Hypertension

ABSTRACT: Guidelines for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction have been updated following results from pivotal controlled trials. The new American College of Cardiology/American Heart Association guidelines stress risk factor modification and long-term management. Medications that have been shown to reduce the incidence of future cardiovascular events in patients with acute coronary syndromes include antiplatelet agents, statins, ß-blockers, and angiotensin-converting enzyme inhibitors. Other long-term management strategies include smoking cessation, achievement and maintenance of optimal weight, daily exercise, appropriate diet, and control of hypertension and diabetes.

Severe abdominal pain radiating to the back prompted a 72-year-old man to go to the emergency department (ED). The patient had experienced similar pain 2 days earlier and was treated at another hospital for renal colic on the basis of concomitant microscopic hematuria. He had a history of poorly controlled hypertension.

Hypertensive crises encompass a spectrum of clinical situations thathave in common elevated blood pressure (BP) and progressive or impendingtarget organ damage. Each year more than 500,000 Americans (about1% of all persons with hypertension in the United States) have a hypertensivecrisis. In large urban areas, 25% of visits to the medical section of any givenemergency department (ED) are attributable to a hypertensive crisis.

ABSTRACT: The metabolic syndrome, which presents as a cluster of atherogenic traits, confers an increased risk of coronary heart disease (CHD) that may be greater than the sum of the risks associated with the individual components. The principal components of the syndrome are abdominal obesity, elevated triglyceride level, low high-density lipoprotein cholesterol level, elevated blood pressure, and elevated fasting glucose. The presence of 3 of the 5 characteristics establishes the diagnosis. First-line therapy for the metabolic syndrome consists of lifestyle modification measures, such as weight reduction and physical activity; however, pharmacologic treatment may be necessary. Statin therapy decreases the elevated levels of low-density lipoprotein cholesterol and triglycerides characteristic of the metabolic syndrome. Control of nonlipid CHD risk factors, such as hypertension and diabetes, is also critical.

ABSTRACT: Most hypertensive patients require lifestyle modification and multiple-drug therapy to achieve current blood pressure (BP) goals of less than 140/90 mm Hg and less than 130/80 mm Hg for those with diabetes mellitus or renal disease. For patients older than 65 years, the recommended initial antihypertensive is a thiazide diuretic. If a diuretic does not adequately control BP or is contraindicated, base the selection of an antihypertensive medication on comorbid conditions. For example, a ß-blocker may benefit a patient with coronary artery disease, while an angiotensin-converting enzyme inhibitor may help forestall renal disease in a patient with type 2 diabetes mellitus. The adage "start low and go slow" is appropriate to help avoid side effects and ensure compliance; however, most elderly patients eventually require standard dosages of medications to adequately control BP.

For several weeks, a 78-year-old woman had an intensely pruritic, diffuse, raised, slightly scaly, erythematous rash that persisted despite the use of several over-the-counter topical medications (such as hydrocortisone and clotrimazole cream). Since her last visit about 3 months earlier for a blood pressure reading, she had been well except for 2 episodes of night sweats.

A 52-year-old man complains of nausea, fever, and malaise following a 2-day diarrhealillness that developed at the end of a family vacation in New England.Two family members suffered a similar illness, characterized by watery diarrhea.Symptoms developed in all who were affected within 24 hours of eatinghamburgers at a local restaurant.

A 70-year-old man who had just completeda course of trimethoprim-sulfamethoxazolefor a urinary tract infectionpresented with palpable purpuraand cutaneous erosions of acute onseton his legs (A). He also had massivescrotal edema and purpura (B).

A 16-year-old girl was bothered byankle pain and “red spots” on herlower legs. These symptoms clearedin a few days without treatment. Sixweeks later, after returning from anall-day outing at a fair, she noticedthat the spots had reappeared (A)and hemorrhagic lesions had developedon the right ankle (B) and leftheel (C). After removing her shoes,the teenager felt severe pain in bothankles, particularly the right.

A 57-year-old man with a history of venous stasis leg ulcerationwondered about the “white spots” on his leg. Thecondition is atrophie blanche, which manifests as smooth,ivory-white macules and plaques of sclerosis stippled withtelangiectasia that often are surrounded by mild to moderatepigmentation.

Redness, irritation, and diplopia developedover 2 to 3 weeks in a 55-yearoldman’s left eye (A). The injectionworsened and was unresponsive toeye drops. Ptosis, mild proptosis, andelevated intraocular pressure developed.A bruit was auscultated overthe affected eye.

Sudden pain and a pulsatile swellingof the right upper medial thigh concernedan 80-year-old woman (A).Coronary angioplasty had been performedthrough this site 5 weeksearlier.

Four months after a patchy, macular,erythematous spot erupted on thedorsum of a 63-year-old woman’s leftfoot, the area became ulcerated,tender, and painful. The 1.2-cm ulcerwas covered by a hemorrhagic crustsurrounded by a cyanotic reticulardiscoloration of the skin.

A 65-year-old woman, who was confined to a wheelchairbecause of severe rheumatoid arthritis, was concernedabout nodules that had erupted on her fingers and handsduring the previous 3 weeks (A). Her medical historyincluded colon cancer, chronic renal insufficiency, anemia,and hypertension. The nonpruritic nodules were painfulwhen they began to form under the skin; however, oncethey erupted, the pain disappeared.

ABSTRACT: The auscultatory features of heart murmurs-intensity, frequency, quality, configuration, timing, duration, and radiation-can help identify a variety of cardiac disorders. Systolic ejection murmurs have a crescendo-decrescendo configuration. These include innocent murmurs and those associated with aortic stenosis and hypertrophic cardiomyopathy. Systolic murmurs associated with retrograde flow from a high-pressure chamber to a low-pressure chamber usually have a holosystolic configuration. Examples of holosystolic murmurs include mitral regurgitation, tricuspid regurgitation, and the murmur associated with a ventricular septal defect. Diastolic murmurs include regurgitant murmurs, such as the decrescendo murmur of aortic regurgitation, and filling murmurs, such as the presystolic rumble of mitral stenosis, which is preceded by an opening snap. The murmur associated with patent ductus arteriosus is continuous.

To distinguish between hypertensive emergencies and urgencies and nonurgent acute blood pressure elevation, evaluate the patient for evidence of target organ damage. Perform a neurologic examination that includes an assessment of mental status; any changes suggest hypertensive encephalopathy. Funduscopy can detect papilledema, hemorrhages, and exudates; an ECG can reveal evidence of cardiac ischemia. Order urinalysis and measure serum creatinine level to evaluate for kidney disease. The possible causes of a hypertensive emergency include essential hypertension; renal parenchymal or renovascular disease; use of various illegal, prescription, or OTC drugs; CNS disorders; preeclampsia or eclampsia; and endocrine disorders. A hypertensive emergency requires immediate blood pressure reduction (although not necessarily to the reference range) with parenteral antibiotics. An urgency is treated with combination oral antihypertensive therapy.

A 67-year-old Hispanic woman is seen for routine physical examination. Has mild hypertension but no other known medical problems. Feels well. No weight loss. No reported difficulty with eating, speaking, or swallowing. Denies any discomfiture in the mouth. States that nothing has changed in her mouth “ever since I lost my baby teeth.” Does not smoke cigarettes nor drink alcohol.

Is hypertension a frequent manifestation of thyroid disease?Which clinical clues suggest hypertension in persons with thyroiddysfunction?

An 86-year-old woman had noted intermittent, transient “shading” and “hazing” of the vision in her right eye. Her best corrected vision in that eye was 20/20. She had pseudophakia from past cataract surgery.

An 87-year-old woman complained ofseeing a red tinge on the wallpaper inher house through her right eye. Thepatient had mild memory loss andmoderate hypertension, for whichshe took atenolol. She had quit smokingcigarettes many years earlier.

During an annual eye examination, a 65-year-old womanwith a 5-year history of type 2 insulin-dependent diabetescomplained that her vision had slightly worsened in botheyes. Her best corrected visual acuity was 20/30 in botheyes.

Sudden profound vision loss in her left eye prompted an82-year-old woman to seek evaluation. She also complainedof “just not feeling well” and reported new-onsettemporal and occipital headaches of 6 weeks’ duration.

A 49-year-old woman presented for aroutine eye examination. She had nohistory of systemic disease and tookno medications.

Q:Which combinations of antihypertensivemedications are most effective-and which arebest avoided?

ABSTRACT: Diuretics remain a mainstay of heart failure therapy. Angiotensin-converting enzyme (ACE) inhibitors and ß-blockers inhibit activation of neurohormonal systems; these agents are recommended for most patients with symptomatic systolic heart failure. Angiotensin II receptor blockers (ARBs) are alternatives for patients who are unable to tolerate ACE inhibitors. Recent trials suggest that ARBs are also useful when added to the regimen of patients with a low ejection fraction. Although digoxin can provide long-term inotropic support in men, it significantly increases the risk of mortality in women; because of the risk of toxicity, use digoxin with caution in older persons and patients with renal dysfunction. Consider an aldosterone antagonist in patients who remain symptomatic at rest despite the use of a diuretic, digoxin, an ACE inhibitor or an ARB, and a ß-blocker. Lifestyle modifications such as dietary restriction and exercise are helpful in all patients.