Soap Note

Internal Medicine 06: 45-year-old male with hypertension User: Beatriz Duque Email: [email protected] Date: October 13, 2020 6:09PM

Learning Objectives

The student should be able to:

Describe/know the hypertension classification system as defined by the ACC/AHA guidelines for high blood pressure. Identify/learn the etiologies and prevalence of essential and secondary hypertension. Explain/understand current guidelines for screening. Perform a targeted physical exam to look for end-organ effects of long-standing hypertension. Obtain an accurate blood pressure reading. Develop a diagnosis and prescribe treatment for chronic hypertension. Develop a diagnosis and manage an episode of hypertensive urgency or emergency. Counsel a patient effectively about lifestyle modifications to reduce risk of end-organ damage.

Knowledge

Hypertension - Prevalence & Etiology

Prevalence, Screening, and Classification

Hypertension is very common, affecting about 50 million people in the United States. Because hypertension is so prevalent, and because treating it results in significant decreases in cardiovascular morbidity and mortality, screening for hypertension is a grade A recommendation of the U.S. Preventive Task Force. Blood pressure readings are taken at almost every office visit. Etiology: essential vs. secondary

Hypertension can be either essential or secondary. Essential hypertension, where no identifiable etiology exists, is overwhelmingly more common in adults. In secondary hypertension there is an identifiable and potentially treatable underlying etiology of the elevated blood pressure. Causes of secondary hypertension include:

sleep apnea use of certain drugs like cocaine or stimulants chronic kidney disease primary hyperaldosteronism renovascular disease Cushing's syndrome or steroid use pheochromocytoma coarctation of the aorta thyroid or parathyroid disease

Secondary causes of hypertension may be sought when: hypertension presents in very young or in older patients when one of the diagnoses listed above is suggested by history, physical exam, or laboratory findings when the patient's hypertension is resistant to therapy (blood pressure remains poorly controlled on three medications including a diuretic)

Genetics & Risk Factors For Hypertension

Idiopathic hypertension, sometimes referred to as essential hypertension, is about twice as common in people with one or both parents who are hypertensive. There may be a genetic component to hypertension, but it likely involves the complex interaction of numerous genes with variable penetrance. Hypertension is more common, more severe, and results in more complications in African-Americans. This may be due to a variety of genetic or socioeconomic factors. Risk factors for developing hypertension:

Obesity and excessive alcohol intake are risk factors for developing hypertension. Hypertension places patients at risk for:

In addition to stroke, hypertension places patients at risk for cardiovascular disease, heart failure, and kidney disease. The higher the blood pressure, the higher the risk. For example, for patients 40 to 70 years of age, each incremental increase of 20 mm Hg in systolic blood pressure and 10 mm Hg diastolic blood pressure in the range of 115/75 to 185/115 doubles the risk of

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cardiovascular disease.

White Coat Hypertension

White coat hypertension is fairly common, seen in 10-20% of patients with mild blood pressure elevation in clinic. White coat hypertension is when a patient has elevated blood pressure in an office setting but normal blood pressure in other settings. Obtaining home blood pressure readings or use of an ambulatory blood pressure monitor can determine whether a patient has true, sustained hypertension. Evidence suggests that the blood pressure readings from ambulatory and home blood pressure monitoring are more predictive of long-term cardiovascular risk than office values.

Conditions Associated with Hypertension and Hypokalemia

Hyperaldosteronism occurs when there is a constitutive secretion of mineralocorticoids from either an adrenal adenoma or adrenal hyperplasia. Such a condition should always be suspected in a patient with hypertension and hypokalemia (normal K value 3.5-5.0 mmol/L), although the hypokalemia is not a particularly sensitive finding. In hyperaldosteronism, the high levels of aldosterone lead to sodium resorption and potassium secretion at the site of the distal tubule. The sodium resorption leads to intravascular volume expansion and hypertension. Renovascular disease may also lead to hypokalemia and hypertension. Measuring renin activity can help distinguish the condition. Renovascular disease leads to renal hypoperfusion and release of renin. Hyperaldosteronism suppresses renin. (Stewart PM. Lancet 1999;353:1341-47.)

Hypertensive Emergency End Organ Damage

Hypertensive emergencies , which damage end organs, are due to acute and life-threatening elevations in blood pressure. Patients present with evidence of active target organ dysfunction attributable to the hypertension. End organ damage can include all of the above except for pancreatitis, which is not a typical "end organ" in terms of the effects of hypertension. Antihypertensive drugs usually are given intravenously to try to lower the blood pressure within an hour. Hypertensive urgency is defined as a markedly elevated blood pressure (systolic > 180 mmHg, diastolic > 110 mmHg) without current ongoing target organ damage. It is essential to differentiate between these two entities, because hypertensive emergencies require immediate treatment, often with intravenous agents such as labetalol or nitroprusside, and hypertensive urgencies can usually be treated over a longer period of time with oral agents. In addition to looking for target organ damage, it is important to use the history and physical to look for causes of the markedly elevated pressure. Such causes include acute left heart failure, stroke, postictal states, collagen vascular diseases, and ingestions of drugs like cocaine or other sympathomimetics. Elevated blood pressures attributable to one of these conditions should be treated by addressing the underlying condition.

Clinical Skills

Hypertension - Physical Exam

Evidence of long-standing hypertension

When evaluating a patient who is hypertensive in the office, it is essential to assess for evidence of the effects of long-standing hypertension on organ structure and function. This includes a retinal exam to look for evidence of hypertensive retinopathy, a detailed cardiac exam to look for cardiomegaly or signs of heart failure, and a thorough examination of peripheral pulses and assessment of aortic width. An enlarged aortic width and/or a pulsatile abdominal mass is suggestive of an abdominal aortic aneurysm. Risk factors for an AAA include hypertension (however this is a relatively weak risk factor), tobacco use, male gender, family history and hyperlipidemia. Evidence of secondary causes of hypertension

Some secondary causes of hypertension may also be evident on exam. It is important to check for thyromegaly, as this may be seen in conditions such as Graves' disease. Renal artery stenosis may cause a bruit in the epigastric area. A systolic bruit is sensitive, but a combined systolic-diastolic bruit is more specific. Coarctation of the aorta may result in discordant blood pressure with higher pressure in the arms.

Neurologic Findings in the Setting of Hypertension

When performing a screening neurologic exam in the setting of hypertension, you are assessing for any signs of previous central nervous system events, or strokes. There is great variability in the neurologic sequelae of strokes, but common presentations include dysarthria and hemiparesis (often with ipsilateral face and contralateral arm and leg weakness). After a stroke patients may have "upper motor neuron signs" within the distribution of the stroke; these include increased reflexes and muscle spasticity and the Babinski reflex is often present-the patient's great toe will be up-going. Pronator drift is a more subtle sign of upper motor neuron damage. The distribution and neurologic exam abnormalities differ from those of peripheral neurologic diseases. Here, too, there is great

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heterogeneity based on the underlying disease process, but patterns that will hint at a peripheral cause include deficits isolated to a radicular distribution, paresthesias in a stocking-glove distribution, and "lower motor neuron signs," such as decreased muscle bulk and decreased reflexes.

Obtaining Accurate Blood Pressure Readings

To obtain accurate blood pressure readings, it is important that the patient is relaxed. Patients should avoid exercise, smoking or alcohol for at least 30 minutes before a blood pressure reading. Patients should sit quietly for at least five minutes prior to blood pressure being checked (often, in busy ambulatory clinics, patients' blood pressure is taken much sooner than this). The patient should be supine or sitting comfortably with his arm at heart level. It is important, especially on a first encounter with a patient, to measure pressure in both arms. Obtaining more than one measurement can be helpful, because the blood pressure fluctuates and also the patient tends to become more relaxed. In recording an accurate blood pressure, it is essential to use an appropriately sized cuff. A cuff that is too small for the patient's arm circumference can overestimate blood pressure, whereas a cuff too large can underestimate it.

Retinal Evaluation for Possible Hypertensive Emergency

In a patient being evaluated for hypertensive emergency versus urgency, the most important retinal findings to look for include papilledema and hemorrhages, both of which indicate a more severe response to the hypertensive episode(s). These are associated with a high risk of stroke and require that the patient be treated emergently for his or her hypertension with intravenous antihypertensive medications. Retinal arteriolar narrowing and arteriovenous crossing changes ("AV nicking") may be seen in patients with long-standing hypertension. Moderate or severe lightening in the appearance of the arteries (so called "copper-wiring" or "silver-wiring" respectively) may also be seen with long-standing hypertension. These are caused by the arteriolar thickening, which is an adaptive response to long-standing hypertension. These findings do not imply a hypertensive emergency.

Management

Recommended Follow-Up for Elevated Blood Pressure (BP 120-129/<80 mmHg)

Given that the prevalence of hypertension increases with age, patients with elevated blood pressure should be followed regularly. This patient would ideally be advised of the following: 1) he has an elevated blood pressures reading in clinic, 2) he should implement non-pharmacologic therapies to reduce his blood pressure and 3) he should have his blood pressure rechecked in the next 3-6 months, ideally this would include out-of-office readings to assess for a ‘white-coat’ effect.

Effect of Antihypertensive Therapy on Risk of Stroke and Heart Disease

In clinical trials, patients taking antihypertensive therapy had a 35% to 40% reduction in stroke, a 20% to 25% reduction in myocardial infarction and a more than 50% reduction in heart failure. This reduction was even more robust in patients who already had target-organ damage.

Hypertension Management in Chronic Kidney Disease

2017 ACC/AHA Hypertension Guideline Management Algorithm

All adults with chronic kidney disease and hypertension should be treated if their blood pressure is > 130/80 per the 2017 ACC/AHA guidelines.

Population 2017 ACC/AHA Medication Recommendations

General black / African American population (including those with diabetes but without evidence of renal disease)

Use a thiazide diuretic or calcium channel blocker as initial therapy.

Black / African Americans with chronic kidney disease and proteinuria Use ACE inhibitor or angiotensin receptor blocker (ARB) asinitial therapy given the renal benefits.

To learn more required information about the management of hypertension, see the Aquifer Hypertension Guideline Module. K/DOQI Clinical Practice Guidelines on Hypertension and Antihypertensive Agents in Chronic Kidney Disease

Monotherapy with ACE inhibitors or ARBs is associated with smaller reductions in blood pressure in African American patients compared to white patients. It is for this reason that they are not generally considered first line therapy in African American patients unless they have kidney disease. ACE inhibitors or ARBs are preferred agents for diabetic kidney disease and nondiabetic kidney diseases with proteinuria. In these diseases, they lower blood pressure, reduce proteinuria, slow the progression of kidney disease, and likely reduce CVD risk by

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mechanisms in addition to lowering blood pressure. The use of ACE inhibitors and ARBs may result in adverse effects, which are more common in CKD. The most common side-effects- early decrease in GFR, hypotension and hyperkalemia-can usually be managed without discontinuation of the agent. With careful monitoring of therapy, most patients can be treated with ACE inhibitors and ARBs, even at low levels of GFR. In most patients, the ACE inhibitor or ARB can be continued if:

GFR decline over 4 months is <30% from baseline value Serum potassium is ≤5.5 mEq/L

Potential Side Effects of ACE-I

Angiotensin-converting enzyme inhibitors (ACE-I) such as lisinopril are generally well-tolerated. Common side effects are a dry, hacking cough and hyperkalemia. Angioedema is rare but can be life-threatening. These agents work in part by reducing pressure across the glomerulus, thereby slightly reducing the glomerular filtration rate; an increase in creatinine by up to 30% is generally tolerated. A more marked rise in creatinine, however, is not expected. A marked increase in creatinine should raise suspicion of bilateral renal artery stenosis, although this is a rare cause of hypertension in African-Americans. Hypotension and fatigue are side effects seen with most antihypertensive agents and can be seen with ACE-I drugs as well. In order to monitor for complications, potassium and creatinine should be checked one to two weeks after starting therapy.

DASH Diet to Reduce Blood Pressure

When combined with reduced sodium, the Dietary Approaches to Stop Hypertension (DASH) diet, which involves foods low in saturated fats and rich in potassium and calcium, results in a blood pressure reduction similar to that achieved with a single antihypertensive agent.

Goal Blood Pressure for Hypertensive Urgency

The worry about lowering the blood pressure too quickly in the setting of hypertensive urgency is that one could precipitate an ischemic stroke. In patients with long-standing hypertension, the intracerebral arteries have adjusted to keep a consistent pressure in the brain. These adjustments generally take hours to days to reequilibrate when pressures are changed. Therefore in a hypertensive urgency, the goal of treatment is a blood pressure reduction of about 25% over the first hours to days.

Obstacles to Chronic Disease Management Adherence

Chronic disease management is challenging on many levels, and it is important to explore obstacles to adherence such as misunderstandings of the treatment plan or the importance of treatment, or cost of medical appointments and medications. Building a good therapeutic relationship in which the patient feels comfortable asking questions and voicing concerns and also feels cared for, can be a powerful motivator for healthy behavior. Patient resources:

Online Guide to Quitting Smoking from the National Cancer Institute Lowering Your Blood Pressure With DASH, a booklet from NIH Mayo Clinic DASH recipes High Blood Pressure and Exercise: A Drug-Free Approach to Lowering High Blood Pressure

Studies

Initial Evaluation of Hypertension

ECG Assess for left ventricular hypertrophy or evidence of coronary artery disease.

Chemistries Look for evidence of renal insufficiency; hypokalemia may suggest a secondary cause like hyperaldosteronism.

TSH Hypertension can be secondary to hyper- or hypothyroidism, if a patient has additional symptoms consistent withthyroid dysfunction, a TSH would be an appropriate lab to order.

Urinalysis An active sediment (e.g. dysmorphic red blood cells and/or red blood cell casts) can suggest either acute glomerular damage as the cause of hypertension, or may suggest a primary glomerular process leading to hypertension. If there is protein in the urine this may influence what medication you treat the patient with.

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Diabetes screening and a lipid panel

If positive, these reveal an additional risk factor for cardiovascular disease that needs to be modified, particularly in a patient with hypertension.

Hematocrit Obtaining a hematocrit may be helpful to identify the severity of renal involvement and may indicate the presence of a pheochromocytoma (associated with hemoconcentration). Obtaining a hematocrit is recommended in patients with hypertension before initiating therapy.

Evaluation of Potential Hypertensive Emergency

You are looking for further evidence of end organ damage. Dilated retinal exam is appropriate to look for acute hypertensive retinopathy, such as retinal hemorrhages, exudates and papilledema. ECG and cardiac enzymes should be obtained to evaluate for myocardial ischemia or infarction. Urinalysis is indicated to look for malignant nephrosclerosis. Evidence of this would include hematuria and worsening proteinuria. Basic chemistries with BUN and creatinine should be obtained to look for worsening renal failure and resulting electrolyte disturbances.

References

Bibbins-Domingo K Chertow GM, et al. Projected Effect of Dietary Salt Reductions on Future Cardiovascular Disease. N Engl J Med 2010; 362:590-599.

Chou TC. Electrocardiography in Clinical Practice, 4th ed. Philadelphia: W.B. Saunders Co.; 1996.

Cohen DL, Townsend RR. How significant is white coat hypertension? J Clin Hypertens (Greenwich). 2010 Aug;12(8)

James PA, Oparil S, et at. 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults. JAMA, published online Dec 18,2013.

K/DOQI Clinical Practice Guidelines on Hypertension and Antihypertensive Agents in Chronic Kidney Disease https://www.kidney.org/professionals/kdoqi/guidelines_bp/guide_11.htm

Patel KK, Young L, Howell EH, Hu B, Rutecki G, Thomas G, Rothberg MB. Characteristics and Outcomes of Patients Presenting With Hypertensive Urgency in the Office Setting. JAMA Intern Med. July 2016;176(7):981-8.

Verberk WJ, Kroon AA, Kessels AG, et al. Home blood pressure measurement: a systematic review. J Am Coll Cardiol 2005 Sep 6;46(5):743-51.

Whelton PK et al. ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. November 2017.

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