bradtPA Posted March 12, 2013 Share Posted March 12, 2013 For uncomplicated HTN? Working in rural southeastern NC where diabetes, strokes, and tobacco abuse is epidemic. I would love simple HTN cases but they seem the exception not the rule. For uncomplicated cases, I tend to start an ACEI, for menstruating females I prefer chlorthalidone or HCTZ to avoid an accidental miscarriage (cat X in second trimester for all ACEI, ARB). Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted March 12, 2013 Moderator Share Posted March 12, 2013 the issue with ACEI and diuretics for me is that you need to check labs before giving them. typically if I am starting one htn isn't the primary issue and their primary condition doesn't need labs. for example I see a guy with a lac, suture him up, then realize his bp in the er for the last yr(his only clinical visits anywhere) has always been high regardless of complaint. he needs to be on something for the next several months until I can get him into a pcp who will see folks without insurance. labs both increase his length of stay and cost him money he doesn't have so I need a med I can rx with minimal workup which is safe and effective and most importantly cheap. beta blockers fill this void for most folks. as a pcp I would probably do the labs and use ACEIs for most folks. if I ever needed an rx for htn I would probably want an acei or arb. Link to comment Share on other sites More sharing options...
UGoLong Posted March 13, 2013 Share Posted March 13, 2013 Actually we hardly ever use atenolol; I'd rather use metoprolol... As far as the 180/110 case, assuming a normal pulse rate, I'd probably start at 12.5 mg bid and then titrate up. He might get to 25 or 37.5 from there. It would be unusual for someone with a pressure like that to be fully controlled on one agent though. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted March 13, 2013 Moderator Share Posted March 13, 2013 Actually we hardly ever use atenolol; I'd rather use metoprolol... As far as the 180/110 case, assuming a normal pulse rate, I'd probably start at 12.5 mg bid and then titrate up. He might get to 25 or 37.5 from there. It would be unusual for someone with a pressure like that to be fully controlled on one agent though. ok. Thanks and it's on 4 dollar lists as well. Link to comment Share on other sites More sharing options...
bradtPA Posted March 13, 2013 Share Posted March 13, 2013 The benefit of working a rural PA owned practice is I can offer these folks an office visit for $55, and additional labs if needed to start meds are usually $50 combined for U/A, CBC, and BMP. We also allow them to make payments.... Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted March 13, 2013 Moderator Share Posted March 13, 2013 lytes and a chem panel through the er probably costs something like 300 bucks..... Link to comment Share on other sites More sharing options...
bradtPA Posted March 13, 2013 Share Posted March 13, 2013 That's probably the take home pay for a week for the folks I see that work for the turkey, chicken, and hog processing plants around here.... Link to comment Share on other sites More sharing options...
d2305 Posted March 13, 2013 Share Posted March 13, 2013 The only problems I've had with an ace is a cough and occasionally angioedema. It is the treatment for CRF. I use b blockers, but more metoprolol than atenolol. Link to comment Share on other sites More sharing options...
Contrarian Posted March 13, 2013 Share Posted March 13, 2013 the issue with ACEI and diuretics for me is that you need to check labs before giving them.typically if I am starting one htn isn't the primary issue and their primary condition doesn't need labs. for example I see a guy with a lac, suture him up, then realize his bp in the er for the last yr(his only clinical visits anywhere) has always been high regardless of complaint. he needs to be on something for the next several months until I can get him into a pcp who will see folks without insurance. labs both increase his length of stay and cost him money he doesn't have so I need a med I can rx with minimal workup which is safe and effective and most importantly cheap. beta blockers fill this void for most folks. as a pcp I would probably do the labs and use ACEIs for most folks. if I ever needed an rx for htn I would probably want an acei or arb. BINGO...!!!!! "10 ring" Or even if they have Medicare/Caid that would pay for it.. will they even show up to the lab...??? So Yeah... you describe a unfortunately VERY COMMON patient that I would believe many/most of us encounter. Link to comment Share on other sites More sharing options...
deborah212 Posted March 13, 2013 Share Posted March 13, 2013 Don't forget that atenolol is metabolized and excreted renally. It's not a good choice for patients with CKD or those who you don't know their renal function. I would think that in the above scenario (HTN urgency in the ED with no PCP follow-up) norvasc would be the safest option. Link to comment Share on other sites More sharing options...
bradtPA Posted March 13, 2013 Share Posted March 13, 2013 Norvasc is a favorite of mine, but it's so damn expensive without insurance..... Link to comment Share on other sites More sharing options...
Contrarian Posted March 13, 2013 Share Posted March 13, 2013 Naaahh.... Cause we don't know their Ventricular Function... Its a chance encounter... so I would avoid CCBs unless I had sufficent info on them... AND as was said above, "they are expensive.' Link to comment Share on other sites More sharing options...
cbrsmurf Posted March 13, 2013 Author Share Posted March 13, 2013 Why is hypertensive urgency treated with beta blockers? I dont understand the reasoning? Link to comment Share on other sites More sharing options...
deborah212 Posted March 13, 2013 Share Posted March 13, 2013 Naaahh....Cause we don't know their Ventricular Function... Its a chance encounter... so I would avoid CCBs unless I had sufficent info on them... AND as was said above, "they are expensive.' I am not aware of amlodipine having negative ionotropic effects as it works peripherally, which is different from 1st generation dihydropyridines like nifedipine. Do you have data on this? The cost without insurance is another issue. Link to comment Share on other sites More sharing options...
Contrarian Posted March 13, 2013 Share Posted March 13, 2013 I am not aware of amlodipine having negative ionotropic effects as it works peripherally, which is different from 1st generation dihydropyridines like nifedipine. Do you have data on this? The cost without insurance is another issue. No data... but know that it INHIBITS Ca Ion Influx into myocardium, can cause MI and Angina exacerbation and should be used cautiously in patients with Severe CAD, Aortic Stenosis, patients with LV dysfunction (CHF), and Hepatic Impairment. Now granted, aside from my regular Internal medicine patients, I've been out of Cardiology for about a decade, so maybe I'm a bit conservative... but the above cautions seem to LOGICALLY fit the description of the Patients EMEDPA is talking about. Namely... those underinsured that we don;t have the luxury of getting a Echo, Cardiac Cath and Full Lab work up on... But hey... I'm often wrong...!!! :wink: Just would hate to have a Plantiff's attorney direct ME to reach in my pocket, turn on my Cell Phone, and read the "Contraindications/Cautions/Adverse Reactions and Common Reactions" aloud to the jury straight from Epocrates... after asserting that the "poorly/inssuficiently trained" ASSISTANT cavalierly prescribed a CCB to a patient without properly assessing their LV & Liver Function... then produce a piece of paper showing a longstanding EF of 18% and a history of Hepatitis... Naaahhh... I worked HARD for my un-encumbered license. Link to comment Share on other sites More sharing options...
deborah212 Posted March 13, 2013 Share Posted March 13, 2013 These same patients are coming into my office with hypertensive urgency/SBPs in the 180s-200s which is why I care about this. I'm fairly certain that amlodipine has been shown not to affect LV function, but will check tomorrow certainly. When I don't know a patient's renal function, I'm reaching for that or labetalol. Most hypertensive patients in primary care don't end up with cardiac imaging either. Link to comment Share on other sites More sharing options...
UGoLong Posted March 13, 2013 Share Posted March 13, 2013 We don't use Norvas (amlodipine) in patient's with severe cardiomyopathy, but do use it in others, especially African-Americans, who respond really well with it in general. It is kind of "the little black dress" of antihypertensives -- it affects blood pressure, but not heart rate or significant changes to renal function, so it's a nice add-on agent. There is an issue with lower extremity edema is some folks. I usually start low (2.5 mg daily) with 10 as the max. Link to comment Share on other sites More sharing options...
Contrarian Posted March 13, 2013 Share Posted March 13, 2013 As I remember it... We also avoided it in females that liked to wear heels... cause "Cankles" ain't sexy...!!!!:;;D: Link to comment Share on other sites More sharing options...
deborah212 Posted March 13, 2013 Share Posted March 13, 2013 Just would hate to have a Plantiff's attorney direct ME to reach in my pocket, turn on my Cell Phone, and read the "Contraindications/Cautions/Adverse Reactions and Common Reactions" aloud to the jury straight from Epocrates... after asserting that the "poorly/inssuficiently trained" ASSISTANT cavalierly prescribed a CCB to a patient without properly assessing their LV & Liver Function... then produce a piece of paper showing a longstanding EF of 18% and a history of Hepatitis... Naaahhh... I worked HARD for my un-encumbered license. Our society is undoubtedly litigious. I try to stay up to date on EBM as much for this as for giving patients the kind of care I'd want for my family. :) The situation as I understood it was hypertensive urgency with no labs as is often the case in EM or primary care on initial visit. I do not believe is is below standard of care to use norvasc in this setting until a clearer picture is formed. By history, physical exam, and ekg, a fair formulation of of their cardiac status can be made. Severe CAD or an EF of 18% has both symptomatic and objective manifestations. From my point of view, that is not the type of patient we are describing. Link to comment Share on other sites More sharing options...
rxtechhk Posted March 13, 2013 Share Posted March 13, 2013 In my day to day practice (cardiac electrophysiology ) I use atenolol often. I use it for rate control in a fib, in a subset of patients it seems to be more effective than metoprolol. The combo of atenolol and verapamil can be quite potent for rate control in a fib. Link to comment Share on other sites More sharing options...
Contrarian Posted March 13, 2013 Share Posted March 13, 2013 ... Severe CAD or an EF of 18% has both symptomatic and objective manifestations. From my point of view, that is not the type of patient we are describing. Umm.. ok.. Just Know that some of us who has practiced in Cardiology have seen LOTS of Asymptomatic folks with Cardiomyopathy walking around with Ejection Fractions of 15%. And YES... the "Objective Manisfestations" may have soley been resistant/Secondary Hypertention in a patient in the clinic but exertional SOB in these folks who may live sedentary lives and thereby intentionally/unintentional avoid exertion. When I ran the HF clinic HERE... I had about 20-30 patients who fit this description. Cardiomyopathy Cardiomyopathy is a chronic disease of the heart muscle (myocardium), in which the muscle is abnormally enlarged, thickened, and/or stiffened. The weakened heart muscle loses the ability to pump blood effectively, resulting in irregular heartbeats (arrhythmias) and possibly even heart failure. Description Cardiomyopathy, a disease of the heart muscle, primarily affects the left ventricle, which is the main pumping chamber of the heart. The disease is often associated with inadequate heart pumping and other heart function abnormalities. Cardiomyopathy is not common (affecting about 50,000 persons in the United States) but it can be severely disabling or fatal. Severe cases may result in heart failure and will require a heart transplant for patient survival. Cardiomyopathy is a heart condition that not only affects middle-aged and elderly persons, but can also affect infants, children, and adolescents. There are four major types of cardiomyopathy: Dilated (congestive cardiomyopathy). This is the most common form of the disease. The heart cavity is enlarged and stretched (cardiac dilation), which results in weak and slow pumping of the blood, which in turn can result in the formation of blood clots. Abnormal heart rhythms (arrhythmias) and disturbances in the electrical conduction processes in the heart may also occur. Most patients with this type of cardiomyopathy develop congestive heart failure. There is also a genetically-linked cardiac disease, Barth syndrome, that can cause dilated cardiomyopathy. This syndrome affects male children, and is usually diagnosed at birth or within the first few months of life. Pregnant women during the last trimester of pregnancy or after childbirth may develop a type of dilated cardiomyopathy referred to as peripartum cardiomyopathy. Hypertrophic cardiomyopathy. With this type of cardiomyopathy, the muscle mass of the left ventricle enlarges, or hypertrophies. In hypertrophic obstructive cardiomyopathy (HOCM), the septum (wall) between the two heart ventricles (the pumping chambers) becomes enlarged and obstructs blood flow from the left ventricle. The thickened wall can also distort one leaflet of the mitral valve, which results in leakage. HOCM is most common in young adults. HOCM is often hereditary, caused by genetic mutations in the affected person's DNA. The disease is either inherited through one parent who is a carrier or through both parents who each contribute a defective gene. HOCM is also referred to as asymmetrical septal hypertrophy (ASH) or idiopathic hypertrophic subaortic stenosis (IHSS). In another form of hypertrophic cardiomyopathy, non-obstructive cardiomyopathy, the enlarged heart muscle does not obstruct the blood flow through the heart. Restrictive cardiomyopathy. This is a less common type of cardiomyopathy, in which the heart muscle of the ventricles becomes rigid. Restrictive cardiomyopathy affects the diastolic function of the heart, that is, it affects the period when the heart is relaxing between contractions. Since the heart cannot relax adequately between contractions, it is harder for the ventricles to fill with blood between heartbeats. This type of cardiomyopathy is usually the result of another disease. Arrhythmogenic right ventricular cardiomyopathy (ARVC). ARVC is very rare and is believed to be an inherited condition. With ARVC, heart muscle cells become disorganized and damaged and are replaced by fatty tissues. The damage appears to be a result of the body's inability to remove damaged cells. The damaged cells are replaced with fat, leading to abnormal electrical activity (arrhythmias) and abnormal heart contractions. ARVC is the most common cause of sudden death in athletes. Causes & symptoms Cardiomyopathy may be caused by many different factors, including viral infections (e.g., myocarditis), heart attacks, alcoholism, long-term, severe high blood pressure, genetic neuromuscular diseases (e.g., muscular dystrophies and ataxias), genetic metabolic disorders, complications from AIDS, and other reasons that have not yet been identified (idiopathic cardiomyopathy). Cardiomyopathy caused by heart attacks (referred to as ischemic cardiomyopathy) results from scarring in the heart muscle. Larger scars or more numerous heart attacks increases the risk that ischemic cardiomyopathy will develop. Alcoholic cardiomyopathy usually develops about 10 years after sustained, heavy alcohol consumption. Other toxins that may cause cardiomyopathy include drugs and radiation exposure. The major symptoms of cardiomyopathy include: shortness of breath temporary and brief loss of consciousness, especially after engaging in activity lightheadness, especially after engaging in activity decreased ability to tolerate physical exertion fatigue dizziness palpitations, that is, the sensation of feeling the heart beat chest pain (angina), whereby there is a feeling of sharp and unrelenting pressure in the middle of the chest (especially experienced by persons whose cardiomyopathy is a result of a previous heart attack) high blood pressure Other symptoms that may be associated with cardiomyopathy include: abdominal swelling or enlargement swelling of legs or ankles low amount of urine during the daytime, but a need to urinate at night decreased alertness and difficulty concentrating cough loss of appetite Link to comment Share on other sites More sharing options...
Just Steve Posted March 13, 2013 Share Posted March 13, 2013 Metoprolol tartrate is BID dose, on Wally's cheap list, metoprolol succinate is the qd dose and is not cheap nor covered by WA state DSHS Link to comment Share on other sites More sharing options...
Joelseff Posted March 13, 2013 Share Posted March 13, 2013 In the selective beta blocker world, we often use metoprolol (either the bid or XR form). If their insurance will hack it, we actually prefer Bystolic (nebivolol). Bystolic is a racemic-like mixture of a selective beta blocker (very highly selective in fact) and a vasodilator. It also seems to have fewer complaints about fatigue and sexual side effects. This is usually my approach when I need beta blockade to control BP. If I need a higher ceiling and pts HR can take it I use labetalol. I like bystolic but get some push back from insurance. Sent from my myTouch_4G_Slide using Tapatalk Link to comment Share on other sites More sharing options...
Contrarian Posted March 13, 2013 Share Posted March 13, 2013 Metoprolol tartrate is BID dose, on Wally's cheap list, metoprolol succinate is the qd dose and is not cheap nor covered by WA state DSHS Yep... And if my memory serves me correct... it is the "succinate" that has the support of the data in Heart Failure/Cardiomyopathy... NOT the tartrate. Again... it was atleast a decade ago so I coulld be mistaken. Link to comment Share on other sites More sharing options...
bradtPA Posted March 13, 2013 Share Posted March 13, 2013 Yep... And if my memory serves me correct... it is the "succinate" that has the support of the data in Heart Failure/Cardiomyopathy... NOT the tartrate. Again... it was atleast a decade ago so I coulld be mistaken. You are not wrong, the three that have FDA approval are carvedilol, Toprol XL, and bisoprolol. Link to comment Share on other sites More sharing options...
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