Our talk this
evening was given by Jake Decker, PGY2 in Primary Care on a specific facet
of hypertension discussed the previous week: Primary Hypertension.
HTN Definition and Goals:
- Elevated BP: a reading of elevation or not.
- HTN: a diagnosis, disease state. The average of 2+ properly measured reading at each of two or more visits after initial screen.
- Clinically we use these guidelines of whether patients are at these goals:
- ages 18-59: <140/<90
- ages >60: <150/<90
- DM (all ages):
- <140/<90 because of comorbidities
- Cutoff still controversial because not sure if want to be aggressive with older patients' BP because it might be harmful.
- Kidney disease (all ages): <140/<90
HPI:
- Diet, obesity
- Episodic/constant
- Associated with other conditions?
- Recent caffeine intake
- Kidney problems
- What meds patients is on (NSAIDs, steroids, SSRIs, TCAs, OCPs)
- Smoking, alcohol, and cocaine use (raises BP)
- HA, dizziness
- Vision change
- chest pain, palpitations
- snoring, daytime tiredness
- Sweating, tremors
Physical exam:
- General impressions
- Take vitals at least twice
- Eye exam (retinal hemorrhages)
- Vascular exam (asymmetric or diminished pulses)
- Cardiac (stenosis, dilated heart muscle)
- Lungs (crackles)
- Basic metabolic panel; creatnine reading to assess end organ damage.
- Urinalysis; CKD can cause HTN, chronic HTN causes CKD.
- EKG: conduction abnormalities, previous/current ischemia or infarction, LV hypertrophy.
Treatment:
- 1) Lifestyle modification
- Diet/exercise, quitting smoking/drinking.
- Dash and Mediterranean diets are most largely studied for HTN.
- Limit sodium to <2400 mg/daily.
- If end organ damage and reading of 160/90, skip to step 2.
- 2) Pharmacotherapy
- Thiazide diuretics
- Calcium channel blockers
- ACE inhibitors
- ARBs
- For non-black patients: all equal choices
- For black patients: thiazide or CCB
- For CKD patients: ACEi or ARB because they reduce pressure in glomerulus.
- For women of childbearing age: CCB
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