Patient Case - Elevated Blood Pressure

[cbrsmurf]

"Simple" cases, brought on by a recent preceptoring of a nearly graduated PA student as well as memories of when I first started off.  Writing that first prescription without someone looking over shoulder can be scary the first time.  Students only, please, although discussion will be open to all once we figured out what is best for our hypothetical patients.

 

Pt #1:

42 year old African-American male, annual f/u, no complaints.  Labs done prior to visit are normal.

Wt: 180lbs Ht: 70in  BP: 155/65  HR: 65

PMH: History of gout many years ago, otherwise healthy, no hx of smoking, 3-4 drinks/wk Meds: None, other than multivitamin daily; 

Previous annual BP measurements in office have ranged from systolic BP of 120's to 140's.

 

Pt #2

65 y/o Caucasian female new patient, no complaints, here to establish care.  Brings in labs done 6 months ago, fasting glucose 115, otherwise labs are normal.  Retired, gardens daily.

Wt: 150 lbs Ht: 55in BP: 160/60 HR: 75

PMH: Hyperlipidemia. Distant history of breast cancer, s/p R mastectomy & radiation, distant hx of smoking

FHx: Father died MI at 60 y/o.

Meds: pravastatin 10mg, Flonase PRN, fish oil, CoQ-10, ASA 81mg 

 

Your questions, thoughts, and plans?

[patachok]

For pt 1, ask about symptoms of gout if any from the PMH. Also, probably start a diuretic for his BP like a thiazide and periodically check potassium.

[cinntsp]

For pt 1, ask about symptoms of gout if any from the PMH. Also, probably start a diuretic for his BP like a thiazide and periodically check potassium.

 

Gotta watch the diuretics because of the gout hx.  Maybe a CCB?

[orangepuma]

PT 1 : check serum uric acid levels and start CCB or losartan

[Timon]

Does PT1 have white coat syndrome? I get that they have stage 1 HTN and should be on a CCB or ACEI. I'd like to know his lipids & LFTs and have a home BP measurement for a week and FU in 1 week to confirm Rx vs life style changes / anxiety.

 

For PT2 I'd put her on an ACEI and f/u for cough and I'd draw her H1C and probably put her on metformin. I'd probably ask my SP what they think if this PT is a candidate for Byetta for the wt loss side effect since her BMI is 34.9. Defiantly put her on a diet / weight loss program along with meds though if we haven't done lifestyle changes yet.

[cbrsmurf]

Good answers that we can into further detail later.  

 

But if this is your own patient at your clinic, you have to address the following, which can be tricky:

 

Do you discuss lifestyle modifications?

Do you discuss the risks of HTN?

When do you follow up?

If you are starting medication, do you want bloodwork?  If so, when do you want to get it?

If you are starting meds, how many months/refills do you write for?  Do you spend time to talk about possible side effects?  If so, which side effects do you talk about?

[winterallsummer]

Patient one is doing well.  Assuming labs done prior include his lipids, CMP, CBC.  A single BP reading is not diagnostic of HTN.  However I would do a couple things since it looks like in the past "to 140s" he may be hypertensive.  Tell him to get a couple readings at the self reading at CVS or pharmacy and jot them down.  Instruct him about no caffeine, sit still for 4-5 mins before getting the BP done, etc.  Schedule a f/u for 3 months.  At that time we can assess if he has HTN or not.  If he does, my tx of choice would likely be a CCB.  ACEI per latest guidelines are not as effective in AAs due to lower renin levels.  HCTZ could be a problem with a hx of gout and many pts don't like the SE of peeing all the time anyway, since he's not on any meds not sure how compliant he would/may be.  At the time we do (if we do) start a ccb, yes I would discuss ADRs.  At this visit, discuss lifestyle mods (diet, etc).

 

 

Pt two needs mammogram and colonoscopy (assuming she never had one or it's been 10+ yrs) also offer pneumonia and zoster vaccines. Discuss lifestyle mods and tell her she is pre diabetic and educate. Starting metformin in pre diabetics is backed by some evidence; however I would not want to do so right now for a couple reasons.  First, give her a chance to do lifestyle mods, she is new to the practice and may just need my encouragement to get things in control.  Second since this is a first visit and there is a significant ADR profile of metformin I would not mind establishing a little bit more rapport before starting her on the med for a pre-diabetic indication (and a 1 time reading that is 6 months old at that).  Can get a quick finger stick BC in the office today.  Per hx of breast CA I would offer a breast exam as well, or referal to ob/gyn if she preferred, assuming she hasn't had one.  Hopefully someone is checking this for her but sometimes pts fall through the cracks.

 

Same for BP or would offer starting low dose of ace inhib at next visit but need two BP readings to dx HTN.  Could ask her also to get some BP readings at CVS like with pt one. Give slip for fasting BMP with A1C (she could get it done a couple days before coming for f/u) to review at next visit.  Her next visit would be scheduled in 3-4 mos.  Give her a chance to try to make some leeway in diet, etc, so we can assess how it's going.

 

Also how distant was the cancer and what was the stage?  Some studies show that up to 10 yrs of tx with aromatase inhibitors are indicated.  Final topic would be discuss if she's happy with her meds.  Just read an article questioning the helpfulness of fish oil so it's just something I would discuss with her if she didn't like it (since many people on fish oil don't), if we had time.

[cbrsmurf]

Here's some important thoughts I was trying to convey

 

1) A single reading, especially at SBP's (systolic blood pressure) <170 (my cut-off), are not diagnostic of hypertension.  Get another reading, near the end of the exam, and one more reading on another day (pt's own BP cuff, supermarket reading, follow-up exam) to get more data in order to diagnose HTN.  Also consider caffiene, recent exercise, acute illness/infection and whitecoat syndrome, the latter which is very common.

2) If you decide to treat, remember that the most effective treatment of HTN is diet and exercise.  Sodium reduction, DASH, decreased EtOH intake, weight loss if obese, and aerobic exercise.

3) SBP's of 140's-160's don't necessarily require treatment.  Renal and cardiovascular complications/risks increase less than what most people think, especially when there are no other comorbidities.  Also remember, if they do have HTN, they have probably have had it for years.  A few months more of nontreatment isn't really going to change anything.

4) Pharmacological treatment.  Watch for side interactions/warnings, such as thiazides and gout.  Pick some favorites from each class and know their interactions/side effects.  Personally, I only give 2 months worth of anti-HTN's and follow up.  Also, start low, go slow.  You get diminishing returns as you increase the dose, and side effects increase.

5) Discussion of side effects.  It's up to you.  Most people won't experience any side effects, but I usually give a brief blurb on hypotension and allergic reactions.

 

My plans for the 2 example patients, would be as follow:

 

Patient #1: Get another measurement near end of exam, and have patient get some readings at home or supermarket or nurse visit.  F/U in 2-4 weeks if SBP > 140.  Discuss nonpharmacologic treatment.  Does patient want to be on meds?  If not, I'm okay with that.  If so, I would go with a CCB, like amlodipine and start at lowest, or even 1/2 of lowest dose.  Discuss side effects (a unique one to amlodipine can be pedal edema). F/U in 2 months.

 

Patient #2: Same as above: get more measurements.  She is at a slightly higher cardiovascular risk, but that doesn't really change which anti-HTN you will give.  Thiazides, ACEi, or CCB would be appropriate.  If first two, get a BMP in 2-3 mos to check for electrolyte (sodium and potassium) imbalance.  F/U 2 months.

 

I would say none of these patients are critical or particularly unique, so you can get a somewhat wide range of treatment plans.

[cbrsmurf]

Gotta watch the diuretics because of the gout hx.  Maybe a CCB?

 

Agreed.  Thiazides increase the absolute risk of gout in patients with a history of gout by about 2.1%.  Not a big deal since gout doesn't kill, but your patients will appreciate it.  And avoid ACEi in African Americans if possible, due to higher risk of angioedema.

 

http://www.jwatch.org/jw201201260000001/2012/01/26/gout-and-diuretics-hypertensive-patients

[cbrsmurf]

PT 1 : check serum uric acid levels and start CCB or losartan

 

Good choice, although there's no indication to check serum uric acid levels in an asymptomatic patient.

[GetMeOuttaThisMess]

If you want to get technical, there isn't a true indication to check uric acid levels in what you clinical diagnose as gout either.  The uric acid level can be used to manage dosing of medication however since there are built-in parameters in the medication literature.

[orangepuma]

Thanks for the post cbrsmurf! It was very informative

[cbrsmurf]

Does PT1 have white coat syndrome? I get that they have stage 1 HTN and should be on a CCB or ACEI. I'd like to know his lipids & LFTs and have a home BP measurement for a week and FU in 1 week to confirm Rx vs life style changes / anxiety.

 

For PT2 I'd put her on an ACEI and f/u for cough and I'd draw her H1C and probably put her on metformin. I'd probably ask my SP what they think if this PT is a candidate for Byetta for the wt loss side effect since her BMI is 34.9. Defiantly put her on a diet / weight loss program along with meds though if we haven't done lifestyle changes yet.

I like your pt #1 plan, although ACEi have a 5x higher incidence of angioedema in African Americans, so that is something to consider.  What is your reasoning for lipids and LFT's?  standard screening?

 

I think your anti-HTN selection is reasonable for pt #2.  You could consider an A1c, although she will probably be borderline at best.  Pharmacological therapy at borderline A1c, along with an inherent 0.3% variation in A1c measurements, have little impact on patient mortality/morbidities.  Metformin is the best choice for DM2 patients, however, as there have been large studies that have proven its effectiveness.  No other antidiabetic agent, including Byetta (or even insulin), have demonstrated superiority over metformin in Type 2 diabetics (and likely will not for a very time).  I agree she should definitely consulted about lifestyle changes and increased cardiovascular risk.

[cbrsmurf]

 

Patient one is doing well.  Assuming labs done prior include his lipids, CMP, CBC.  A single BP reading is not diagnostic of HTN.  However I would do a couple things since it looks like in the past "to 140s" he may be hypertensive.  Tell him to get a couple readings at the self reading at CVS or pharmacy and jot them down.  Instruct him about no caffeine, sit still for 4-5 mins before getting the BP done, etc.  Schedule a f/u for 3 months.  At that time we can assess if he has HTN or not.  If he does, my tx of choice would likely be a CCB.  ACEI per latest guidelines are not as effective in AAs due to lower renin levels.  HCTZ could be a problem with a hx of gout and many pts don't like the SE of peeing all the time anyway, since he's not on any meds not sure how compliant he would/may be.  At the time we do (if we do) start a ccb, yes I would discuss ADRs.  At this visit, discuss lifestyle mods (diet, etc).

 

 

Pt two needs mammogram and colonoscopy (assuming she never had one or it's been 10+ yrs) also offer pneumonia and zoster vaccines. Discuss lifestyle mods and tell her she is pre diabetic and educate. Starting metformin in pre diabetics is backed by some evidence; however I would not want to do so right now for a couple reasons.  First, give her a chance to do lifestyle mods, she is new to the practice and may just need my encouragement to get things in control.  Second since this is a first visit and there is a significant ADR profile of metformin I would not mind establishing a little bit more rapport before starting her on the med for a pre-diabetic indication (and a 1 time reading that is 6 months old at that).  Can get a quick finger stick BC in the office today.  Per hx of breast CA I would offer a breast exam as well, or referal to ob/gyn if she preferred, assuming she hasn't had one.  Hopefully someone is checking this for her but sometimes pts fall through the cracks.

 

Same for BP or would offer starting low dose of ace inhib at next visit but need two BP readings to dx HTN.  Could ask her also to get some BP readings at CVS like with pt one. Give slip for fasting BMP with A1C (she could get it done a couple days before coming for f/u) to review at next visit.  Her next visit would be scheduled in 3-4 mos.  Give her a chance to try to make some leeway in diet, etc, so we can assess how it's going.

 

Also how distant was the cancer and what was the stage?  Some studies show that up to 10 yrs of tx with aromatase inhibitors are indicated.  Final topic would be discuss if she's happy with her meds.  Just read an article questioning the helpfulness of fish oil so it's just something I would discuss with her if she didn't like it (since many people on fish oil don't), if we had time.

 

Those are reasonable plans for both patients.

 

In regards to her history of cancer, there is no indication for AI's or SERM's if the patient did not have ER/PR+ breast cancer.  The current standard of care is to treat postmenopausal hormone positive breast cancer with an AI for 5 years.  Or, if premenopausal, a SERM for 5 years, then followed by an AI for another 5 years.

[Timon]

I like your pt #1 plan, although ACEi have a 5x higher incidence of angioedema in African Americans, so that is something to consider. What is your reasoning for lipids and LFT's? standard screening?

 

I think your anti-HTN selection is reasonable for pt #2. You could consider an A1c, although she will probably be borderline at best. Pharmacological therapy at borderline A1c, along with an inherent 0.3% variation in A1c measurements, have little impact on patient mortality/morbidities. Metformin is the best choice for DM2 patients, however, as there have been large studies that have proven its effectiveness. No other antidiabetic agent, including Byetta (or even insulin), have demonstrated superiority over metformin in Type 2 diabetics (and likely will not for a very time). I agree she should definitely consulted about lifestyle changes and increased cardiovascular risk.

Thank you =o)

 

For PT1 I wanted to do a standard screening to ensure they can lower their cardiac risk better. Also wanted to get a baseline on live function in case of metabolic syndrome and to ensure good hepatic function in the event the lipids come back elevated. I also had a brain fart on the AA part (BBs and ACEI are less effective) and had to refresh my memory as cardiology was a few months back for me. Which is something I did after writing that post and then following the other forum post regarding JNC8 and AA (which I did state in there BBs and ACEI are ineffective).

 

For PT2 I wanted to have an accurate history on her diabetes. Maybe she ate before she had her blood drawn or maybe her A1C is high and she needs to be medicated since we were only looking at a snapshot in time. I was thinking of combo therapy with her with metformin and ACEI but I was looking at the patients age and thinking that lifestyle changes would probably be unlikely although it would be worth a shot before pharmacologic therapy.

[cbrsmurf]

Thank you =o)

 

For PT1 I wanted to do a standard screening to ensure they can lower their cardiac risk better. Also wanted to get a baseline on live function in case of metabolic syndrome and to ensure good hepatic function in the event the lipids come back elevated. I also had a brain fart on the AA part (BBs and ACEI are less effective) and had to refresh my memory as cardiology was a few months back for me. Which is something I did after writing that post and then following the other forum post regarding JNC8 and AA (which I did state in there BBs and ACEI are ineffective).

 

For PT2 I wanted to have an accurate history on her diabetes. Maybe she ate before she had her blood drawn or maybe her A1C is high and she needs to be medicated since we were only looking at a snapshot in time. I was thinking of combo therapy with her with metformin and ACEI but I was looking at the patients age and thinking that lifestyle changes would probably be unlikely although it would be worth a shot before pharmacologic therapy.

 

It may be a stretch to go searching for metabolic syndrome in someone with only elevated blood pressure/HTN.  I am pretty guilty of ordering CMP's (along with a CBC) for standard bloodwork screening, even though there's no real justification for it.  It's cheap, which is why many providers do it, but it's pretty low yield if there is really nothing going on.  Even in the setting of hyperlipidemia, elevated LFT's are not common.  And if LFT's DO come back elevated, you do a bunch of testing: hepatitis, abd u/s and 90% of the time it's fatty liver.  Then you just tell the patient to stop eating crap food and exercise :/

[pdjags]

Good choice, although there's no indication to check serum uric acid levels in an asymptomatic patient.

 

I liked the idea! Wouldn't checking uric acid levels possibly show an indication for gout maintenance medication (Allopurinol),although he may be asymptomatic. If results come back normal, possibly prescribing Indomethacin for flare up? Additionally, discuss lifestyle/diet choices that effect uric acid levels.

 

Great responses from everyone!! 

[AREID]

I liked the idea! Wouldn't checking uric acid levels possibly show an indication for gout maintenance medication (Allopurinol),although he may be asymptomatic. If results come back normal, possibly prescribing Indomethacin for flare up? Additionally, discuss lifestyle/diet choices that effect uric acid levels.

 

Great responses from everyone!!

Uric acid measurement help in dosing adjustments for allopurinol. Not everyone who has had an attack of gout requires allopurinol either. Checking levels in asymptomatic patients yields no benefit. Also, indomethacin isn't unique to gout (as so many students think). ANY NSAID does the trick ;)

 

 

Sent from my iPhone using Tapatalk

[pdjags]

Thanks for the response Areid!!