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Meet Amor
47 year old, teacher, consulted for headaches and nape pains.
She is a non smoker, non alcoholic drinker.
Family History: Father and Mother (+) HPN, (+) DM
G2P2 with regular menstruation.
On PE, her BMI was 24 kg/m2. BP of 140/100. Other systems unremarkable.
Laboratory:
FBS 120 mg/dl,
Crea 0.73 mg/dl,
TC = 258mg/dl, TG=181.73 mg/dl, LDL=165.76 mg/dl, HDL=55.83 mg/dl,
ALT 35 u/l
HBA1C= 6.3%
12 lead ECG Normal, CXR No Significant Chest Findings.
She was given Losartan 100 mg OD
PRIMARY PREVENTION
Statement 2
For non-diabetic individuals aged 45 years with LDL-C 130
mg/dL and 2 risk factors*, without ASCVD, statins are
RECOMMENDED for the prevention of cardiovascular events.
*Risk factors are:
Male, postmenopausal women, smoker, hypertension, BMI > 25 kg/m2, family
history of premature CHD, familial hypercholesterolemia, microalbuminuria,
proteinuria, and left ventricular hypertrophy
Estimates of 10-year risk for ASCVD are based on data from multiple
community-based populations and are applicable to African-American and
non-Hispanic white men and women 40 through 79 years of age.
For other ethnic groups, ATP 4 recommends using the equations for nonHispanic whites as well. These estimates may underestimate the risk for
persons from some race/ethnic groups.
Meet Amor
PRIMARY PREVENTION
Statement 2
For non-diabetic individuals aged 45 years with LDL-C 130
mg/dL and 2 risk factors*, without ASCVD, statins are
RECOMMENDED for the prevention of cardiovascular events.
*Risk factors are:
Male, postmenopausal women, smoker, hypertension, BMI > 25 kg/m2, family
history of premature CHD, familial hypercholesterolemia, microalbuminuria,
proteinuria, and left ventricular hypertrophy
Labs:
HBA1C = 11%
TC 246 mg/dl, TG 312.15 mg/dl, LDL 138.13 mg/dl, HDL 44.66 mg/dl
Creatinine 1.04 mg%, ALT 20 u/l (nv < 85)
PRIMARY PREVENTION
Statement 3
For diabetic individuals without evidence of ASCVD,
statins are RECOMMENDED for primary prevention of
cardiovascular events.
HBA1c: 9.0
Total chol: 220mg/dl
LDL: 102 mg/dl
HDL: 48 mg/dl
Trig: 250 mg/dl
AST: 112 ( normal <85)
SECONDARY PREVENTION
Statement 5
For individuals with ASCVD, statin therapy is
RECOMMENDED
Result
Normal Value
Total CPK
6,018.33 u/l
30 135 u/l
CPK - MM
5,966.23 u/l
CPK - MB
52.0 u/l
Statin +
Ezetimibe
Fibrates
Lipid Effect
Outcome Information
LDL
Omega-3 FAs
Tg HDL
LDL Tg
Niacin
Tg HDL
LDL
Lp(a)
High- and moderate-intensity statin treatment emphasized; lowintensity statin treatment eliminated.
ASCVD now includes stroke in addition to ischemic heart disease and
peripheral arterial disease.
Four groups are targeted for treatment.
Non-statin treatments de-emphasized.
Hypertension
Management:
Deborah David-Ona, MD, FPCP
Clinical Associate Profession
Section of Hypertension , Department of Medicine
University of the Philippines-Philippine General Hospital
45-yo , Executive
Chief complaint: intermittent headache and nape pain (6/10
in pain scale) 3 days PTC
PMHX: unremarkable
10 pack-years smoking history
Occasional alcohol drinker
No blurring of vision, vomiting, chest pain, shortness of breath,
numbness or weakness
BP 190/110 HR 110 RR 22
PE findings unremarkable
Hypertensive emergency
Hypertensive urgency
Malignant Hypertension
Resistant Hypertension
SBP 180 mm Hg
and/or
DBP 120 mm Hg
Progressive end
organ damage
Hypertensive
Crisis
YES
NO
Hypertensive
Emergency
Hypertensive
Urgency
(24%)
(76%)
1. Ramos AP et al. Curr Hypertens Rep 2014;16:450. 2. Papadopoulos DP et al. Blood Pressure 2010;19:328. 3. Chobianan
AV et al. Hypertension 2003;41:1178.
Past medical hx: HTN, CAD, renal disease, peripheral vascular disease, cerebral
vascular disease
Meds that can raise BP: liquorice, nasal drops, oral contraceptives, steroids,
non-steroidal anti-inflammatory drugs, erythropoietin, cyclosporine)
Papilledema (ICP),
retinal hemorrhages,
exudates (retinopathy)
Inspiratory crackles
(pulmonary edema)
Peripheral edema
(LV failure)
1. Ramos AP et al. Curr Hypertens Rep 2014;16:450. 2. Papadopoulos DP et al. Blood Pressure 2010;19:328. 3. Vidt DG.
Journal of Clinical Hypertension 2001;3:158. 4.
Group 1 High BP
Group 2 Urgency
Group 3 Emergency
BP
>180/110
>180/110
Usually >220/140
Symptoms
Headache
Anxiety
Asymptomatic
Severe headache
Shortness of breath
Edema
Shortness of breath
Chest pain
Nocturia
Dysarthria
Weakness
Altered mental status
Exam
No end organ
damage
No clinical CVD
Encephalopathy
Pulmonary edema
Renal insufficiency
Stroke
ACS
1. Ramos AP et al. Curr Hypertens Rep 2014;16:450. 2. Papadopoulos DP et al. Blood Pressure 2010;19:328. 3. Vidt DG.
Journal of Clinical Hypertension 2001;3:158. 4.
Group 1 Urgency
Goal
Group 2 Urgency
Group 3 Emergency
Reduce BP by 10 to
15% over 3060 min*
Therapy
Initiate /resume
medication
Increase dosage of
inadequate agent
Observe 1-3 hrs
Lower BP with
short-acting oral
agents
Adjust current
therapy
Observe 3-6 hrs
Plan
Arrange follow-up
evaluation in <72
hrs
Arrange follow-up
evaluation within
24 hours
Admission to ICU
Treat to initial goal
BP
Additional dx
studies
Baseline labs
IV line
Monitor BP
Parenteral therapy
in ER
*except aortic dissection and acute intracranial bleed, BP must be reduced in 5 to 10 mins or to a target SBP
<140 mm Hg and MAP <80 mm Hg.
1. Ramos AP et al. Curr Hypertens Rep 2014;16:450. 2. Papadopoulos DP et al. Blood Pressure 2010;19:328. 3. Vidt DG.
Journal of Clinical Hypertension 2001;3:158. 4.
Agent
Dose
Onset/
Duration of
Action
Precautions
Catopril
25 mg p.o., repeat as
needed
1530 min/
26 hr
Clonidine
3060 min/
816 hr
Hypotension, drowsiness,
dry mouth
Labetalol
200400 mg p.o.,
repeat every 23 hr
30 min2hr/
212 hr
Bronchoconstriction, heart
block, orthostatic
hypotension
Prazosin
12 mg p.o., repeat
hourly as needed
12 hr/
812 hr
1. Ramos AP et al. Curr Hypertens Rep 2014;16:450. 2. Papadopoulos DP et al. Blood Pressure 2010;19:328. 3. Handler J. .
Journal of Clinical Hypertension 2006;8:61. 4. Vidt DG. Journal of Clinical Hypertension 2001;3:158.
Hypertensive urgency
In general, treatment is:
Resumption of antihypertensive therapy (in nonadherent patients)
Initiation of antihypertensive therapy (in
treatment nave patients)
Addition of another antihypertensive drug (in
currently treated patients)
<150/90
<140/90
<130/80
<120/80
JNC 7
JNC 8
ASH/ISH
ESH/ESC
CHEP
ADA
2004
2014
2013
2013
2013
2016
<140/90
<140/90
<140/90
<140/90
<140/90
60-79 yo
<140/90
<150/90
<140/90
<140/90
<140/90
80 yo
<140/90
<150/90
<150/90
<150/90
<150/90
Adults
<130/80
<140/90
<140/90
<140/85
<130/80
<140/90
<130/80
<140/90
<140/90
<130/90
<140/90
- protein
<130/80
<140/90
<140/90
<140/90
<140/90
1. Salvo M et al. Annals of Pharmacotherapy 2014;48:1242. 2. Cefalu Wt et al. Diabetes Care 2016;39:Suppl 1.
150
Standard Treatment
Average # of meds: 1.9
140
130
120
Intensive Treatment
Average # of meds: 3.0
110
0
Years
SPRINT Research Group. N Engl J Med 2015; DOI:10.1056/NEJMoa1511939.
25%
NNT 62
Outcome
Intensive Tx
Standard Tx
Hazard Ratio
p-value
# of patients
(%)
# of patients
(%)
n = 4678
n = 4683
MI
97 (2.1)
116 (2.5)
0.19
ACS
40 (0.9)
40 (0.9)
0.99
Stroke
62 (1.3)
70 (1.5)
0.50
Heart Failure
62 (1.3)
100 (2.1)
0.002
38%
CV Death
37 (0.8)
65 (1.4)
0.005
43%
All-Cause
Death
155 (3.3)
210 (4.5)
0.003
1o Outcome
or Death
332 (7.1)
423 (9.0)
<0.001
27%
22%
Adverse Events
His BP reading before discharge from the clinic was 165/90. His
headache was almost completely relieved. He was given a request
for laboratory tests, advised to monitor BP at home (HMBP) and
follow-up in 1 week. Which of the following medications will you
send him home with?
A.
B.
C.
D.
HBPM
ABPM
Daniel
30
28
22
21
20
11
10
0
1992
1997
2007
2013
80
75
70
65 66
57
Percentage (%)
60
51
50
Prevalence
40
Treated
28
30
22 22
20
11
13 11
10
21
10 10
Compliant
20
13
Natl Registry
1992-1993
PRESYON 1
1997-1998
PRESYON 2
2007
PRESYON 3
2012-2013
Controlled
Trial
Hypertension
Diabetes
Kidney
disease
SBP achieved
(mm Hg)
ALLHAT
138
HOT
138
MDRD
132
ACCORD (intensive)*
119
ACCORD (standard)*
133
INVEST
133
IDNT
138
RENAAL
141
ABCD
132
UKPDS
144
AASK
128
1
2
3
No. of BP medications
Daniel
Description
A
Details
If goal BP not achieved initial drug, titrate to max
recommended dose.
Start 1 drug and add a Start with 1 drug then add a 2nd drug from list, titrate both
2nd drug before
drugs up to max recommended dose to achieve goal BP.
achieving max dose of
the initial drug
If goal BP not achieved, add a 3rd drug from list and titrate to
max dose.
James PA et al. JAMA. doi: 10.1001/jama.2013.284427
Description
C
Details
Daniel
Daniel
Mild BP elevation
Low/moderate CV risk
Choose between
Single agent
Marked BP elevation
High/very high CV risk
Two-drug combination
Switch to
different agent
Previous agent
at full dose
Previous combination
at full dose
Add a
third drug
Full-dose
monotherapy
Two-drug
combination
at full doses
Switch to different
two-drug
combination
Three-drug
combination
at full doses
Thiazide diuretics
BBs
ARBs
Other
Anti-HTN
Calcium
antagonists
Initiate 2-drug
combination for
patients with markedly
elevated BP or high CV
risk.
Fixed-dose
combination may be
favored to improve
adherence, which is low
in hypertensive
patients.
Preferred
ACEIs
Not recommended
Exclude Pseudoresistance
Is patient adherent with the prescribed regimen?
Obtain home or ambulatory blood pressure readings to exclude
white coat effect.
1. Mancia G et al. Journal of Hypertension 2013; 31: 1281-1357 2. Fagard RH et al. Heart 2012;98:254 3. NICE
Hypertension Guidelines 2011 4. Calhoun DA et al. Hypertension 2008;51:1403.
1. Mancia G et al. Journal of Hypertension 2013; 31: 1281-1357 2. Fagard RH et al. Heart 2012;98:254 3. NICE
Hypertension Guidelines 2011 4. Calhoun DA et al. Hypertension 2008;51:1403.
Pharmacologic Treatment
Maximize TZD diuretic if serum potassium is 4.5 mmol
Refer to Specialist
For suspected secondary causes of hypertension
or
If blood pressure remains uncontrolled after 6 months of
treatment
1. Mancia G et al. Journal of Hypertension 2013; 31: 1281-1357 2. Fagard RH et al. Heart 2012;98:254 3. NICE
Hypertension Guidelines 2011 4. Calhoun DA et al. Hypertension 2008;51:1403.
1. Mancia G et al. Journal of Hypertension 2013; 31: 1281-1357 2. Fagard RH et al. Heart 2012;98:254 3. NICE
Hypertension Guidelines 2011 4. Calhoun DA et al. Hypertension 2008;51:1403.
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