Name:
A 68-Year-Old with Hypertension
Description:
A 68-Year-Old with Hypertension
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T00H13M42S
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Upload Date:
2022-02-28T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
[intro music]
DR. HANDY: Hi, welcome to Harrison's Podclass where we discuss important concepts in internal medicine. I'm Cathy Handy.
DR. WIENER: And I'm Charlie Wiener, and we're coming to you from the Johns Hopkins School of Medicine. Welcome to today's episode, a 68-year-old with hypertension. Hey Cathy, today we're doing another special segment with one of our Harrison's editors joining us.
DR. HANDY: Great, let's jump right into the case and the question.
DR. WIENER: Okay, today's patient is Mr. W. He's a 68-year-old African-American male who's brought to the emergency room by his wife because of worsening headache over the last day and confusion starting about an hour ago. His blood pressure on presentation is 230/140, and his heart rate is 90 per minute. His arterial oxygen saturation is 95%. On examination, he's moving all his extremities equally, and there are no obvious deficits in his cranial nerve function, but he's clearly delirious.
DR. WIENER: Cardiac examination reveals an enlarged and a forceful PMI and an S4 gallop. His lungs are clear to auscultation. You get some quick laboratories and they show a creatinine of 2.4 mg/dL, ++ protein in his urine with hematuria, a hematocrit of 32% with a normal platelet count. You examine his peripheral blood smear and notice schistocytes.
DR. WIENER: His ECG shows findings consistent with left ventricular hypertrophy, but no acute ST segment elevations or depressions. An emergent brain MRI shows old microvascular changes, but no acute infarction or hemorrhage. So that's a lot, let's pause for a second and just talk about what's going on.
DR. HANDY: So it sounds like malignant hypertension, given the very elevated blood pressures that you mentioned to 230/140, and evidence of end organ damage in multiple systems. So he has evidence of CNS involvement with his delirium, the kidney damage is evident by his elevated creatinine and proteinuria, and he has hemolytic anemia on his blood smear. I'm assuming that he has longstanding hypertension, but you didn't mention that.
DR. WIENER: Yes, his wife tells you that he's had hypertension for over 20 years, and recently she's been concerned that he's not been taking his medications. He also has hyperlipidemia, but has never had a known myocardial infarction, stroke or other cardiovascular event.
DR. HANDY: All right, well, let's take care of the acute problem, so maybe we'll have time to discuss the chronic issues a little bit later.
DR. WIENER: Okay, well, that's what the question is addressing, the question says, regarding his acute blood pressure management, which of the following would be the most reasonable therapeutic course? And the options are A. 0.1 mg of clonidine orally; And the options are A. 0.1 mg of clonidine orally; B. 20 mg of oral lisinopril; C. 20 mg of intravenous labetalol and start a continuous parenteral drip for a goal mean arterial blood pressure of 125 mmHg in the first hour; D. 90 mg of immediate release oral nifedipine; or E. emergent plasmapheresis.
DR. HANDY: In the setting of hypertensive emergency, which we discussed already he has that, you want a reduction of the mean arterial pressure in minutes to hours by 25%. And that's because most patients, including this patient, presenting with malignant hypertension will also have longstanding chronic elevations in blood pressure. So they have a change in the set point of the cerebral autoregulation. Reducing the blood pressure rapidly to normal levels for the regular population often leads to hypoperfusion and can lead to watershed cerebral infarcts.
DR. WIENER: Okay, so which of the choices that I mentioned of the medications would be best to achieve that?
DR. HANDY: Parenteral therapy is more rapid onset and much more easily titrated than oral therapy, so I would go with an IV option over an oral option. Oral options in this setting really would be inappropriate. So of the choices that you listed answer C. is what I would go with, the 20 mg of IV labetalol, and then I'd start a continuous IV drip. And thinking about some of the other options, immediate release nifedipine, it is particularly potent, but it's associated with a higher risk of myocardial infarction when used in this setting.
DR. WIENER: Okay, so four of the options mentioned drugs, you excluded the three oral drugs and you chose the parenteral therapy, what about plasmapheresis? This patient has shistocytes, does that make me think that this patient has some other disorder besides just simple hypertension?
DR. HANDY: Well, so malignant hypertension or hypertensive emergency can cause an intravascular hemolytic anemia, so that is not abnormal for the case that's presenting, but in terms of plasmapheresis, that would be warranted if this were a case of thrombotic thrombocytopenic purpura or TTP, but that's unlikely in this case and he has normal platelets as well.
DR. WIENER: Great, so the question also includes that the patient is an African-American man, let's turn to our expert, Dr. Loscalzo.
DR. HANDY: Welcome back to the podclass, Dr. Loscalzo.
DR. LOSCALZO: Thank you, glad to be here. I'm glad I wasn't tossed off the program for my last performance. [Dr. Weiner and Dr. Handy chuckle] [Dr. Weiner] Well, let's get right into it. Dr. Loscalzo, the patient in this question is an African-American man with hypertensive emergency or urgency. We have all of these huge epidemiologic studies that frequently include subanalyses by race and sex, but we know that there's a lot of variability within these groupings, not only with race, but also with social constructs and socioeconomics and even variability in how some of these determinants are defined.
DR. LOSCALZO: How do you use these data from these large studies, if at all, in determining the treatment of an individual patient in the outpatient setting?
DR. LOSCALZO: Well, thank you for posing that important question, Charlie. First of all, let me just remind the listeners that hypertension affects about 83 million Americans, that's using the latest cutoff of 130/80 and hypertensive emergency as in this case, is defined as an acutely marked elevation in blood pressure with target organ damage, so fairly far advanced vascular disease. Epidemiology studies, as you point out, have consistently shown that hypertension disproportionately affects blacks, and in particular, black males who also have higher rates of complications, such as myocardial infarction, stroke, and sudden death.
DR. LOSCALZO: But as you also highlighted, Charlie, race is a really poor surrogate for the biological basis of any disease or response to therapy. There's growing recognition of the inappropriate use of race in diagnostic or therapeutic decisions as it is a self-defined construct and less likely biological in basis than socioeconomic in origin. And really what we're thinking about here in this discussion is race-based medicine as a reflection of the structural racism that's permeated our medical care system for the past 400 years.
DR. LOSCALZO: Socioeconomic disparities that have grown out of that global structural racism are much more likely to contribute to the prevalence of hypertension and its complications, including hypertensive emergencies among self-identified blacks. So rather than using a race-based decision algorithm in pursuing therapeutic goals, my view is to really tailor the treatment to a patient's individual hypertensive phenotype.
DR. LOSCALZO: We will touch more on that in a little bit I think in one of the later questions. And most important, to develop a trusting relationship with the patient either directly, or through another member of the care team who has good chemistry with the patient to ensure the patient feels comfortable about recommendations and is willing to adhere to the therapies that are recommended.
DR. HANDY: Now, over the past few decades, there has been tremendous progress in improving the rates of complications from hypertension, but heart disease is still the most common cause of death in the United States, and we know that adherence to oral medications like you started to mention in the outpatient setting can be challenging. How do you think we can improve adherence with therapy? And what do you see as the major goals over the next 10-20 years to improve the mortality rate from heart disease even further?
DR. LOSCALZO: Thank you for that question, Cathy, I think the key is again, establishing some kind of working social structure that supports a trusting relationship between the patient and the caregiver. And there were a couple of interesting studies that highlighted this point, that involved barbershops in black neighborhoods, beginning in Dallas. The BARBER-1 and BARBER-2 trials were quite intriguing in that regard, barbershops are sites of social gathering in African-American communities, more so than in white communities, and the barber is a trusted member of the community.
DR. LOSCALZO: Barber guidance, in this case barbers were taught how to take blood pressures properly by a healthcare provider, barber guidance almost doubled blood pressure control among patients who participated in this trial compared to those who weren't guided by their barber. This is in BARBER-1, in BARBER-2, there was an added element of pharmacists guided algorithm driven blood pressure control, so that one could titrate drugs or add second or third drugs.
DR. LOSCALZO: And this further improved control greatly up to 84% versus 64% by conventional titration measures. So finding a socially acceptable strategy, barbershops, churches, other social gathering sites is one approach that I think has gathered lots of interest and may have some real traction. Now, as you point out, hypertension and cardiovascular disease in general continue to plague our society in general and the African-American community in particular.
DR. LOSCALZO: Globally, cardiovascular diseases account for more than half of all non-communicable disease mortality, 18 million out of 35 or so million. And the American Heart Association and the United Nations and World Health Organization have as a goal a decrease in the risk of non-communicable diseases by 25% between 2025 and 2030. of non-communicable diseases by 25% between 2025 and 2030. Things got a little delayed with the pandemic.
DR. LOSCALZO: And I think that's an admirable goal that is potentially achievable, and the emphasis should, of course, not just be on treatment and adherence, but also prevention, which could be region specific, must involve implementation of cost-effective strategies by country and culture, and most importantly, collaboration in public-private partnerships across multiple social sectors.
DR. WIENER: Joe, I love the fact that you're highlighting the interaction between the social determinants of effective therapy, adherence to therapy, which obviously are going to be very variable by community and individual, and as we broaden that internationally, it's going to be different in every different country. But if you wouldn't mind stepping back and talk to us a little bit about the biological basis of how you approach treatment for hypertension in individual patients, and also what future translational or mechanistic research do you think is going to impact how we control hypertension separate from the question of adherence, which obviously is vitally important?
DR. LOSCALZO: That's a critical issue in the management of any of our patients, and the first point to make is that hypertension is really a terrible phenotype, right? Just think about how we measure it. We listen to these Korotkoff sounds that appear and then disappear, and there are varying levels of sensitivity in the way one picks them up. There's the notion of white coat hypertension, there's the effects of routine caffeine and tobacco use, there's the pseudohypertension of the elderly with stiff pipes that suggest there's a wide pulse pressure, but if one measures central pressures, patients aren't truly hypertensive in the same way.
DR. LOSCALZO: So we have that problem of how you define hypertension and most important, of course, is how does blood pressure vary as a function of time throughout the day? And newer methods for looking at 24-hour ambulatory blood pressure measurements are an important strategy for getting a better sense of the hypertensive burden as a function of time, but those have their problems as well.
DR. LOSCALZO: There's the sort of Pavlovian response to an increase in blood pressure as a consequence of feeling that the blood pressure cuff's being inflated. There are some new technologies, in fact, one that was just published this year by Forten in Nature Communications, in which they developed a non-invasive, real-time monitoring device that uses a combination of oscillometry, an old-fashioned method for looking at blood pressure and photoplethysmography built into a tiny fingertip device.
DR. LOSCALZO: It doesn't involve any detectable change in pressure around the fingertip that you could use throughout the day. I think devices like that, and there are others that folks have been working on for a while, will give us a better sense of really what blood pressure variation is like throughout the day, and a better sense of what our blood pressure targets should be. So once we make the diagnosis of blood pressure, I really try to define it in the context of what are the medical problems the patient has?
DR. LOSCALZO: Is the patient anxious? Does the patient seem to have a sort of hyper-sympathetic response to stress? Is the patient in heart failure? Does the patient have ischemic heart disease? Each of these, of course, would govern the choice or help me decide about the choice of types of antihypertensives I might use. In contrast to someone who comes in completely asymptomatic, who winds up having significantly elevated blood pressures, in which case you might begin in the standard way, as recommended by the AHA, in standard way with one of the simplest classes including thiazide diuretics, including ACE inhibitors depending upon renal function, including calcium channel blockers depending upon the patient's age.
DR. LOSCALZO: So those are sort of the three principle subtypes of antihypertensives that I use for asymptomatic patients initially, depending upon the other demographic parameters that I mentioned.
DR. HANDY: Thank you so much, and thank you so much for joining us today and your insight into hypertension, and also how we think about some of these epidemiology studies, and how really we need to change our model of care to reach patients where they are in order to get the best outcomes. So we look forward to talking with you again soon, and for our audience, if you want to learn more, you can go to Harrison's chapter on hypertension. [outro music] [Mr. Shanahan] This is Jim Shanahan, publisher at McGraw Hill.
DR. HANDY: Harrison's Podclass is brought to you by McGraw Hill's Access Medicine, the online medical resource that delivers the latest trusted content from the best minds in medicine. Go to accessmedicine.com to learn more.