Hypertension Management
<13Learning Objectives
By the end of the session, participants will be able to:
1. Describe criteria for the diagnosis of hypertension given the new 2017 ACA/AHA
blood pressure thresholds
2. Discuss when to initiate anti-hypertensive therapy
3. Describe targeted blood pressure goals and when targeted goals should be
individualized
4. Compare the potential new benefits and harms of the 2017 ACA/AHA guidelines
5. Counsel patients on what lifestyle interventions are beneficial and what the
expected impact on their blood pressure will be
6. Evaluate resistant hypertension
Resources for this session:
Annals ITC Hypertension
Podcasts ([Link] located under the “2017
Hypertension Guideline” section. There are two for you to listen to:
o Battle of the Heart Societies: Who Is Right--the US or Europe--Regarding How
to Manage Hypertension? (How they are similar)
o Battle of the Heart Societies Part 2: Who Is Right--the US or Europe--
Regarding How to Manage Hypertension? (How they are different)
Summary and reference tables from full guidelines
Additional resources
2017 ACC/AHA Hypertension Guidelines-- optional for this session but important
for an internist to know and understand. Find at:
[Link]
Table of commercially available combination antihypertensive agents--Thank you
Amber!
Case 1
HPI: 32-year old gentleman who you have seen in clinic since he was 21 reports that he
overall feels well, and he has no concerns today. PHQ-9 score is 0.
Other Medical History: None
Allergies: None
Medications: None
Family History: No history of CAD, MI, heart failure, stroke, diabetes, renal disease, or
peripheral arterial disease.
Hypertension Management
Occupation: Advertising and sales. He travels, via airplane, 4 days/week. Enjoys his job.
Social: Lives alone in a home he owns. Goes to the gym on the weekend when he is in town.
He does approximately 30 minutes of running on the treadmill and 30 minutes of
resistance training. During the remainder of the week he is not active. He often eats out due
to his travel schedule (breakfast and dinner at airport; lunch typically whatever is available
at the office he is traveling to). Sexually active with 1 female partner, uses condoms,
monogamous for 3 years.
Alcohol use: Drinks 2-3 beers a week.
Tobacco: Non-smoker.
Exam: BMI is 31 (up from 24 when you last saw him 2 years ago), BP: 138/82 (up from
124/60 last visit), otherwise normal exam. Labs obtained this visit show normal TSH, A1C,
CMP, and lipid profile.
1. What is the diagnosis?
a. What is the blood pressure goal for this patient? <130/80
b. Based on the new 2017 ACC/AHA guidelines, is this office blood pressure
sufficient or should you make a recommendation for further evaluation of his
blood pressure? Should be over 2 clinic visits. Should also tell them to do
ambulatory monitoring or home BP monitoring to r/o white coat HTN.
c. What are the potential benefits and harms of this diagnosis based on the new
guidelines? Reduce risk for developing CVD, renal disease, CVA, basically all
HTN-related diseases. Harms are subjecting patients to side effects of
treatment.
2. What is the recommended treatment for this patient based on the 2017 ACC/AHA
guidelines (assuming additional evaluation confirmed the diagnosis)? Lifestyle
changes: salt restriction, weight loss to 20% above ideal weight
a. Would the recommended treatment be different if his blood pressure was
146/92? What would be the treatment? You would treat with meds, either
Ace-I, CCB, or thiazide
b. Would the recommended treatment be different if his blood pressure was
still 138/82, but his A1C was 7.2? Yes, he would be Class 1 HTN w/ a risk
factor of DM
3. What lifestyle guidance would you provide? Decrease sodium intake, increase
aerobic exercise 30 minutes/day
a. What benefit on his blood pressure can he expect if he follows through on the
lifestyle changes? Systolic of 3 (reducing by 1000 mg/d), weight loss of 1
mmHg/kg lost
b. When should he follow-up with you? Yearly, but depends on the pt
c. What would be the next step if at follow-up his blood pressure remained the
same? Assess what he has done in terms of changes, possibly start on a
medication
Case 2
Hypertension Management
HPI: A 72-year-old African American woman comes in today to establish care, her prior PCP
retired. She has no specific concerns today.
Other Medical History: Hyperlipidemia
Allergies: None
Medications: Atorvastatin 20mg daily.
Family History: No history of CAD, MI, heart failure, stroke, diabetes, renal disease, or
peripheral arterial disease.
Occupation: She is a retired nurse.
Social: Lives alone in a home she owns. She babysits her grandchildren after school until
their parents return from work. She volunteers at their school and she hosts a weekly
euchre (card) game. She does water-based exercises 3 days/week. She cooks her own
meals and does her own IADLs/ADLs without issue.
Alcohol use: Drinks 3-4 glasses of wine each week.
Tobacco: Non-smoker.
Exam: BMI is 24, BP: 135/83, otherwise normal exam. Labs obtained prior to this visit
show an LDL of 150 mg/dl, otherwise her CMP, TSH, A1C, and CBC were normal.
1. What is the diagnosis? Class 1 HTN
a. What is the blood pressure goal for this patient? <130 with no diastolic BP
goal
i. What factors led you to select that BP goal for this patient? What types
of co-morbidities or “functional status” measures might alter that
goal? She is age > 65 and lives in the community. If more frail, can do
140 systolic
ii. Is this BP goal different from prior guidelines? What are the potential
new benefits and harms? JNC 8 shoots for <140/80, new benefit is
greater absolute risk reduction cardiovascular events. The Harms is
that more people are diagnosed and more people could have side
effects. Also may be more difficult to achieve and cause stress and
financial burden.
b. Based on the new 2017 ACC/AHA guidelines, is this office blood pressure
sufficient or should you make a recommendation for further evaluation of his
blood pressure? Will need an additional reading in the clinic, also outside BP
checking
2. What is the recommended treatment for this patient based on the 2017 ACC/AHA
guidelines (assuming additional evaluation confirmed the diagnosis)? Will need
another check, then if still the same, she would qualify (10 year risk score was
14.3%)
a. What would your recommended treatment be if her blood pressure were
162/92? Would start her on a medicine for sure, recheck and uptitrate as
tolerated.
Hypertension Management
Case 3
HPI: A 45 year old gentleman with a history of hypertension, type 2 diabetes, obstructive
sleep apnea, and obesity, here for a follow up visit, missed his last 2 visits with you. He
comes in reporting that he forgot to take his medications this morning and he will need
refills today or he will run out of medication. He reports he has not used his CPAP because
it is very uncomfortable, and they took it away. He denies, headache, vision changes, chest
pain/pressure, palpitations, SOB/DOE, abdominal pain, urinary changes, and LE edema. He
has been eating at Chipotle and Country Sweet for most of his meals. He reports that he
takes some of his medications everyday, but not all of them because there are “too many to
take.” He reports no difficulty affording his medications or food. He reports he knows that
Foodlink is a resource and it would be easy for him to access, but he does not want to eat
“green stuff.” He does not recall which medications he took today, but says he did his
injection, didn’t take “those horse pills,” and took 2 others. He reports that he missed his
last 2 visits because his car broke down, but it has since been repaired and he no longer has
any transportation difficulties, though he wishes parking was free.
Other Medical History: HTN, DM2, OSA, and obesity
Allergies: None
Medications: amlodipine 10mg daily, valsartan 320mg daily, HCTZ 25mg daily, ASA 81mg,
metformin 2000mg XR daily, liraglutide 1.8mg daily, and rosuvastatin 20mg daily.
Family History: No history of CAD, MI, heart failure, stroke, diabetes, renal disease, or
peripheral arterial disease.
Occupation: He works as a bus driver.
Social: Lives alone in a home he owns. He does not exercise.
Alcohol use: Drinks 4 beers a week.
Tobacco: Non-smoker.
Exam: BMI is 36, BP: 160/97, otherwise normal exam. Labs obtained prior to this visit
show an LDL of 150 mg/dl, A1C 7.8, creatinine of 1.6, microalbumin/creatinine of 73 mg/g.
The remainder of his CMP, TSH, and CBC were normal.
1. What is the diagnosis? Class 2 HTN
a. What is the blood pressure goal for this patient? <130/80
b. What is the rationale for each of his medications?
i. Amlodipine: Added benefit in African American
ii. Valsartan: renoprotective, also good for HF
iii. HCTZ: also good for African Americans, first line agent
2. Discuss the following possible obstacles to achieving blood pressure control in this
patient and possible solutions/counseling to provide the patient:
a. Health literacy
b. Pill burden
c. Lifestyle/diet
Hypertension Management
d. What others are there? Difficulty with transportation, cost of parking in the
ramp.
e. What resources are present in clinic to try and assist this patient? Dietary
consult
3. What would your treatment plan be for today? What follow-up would you request?
Try to consolidate some of the blood pressure pills, reassess by phone.
4. Let’s say the patient is taking all of his medication at your follow-up visit but his
blood pressure is still >130/80. Evaluate this patient by walking through the steps
outlined in Figure 10. Resistant Hypertension: Diagnosis, Evaluation, and
Treatment. What are the next steps in your treatment plan based on this evaluation?
In these patients,
clinicians should ask about symptoms that might reveal the cause.
For example, palpitations, tachycardia, paroxysmal headache,
and sweating suggest pheochromocytoma. Muscle weakness and
polyuria suggest hypokalemia
from severe primary aldosteronism. Snoring and daytime sleepiness can indicate sleep
apnea,
and heat intolerance and weight
loss suggest hyperthyroidism.
The clinician should ask about
current medications that may affect BP, such as oral contraceptives; corticosteroids;
sympathomimetics; antimigraine drugs;
and over-the-counter drugs, such
as nonsteroidal anti-inflammatory
drugs other than aspirin. The clinician also should ask about licorice and supplements, such
as
ma huang, ephedra, guarana,
bitter orange, and black cohosh.
Hypertension Management
Case 4
HPI: A 42 year old woman with a history of anxiety comes in for follow-up. She reports that
she has been doing well, her anxiety has much improved since starting buspirone. She
doesn’t note any side effects of the medication. When asked about her blood pressure
today, she reports that she’s always anxious when she comes to the doctor or when she has
to park in the garage here. She denies headaches, vision changes, chest pain, palpitations,
DOE, LE edema.
Other Medical History: Anxiety
Hypertension Management
Allergies: None
Medications: buspirone 15mg twice daily
Family History: +family history of CAD. No history of MI, heart failure, stroke, type 1 or 2
diabetes, or kidney disease.
Occupation: She works as a school teacher’s aide in a local pre-school.
Social: Lives alone in a home she owns. She exercises once a week on the weekends, about
30 minutes on the treadmill.
Alcohol use: Drinks 8 glasses of wine/week.
Tobacco: Non-smoker.
Exam: BMI is 26, BP: 147/90, otherwise normal exam. Labs obtained prior to this visit
show a normal CMP and CBC about a year ago.
1. What is the diagnosis?
a. What is the blood pressure goal for this patient?
b. Is there any additional evaluation that you would do?
c. What lifestyle changes would you counsel her on? Could reduce wine intake.
d. What are the next steps in your management plan?
