Cardiology (Case Discussion Of Htn)

Front 1

Mr. Smith is a 55-year-old man, a business executive who presented to your office for a routine check-up. A year ago, he had his annual physical exam and medical check-up and was told that his BP was 120/76 mm Hg. He was not known to have any coronary risk factors except for smoking 2 packs of cigarettes daily for the last 20 years (2x20 = 40 pack years of smoking).
He takes no medications (including no over-the-counter drugs). Family history: his father died suddenly and unexpectedly at 42 years of age (first degree, male relative, often a sign of coronary disease) and his mother died of breast cancer.

Physical examination:
Mildly overweight man in no acute distress.
WT= 210 lbs, HT= 5’ 6”

Vital signs: BP=136/88 mm Hg (confirmed twice on two separate days by your clinic nurse) and HR=62/min.

Pertinent laboratory findings:
Fasting blood sugar (FBS)= 180 mg% (normal 100-125)
Hemoglobin a1c, glycosylated hemoglobin (this is a measure of the average blood sugar over about two months) = 9 (normal value: <7%).

BUN= 24 (normal 8-20)
Serum creatinine= 1.5 mg% (normal 0.7-1.1 mg%).
Last year, his BUN and creatinine values were normal: 18 and 1.0 mg%.

Lipid Profile:
Total cholesterol= 250 mg% (high cholesterol is >240 and intermediate high is 200-240 mg%)
LDL cholesterol= 180 mg% (high LDL is defined as >130 mg%) and
HDL= 35 mg% (low HDL is <40 and high HDL is >60 mg%)

Question # 1: Which of the following coronary risk factors does Mr. Smith have?

A. Diabetes mellitus (DM) and hypertension (HT)
B. DM and high LDL cholesterol
C. DM, high LDL, low HDL & family history (FH) of CAD
D. Male>45, DM, smoking, high LDL, low HDL & FH of CAD
E. Male>45, DM, smoking, high LDL, low HDL, FH of CAD & HT

Back 1

D. FH of HT is not a risk factor for CAD

Front 2

How would you best characterize Mr. Smith’s blood pressure?

A. Normal blood pressure
B. Isolated systolic hypertension
C. Pre-hypertension
D. Hypertension
E. Optimal blood pressure

Back 2

C.

Front 3

hich of the following strategies would you now recommend to Mr. Smith?

A. Salt restriction & weight reduction
B. Drug therapy to lower BP despite a BP < 140/90
C. Exercise, salt restriction & weight reduction
D. Stop smoking, exercise, salt restriction & weight reduction
E. Both B and D

Back 3

E. you start drug therapy only in pts with BP of 140/90, EXCEPT FOR PTS WITH DIABETES!!!

Front 4

Assuming that this patient’s BP is confirmed on two other occasions, is this patient at a higher risk of developing stroke or coronary heart disease, despite a normal diastolic BP?

A. Yes
B. No

Back 4

A. the relationship of BP to risk is a linear relationship, with systole most important risk factor (when compared to diastole)

Front 5

Assuming BP lowering drug therapy is appropriate in Mr. Smith, which of the following would you recommend?

A. Diuretic such as hydrochlorothiazide (HCTZ)
B. Beta blocker such as atenolol
C. Alpha blocker such as prazosin
D. Angiotensin converting enzyme inhibitor (ACEI) such as lisinopril
E. Centrally acting sympatholytic such as clonidine

Back 5

D. in most ppl its thiazide diuretic except for those with compelling indication. in these conditions, you need to use ACEI (first line) or ARB (second line, but more expensive)

Front 6

You should be familiar with various anti-hypertensive drug classes p 23.11 pharmacologic therapy

You should be familiar with the mechanism of their anti-hypertensive effects

Recommend looking at www.allhat.org ALLHAT design and key findings (p 23.12)

Familiarize yourself with 5 key messages of ALLHAT in allhat/JNC7 dissemination section on the website.

Back 6

you got it? <edit this!!>

Front 7

The most important reason for the selection of an ACEI in a diabetic patient as the preferred anti-hypertensive drug is that in diabetics:

A. ACEI reduce the risk of CAD
B. ACEI reduce the risk of stroke
C. ACEI reduce the risk of LVH
D. ACEI reduce the risk of renal failure

Back 7

D. in fact, this is the most important reason, but ACEI do all the others as well.

Front 8

You started your favorite anti-hypertensive drug at the lowest recommended dose. At the next clinic visit, his BP is 124-126/74-76 both at home and in the office. Which of the following do you now advise?

A. Up-titrate dose to target a normal BP
B. Discontinue the anti-hypertensive drug
C. Up-titrate to maximum recommended dose
D. Add a thiazide diuretic or a beta-blocker to target normal BP
E. Continue same drug regimen

Back 8

E. bc at that point, BP is at goal...130/80

Front 9

What is the goal BP in Mr. Smith?

A. 120/80 mm Hg
B. 130/80 mm Hg
C. 130/85 mm Hg
D. As low as tolerated by the patient

Back 9

B.

Front 10

Mrs. Jones is a 74-year-old African-American woman who has enjoyed good health all her life. She is referred to you by her family doctor for evaluation of her blood pressure.

She had repeated BP measurements of about 168/82 mm Hg in the last three months. Otherwise, her physical exam is entirely normal except that she appeared anxious and concerned about her blood pressure.

ECG: Sinus bradycardia, normal QRS axis, mild LVH voltage (R in V5 + S in V1 = 35 mm).
CXR: No cardiomegaly. Clear lung fields

Question #1: Mrs. Jones has which of the following?

A. Normal BP for her age
B. Isolated systolic hypertension
C. Borderline hypertension
D. Hypertension
E. Optimal BP

Back 10

B. (only systolic is more than 140, and diastolic is NOT over 90). older people still benefit from drug therapy if you lower their BP.

Front 11

Which of the following statements best applies to Mrs. Jones?

A. Systolic BP of 168 mm Hg is normal for a 74-year-old woman
B. Pulse pressure is normal despite mild elevation of her SBP
C. Higher risk for stroke and CHD despite a DBP of 82 mm Hg
D. Reducing SBP is potentially harmful in this elderly asymptomatic woman.

Back 11

C. this lady is still at risk despite the normal diastole; systole continues to impart a greater risk and it does so through the 80s.

Front 12

Which of the following is the BEST management approach?

A. Salt restriction
B. Anti-hypertensive drug therapy and salt restriction
C. Reassurance
D. Anxiety-relieving (anxiolytic) medication

Back 12

B. bc the cut off of 140 is reached...that's all you need! so you need to treat pharmacologically (in addition to lifestyle modification)

Front 13

Assuming that drug therapy is recommended, which of the following drug classes would you advise?

A. Diuretic
B. Beta-blocker
C. Alpha blocker
D. ACE inhibitor
E. A and D
F. C and D.

Back 13

E. alpha blocker, remember, should NEVER be used for HTN, unless its for an older pt with BPH. but since the BP is over 160, it fits into stage 2 HTN....so you should use 2-drug combination therapy.

Front 14

After you started an anti-hypertensive drug, BP decreased to about 156/78 and she remained asymptomatic. Which of the following would you now recommend?

A. Up-titrate to target normal BP
B. Discontinue drug since DBP is <80 mm Hg
C. Up-titrate to target SBP < 140 AND DBP < 90 mm Hg
D. Add a calcium channel blocker to achieve better BP control

Back 14

C.

Front 15

what are the main messages and key JNC guidelines?

Back 15

1) Help most patients achieve a blood pressure goal of <140/90 mm Hg.

2) Encourage and influence patients to make lifestyle changes.

3) To prescribe THIAZIDE-TYPE DIURETICS for most patients diagnosed with Stage 1 hypertension.

4) To prescribe THIAZIDE-TYPE DIURETICS as part of a multi-drug regimen for most patients with Stage 2 hypertension.

5) To add a THIAZIDE-TYPE DIURETIC to the treatment regimens of most patients with uncontrolled hypertension.