HTN case

Table of Contents

• College of Medicine Almaarefa University
  • Sheet 1
    • Candidate Directions
  • Sheet 2
    • Role Player Information
      • Social History
      • Analysis of Complaint
      • Family History
      • Questions to Ask
    • Notes

College of Medicine Almaarefa University

Sheet 1

Candidate Directions

Candidate Directions Name: Ahmed Elzahrany

Gender: Male

Age: 50 years

Social History: Accountant, married, has 3 kids.

Complaint: Blood pressure measurement 160/100 mmHg

In the next seven minutes, please:

• Obtain focused history.
• Order proper investigations.

Sheet 2

Role Player Information

Your Name: Ahmed Elzahrany

Age: 50 years

Reason for Visit: You measured your blood pressure at the pharmacy twice and the pharmacist told you to consult your physician.

If Asked to Talk More About Your Problem:

• You were well until last month when you started to feel unwell and tired. Sometimes you get headaches, but it is very mild and a relief by itself. Your neighbor advised you to measure your blood pressure.
• You presented today to measure your blood pressure, which was 160/100, and measured it on three occasions. The nurse told you that it was high.
• You have no other complaints.

Do Not Provide the Following Information Unless Asked:

Social History

• You are an accountant, married, and have 1 daughter and 2 sons.
• You drink 2 cups of tea and 1 cup of coffee daily.
• You eat fast and junk food frequently with a lot of beverages.
• You do not practice any physical sports.
• The relationship with your wife, siblings, family, and neighbors is very good with no social problems or problems in your work.
• You are a smoker and smoke a pack every day.

Analysis of Complaint

• You do not complain of any symptoms suggesting any disease, just this light headache around your head that spontaneously relieved.

• You did not receive any medications.

• You do not have a history of any chronic disease such as diabetes or renal diseases.

• You did not perform any investigations.

  • You don’t suffer from headache, any muscle weakness or numbness, blurring of vision, chest pain, dyspnea, palpitation, dysuria, hematuria, oliguria, or claudication, leg pain during walking, lower limb edema, vomiting, syncope, sensory or motor deficit, chest pain or shortness of breath, palpitation.
  • You don’t have sleep problems, neck swellings, any heat or cold intolerances, change in bowel habits, renal disease, tremors, or endocrinal symptoms suggesting secondary hypertension.

• You are concerned that you might have a myocardial infarction like your father.

Family History

• Your mother is hypertensive and diabetic, and your father had a myocardial infarction at the age of 53 years old.

Questions to Ask:

• Will I need any investigations for my condition?
• Doctor, I don’t feel anything, why must I use medication?

HTN Session Discussion Questions

Table of Contents

• Instructions to the Students
  • A General
  • B History
  • C Clinical Presentation and Diagnosis
  • D Clinical Examinations
  • E Investigation
  • F Treatments
  • G Special Conditions/Groups
  • H Referral
  • I Complications
  • J Screening Criteria

HTN Session Discussion Questions

Instructions to the Students

A General

1. How to define hypertension?

   • HTN is defined as persistent SBP and/or DBP levels above which harm and significant increment of morbidity and mortality are observed if left untreated.

2. What are the different stages of HTN? How could be diagnosed.

   • Stage-1 hypertension

     • Clinic BP 140/90 to 159/99 mmHg
     • ABPM daytime average or HBPM 135/85 mmHg to 149/94 mmHg.

   • Stage 2 hypertension

     • Clinic BP 160/100 mmHg to <180/120 mmHg and
     • ABPM or HBPM average BP of 150/95 mmHg or higher.

   • Stage 3 or severe hypertension

     • Clinic BP ≥180 or clinic diastolic BP of ≥120 mmHg

3. How BP should be measured?

   • I. Patient-Related Standards:
   • II. Equipment-Related Standards:
   • III. Examiner-Related Standards:

4. What is the isolated systolic HTN?

   • Persistent high Office SBP ≥140 mm Hg and Office DBP <90 mm Hg.

5. What is the white coat HTN?

   • White coat HTN is defined as an elevated BP in the office at repeated visits, while it is normal out of the office.

6. What is Home Blood Pressure Monitoring (HBPM), and what is the indication?

   • HBP may be used for both diagnosis and monitoring of BP.
   • Home SBP values ≥135 mmHg or DBP values ≥85 mmHg should be considered as elevated.

7. Home BPM should be based on duplicate measurements (one minute apart), morning and evening, for an initial 7-day period.

   • First-day home BP values should not be considered.

8. What is the Ambulatory BP Monitoring (ABPM)?

   • It is performed by a validated automated device over a period of 24 hours.
   • BP is measured at repeated intervals (every 15–30 mins while awake, and every 30–60 mins during sleep).
   • ABPM is a more sensitive risk predictor of CV outcome than is office BPM.
   • The incidence of CV events is higher in non-dippers.
   • Normal average daytime BP is <135/85 mm Hg.

9. What are the indications for Ambulatory BP Monitoring (ABPM)?

10. 1. Suspected white-coat HTN
11. 2. Confirm diagnosis, if available
12. 3. Suspected masked HTN
13. 4. Resistance to drug therapy
14. 5. Suspicion of nocturnal HTN
15. 6. Obstructive sleep apnea
16. 7. Assessing hypertension in children and adolescents
17. 8. Assessing hypertension in pregnancy
18. 9. Assessing hypertension in high-risk patients
19. 0. Suspected drug-induced hypotension
20. 1. Assessment of BP variability
21. 2. Assessing hypertension in the elderly

22. What are the secondary causes of HTN?

    • Endocrine
    • Cardiovascular
    • Renal
    • Chronic alcohol abuse
    • Medications

B History

11. What are the points to be included during taking history in a patient with hypertension?

When taking a history in a patient with hypertension, the following points should be included:

• Duration of Hypertension: Ask when the patient was first diagnosed and any previous blood pressure readings.
• Symptoms: Inquire about symptoms such as headaches, dizziness, chest pain, shortness of breath, or visual changes.
• Risk Factors: Assess for risk factors such as smoking, alcohol use, diet (especially salt intake), physical activity, and stress levels.
• Family History: Determine if there is a family history of hypertension, cardiovascular disease, or other related conditions.
• Medication History: Review current and past antihypertensive medications, adherence to treatment, and any side effects experienced.
• Other Medical Conditions: Ask about other medical conditions such as diabetes, kidney disease, or hyperlipidemia.
• Lifestyle Factors: Discuss weight, diet, exercise habits, and any recent changes in lifestyle.
• Social History: Consider occupational stress, socioeconomic factors, and support systems.
• Previous Investigations and Treatments: Review any previous investigations like blood tests, ECGs, or imaging studies, and treatments received.

12. What are the modifiable and non-modifiable risk factors for CV events?

• Modifiable Risk Factors:

  • Hypertension
  • Smoking
  • Diabetes mellitus
  • Dyslipidemia (abnormal cholesterol levels)
  • Obesity
  • Physical inactivity
  • Unhealthy diet (high in saturated fats, trans fats, and cholesterol)
  • Excessive alcohol consumption
  • Stress

• Non-Modifiable Risk Factors:

  • Age (risk increases with age)
  • Gender (males are generally at higher risk, though risk increases for women post-menopause)
  • Family history of cardiovascular disease
  • Ethnicity (certain ethnic groups may have higher risk)
  • Genetic predisposition

C Clinical Presentation and Diagnosis

13. What is the term used if the systolic blood pressure falls by 20 mmHg or more when a person is standing? What we supposed to do for such patients?

• Review medication
• Measure subsequent blood pressures with the person standing
• Consider referral to specialist care if symptoms of postural hypotension persist.

D Clinical Examinations

14. What are the clinical examinations to be done in the first visit of a HTN patient?

Physical examination should include:

• Blood pressure (BP)
• Examination of optic fundi
• Calculation of BMI from height and weight
• Auscultation for possible carotid, abdominal, or femoral bruits
• Palpation of the thyroid gland
• Examination of the heart and lungs
• Examination of the abdomen for enlarged kidneys, masses, distended urinary bladder, or abnormal aortic pulsation
• Palpation of the lower extremities for oedema and pulses
• Neurological assessment.

Physical examination may reveal end-organ damage associated with untreated hypertension: for example, retinopathy, vascular bruits, signs of congestive heart failure, evidence of aortic aneurysm (pulsatile mass/bruit), left ventricular hypertrophy (displaced point of maximal impact), or neurological deficit(s). Absence of femoral pulses suggests coarctation of the aorta. An abdominal bruit may suggest aortic aneurysm or renal artery stenosis. Occasionally, patients may have stigmata of endocrinopathy such as Cushing’s disease (moon face, centripetal obesity, striae), acromegaly (acral enlargement), Graves’ disease (goitre, exophthalmos, pretibial myxoedema), or hypothyroidism (dry skin, delayed return of deep tendon reflexes), indicating a secondary cause of hypertension.

E Investigation

15. What are the initial investigations to be offered to a hypertensive patient?

• ECG
• Fasting metabolic panel with estimated GFR
• Lipid panel
• Urinalysis Increased albumin excretion suggests end-organ damage.
• Hb Anaemia accompanies chronic renal failure. Polycythaemia may be seen with phaeochromocytoma.
• Thyroid-stimulating hormone

F Treatments

16. What are the non-pharmacological approaches for hypertensive patients?
    Non-pharmacological approaches for hypertensive patients include lifestyle modifications such as dietary changes, regular physical activity, weight loss, reducing sodium intake, increasing potassium intake, moderating alcohol consumption, and quitting smoking.

17. What is DASH?
    DASH stands for Dietary Approaches to Stop Hypertension. It is a dietary plan that emphasizes the consumption of fruits, vegetables, whole grains, lean proteins, and low-fat dairy products while reducing the intake of saturated fats, cholesterol, and sodium.

18. Name medications that could be used in HTN treatment.
    Medications used in hypertension (HTN) treatment include diuretics, ACE inhibitors, angiotensin II receptor blockers (ARBs), calcium channel blockers, beta-blockers, and aldosterone antagonists.

19. Who should be treated with pharmacotherapy?
    Pharmacotherapy is typically recommended for individuals with stage 2 hypertension or those with stage 1 hypertension who have a high risk of cardiovascular events, such as those with existing cardiovascular disease, diabetes, chronic kidney disease, or a high calculated risk of cardiovascular disease.

20. In which condition should you start treatment after just one set of BP measurements?
    Treatment should be started after just one set of blood pressure (BP) measurements if the patient presents with hypertensive urgency or emergency, characterized by severely elevated BP with or without acute target organ damage.

21. When are you going to change your hypertension treatment if the initial therapy is not attaining and maintaining your goal BP?
    Hypertension treatment should be changed if the initial therapy is not attaining and maintaining the goal BP after a reasonable trial period, typically around 1 to 3 months, depending on the patient’s risk factors and the severity of hypertension.

22. When a target goal is not reached in a patient, what we suppose to do?
    If a target goal is not reached in a patient, it is recommended to reassess the treatment regimen, which may include adjusting the dosage, adding another antihypertensive medication, or considering alternative therapies. Additionally, adherence to lifestyle modifications and medication should be evaluated.

23. What are three strategies regarding dosage and medication titration for hypertensive patients?
    Three strategies for dosage and medication titration in hypertensive patients include:

24. Starting with a low dose of a single medication and gradually increasing it until the target BP is reached.

25. Initiating treatment with two medications at low doses, especially in patients with significantly elevated BP.

26. Switching to or adding another class of medication if the initial choice is not effective or causes adverse effects.

27. what is the best choice of medication if a patient is suffering from isolated systolic HTN The best choice of medication for a patient suffering from isolated systolic hypertension is often a thiazide diuretic or a long-acting calcium channel blocker, as these have been shown to be effective in reducing systolic blood pressure.

G Special Conditions/Groups

25. Define resistant HTN?

Resistant hypertension (HTN) is defined as blood pressure that remains above the target level despite the concurrent use of three antihypertensive agents of different classes. Ideally, one of these agents should be a diuretic, and all agents should be prescribed at optimal dose amounts. Resistant hypertension can also be diagnosed if a patient’s blood pressure is controlled but requires four or more antihypertensive medications to achieve that control.

25. How to manage resistant HTN?

• Both diuretics and ARB may affect treatment outcomes. The thiazide-like diuretics chlorthalidone and indapamide might be favored.
• Spironolactone should be considered in treatment-resistant hypertension.

27. How to manage HTN with DM?

• ACEs or ARBs are recommended especially in the presence of albuminuria or renal involvement.

28. How to manage HTN with chronic kidney disease?

• The most effective are ACEs and ARBs.

29. How to manage HTN with coronary artery disease?

• Beta blockers and RAS blockers (ACEs or ARBs) are preferred.

30. How to manage HTN with heart failure?

• Trials have demonstrated the efficacy of diuretics, beta-blockers, and RAS blockers (ACEs or ARBs).

31. How to manage HTN with Acute stroke and Cerebrovascular disease?

• RAS blocker in combination with a CCB or a thiazide-like diuretic is recommended for stroke prevention.

32. How to manage HTN with Atrial Fibrillation?

• Beta blockers or non-dihydropyridine CCBs are recommended.

33. How to manage HTN with pregnancy?

• Treatment of choice for non-severe HTN includes methyldopa, labetalol, and CCBs.

34. How to manage HTN in older age (>65 years old)?

• Avoid loop diuretics and alpha blockers due to risk of fall.

H Referral

35. What are the indications to refer a hypertensive patient to a specialist?

• Resistant hypertension not controlled with optimal treatment.
• Suspected secondary hypertension.
• Hypertensive emergencies or urgencies.
• Presence of significant end-organ damage.
• Unusual blood pressure variability.
• Need for specialized diagnostic or therapeutic procedures.

36. When you refer the person to specialist care on the same day?

• Severe hypertension with acute end-organ damage (e.g., hypertensive emergency).
• Malignant hypertension.
• Rapidly progressive renal failure.
• Suspected pheochromocytoma or other secondary causes requiring urgent evaluation.

37. What interventions might be used to increase patient adherence to treatment?

• Simplifying medication regimens.
• Using combination pills to reduce pill burden.
• Providing patient education on hypertension and its risks.
• Implementing reminder systems (e.g., phone apps, alarms).
• Regular follow-up appointments to monitor progress.
• Involving family members or caregivers in the treatment plan.
• Addressing side effects and adjusting treatment as necessary.

I Complications

38. What are the long-term complications/end-organ damage in a patient with hypertension?

• Cardiovascular disease (e.g., coronary artery disease, heart failure).
• Stroke or transient ischemic attack.
• Chronic kidney disease.
• Retinopathy.
• Peripheral artery disease.
• Left ventricular hypertrophy.

J Screening Criteria

39. What are the screening criteria and who are the persons to be screened?

• Individuals with risk factors such as obesity, diabetes, or a family history of hypertension.
• Pregnant women, as part of prenatal care.
• Individuals with symptoms suggestive of hypertension or related complications.
• Those with a history of cardiovascular disease or other related conditions.