA1c. The dose of the medication can be maximized if blood pressure is not controlled after 1 month, or another agent can be added.

30.4 C. Essential hypertension is rarely found in children less than 10 years of age and should be a diagnosis of exclusion. The most common cause of hypertension is renal parenchymal disease, and a urinalysis, urine culture, and renal ultrasonography should be ordered for all children presenting with hypertension.

CLINICAL PEARLS

⯈ Check every adult patient's blood pressure at every office visit.

⯈ Thiazide diuretics or calcium channel blockers should be the first-line drug treatment in African-American patients with hypertension.

⯈ Diuretics, calcium channel blockers, ACE inhibitors, or ARBs are the first line for non-African-American patients less than age 60. Choice of firstline medication can be tailored to mitigate other comorbidities.

⯈ All patients with chronic kidney disease should have ACE inhibitors or ARBS as first line or add-on treatment.

⯈ All patients with hypertension are at risk for cardiovascular and cerebrovascular disease. Be sure to address their other significant risks for these diseases, including lipids, smoking, diabetes, and obesity.

REFERENCES

James PA, Oparil S, Carter BL, et al. Evidence-based guideline for the management of high blood pressure in adults: report from the pand members appointed to the Eighth Joint National Committee (JNC B).JAMA. 2014:311(5):507-520. 

Kotchen TA. Hypertensive vascular disease. In: Kasper D, Fauci A, Hauser S, et al., eds. Harrison's Principles of Internal Medicine. 19th ed. New York, NY : McGraw-Hill; 2015. Available at: http:// accessmedicine.mhmedical.com. Accessed May 25, 2015 

Langan, R, Jones, K. Common questions about the initial management of hypertension. Am Fam Physician. 2015:91(3):172-177. 

Riley M, Bluhm B. High blood pressure in children and adolescents. Am Fam Physician. 2012;85(7): 693-700.

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