A 53-year-old woman presents to the emergency room with a minor injury and is found to have a blood pressure of 150/102, possibly elevated as a result of pain. On follow-up at your office, her BP on two occasions is 142/94 despite good dietary habits and reasonable exercise. Her history and physical are otherwise normal. Urinalysis and serum creatinine and potassium are normal. Based on recent recommendations of the JNC 7 (The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure),
which of the following is accurate information to give her?
A key point in the JNC 7 is that a thiazide diuretic should be used in most patients with uncomplicated hypertension when diet and lifestyle modifications are not sufficient. Other major points include (1) systolic BP greater than 140 is a more important cardiovascular risk factor than diastolic BP in persons older than 50; (2) individuals normotensive at age 55 still have a 90% lifetime risk of developing hypertension; (3) CVD risk doubles, beginning at 115/75, for each rise in BP of 20/10; (4) a new category of prehypertension has been designated with systolic BP 120 to 139 or diastolic BP 80 to 89, with emphasis on healthy diet and lifestyle modifications; (5) if BP greater than 20/10 above goal is present at the outset, consider initiating therapy with two agents. Estrogen-replacement therapy does not lower blood pressure.
A 69-year-old woman complains of gradually worsening vision over the last 2 years. She can no longer read the newspaper on her porch in the early evening, and sometimes has difficulty seeing faces and distinguishing colors. She has hypertension and smokes cigarettes, but does not have diabetes. Her only regular medication is lisinopril. Funduscopic examination is shown below.
What is the next best step in the evaluation of this patient?
The ophthalmologic examination shows drusen. These pale yellowish retinal lesions can often be seen with a handheld ophthalmoscope. Drusen are caused by deposition of acellular debris between the retinal epithelium and Bruch membrane. These lesions are the hallmark of age-related macular degeneration, which is the leading cause of blindness in older adults in the United States. Evidence suggests that antioxidants (such as beta-carotene, vitamin C, or vitamin E) and zinc can prevent the progression of age-related macular degeneration. About 15% of patients with macular degeneration have a “wet form” which leads to more severe visual loss and which is treated by photocoagulation and intraocular injections of anti-vascular endothelial growth factor antibodies (anti-VEGF). Ophthalmologic evidence of open angle glaucoma consists of an increased cup-to-disc ratio. Glaucoma is diagnosed by the characteristic optic nerve appearance and visual field loss. Many (but not all) patients with open angle glaucoma have an elevated intraocular pressure which can be detected by tonometry. Diabetic retinopathy is characterized by microaneurysms and neovascularization and is treated by photocoagulation and optimizing blood sugar control. Cataracts are a common cause of vision loss in the elderly, but do not cause retinal abnormalities. Pituitary tumors can cause visual field defects and/or papilledema, but do not cause drusen.
A 60-year-old white man has just moved to town and needs to establish care. He had a “heart attack” last year. Preferring a “natural” approach, he has been very conscientious about low-fat, low-cholesterol eating habits and a significant exercise program. He has gradually eliminated a number of prescription medications (he does not recall their names) that he was on at the time of hospital discharge. Past history is negative for hypertension, diabetes, or smoking. The lipid profile you obtain shows the following:
Which of the following recommendations would most optimally treat his lipid status?
The National Cholesterol Education Program Adult Treatment Panel III recommendations include lowering the LDL cholesterol to less than 100 mg/dL in those with known coronary heart disease (secondary prevention). The 2004 update to these guidelines adds an optional goal of LDL less than 70 mg/dL in very high-risk patients. In this case, with dietary efforts and exercise already well established, it is unlikely that the LDL will be further reduced hence a statin drug is indicated. Statins typically lower LDL by 20% to 50%. Gemfibrozil is used primarily for hypertriglyceridemia; this patient’s triglyceride level is normal (< 150 mg/dL). ACE inhibitors have no significant effect on lipids. While high-dose fish oil does lower triglyceride levels, it is not effective at lowering LDL cholesterol levels. Lowering LDL cholesterol is of prime importance in the prevention of coronary heart disease of coronary heart disease prevention.
A 60-year-old man had an anterior myocardial infarction 3 months ago. He currently is asymptomatic and has normal vital signs and a normal physical examination. His echocardiogram shows a mildly depressed ejection fraction of 40%. He is on an antiplatelet agent and an ACE inhibitor. What other category of medication would typically be prescribed for secondary prevention of myocardial infarction?
Beta-blockers are documented to lower the risk of myocardial reinfarction, whereas some calcium channel blockers may increase the risk. Alpha-blockers have been associated with an increased risk of congestive heart failure. ACE inhibitors are beneficial in this setting and should be continued. Despite their decades-long use for the symptomatic treatment of angina, nitrates are not indicated for secondary prevention of infarction. Recently, long-term use of some nonsteroidal anti-inflammatory drugs (including naproxen sodium) has been associated with an increased risk of myocardial infarction.
A patient with type 2 diabetes mellitus is found to have a blood pressure of 152/98. She has never had any ophthalmologic, cardiovascular, or renal complications of diabetes or hypertension.
Which of the following is the currently recommended goal for blood pressure control in this case?
(JNC 7 Express, http://www.nhlbi.nih.gov/guidelines/hypertension/express.pdf.) Goals for blood pressure control and lipid levels are typically more stringent in the diabetic compared to the nondiabetic. The goal blood pressure for diabetics and patients with renal disease is less than 130/80. Blood pressure goal for the standard patient is less than 140/90. Both systolic and diastolic pressures should be below goal in order to achieve optimal blood pressure control.
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