diagnosis

Mr. Martin, a 54-year-old man, is new to the clinic and came in for a checkup. He has not received medical care for more than a decade. He currently has no health concerns.

Elevated BP on exam: 150/85 mmHg right arm BP 151/82 mmHg left arm

No health insurance

BMI of 27 kg/m2 (overweight)

Weight gain of 20 pounds in the last few years.

No medical care for over 10 years

Work 12 hours shifts six days a week as a taxi driver

Physical inactivity

Some financial stressors

No history of hypertension, hypercholesterolemia, or diabetes

54-year-old male

Fast food consumption

No medical care for over 10 years

Does not smoke, drink alcohol, or use any recreational drugs

Does not use complementary or herbal medicine

Family history of myocardial infarction (MI)-Father and hypercholesterolemia and diabetes (mother)

Mr. Martin is a 54-year-old male who presents for a routine physical exam after not engaging in regular health care for over a decade. He has no concerns, but his blood pressure is elevated today. Other than being overweight, the remainder of his physical exam is unremarkable. In terms of his cardiac risk factors, due to his work as a taxi driver, he often eats fast food; he does not smoke tobacco. His father also had a myocardial infarction at age 64, though this is not considered "premature" cardiac disease (which is officially de-fined as <55 in males). He has some financial stressors and does not have health insurance

No health insurance and no medical care for 10 years

BP 150/85 mmHg right arm

BP 151/82 left arm

Consumes a lot of fast food

BMI of 27 kg/m2 (overweight)

Physical Inactivity

Family history of heart attack (father)

Some financial worries related to rents and fees for his daughter

No health insurance and no medical care for 10 years

BP 150/85 mmHg right arm

BP 151/82 left arm

No health insurance and no medical care for 10 years.

BP 150/85 mmHg right arm BP 151/82 left arm

Family history of high cholesterol and diabetes (mother)

Family history of heart attack (father)

Out-of-office blood pressure monitoring (Basile & Bloch, 2021).

It is important to check blood pressure outside of a physician's office since some patients only have high blood pressure readings when they visit their physician. If the patient's home blood pressure measurements are normal, he or she likely has white coat hypertension. If the patient's home blood pressure readings remain elevated, hypertension is likely present. Individuals with white coat hypertension must continue to be monitored for the development of essential hypertension (Basile & Bloch, 2021).

Lipid panel (Basile & Bloch, 2021).

A lipid profile that includes measurements of high-density lipoprotein (HDL), low-density lipoprotein (LDL), and triglycerides is necessary for further evaluation and treatment of cardiovascular risk factors (Basile & Bloch, 2021).

Fasting metabolic panel with estimated GFR (Basile & Bloch, 2021).

Fasting Blood Glucose: An elevated fasting blood glucose may be evidence of undiagnosed diabetes or poorly controlled diabetes (a potential co-morbidity and sign of metabolic syndrome) (Basile & Bloch, 2021).

Serum Potassium: Several blood pressure medications can cause hyperkalemia (Angiotensin Converting Enzyme (ACE) inhibitors, Angiotensin Receptor Blockers (ARBs); diuretics can cause hypokalemia. A baseline potassium level will help determine any future changes due to antihypertensive therapy. Potassium disturbances can also occur in Cushing's syndrome or primary hyperaldosteronism, which could point to a secondary cause of hypertension (Basile & Bloch, 2021).

Serum Sodium: Blood pressure medications (especially diuretics) can also cause hyponatremia, particularly in older adults. Again, a baseline sodium level will help determine any future changes due to antihypertensive therapy (Basile & Bloch, 2021).

Serum Creatinine: This may be indicative of end organ damage (hypertensive nephropathy) from long-term uncontrolled hypertension. Some blood pressure medications can also elevate creatinine (ACE inhibitors, ARBs, and diuretics) (Basile & Bloch).

Serum calcium: A serum calcium is useful to evaluate for primary hyperparathyroidism, which can be associated with hypertension (Basile & Bloch, 2021).

TSH (Cash et al., 2021).

A TSH can screen for hypothyroidism or hyperthyroidism, both causes of secondary hypertension (Cash et al., 2021).

Urinalysis (Basile & Bloch, 2021).

A urinalysis will evaluate proteinuria, which can be evidence of hypertensive nephropathy. Urinalysis can also detect glucosuria, which may be evidence of undiagnosed diabetes or poorly controlled diabetes (a potential co-morbidity and sign of metabolic syndrome) (Basile & Bloch, 2021).

Electrocardiogram (Basile & Bloch, 2021).

An electrocardiogram is indicated to assess rate and rhythm issues such as bradycardia, tachycardia, or an underlying heart block. You can also look for evidence of ischemic disease, previously undiagnosed myocardial infarctions, or cardiac hypertrophy. Left ventricular hypertrophy (LVH) is an important prognostic factor for death in all people with or without hypertension. LVH is reversible with proper attention and medical management (Basile & Bloch, 2021).

Calculation of 10-year atherosclerotic cardiovascular disease risk (Basile & Bloch, 2021).

The patient has several risk factors for atherosclerotic cardiovascular disease (ASCVD). This calculation may serve as a guide to lipid management as well as the initiation of low-dose aspirin. The USPSTF recommends initiating low-dose aspirin use for the primary prevention of cardiovascular disease (CVD) in adults aged 50 to 59 years who have a 10% or greater 10-year CVD risk (Basile & Bloch, 2021). Since his risk is <7.5% aspirin therapy will not be started at this time (Basile & Bloch, 2021)

Lifestyle modification/non-pharmacological therapy:

1. Dietary sodium restrictions 2. Potassium supplementation: (3.5 to 5.0 g/day, preferably consumption of potassium-rich diet)

3. Weight reduction 4. DASH Diet :(8-10 serving of fruit and vegetable daily). 5. Exercise: (30 minutes of moderate intensity exercise 5 days per week) as tolerated. 6. Limit alcohol consumption

7. Identification and management of stressors

(Whelton et al., 2018)

1. The overall impact of moderate sodium reduction is a fall in blood pressure in hypertensive and normotensive individuals (Basile & Bloch, 2021).

2. Low dietary potassium intake has been associated with an elevation in blood pressure and an increased risk of stroke, as well as an increase in risk of chronic kidney disease (CKD) (Whelton et al., 2018).

3. Weight loss in overweight or obese individuals can lead to a significant fall in blood pressure independent of exercise (Whelton et al, 2018).

4. DASH dietary pattern reduced blood pressure by 11 mmHg compared with a typical American-style diet that contained the same amount of sodium and the same number of calories The Dietary Approaches to Stop Hypertension (DASH) dietary pattern is high in vegetables, fruits, low-fat dairy products, whole grains, poultry, fish, and nuts and low in sweets, sugar-sweetened beverages, and red meat (Whelton et al., 2018).

5. Aerobic exercise, and possibly resistance training, can decrease systolic and diastolic pressure (Basile & Bloch, 2021). Exercise also helps in the management of stress.

6. Men who have three or more drinks per day have a significantly increased incidence of hypertension compared with nondrinkers. Adult men and women with hypertension should consume, respectively, no more than two and one alcoholic drinks daily (Basile & Bloch, 2021).

Pharmacological therapy: Thiazide like or thiazide-type diuretics (Chlorthalidone: 12.5 mg PO once daily initially, increase gradually according to the response, maximum 25 mg daily preferable in the evening for this patient) (Whelton et al., 2018).

Chlorthalidone is preferred based on prolonged half-life and proven trial reduction of CVD. Monitor for hyponatremia and hypokalemia, monitor uric acid, and calcium levels. Use with caution in patients with a history of acute gout unless the patient is on uric acid–lowering therapy. The goal blood pressure for patients with hypertension is <130/80 mmHg. If this goal is not met with Chlorthalidone at follow-up visits, then additional blood pressure medication may have to be added from the other preferred classes (calcium channel blockers, ACE inhibitors, ARB’s) (Whelton et al., 2019).