Beruflich Dokumente
Kultur Dokumente
D. Jeffrey Mohr, MD
dmohr@lsuhsc.edu
Assistant Professor
LSU Rural Family Medicine Residency
Our Lady of the Angels Hospital
Bogalusa, Louisiana
Objectives
I. Case Study
II. Exam Question
III. Essential Hypertension, JNC 7 & JNC 8
IV. Exam Answers
Case Study
• Should he be treated?
A) Hydrochlorothiazide
B) Amlodipine (Norvasc)
C) Atenolol (Tenormin)
D) Clonidine (Catapres)
E) Losartan (Cozaar)
188. An 11-year-old male is brought to your clinic for follow-up after a
recent well child visit revealed elevated blood pressure. The parents
have restricted his intake of sodium and fatty foods during the last
several weeks. His blood pressure today is 140/92 mm Hg, which is
similar to the reading at his last visit. The parents checked the child’s
blood pressure with a home unit several times and found it consistently
to be in the 130s systolic and low 80s diastolic. The child had a normal
birth history and has no known chronic medical conditions. Both of his
parents and
his two younger siblings are healthy. He is at the 75th percentile for both
height and weight with a BMI in the normal range. He eats a balanced
diet and is active.
What should be the next step for this patient?
A) Reassurance that this is likely white-coat hypertension
B) A goal weight loss of at least 5 lb
C) Evaluation for causes of secondary hypertension
D) Hydrochlorothiazide
E) Lisinopril (Prinivil, Zestril)
201. For several years, a hypertensive 65-year-old female has
been treated with hydrochlorothiazide, 25 mg/day; atenolol
(Tenormin), 100 mg/day; and hydralazine, 50 mg 4 times/day.
Her blood pressure has been well controlled on this regimen.
Over the past 2 months she has experienced malaise, along
with diffuse joint pains that involve symmetric sites in the
fingers, hands, elbows, and knees. A pleural friction rub is
noted on examination. Laboratory testing shows that the
patient has mild anemia and leukopenia, with a negative
rheumatoid factor and a positive antinuclear antibody (ANA)
titer of 1:640.
Which one of the following would be the most appropriate
INITIAL step?
A) Replace hydrochlorothiazide with furosemide (Lasix)
B) Discontinue hydralazine
C) Start prednisone, 40 mg/day orally
D) Start hydroxychloroquine (Plaquenil), 400 mg/day
E) Order renal function studies and anticipate that a renal
biopsy will be needed
221. A 54-year-old male sees you for a 6-month follow-up
visit for hypertension. He feels well, but despite the fact
that he takes his medications faithfully, his blood pressure
averages 150/90 mm Hg. He has had an intensive workup
for hypertension in the recent past, with normal repeat
laboratory results, including a CBC, serum creatinine, an
electrolyte panel, and a urinalysis. His medications include
chlorthalidone, 12.5 mg daily; carvedilol (Coreg), 25 mg
twice daily; amlodipine (Norvasc), 10 mg daily; and
lisinopril (Prinivil, Zestril), 40 mg daily. He has been
intolerant to clonidine (Catapres) in the past.
Which one of the following medication changes would be
most reasonable?
A) Adding isosorbide mononitrate (Imdur)
B) Adding spironolactone (Aldactone)
C) Substituting furosemide (Lasix) for chlorthalidone
D) Substituting losartan (Cozaar) for lisinopril
Hypertension-Who Cares?
• Family Doctors: Hypertension is the most
common reason for office visits in the United
States.
• Drug companies: HTN is also the most
common reason for the use of prescription
drugs.
• Americans: 30% of them/us (~60 million!)
have it. As we get older and fatter, this
number will get worse.
Hypertension-So what?
• Approximately half of hypertensive people
have their BP controlled (<140/90)
• Hypertension is a risk factor for: CAD, CHF,
LVH, CVA (ischemic and bleeding), CKD
Hypertension-Modifiable Risk Factors
• Obesity
• Inactivity
• Excessive Alcohol Intake
• Excessive Sodium Intake
• Smoking
• Dyslipidemia (independent of obesity)
• Medications (NSAIDs, venlafaxine, decongestants)
• Obstructive Sleep Apnea
Hypertension-Risk Factors
Not Modifiable
Figure Legend:
Comparison of Current Recommendations With JNC 7 Guidelines
Recommendation 2
In the general population <60 years,
initiate pharmacologic treatment to
lower BP at DBP ≥90 mm Hg and treat
to a goal DBP <90 mm Hg. (For ages 30-
59 years, Strong Recommendation –
Grade A; For ages 18-29 years, Expert
Opinion – Grade E)
JNC 8: Recommendations for the
Management of Hypertension
Recommendation 3
In the general population <60 years,
initiate pharmacologic treatment to lower
BP at SBP ≥140 mm Hg and treat to a goal
SBP <140 mm Hg. (Expert Opinion – Grade
E)
JNC 8: Recommendations for the
Management of Hypertension
Recommendation 4
In the population aged ≥18 years with
chronic kidney disease (CKD), initiate
pharmacologic treatment to lower BP at
SBP ≥140 mm Hg or DBP ≥90 mm Hg
and treat to goal SBP <140 mm Hg and
goal DBP <90 mm Hg. (Expert Opinion –
Grade E
JNC 8: Recommendations for the
Management of Hypertension
Recommendation 5
In the population aged ≥18 years
with diabetes, initiate
pharmacologic treatment to lower
BP at SBP ≥140 mm Hg or DBP ≥90
mm Hg and treat to a goal SBP
<140 mm Hg and goal DBP <90 mm
Hg. (Expert Opinion – Grade E)
JNC 8: Recommendations for the
Management of Hypertension
Recommendation 6
In the general nonblack population,
including those with diabetes, initial
antihypertensive treatment should
include a thiazide-type diuretic, calcium
channel blocker (CCB), angiotensin-
converting enzyme inhibitor (ACEI), or
angiotensin receptor blocker (ARB).
(Moderate Recommendation – Grade B)
JNC 8: Recommendations for the
Management of Hypertension
Recommendation 7
In the general black population, including
those with diabetes, initial antihypertensive
treatment should include a thiazide-type
diuretic or CCB. (For general black
population: Moderate Recommendation –
Grade B; for black patients with diabetes:
Weak Recommendation – Grade C)
JNC 8: Recommendations for the
Management of Hypertension
Recommendation 8
In the population aged ≥18 years with CKD,
initial (or add-on) antihypertensive
treatment should include an ACEI or ARB to
improve kidney outcomes. This applies to all
CKD patients with hypertension regardless
of race or diabetes status. (Moderate
Recommendation – Grade B)
JNC 8: Recommendations for the
Management of Hypertension
Recommendation 9
The main objective of hypertension treatment is to attain and maintain goal BP.
If goal BP is not reached within a month of treatment, increase the dose of the
initial drug or add a second drug from one of the classes in recommendation 6
(thiazide-type diuretic, CCB, ACEI, or ARB). The clinician should continue to
assess BP and adjust the treatment regimen until goal BP is reached. If goal BP
cannot be reached with 2 drugs, add and titrate a third drug from the list
provided. Do not use an ACEI and an ARB together in the same patient. If goal
BP cannot be reached using only the drugs in recommendation 6 because of a
contraindication or the need to use more than 3 drugs to reach goal BP,
antihypertensive drugs from other classes can be used. Referral to a
hypertension specialist may be indicated for patients in whom goal BP cannot
be attained using the above strategy or for the management of complicated
patients for whom additional clinical consultation is needed. (Expert Opinion –
Grade E)
From: 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults: Report From the
Panel Members Appointed to the Eighth Joint National Committee (JNC 8)
JAMA. 2014;311(5):507-520. doi:10.1001/jama.2013.284427
Figure Legend:
Evidence-Based Dosing for Antihypertensive Drugs
James PA, Oparil S, Carter BL, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report
from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA 2014; 311:507.