NR 667 VISE _2021
,1. Hypertension
Presentation: Most are not symptomatic, Occipital Headaches, headache on awakening in am, burry
vision.
Look for these clinical findings to rule out organ damage:
Microvascular
• Eyes (HTN retinopathy): AV nicking (causes when arteriole crosses on top of
vein), papilledema
• Kidneys: microalbuminuria and proteinuria, elevated serum creatinine and abnormal eGFR,
peripheral or generalized edema
Macrovascular
• Heart: S3 (CHF), S4 (LVH), carotid bruits, decreased or absent peripheral pulses
• Brain: TIA or hemorrhagic stroke
Assessment/Exam:
• Asymptomatic
• Occipital headache
• Blurry vision
• Headache upon wakening
• Exam of optic fundi: Look for AV nicking, hemorrhage, papilledema
• LVH (long standing HTN)
• Perform exam of symmetrical pulses
• Auscultate for Carotid bruits, abdominal bruits, and kidney bruits
Diagnostic studies: EKG, fasting lipid profile, fasting blood glucose, TSH, CXR to R/O
cardiomegaly. CBC, CMP, and urinalysis. Measure BP 5 minutes apart. Assess the patients 10- year
risk for heart disease (ASCVD)
Diagnosis: > 140/90 mm Hg start on B/P medication.
Pharmacologic Management:
• FIRST LINE DIURETIC: Hydrochlorothiazide (HCTZ) 25 mg/day
(max 50mg/day) *May worsen gout and elevate lipids and glucose
• ALTERNATIVE CCB: Amlodipine besylate 5 mg /day. (Watch for lower
extremity edema)
• ACE: lisinopril 10mg/day complicated HTN first line
• Consider ACE/ARB in patient with DM, proteinuria, HF. CONTRAINDICATED IN
PREGNANCY
• If stage 2, initiate 2 drug classes (Diuretic & CCB most effective in
African American)
Follow up:
• 2-4weeks
Referral:
• Cardiology if EKG is abnormal
Secondary HTN causes to consider:
• CKD, renal artery stenosis, hyperthyroidism, phenochromocytoma, OSA, coartication of the
heart (SBP higher in the legs), oral contraceptives, corticosteroids, cocaine, NSAID,
decongestants
Differential:
• Secondary hypertension
• White coat syndrome
• Pregnant
• Pregnancy induced hypertension
Education:
, • First: Lifestyle modifications: diet and exercise 30 minutes aerobic exercise 5 days per
week.
• Weight loss (BMI 25 and up)
• Limit alcohol (men:2 drinks or less per day; women: one drink or less per day)
• Stop smoking
• Stress management
• Eat fatty cold water fish (salmon, anchovy) 3x a week
• DASH
• Medication compliance
• Reduce sodium intake <1,500 mg/day)
• Measure BP daily, bring log to next visit, bring home cuff to compare to office
•
Liek: 1
Hollier: 17, 1
2. Hyperlipidemia
Presentation: Most patients are asymptomatic until they develop ASCVD.
• Xanthomata (lipid deposits around the eyes)
• Corneal Arcus prior to age 50 years (white iris), normal
• Angina
• Bruits
• MI
• Stroke
Diagnostics:
• Fasting/non-fasting lipid profile
• Glucose,
• UA and creatinine (for detection of nephrotic syndrome which can induce
dyslipidemia),
• TSH (for detection of hypothyroidism)
• CMP
Diagnosis: Optimal goal is <100 mg/dL
Pt with LDL >= 190mg/dL (without ASCVD or DM is a candidate for high-intensity statin)
Non-pharmacologic Management/Education:
• FIRST LINE: Lifestyle Modification; diet and exercise.
• Diet to improve serum lipids: Mediterranean diet, DASH, vegetarian, low-carb, and
low-trans fat.
• Decrease sugar and simple carbs
• Avoid alcohol
• Increase fish diet with Omega-3 (salmon and sardines) twice a week
• Weight loss
• Aerobic type exercise
Pharmacologic Management:
• First Line: Atorvastatin 10mg once a day at bedtime (perform liver function tests
before initiation therapy and then 4-6 and 12 weeks and after dose increase).
a) Low Intensity (lowers LDL on average by <30%): Simvastatin 10mg, Pravastatin
10- 20mg, Lovastatin 20mg
b) Moderate Intenstiy (lowers LDL on average by 30-49%): Atorvastatin 10-20mg
daily, Rosuvastatin 5-10mg, Simvastatin 20-40mg, Pravastatin 40-80mg.
,1. Hypertension
Presentation: Most are not symptomatic, Occipital Headaches, headache on awakening in am, burry
vision.
Look for these clinical findings to rule out organ damage:
Microvascular
• Eyes (HTN retinopathy): AV nicking (causes when arteriole crosses on top of
vein), papilledema
• Kidneys: microalbuminuria and proteinuria, elevated serum creatinine and abnormal eGFR,
peripheral or generalized edema
Macrovascular
• Heart: S3 (CHF), S4 (LVH), carotid bruits, decreased or absent peripheral pulses
• Brain: TIA or hemorrhagic stroke
Assessment/Exam:
• Asymptomatic
• Occipital headache
• Blurry vision
• Headache upon wakening
• Exam of optic fundi: Look for AV nicking, hemorrhage, papilledema
• LVH (long standing HTN)
• Perform exam of symmetrical pulses
• Auscultate for Carotid bruits, abdominal bruits, and kidney bruits
Diagnostic studies: EKG, fasting lipid profile, fasting blood glucose, TSH, CXR to R/O
cardiomegaly. CBC, CMP, and urinalysis. Measure BP 5 minutes apart. Assess the patients 10- year
risk for heart disease (ASCVD)
Diagnosis: > 140/90 mm Hg start on B/P medication.
Pharmacologic Management:
• FIRST LINE DIURETIC: Hydrochlorothiazide (HCTZ) 25 mg/day
(max 50mg/day) *May worsen gout and elevate lipids and glucose
• ALTERNATIVE CCB: Amlodipine besylate 5 mg /day. (Watch for lower
extremity edema)
• ACE: lisinopril 10mg/day complicated HTN first line
• Consider ACE/ARB in patient with DM, proteinuria, HF. CONTRAINDICATED IN
PREGNANCY
• If stage 2, initiate 2 drug classes (Diuretic & CCB most effective in
African American)
Follow up:
• 2-4weeks
Referral:
• Cardiology if EKG is abnormal
Secondary HTN causes to consider:
• CKD, renal artery stenosis, hyperthyroidism, phenochromocytoma, OSA, coartication of the
heart (SBP higher in the legs), oral contraceptives, corticosteroids, cocaine, NSAID,
decongestants
Differential:
• Secondary hypertension
• White coat syndrome
• Pregnant
• Pregnancy induced hypertension
Education:
, • First: Lifestyle modifications: diet and exercise 30 minutes aerobic exercise 5 days per
week.
• Weight loss (BMI 25 and up)
• Limit alcohol (men:2 drinks or less per day; women: one drink or less per day)
• Stop smoking
• Stress management
• Eat fatty cold water fish (salmon, anchovy) 3x a week
• DASH
• Medication compliance
• Reduce sodium intake <1,500 mg/day)
• Measure BP daily, bring log to next visit, bring home cuff to compare to office
•
Liek: 1
Hollier: 17, 1
2. Hyperlipidemia
Presentation: Most patients are asymptomatic until they develop ASCVD.
• Xanthomata (lipid deposits around the eyes)
• Corneal Arcus prior to age 50 years (white iris), normal
• Angina
• Bruits
• MI
• Stroke
Diagnostics:
• Fasting/non-fasting lipid profile
• Glucose,
• UA and creatinine (for detection of nephrotic syndrome which can induce
dyslipidemia),
• TSH (for detection of hypothyroidism)
• CMP
Diagnosis: Optimal goal is <100 mg/dL
Pt with LDL >= 190mg/dL (without ASCVD or DM is a candidate for high-intensity statin)
Non-pharmacologic Management/Education:
• FIRST LINE: Lifestyle Modification; diet and exercise.
• Diet to improve serum lipids: Mediterranean diet, DASH, vegetarian, low-carb, and
low-trans fat.
• Decrease sugar and simple carbs
• Avoid alcohol
• Increase fish diet with Omega-3 (salmon and sardines) twice a week
• Weight loss
• Aerobic type exercise
Pharmacologic Management:
• First Line: Atorvastatin 10mg once a day at bedtime (perform liver function tests
before initiation therapy and then 4-6 and 12 weeks and after dose increase).
a) Low Intensity (lowers LDL on average by <30%): Simvastatin 10mg, Pravastatin
10- 20mg, Lovastatin 20mg
b) Moderate Intenstiy (lowers LDL on average by 30-49%): Atorvastatin 10-20mg
daily, Rosuvastatin 5-10mg, Simvastatin 20-40mg, Pravastatin 40-80mg.
