HYPERTENSION

LEARNING OBJECTIVES :

KNOWLEDGE - Students should be able to describe the:

1. Pathophysiologic difference between benign and malignant hypertension.
2. Long-term consequences of untreated benign essential hypertension.
3. Indications for treatment of hypertension.
4. Management of the patient with benign essential hypertension.

SKILLS - Students should be able to:

1. History: assess baseline blood pressure profile, family history of hypertension, potential exposures to agents which may cause hypertension (e.g., lead, cocaine, amphetamines), for co-morbid conditions which may be a secondary cause of hypertension.
2. Physical exam: evaluate blood pressure, funduscopic examination, for the presence of vascular disease (i.e., bruits, diminished pulses), hypertensive cardiac disease (prominent PMI, S4 etc.).
3. Differential Diagnosis: differentiate benign from malignant hypertension, primary from secondary causes of hypertension.
4. Laboratory Findings: interpret lipid profile, urinalysis, basic metabolic profile, 24-hour BP recording, electrocardiogram.
5. Communication Skills: provide patient education, take into consideration each patient's psycho-social status, develop effective doctor-patient communication skills.
6. Procedure Skills: perform IV placement, blood pressure measurement.
7. Management skills: manage indicated lifestyle alterations, dietary restrictions, antihypertensive medications.

    

ATTITUDES AND PROFESSIONAL BEHAVIORS - Students should:

1. Demonstrate respect for the patient.
2. Be aware of the importance of blood pressure identification/control as preventive approach to cardiovascular disease.
3. Understand the difficulty, for the patient, of lifestyle modifications that play a key role in management of hypertension.
4. Be sensitive to barriers that may prevent successful long-term compliance with drug therapy in an asymptomatic condition.

    

REFERENCES:

1. The Seventh Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure. The JNC7 Report. JAMA 2003;289:2560-2572.
• This is the single best reference covering all clinically important aspects of hypertension.
2. Drugs for hypertension. The Medical Letter 2001; 43:17-22 (available online via the LUMC library).
• An excellent summary of the major classes of antihypertensive agents.
3. August, P. Initial treatment of hypetension . N Engl J Med 2003;348:610-7.
• Good overview of the major issues, current guidelines and controversies in the treatment of hypertension.
4. Psaty BM, Lumley T, Furberg CD, et al. Health outcomes associated with various antihypertensive therapies used as first line agents. JAMA 2003;289:2534-44.
• A synthesis of the evidence from 42 controlled clinical trials including 192,478 patients randomized to 7 major treatment strategies. The authors conclude that “low dose diuretics are the most effective first-line treatment for preventing the occurrence of cardiovascular disease morbidity and mortality.”
5. Hansson L, Zanchetti A, Carruthers S etal. Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomised trial. Lancet 1998;351:1755-62
• Nineteen thousand hypertensive patients were treated to lower diastolic blood pressure to 85-90, 80-85, or less than 80 mmHg. Cardiovascular risk was minimized at a BP of 138/83 mmHg. Further reduction had no additional effect. A subgroup analysis in diabetic patients indicated that cardiovascular risk was lowest in those with diastolic pressure less than 80 mmHg.
6. Messerli FH, Gorssman E, and Goldbourt U. Are beta blockers efficacious as first-line therapy for hypertension in the elderly? A systematic review. JAMA 1998; 279:1903-7.
   • Excellent, evidence based review that strongly suggests beta blockers do not reduce risk of stroke or cardiovascular events when used as first line therapy in elderly patients. This data is consistent with JNC 7 recommendations that diuretics should be used as first line therapy of hypertension in patients over the age of 65unless there is a compelling indication for another agent.