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Hypertension and High Blood Pressure

High blood pressure has now been reclassified, no longer do we talk about mild and moderate and severe, we call it stage I, stage II, and stage III, the reason for that is that the vast majority of people with high blood pressure are in this area and on a population level, the vast majority of strokes and myocardial and kidney disease from hypertension.

Stage I is 140/90 or above, and that’s really all you need to remember on the slide, that is what hypertension is, 140/90 above, but measured on multiple occasions. Many patient’s who see a physician for the first time have high sympathetic nervous system and have tachycardia, they are sweating and their blood pressure is up a little bit and it is inappropriate for you to label them as having chronic hypertension simply because they are nervous, so the JNC cautions us to confirm elevated blood pressures.

I would also caution you about this circumstance being particularly common in hospitalized patient’s. Just because somebody is in the hospital to have a GYN procedure, very often patient’s will have mild elevations in their blood pressure, please don’t jump to the conclusion that they have sustained elevations in their pressure if they have not had multiple recorded pressures that are elevated.

Once you have decided that the patient does indeed have multiple readings over 140 or over 90 and that the do have confirmed hypertension, you have through history and physical and a very small set of laboratories, you need to answer three question; does the patient have primary, essential or doctor not smart enough to understand why hypertension, which will be every case in your entire career, save a few, or does the patient have some sort of secondary cause of hypertension, or what internists like to talk about, things like pheochromocytoma, there are a few important things you need to understand for secondary causes.

Hypertension is an asymptomatic disorder. It is very much like hypercholesterolemia, the vast majority of patient’s who have stage I or II hypertension, cannot feel their blood pressure, despite what they tell you. The reason that hypertension is an important problem, is not because elevated blood pressure causes people to be sick, the reason it is an important problem is because it causes arterial and atherosclerosis. It is important for the same reason that hypercholesterolemia is an important problem. Caring for the patient with hypertension without caring for their other cardiovascular disease risk factors.

If it’s your sense that the patient’s diet is very highly laden in salt, it is a reasonable thing to ask them to try to reduce their sodium intake to a reasonable level. This does not mean that you should ask the patient to eat cardboard three times a day, which is what heart failure diet tastes like, what we’re saying is no added salt, avoid things that have lots of salt in them.

After you do that, and you decide that your patient might need medicine for high blood pressure, I am going to suggest to you that you can do this, you can do the vast majority of drug therapy of stage I hypertension and I am going to show you why you might want to do it, and how you might want to do it. First, it’s important to know that medicines work. Here is the evidence, trials of low dose diuretics, that’s 12.5 or 25 mg of hydrochlorothiazide, and beta blockers demonstrate important substantial clinically significant decreases in strokes heart attacks, heart failure and dying from one of these things.

I am going to talk to you now about stage I hypertension and what is an indication for beginning drug therapy, all of this presumes that you have measured the blood pressure repeatedly over several months, that you have counseled the patient about life style issues, you have made sure they are not on oral contraceptives, that they are not taking 14 ibuprofen a day, that they are doing reasonably what they can in terms of their dietary salt and alcohol intake. If the patient has a blood pressure of greater than 140/90 for more than a month, and they have something wrong with their heart, kidney or brain, or they have diabetes, they ought to be on a pill. If they have this kind of a blood pressure over this period of time and despite life style counseling.

If the patient is elderly, this may or may not be possible, it may well be when the patient stands up, they are dizzy, so you may have to compromise, but 140 is a reasonable target, or slightly below for an elderly patient. The pharmaceutical industry has provided us with maybe 300 medicines for high blood pressure, maybe 300, so this is every bit as daunting for you as prescribing oral contraceptives is for me. So I am going to try to distill this into something manageable, these are the categories of antihypertensive agents. Fortunately, you don’t have to know all of that. What this slide shows is that all of the classes of antihypertensive agents, diuretics, alpha blockers, beta blockers, calcium channel blockers, and ACE inhibitors all lower blood pressure.

Start with a low dose diuretic or a beta blocker, they are equally effective as the new more expensive agents, they are known to provide important benefits to patient’s. I f you want to use long acting calcium channel blockers, there is evidence in the elderly that they are beneficial, it appears as though African Americans and the elderly are more responsive to diuretics so if you have patient’s in that category, a diuretic is the first drug, the contraindications to diuretics are only allergies and gout.

Followup care once drugs are initiated, one to two months, figure out if the patient is still taking the medicine, whether it’s making him sick, take their blood pressure when standing up to make sure they are not going to fall down in the bathroom and break their hip from hypotension. The lab tests you need to get are small in diuretics, basically it’s basic chemistry panel and calcium because diuretics on rare occasions can elevate calcium and see the patient every two months, once their blood pressure.

If you can’t counsel the patient or choose not to, get your nurse to do it. Therapy is life long for hypertension. It is the very rare patient who will get skinny and come off medicines. It happens but it’s rare. Indications for referral. You can refer if you don’t feel comfortable treating at all but if you feel comfortable treating stage I hypertension with diuretic therapy, I would encourage you to do that. The patient has severe hypertension, end organ disease or some other important medical disease, it is reasonable to refer that patient to a general internist or cardiologist.