FAMILY MEDICINE ASSIGNEMENT 2a BY SCOTT D. NEFF DC DABCO MPS-BT DABFE FFABS FFAAJTS

BEATING HYPERTENSION THROUGH MEDICAL INFORMATION MASTERY AND POEMs

 INTRO INTO HYPERTENSION-THE UNCONVINCIBLE DISEASE

Hypertension Diagnosis:  

Hypertension is not controlled.  Patients today often make excuses for why things go wrong?  Often they fail to believe in scientific knowledge, or even if they comprehend, they fail to implement simple changes in their lifestyles which could save their lives once these changes become unconscious good health habits.  Much like obesity, it can be an insidious disease which in many cases could have been avoided, controlled or delayed until the golden years by sound unconscious life habits.  Unlike Obesity, where the patient and the world are readily able to acknowledge the condition even unconsciously, folks often cannot perceive the effects of hypertension and find the condition extremely difficult to put a handle on, or believe they have it once proven so, which often requires much in the way of patient education (Patient education is often a “priory for success”).  This absence of initial symptoms relative to even very high blood pressures, often take the patient by surprise.  As we see later in this discussion under treatment, dependant upon the patient’s presentation blood pressure levels, mild, moderate, severe, and so forth, determines lifestyle changes combined with diet and exercise, where a patient with a blood pressure of 230/110 absent symptoms would need appropriate immediate medication.  Many patients remain inconvincible, and if patent education is absent early on, patient abstinence from home and work lifestyle changes, adherence to exercise and diet and taking necessary and often life saving medications remains an obstacle for the patient’s true desire to “live” healthfully. Often a part of patient education is explaining the catastrophic end organ damage and circumstances or damage to the heart and kidneys as a direct result of hypertension.  (We make excuses for why things go wrong?  We fail to believe in scientific knowledge, or even if we comprehend, we fail to implement simple changes in our lifestyles.).  

It has been estimated that about 50 million Americans have hypertension, defined as having a systolic blood pressure higher than 140 mm Hg and/or having a diastolic blood pressure higher than 90 mm Hg and/or being on active care.  Prevalence increases with age, changing from 15.2% of 18-24 year old to 60.2% for those ages 65-74 years of age. 

As noted above race, gender and age have dramatic effects on hypertension patients.  For example overall Caucasians have a lower prevalence for hypertension when compared to blacks.  The prevalence for hypertension is 50% higher for African Americans than Caucasian populations.  Mexican Americans prevalence and incidence is similar to the Caucasian populations.  Women have a slightly lower prevalence then men in age adjusted relative to race.  For example African American, Mexican American and Caucasian women were 31%, 21%, and 21.6% relative to the men who were 34%, 25.4%, and 23.2%.  However a disturbing trend is that women over age 70, tend to have a higher prevalence for hypertension then men in the Caucasian grouping; 50% men, 55% women; again over age 70.  Finally, ageing has been correlated with a progressive rise in blood pressure and the incidence of hypertension is believed to increase five percent for each 10-year age interval.   

Other risk factors are of course obesity, diabetes, smoking, a family history of hypertension or heart disease, 11-β-hydroxylase deficiency ( HTN due to  salt & water retention.), Pheochromocytoma, a high-sodium diet, smoking, obesity, and again race : African American > Caucasian > Asian.  The majority of hypertension cases are considered primary or essential and related to increases in cardiac output or increases in total peripheral resistance with the remaining 10% mostly secondary to renal disease.  For example physiologic principles indicate that pressure is a direct function of flow and resistance.  The blood pressure, therefore, is related to the cardiac output and the total peripheral vascular resistance.  The cardiac output depends upon the contractility of the myocardium, the heart rate, and the intravascular blood volume.  The regulation of normal blood pressure depends upon several interrelated factors that modulate the output and resistance (Catecholamines, Humoral Angiotensin II, Aldosterone (Sodium resorption), Bradkykinins ((vasodilator)), Atriopeptins ((Natriuretic, vasodilate), and vascular factors such as prostaglandins, Endothelins, and Nitric oxide).  Further the autonomic nervous system is responsible for the regulation of abrupt hemodynamic alterations which may occur.  Baroreceptors located in the carotid sinus can detect minute fluctuations in the arterial blood pressure. The afferent limb of the neural loop relays the message to the brain stem, from which adrenergic outflow directly regulates the myocardial contractility, the heart rate, and the systemic vascular resistance.  The efferent limb of the autonomic nervous system also plays a role in the release of Catecholamines from the adrenal medulla.  The circulating adrenocoticoids act directly on the myocardium and the peripheral vasculature.  Thus, the mechanisms which regulate normal cardiovascular and peripheral vascular blood pressure.  Unfortunately, somewhere along any of the pathways, usually through improper health habits, heredity, disease, denial of hypertension once set in, which results in end organ damage, and a combination of any and all variables then brings about hypertension and its insidious and possibly deleterious effects. 

Finally, hypertension causes a predisposition toward atherosclerosis, stroke, congestive heart failure, renal failure, retinopathy, and aortic dissection. 

Often, precise diagnosis does not occur until an accidental discovery during a routine examination or examination for another cause.  Once the physician records a blood pressure suggestive of hypertension, careful consideration and three repeated blood pressure measurements separated by two weeks’ time follows. Clearly those at highest risk will require more rapid assessment to confirm the diagnosis, facilitate investigation and commence treatment.

As stated earlier, systolic hypertension in the elderly is common and is diagnosed when the diastolic pressure is normal or low, but the systolic is elevated, e.g.170/70 mm Hg. This condition usually co-exists with hardening of the arteries (atherosclerosis).

Recorded blood pressure measurements can be classified in stages, according to severity:

• normal blood pressure: less than less than 120/80 mm Hg
• pre-hypertension: 120-129/80-89 mm Hg
• Stage 1 hypertension: 140-159/90-99 mm Hg
• Stage 2 hypertension: at or greater than 160-179/100-109 mm Hg

Laboratory tests for patients with hypertension (unless recent examinations were normal) include:

Urinalysis

Blood chemistry (potassium, sodium and creatinine).

Fasting glucose

Fasting total cholesterol, high-density lipoprotein (HDL) cholesterol, low-density lipoprotein (LDH), cholesterol, and triglycerides

Standard 12 lead ECG

Hypertensive Urgency and Emergency:

Hypertensive Urgency is defined as a blood pressure recording greater than 180/>130 that is asymptomatic or moderately symptomatic (headache, chest pain, syncope).

A hypertensive emergency is defined as signs or symptoms of impending end-organ damage such as acute renal failure or hematuria; altered mental status or evidence of neurologic disease; intracranial hemorrhage; ophthalmologic findings (papilledema, vascular changes); unstable angina/MI or pulmonary edema.

Malignancy hypertension is defined as progressive renal failure and/or encephalopathy with papilledema.

Diagnosis of Hypertensive Urgency and Emergency:

The diagnosis of hypertensive urgency and emergencies are relative to cardiovascular, neurologic, ophthalmologic, and abdominal examination findings.  In these patients obtain a head and/or abdominal CT, UA BUN/creatinine, CBC, and electrolytes to asses the extent of end-organ damage.

Initial Evaluation:

Following the documentation of this condition, it is essential to discern essential from secondary hypertension as well as elucidating the potential end organ effects of established hypertension.  Thus the initial evaluation begins with a medical history which includes a determination of factors that may predispose to the development of hypertension, including the dietary intake of sodium and caffeine, concomitant medical therapy (especially oral contraceptives or other estrogen preparations), a positive family history of hypertension, and a stressful lifestyle.  Any history of weakness, muscle cramps, and polyuria suggests hypokalemia and possible hyperaldosteronism.  The presence of headaches, palpitations, or hyperhidrosis suggests catecholamine excess.  The end organ effects of hypertension are usually manifested in the heart, brain, and kidneys, so that the history should include symptoms of coronary artery disease, congestive heart failure, cerebrovascular disease and uremia. 

The physical examination will focus on potential end organ damage.  However as with any given visit, the recording of blood pressure is mandatory.  The patient should rest quietly for at least 5 minutes before the measurement.

Next the optic fundi must be carefully observed for evidence of arteriolar sclerosis.  The presence of hemorrhages and exudates or papilledema indicates severe, life-threatening hypertension.  Signs of congestive heart failure or peripheral vascular disease should be derived.  The abdomen should be auscultated for the presence of a bruit.  A careful neurologic examination should be performed to determine possible deficits related to a stroke. 

As noted above routine laboratory screening prior to instituting pharmacologic therapy must include serum electrolytes to determine potential metabolic disorders that may be associated with secondary cause of hypertension.  The serum creatinine and a urinalysis to determine potential renal dysfunction, which could be related as either a cause or an effect of hypertension.  The serum glucose, cholesterol, and uric acid levels are helpful in assessing other cardiovascular risk factors and can be used as a baseline for monitoring the effects of antihypertensive therapy.  Serial electrocardiograms and echocardiograms may be useful in assessing the effects of hypertension and antihypertensive treatment on the heart. 

Thus the initial evaluation of the patient should focus on:

• Recording the blood pressure
• Assessment of severity of hypertension
• Assessment of target organ damage
• Assessment of cardiovascular risk
• Identification of underlying causes
• Selection of specific care.

Next an assessment of severity of hypertension

Accelerated phase (malignant) hypertension is now rare, but the appearance of bilateral hemorrhages and cotton wool spots during the retinal examination points to the diagnosis. Without effective treatment the prognosis is poor - fewer than 10% of patients survive one year - whereas with treatment more than 80% survive five years.

Treatment:

There is no cure for primary hypertension, but blood pressure can almost always be lowered with the correct treatment. The goal of treatment is to lower blood pressure to levels that will prevent heart disease and other complications of hypertension. In secondary hypertension, the disease that is responsible for the hypertension is treated in addition to the hypertension itself. Successful treatment of the underlying disorder may cure the secondary hypertension.

Guidelines advise that clinicians work with patients to agree on blood pressure goals and develop a treatment plan for the individual patient.  Actual combinations of medications and lifestyle changes will vary from one person to the next.  Treatment to lower blood pressure may include changes in diet, getting regular exercise, and taking antihypertensive medications. Patients falling into the pre-hypertension range who don't have damage to the heart or kidneys often are advised to make needed lifestyle changes only.  A 2003 report of a clinical trial showed that adults with elevated blood pressures lowered them as much as 38% by making lifestyle changes and participating in the DASH diet, which encourages eating more fruit and vegetables.

Lifestyle changes that may reduce blood pressure by about 5 to 10 mm Hg include:

• reducing salt intake
• reducing fat intake
• losing weight
• getting regular exercise
• quitting smoking
• reducing alcohol consumption
• managing stress

Because obesity causes severe hypertension and hypertension causes obstacles for physical exercise and rehabilitation, weight loss and weight control can also be essential in controlling essential or obesity relative hypertension.  The following is a wonderful study on the comparison of weight loss on systolic and diastolic blood pressure. 

Weight loss decreases systolic and diastolic blood pressure. The Trials of Hypertension Prevention, Phase II (TOHP II) studied the effect of weight loss on blood pressure [1]. Approximately 1200 overweight and obese subjects were randomized to a 3-year weight loss program, involving diet and physical activity, or usual care. The results demonstrate a linear relationship between weight loss and blood pressure. An average weight loss of 8.8 kg was associated with a reduction of 7 mm Hg in diastolic blood pressure (DBP) and 5 mm Hg in systolic blood pressure (SBP). A loss of 2.6 kg caused reductions of 4.5 mm Hg in DBP and 2.5 mm Hg in SBP. A loss of 0.1 kg was associated with reductions of 2.0 mm Hg in DBP without a change in SBP. Participants who regained most or all of their lost weight experienced an increase in blood pressure to near baseline values.

In extremely obese patients with hypertension, marked weight loss induced by gastric surgery improves or completely resolves hypertension in approximately two thirds of patients [2,3]. However, recent data from the Swedish Obese Subjects Study [4] found that the beneficial effect of weight loss on blood pressure observed at 1 and 2 years after gastric surgery disappeared by 3 years, and both systolic and diastolic blood pressure continued to increase gradually for the next 5 years. More data are needed to fully evaluate the long-term effects of weight loss on blood pressure. 

1.        Stevens VJ, Obarzanek E, Cook NR, et al. Long-term weight loss and changes in blood pressure: results of the trials of hypertension prevention, Phase II. Ann Intern Med 2001;134:1-11.

2.        Foley EF, Benotti PN, Borlase BC, et al. Impact of gastric restrictive surgery on hypertension in the morbidly obese. Am J Surg 1992;163:294-297.

3.        Carson JL, Ruddy ME, Duff AE, et al. The effect of gastric bypass surgery on hypertension in morbidly obese patients. Arch Intern Med 1994;154:193-200.

4.        Sjostrom CD, Peltonen M, Wedel H, Sjostrom L. Differentiated long-term effects of intentional weight loss on diabetes and hypertension. Hypertension 2000;36:20-25.

Thus weight is directly correlated to hypertension in some cases, and weight control and diet are directly correlated with reducing hypertension and person health maintenance or maintaining health once hypertension control has been attained.

Patients whose blood pressure falls into the Stage 1 hypertension range may be advised to take antihypertensive medication. Numerous drugs have been developed to treat hypertension. The choice of medication will depend on the stage of hypertension, side effects, other medical conditions the patient may have, and other medicines the patient is taking.

If treatment with a single medicine fails to lower blood pressure enough, a different medicine may be tried or another medicine may be added to the first. Patients with more severe hypertension may initially be given a combination of medicines to control their hypertension. Combining antihypertensive medicines with different types of action often controls blood pressure with smaller doses of each drug than would be needed for just one.

Antihypertensive medicines fall into several classes of drugs:

• diuretics
• beta-blockers
• calcium channel blockers
• angiotensin converting enzyme inhibitors (ACE inhibitors)
• alpha-blockers
• alpha-beta blockers
• vasodilators
• peripheral acting adrenergic antagonists
• centrally acting agonists

Diuretics help the kidneys eliminate excess salt and water from the body's tissues and the blood. This helps reduce the swelling caused by fluid buildup in the tissues. The reduction of fluid dilates the walls of arteries and lowers blood pressure. New guidelines released in 2003 suggest diuretics as the first drug of choice for most patients with high blood pressure and as part of any multi-drug combination.

Beta-blockers lower blood pressure by acting on the nervous system to slow the heart rate and reduce the force of the heart's contraction. They are used with caution in patients with heart failure, asthma, diabetes, or circulation problems in the hands and feet.

Calcium channel blockers block the entry of calcium into muscle cells in artery walls. Muscle cells need calcium to constrict, so reducing their calcium keeps them more relaxed and lowers blood pressure.

ACE inhibitors block the production of substances that constrict blood vessels. They also help reduce the build-up of water and salt in the tissues. They often are given to patients with heart failure, kidney disease, or diabetes. ACE inhibitors may be used together with diuretics.

Alpha-blockers act on the nervous system to dilate arteries and reduce the force of the heart's contractions.

Alpha-beta blockers combine the actions of alpha and beta blockers.

Vasodilators act directly on arteries to relax their walls so blood can move more easily through them. They lower blood pressure rapidly and are injected in hypertensive emergencies when patients have dangerously high blood pressure.

Peripheral acting adrenergic antagonists act on the nervous system to relax arteries and reduce the force of the heart's contractions. They usually are prescribed together with a diuretic. Peripheral acting adrenergic antagonists can cause slowed mental function and lethargy.

Centrally acting agonists also act on the nervous system to relax arteries and slow the heart rate. They are usually used with other antihypertensive medicines.

Treatment for Hypertensive Urgency and Emergency:

The goal of emergency treatment for hypertension is to reduce the blood pressure slowly (decrease in mean arterial pressure of only 25% over the first two hours) to prevent cerebral hypoperfusion or coronary insufficiency.  Avoid short-acting calcium channel blockers and first employ oral agents such as Beta-blockers, clonidine, and “ACEIs.  If insufficient, use IV agents.  IV agents include nitroprusside, nitroglycerin, labetalol, nicardipine, or hydrallazine.  Add a diuretic if there are signs of fluid overload.

Chronic Evaluation:

There is no cure for hypertension. However, it can be well controlled with the proper treatment.  This includes repeat periodic monitoring of blood pressure and the recording of such consistent findings.  Therapy as a combination of lifestyle changes and antihypertensive medicines usually can keep blood pressure at levels that will not cause damage to the heart or other organs. The key to avoiding serious complications of hypertension is to detect and treat it before damage occurs. Because antihypertensive medicines control blood pressure, but do not cure it, patients must, in moderate to severe disease, continue taking the medications to maintain reduced blood pressure levels and avoid complications.

Once hypertension is under the limits of control, maintenance centers on the patient making life habits of avoiding or eliminating known risk factors. Even persons at risk because of age, race, or sex or those who have an inherited risk can maintain their hypertension control.

The risk of developing hypertension can be reduced by implementing the lifestyle changes employed during the initial treatment for hypertension:

Implement MNT diet

• reducing salt intake
• reducing fat intake
• reducing caloric intake
• losing weight
• getting regular exercise with focus on aerobic fitness regardless of weight
• no smoking
• reducing alcohol consumption or complete elimination
• managing stress
• increase Magnesium to 350 mg/day for magnesium deficient patients or 250 mg/day.
• add one clove of "fresh" Garlic/day or at least two to three times per week to your diet
• eat fresh fish twice/week
• place another emphasis on fruits, vegetables and whole grains
• The Institute of Medicine determined that an adequate water intake (AI) for men is roughly 3 liters (about 13 cups) of total beverages a day. The AI for women is 2.2 liters (about 9 cups) of total beverages a day. Modifications made dependent on the presention of kidney disease.

However and again the hallmark for controlling hypertension is effective long-term control for blood pressure such as routine home blood pressure testing and in office electrocardiograms at regular intervals to monitor LV function and signs of congestive heart failure.  Finally the monitoring of patient BUN and creatinine for renal function as well as all criteria above, will assist in changes in medications if necessary to help the patient maintain a wonderful and productive life.

Hypertension is a chronic disease that may require long-term therapy maintenance supervision for long term control in moderate to severe cases.  In conclusion, after the initial treatment plan duration, return for Chronic Evaluation has been proved by the evidence to help the patient maintain their hypertension control plan, and if we can educate the patient appropriately, it is now clear that with lifestyle changes, and behavior modification combined with medical assistance, years will be added to the patient's life and a wholesome enriched life will be added to the patient's years. 

by Scott David Neff

References:        

Books:

• Sloane, Philip D et al, Essentials of Family Medicine, 4^th Edition, Lippincott-Williams & Wilkins, pages 563-573
• Andreoli Thomas E et al, Cecil Essentials of Medicine, 4^th Saunders, pages 230-237.
• Kasper Dennis L et al, Harrison’s Principles of Internal Medicine, 16^th edition, Mc Graw Hill, pages 1464-1474
• Ibid pages 2390-391
• Ibid pages 1654-1658
• Bellenir, Karen, and Peter D. Dresser, eds. Cardiovascular Diseases and Disorders Sourcebook. Detroit: Omnigraphics, 1995.
• Texas Heart Institute. Heart Owner's Handbook. New York: John Wiley and Sons, 1996.

• McNamara, Damian. "Obesity Behind Rise in Incidence of Primary Hypertension." Family Practice News (April 1, 2003): 45-51.
• McNamara, Damian. "Trial Shows Efficacy of Lifestyle Changes for BP: More Intensive Than Typical Office Visit." Family Practice News (July 1, 2003): 1-2.
• "New BP Guidelines Establish Diagnosis of Pre-hypertension: Level Seeks to Identify At-risk Individuals Early." Case Management Advisor (July 2003): S1.
• "New Hypertension Guidelines: JNC-7." Clinical Cardiology Alert (July 2003): 54-63.
• Stevens VJ, Obarzanek E, Cook NR, et al. Long-term weight loss and changes in blood pressure: results of the trials of hypertension prevention, Phase II. Ann Intern Med 2001;134:1-11.
• Foley EF, Benotti PN, Borlase BC, et al. Impact of gastric restrictive surgery on hypertension in the morbidly obese. Am J Surg 1992;163:294-297.
• Carson JL, Ruddy ME, Duff AE, et al. The effect of gastric bypass surgery on hypertension in morbidly obese patients. Arch Intern d 1994;154:193-200.
• Sjostrom CD, Peltonen M, Wedel H, Sjostrom L. Differentiated long-term effects of intentional weight loss on diabetes and hypertension. Hypertension 2000;36:20-25.
• White WB. Blood Pressure Monitoring in Cardiovascular Medicine and Therapeutics. Humana Press Ltd, Totowa, NJ, 2001.
• Mansoor GA. Secondary Hypertension: Clinical Presentation, Diagnosis, and Treatment. Humana Press Ltd, Totowa, NJ 2004.
• White WB. Ambulatory blood pressure monitoring in clinical practice. New England Journal of Medicine 2003; 348: 2377-2378.
• White WB. Hypertension associated with therapies to treat arthritis and pain. Hypertension. 2004;44(2):123-4.
• Bansal N, Tendler BE, White WB, Mansoor GA. Blood pressure control in the hypertension clinic. American Journal of Hypertension 2003;16 (10):878-80.
• Jackson R, Barham P, Bills J: Management of raised blood pressure in New Zealand: a discussion document. BMJ 1993 Jul 10; 307(6896): 107-1 {eMedicine}
• Kaplan NM, Gifford RW: Choice of initial therapy for hypertension. JAMA 1996 May 22-29; 275(20): 1577-54  {eMedicine}

By Scott David Neff for Family Medicine October 3rd, 2006