The Management of Patients With Hypertension Pt. 3
This podcast series aims to highlight the prevention, diagnosis, and treatment of patients with diseases commonly seen in internal medicine. Host, Anil Harrison, MD, discusses patient cases with residents and with prominent experts to help educate clinicians in treating patients using a multidisciplinary approach.
In this podcast, Dr Harrison and Paul Shiu, DO, discuss hypertension urgency and emergency, what happens if hypertension is not properly managed, managing hypertension in the elderly, and in women who are pregnant, and more. This is part 3 of a 3-part series on hypertension.
For more hypertension content, visit the disease state hub.
For part 1 of this 3-part podcast, click here.
For part 2 of this 3-part podcast, click here.
TRANSCRIPTION:
Speaker 1:
Hello everyone, and welcome to Multidisciplinary Dialogue: Clinical Rounds and Case Reviews with your host, Dr. Anil Harrison, who is the program director and chair of the Internal Medicine Residency Program at the University of Central Florida and HCA Florida West Hospital in Pensacola, Florida. Today, Dr. Harrison and Dr. Paul Shiu will discuss the management of patients with hypertension. Dr. Shiu is an internal medicine resident at St. Joseph's Medical Center in Stockton, California. The views of the speakers are their own and do not reflect the views of their respective institutions or the views of Consultant360.
Dr Anil Harrison:
Good morning everyone.
Dr Paul Shiu:
Good morning, Dr. Harrison.
Dr Anil Harrison:
Good morning, Paul.
Dr Paul Shiu:
See, now we can have some fun and talk about some interesting cases, but before we talk about cases, we have to follow up on what we last talked about. So as a refresher, we left off on hyperaldosteronism, and now we're moving into... Drum roll, please. Actually, we can't tell them. We have to give them a case.
Dr Anil Harrison:
Okay.
Dr Paul Shiu:
So we have a young chap. Strolls into your office, Dr. Harrison, he's having this headache, and he tells you that this headache he gets every once in a while. There's no rhyme or reason. It just happens. Associated with the headache is this profuse sweating. Gets diaphoretic, feels anxious. He feels these palpitations. Kind of feels like me when I walk into the clinic. But one thing is I'm not on multiple anti-hypertensives. Dr. Harrison, what do you think this young lad has?
Dr Anil Harrison:
I think, Paul, you're alluding to pheochromocytomas. However, pheochromocytomas are rare catecholamine secreting neoplasms of the renal medulla or the sympathetic ganglia that occur in less than 0.2% of patients with hypertension. As you know, diagnostic tests include plasma, fractionated metanephrines, and 24-hour urine metanephrines, and catecholamine. So it's rare. Have we seen some? Yes, I have. Just a few months ago, we had a patient with hyperhydrosis, sweating profusely all the time with hypertension and with anxiety. One thing led to another, Paul, and her metanephrines and non metanephrines were elevated in and she had pheo and she underwent surgery. And lo and behold, her hyperhydrosis went away. Her high blood pressure went away, and anxiety is much better.
Dr Paul Shiu:
Life changing. Absolutely life changing. Less than 0.2%, folks. So we're moving on to what happens if we don't treat hypertension? How do they fit into these buckets we call urgency, emergency, these talks about an organ damage? How does that fit in? What about different population, the demographics, the elderly, women and different ethnic groups? Dr. Harrison, would you start us off with hypertensive urgency, please?
Dr Anil Harrison:
Sure. So Paul, hypertensive urgency is defined as very elevated blood pressures, systolic blood pressure more than 180, and/or a diastolic blood pressure that is more than 110 millimeters of mercury without obvious signs or symptoms of acute or impending target organ damage or dysfunction. Because if a person has end organ damage, then you classify it as a hypertensive emergency.
So patients with hypertensive urgency, they're usually asymptomatic or might have fatigue and a mild headache. When you manage patients with hypertensive urgency, of course, it includes the assessment of imminent risk of cardiovascular events from severe hypertension versus the risk of adverse sequela from rapid blood pressure reductions, which could include acute renal insufficiency, myocardial infarction, strokes, organ dysfunction. So therefore, the blood pressure has to be brought down gradually. A 25% reduction within the first hour. Then you get the blood pressure below 160/100 over the next two to six hours, and then cautiously to normal in the next 24 to 48 hours.
What can you use? Faster acting agents, antihypertensive agents, such as oral clonidine can be given to lower blood pressures. Remember, in patients in whom hypertensive urgency developed because of medication non-adherence, you can start the antihypertensive very slowly in a stepwise fashion with care not to drop the blood pressure significantly. A close follow-up is necessary, and further management can include home monitoring of blood pressures.
As opposed to hypertensive emergencies where there is evidence of end organ damage, be it the person has an ischemic or a hemorrhagic stroke or has altered mental status because of encephalopathy or has acute renal insufficiency or has had an MI or heart failure and aortic dissection. Those would be hypertensive emergencies, and these patients need to be admitted in the intensive care unit. And these folks, you have to get the systolic blood pressure below 140 millimeters of mercury very, very soon. And if a person is dissecting the aorta, you need to get the systolic blood pressure below 120 millimeters of mercury.
The other question you asked was, you know about hypertension in women. Now women, particularly if premenopausal, are at a lower risk than men for hypertension complications such as coronary artery disease, stroke, and left ventricular hypertrophy. Clinical trials suggest that women derive similar relative benefits from antihypertensive treatment as men, and therefore the recommendations for blood pressure targets are the same for men and women. But remember, women of childbearing age who anticipate pregnancy should not be prescribed ACE inhibitors, angiotensin receptor blockers, or direct renin inhibitors because of a risk of urogenital developmental abnormality. So what can you use? You can use methyldopa, nifedipine, labetalol. These are reasonable choices. In Black patients with diabetes, a thiazide diuretic or a calcium channel blocker is recommended as initial therapy.
Now, how about folks with diabetes? The ADA, the American Diabetes Association, recommends that patients with diabetes and hypertension with a 10 year ASCVD risk that is less than 15% should be treated to a blood pressure goal of 140/90. A lower target of 130/80 is appropriate for individuals who have a ASCVD risk that is more than 15%. And if this can be achieved safely, then that is great. Now, the American Heart Association and the ACC, the American College of Cardiology, they recommend getting the systolic blood pressure below 130 millimeters in the elderly. However, other organizations say, "Well, getting it below 150 millimeters of mercury is also reasonable."
I would actually rather go with the ACC or the AHA, because one of the concerns with the other organizations was, don't get the blood pressures below 130 systolic because there's a high risk of presyncope and falls, et cetera, et cetera. The studies have been conducted and really there hasn't been much of an evidence that actually happens. What I would recommend is get their systolic blood pressure below 130 millimeters of mercury gradually and look out to see how are they feeling? Are they significantly fatigued? Are they getting lightheaded? But more importantly, check their renal functions to make sure that the renal functions are not deteriorating because of hypoperfusion.
Dr Paul Shiu:
Once again, what we're hearing here is that we have three organizations, two organization with a recommendation for less than 130, and then you have another organization that recommends a slightly less aggressive-
Dr Anil Harrison:
Stringent.
Dr Paul Shiu:
Yeah, stringent, a little bit more conservative, less than 150. Now of course, as we all know, guidelines are guidelines and it represents a starting point. Ultimate decision rests upon your shoulders and you need to take into account the patient's comorbidities, previous history of falls, so and so forth. Without further ado, I think we have built a solid foundation to tackle some very specific case scenarios, some case scenarios which are not uncommon, and you'll see how and about in clinic or on the wards.
We have a 20 year old with consistently elevated blood pressure rhythm 140/90 over the course of six months. What would you do?
Dr Anil Harrison:
So Paul, for a 20 year old with consistently elevated blood pressures greater than 140/90 over a period of six months, as you said, look into a family history and look for end organ damage. Upon my evaluation, I would be looking for things like abdominal or flank bruise in that patient. And the other thing I would be looking for is could this person have renal artery stenosis secondary to fibromuscular dysplasia? I'd probably do a non-invasive test like a duplex arterial ultrasound or a CTA or an MRA of the renal arteries.
Dr Paul Shiu:
All right.
Dr Anil Harrison:
Because if you find that, you fix that and the hypertension disappears, hopefully.
Dr Paul Shiu:
Hopefully.
Dr Anil Harrison:
Correct. If not, then obviously you treat them with your first line antihypertensives.
Dr Paul Shiu:
Right. Okay. So then what about a 45 year old with consistently elevated blood pressure greater than 130/80 over the course of six months?
Dr Anil Harrison:
So on this patient who's 45 years old with blood pressures more than 130/80 consistently, the first thing I would do is calculate the ASCVD risk. If it's greater than 10%, I immediately start the person on first line antihypertensives, and of course, have them continue with lifestyle modifications. As we alluded to, first-line antihypertensives would be an ACE inhibitor or an angiotensin receptor blocker or a thiazide diuretic or a dihydropyridine calcium channel blocker. And of course, once you start them on ACE or an ARB, in about two or three weeks, you check their serum creatinine, and their potassium and monitor the blood pressures, I would say, in the next two to four weeks.
Dr Paul Shiu:
Eventually the blood pressure will be at goal, right? And for this patient, it'll be, I think you mentioned... Well, I mean 130/80, right?
Dr Anil Harrison:
Correct. Yeah. You have to try and get the blood pressure below 130/80. You're absolutely right.
Dr Paul Shiu:
Okay. All right. Well, we talked about a 20 year old, we talked about a 45 year old. What about a 60 year old with a consistent elevated blood pressure greater than 150/94, and this is over a course of six months as well?
Dr Anil Harrison:
Sure. So for this 60 year old with consistently elevated blood pressures of greater than 150/94, I would recommend, or it's been recommended to start two antihypertensives from different classes, and one of them, preferably either thiazide diuretic or amlodipine. I would assess serum creatinine and potassium in two to three weeks and have them monitor the blood pressures and see how it does in the next one month.
Dr Paul Shiu:
Okay. How about a 50 year old with a blood pressure of 135/85?
Dr Anil Harrison:
Yeah, just like the other one we spoke about. I would recommend doing an ASCVD score on this 50 year old with consistently elevated blood pressures of 135/85, and if it's less than 10%, I would advise lifestyle changes for about three to six months and reassess with at-home blood pressure that will monitor during this phase. But if the ASCVD score is greater than 10%, I would start this person on first line antihypertensives, as mentioned before. ACEs or ARBs or thiazide diuretics or a calcium channel blocker like amlodipine.
Dr Paul Shiu:
So how about, let's say the aforementioned patient now has, in addition to being 50 years old, in addition to having high blood pressure, what about if they were to have diabetes as well?
Dr Anil Harrison:
Sure. So in this patient, I would check a urine for micro albumin or do an ACR, albumin creatinine ratio. If the patient has microalbuminuria, you have to start the patient on an ACE inhibitor or an angiotensin receptor blocker. If they don't have microalbuminuria, you could again go with an ACE inhibitor or an ARB, or you could put them on a thiazide diuretic or something like amlodipine. The goal is if they have microalbuminuria, they're at a very high risk for CAD, and so you want to target their blood pressure and also protect their kidneys and the heart with an angiotensin converting enzyme inhibitor or angiotensin receptor blocker.
Dr Paul Shiu:
What about a 60 year old on three anti-hypertensives, consistent blood pressure greater than 150/94?
Dr Anil Harrison:
This 60 year old on three anti-hypertensives and the blood pressure is still elevated, I would call it resistant hypertension. And in this person, one of the anti-hypertensives has to be a thiazide diuretic. So the other one can be an ACE inhibitor, and the third one can be, let's say amlodipine. When I'm thinking about adding the fourth antihypertensive, I would think of spironolactone.
Dr Paul Shiu:
Let's try a 50 year old with a blood pressure of greater than 180/110.
Dr Anil Harrison:
For a 50 year old with blood pressures greater than 180/110 confirmed on two occasions, it is advised to look for end organ damage to classify it as urgent or emergent. If the patient has evidence of end organ damage in the form of alternate mental status, stroke, MI, heart failure, dissection of the aorta, we want to get the blood pressure down to below 140 systolic as soon as possible. And if it's dissection of the aorta, we want the systolic blood pressure to be below 120 millimeters of mercury. If there is no evidence of end organ damage, then you bring the blood pressure down very gradually, 25% in the first hour, then 160/100 in the next four to six hours, and then normalize blood pressure over a period of 24 to 48 hours.
Dr Paul Shiu:
Then what do you do about a 75 year old with a blood pressure greater than 160/70?
Dr Anil Harrison:
Well, if you take the ACC and the American Heart Association recommendations, they recommend getting the systolic blood pressure below 130, while the other organizations, they recommend getting the systolic blood pressure below 140 millimeter millimeters of mercury.
Dr Paul Shiu:
So we're going to move on forward to a 30 year old, and we have three scenarios here. We have a 30 year old pregnant female with consistent elevated blood pressure up greater than 140/90 at three months of gestation. And then we have a 30 year old pregnant female with consistently elevated blood pressure of greater than 160/110 at six months of gestation. And then finally, a 30 year old female of consistent elevated blood pressure of greater than 140/90 three months after delivery.
Dr Anil Harrison:
So based on guidelines from ACOG, blood pressures in pregnant women are not to be treated unless more than 160/110 millimeters of mercury. If there is evidence of elevated blood pressures prior to the fifth month of pregnancy, you call it hypertension. But if the blood pressure is elevated after the fifth month, then this is termed gestational hypertension. With gestational hypertension, blood pressure should normalize 8 to 12 weeks postpartum. If they do not normalize, then this is termed as chronic hypertension.
Treatment, as mentioned, Paul, alpha methyldopa or labetolol or nifedipine would be the preferred agents, and definitely no ACEs, no ARBs and no renin inhibitors in pregnant women. The goals for treating hypertension in pregnant women is to keep systolic blood pressures between 120 and 159 millimeters and the diastolic between 80 and 109 millimeters of mercury.
Dr Paul Shiu:
So that's quite a big departure from non-pregnant patients.
Dr Anil Harrison:
Correct.
Dr Paul Shiu:
And then speaking of non-pregnant patients, there's a grace period 8 to 12 weeks postpartum. So in our example, this patient is right at the cusp of three months, which is 12 weeks.
Dr Anil Harrison:
Correct.
Dr Paul Shiu:
Okay.
Dr Anil Harrison:
So you'd call this chronic hypertension then, because her blood pressures three months after delivery have not come down, so this would be hypertension.
Dr Paul Shiu:
Right. Okay. So that is how we delineate hypertension, folks. With this knowledge in your armamentarium, you can go tackle hypertension in all its various forms, shapes, and sizes. We are at the end of our podcast. This concludes the Hypertension Series, Part 3. I want to thank everyone for tuning in with us.
Dr Anil Harrison:
Absolutely. Thank you everyone.
Dr Paul Shiu:
Take care.
Dr Anil Harrison:
Bye.
Speaker 1:
For more hypertension content, visit consultant360.com