1、Hypertension, Hyperlipidemia: Are our children safe?,Patrick R,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 thou
2、gh they do like to ask about niacin and flushing,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
3、 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,Who are my at risk patients who sh
4、ould I be screening? (basically everyone!),Obesity Dyslipidemia all pts need fasting lipid profile DM Smoking Lack of exercise Age 55 for men, 65 for women FHx of premature cardiovascular disease Microalbuminuria in diabetics,Hypertension,Management should be based on the “JNC-7” guidelines Treatmen
5、t should be instituted at 140/90 in most pts or 130/80 in pts with DM or chronic kidney disease Stage II HTN is 160/100 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
6、 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 persu
7、ading a pt that he needs treatment,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 prev
8、ious TIA. Check for carotid bruits Peripheral artery disease check for AAA and distal pulses Lifestyle modification Medication,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
9、 hypertensive retinopathy ( B ) Diabetic proliferative retinopathy ( C ) Papilledema ( D ) Malignant hypertensive retinopathy,Correct Answer = ACharacteristic changes are noted in the retinas of patients with longstanding hypertension. Narrowing of the terminal branches of retinal arterioles may be
10、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 lig
11、ht 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,
12、 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 patients funduscopic photograph shows both the “copper and silver wires“ characteristic of arteriolar sclerosis a
13、nd the characteristic changes of hypertensive retinopathy.,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
14、 present? ( A ) Optic neuritis ( B ) Arteriolar sclerosis ( C ) Brain tumor ( D ) Malignant hypertension,Correct Answer = D The retinal changes associated with malignant hypertension consist of arteriolar narrowing, severe local vasoconstriction, hemorrhages, exudates, and papilledema. The exudates
15、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 wil
16、l 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 arteriol
17、ar narrowing, vasoconstriction, hemorrhages, or exudates.,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 Cushin
18、gs syndrome or treatment with steroids Hyperaldosteronism Pheochromocytoma Coarctation of aorta Thyroid and parathyroid disease,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 s
19、ustained in a fall while rollerblading 6 months ago; the anesthesiologist noted that the patients 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
20、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 )
21、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),Correct Answer CThis patient has three classic symptoms that suggest pheochromocytoma: headache, sweating, and palpitation
22、s, 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
23、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, pheochromocyt
24、oma 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 the
25、se 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.,A 41-year-old man is evaluated because of easy bruising. His medical hi
26、story 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
27、 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
28、 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 vess
29、el vasculitis,Correct Answer DThis 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 endoge
30、nous 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. S
31、mall 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 f
32、ailure, diabetes, decreased libido, and a bronze discoloration of the skin but not the hypertension, round face, and abnormal fat deposition of Cushings syndrome.,A healthy 52-year-old woman is evaluated for her routine annual physical examination. On physical examination, she is 162 cm (64 in) tall
33、 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
34、mg/dLPlasma glucose 78 mg/dLWhich of the following is the most likely diagnosis?( A ) Primary hyperaldosteronism ( B ) Renovascular hypertension ( C ) Pheochromocytoma ( D ) Bartters syndrome ( E ) Cushings syndrome,Correct Answer = AThis patient presents with the typical features of primary hyperal
35、dosteronism (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
36、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. Renova
37、scular hypertension and pheochromocytoma are not associated with hypokalemia. Bartters syndrome is associated with hypokalemia but not hypertension.,Lifestyle modifications,Should be prescribed to all patients including those in the “pre-hypertension” range ie. 120-140 systolic 80-90 diastolic, and
38、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 2.4
39、g 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 1 drink per day in women, 2 drinks per day in men can reduce BP by 2-4mmHg,Drug choices,Thiazides First line in most patients, but risk of gout, impai
40、red glucose tolerance, impotence and many pts dont like them due to urinary effect blockers Useful in pts with heart failure and post MI, generally not used in diabetic patients on sulfonylureas due to concerns that the blocker masks the symptoms of hypoglycemia. Also contraindicated in pts with bro
41、nchospasm 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 o
42、f 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 u
43、p visit six weeks after starting med or changing dose and then dose titrated accordingly.,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 144/9
44、4 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 patient
45、s blood pressure?( A ) Thiazide diuretic ( B ) Central sympatholytic agent ( C ) Angiotensin-converting enzyme (ACE) inhibitor ( D ) Calcium-channel blocker,Correct Answer = CSeveral medications are effective in treating hypertension in patients with diabetes. Angiotensin-converting enzyme (ACE) inh
46、ibitors, 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
47、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 be
48、cause 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.,A 48-year-old
49、 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 bl
50、ood 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,
