HY lecture notes:
Tx for hypertension? –> if patient has pre-diabetes, diabetes, or any cardiovascular/cerebrovascular disease of any kind, answer = ACEi or ARB first. These agents decrease morbidity and mortality in these patient groups. If patient has none of the above (i.e., your typical fat American middle-age male who’s a little overweight but otherwise just has essential hypertension), the answer = HCTZ or dihydropyridine CCB. You might think that’s really weird (i.e., “why not just give an ACEi or ARB anyway to anyone if they’re good for morbidity/mortality?”), but the basis is: you’re not going to live to 120 just because you start taking a statin when it’s not indicated; well the same is true here: there’s no evidence of further improvement or morbidity/mortality benefit in patients without the above risk factors if started on ACEi or ARB. This knowledge about how to Tx HTN is HY for FM shelves in particular.
32F + pedal + forearm edema after commencing anti-hypertensive agent; Dx? –> answer = fluid retention / edema caused by dihydropyridine CCB (e.g., nifedipine) –> really HY side-effect of d-CCBs.
Side-effects of thiazides –> hyperGLUC –> hyperglycemia, -lipidemia, -uricemia, calcemia.
Whom should you never give thiazides to? –> pre-diabetics or diabetics –> will push people into type II DM and make current DMs worse –> one of the worst/frequent pharmacologic mistreatments. Also don’t give to patients with Hx of gout (bc of hyperuricemia risk).
Diabetic patient on HCTZ for HTN in FM vignette; what do you do? –> take them the fuck off the thiazide and put them on an ACEi or ARB.
Important use of thiazide apart from HTN management in select patients –> decreased risk of calcium nephro- / ureterolithiasis (stones) because they cause hypocalciuria (and hence hypercalcemia).
So bottom line:
Patient has HTN but no CVD or pre-diabetes / diabetes? –> use either HCTZ or dihydropyridine CCB (e.g., nifedipine).
Patient has CVD (i.e., intermittent claudication, angina, Hx of MI, etc.) or CVD equivalent (i.e., diabetes I or II) –> use ACEi or ARB.
If patient has peripheral edema after starting the dCCB, take them off and put them on HCTZ instead.
If patient has calcium renal stone Hx, give HCTZ.
If patient has Hx of gout, use dCCB.
If patient has confusion who’s on HCTZ, check serum calcium –> hypercalcemia can cause delirium.
If patient has fasting sugars 100 mg/dL or greater (impaired fasting glucose) and HTN, give ACEi or ARB.
If patient has normal fasting sugars but HbA1c of 6.0 or greater (6.0-6.4 is prediabetic; 6.5 or greater is diabetic), give ACEi or ARB.
HTN is >140/90 in the general population; in diabetes, >130/80 is considered HTN and patient needs an ACEi or ARB.
If patient with diabetes has either >130/80 and/or evidence of proteinuria, start ACEi or ARB.
African Americans tend to have stiffer vessels and propensity of diastolic HTN; if African American, give dCCB if no other CVD risk factors.
If you start an ACEi or ARB in patient with HTN and the creatinine and/or renin shoot up, Dx = renal artery stenosis (older patient with atherosclerosis; or any patient with diabetes) or fibromuscular dysplasia (young woman without CVD).
