150/95

[IMG SURVIVOR]

Q) 34 yo white man, HTN: 150/95. No other diseases. (not mention primary or secondary HTN). What drug you should prescribe to him:

1.b-blocker
2.ACE I
3.Diuretics
4.Ca blocker


























This is from ghost files

[MDXRS22]

A= 4


I am quite sure: ca Ch blocker should do just fine. Ace could have been, but the scenario does not ask for such.

[rose.82]

Hello IMG SURVIVOR and MDXRS22,

I think the answer is 3 .What do you think?

[winston]

Hydrochlorothoazide or Amlodipine are the first line for essential HTN.....so I think its either 3 or 4......if I had to guess I'd go with 3......though not sure

[MDXRS22]

Hello IMG SURVIVOR and MDXRS22,

I think the answer is 3 .What do you think?

Rose,

Like the previous poster said, too, the answer must be 3 or 4. I am sure you are right.

[qtncaribbean]

diuretics - hctz

[randhawa86]

i also agree answer number three is correct.

[drrajpoonia]

i think first choice in essential htn is diuretics,isn`t it?

[angjr]

Remember that in whites the etiology of Hypertension is due to catecholamines excess (too much stress)...

[lifeAgift]

5. No drugs

Repeat BP myself
Repeat Med Hx to insure/confirm no usage of OTC, herbal supplements, Stacker, Guarana etc...

then

Chiropractic Adjusment
Dietary Change ( Especial Caffeine Elimination, White sugar and Red Meat)
Exercise
Stress Reduction

Pt to repeat and log BP weekly ( same day and time)
If no improvement after 12 weeks and all the above advice is followed then I'd consider treating with a CA Blocker

At the age of 34 with no fam hx - 12 weeks of behavior modification, lifestyle and environment changes would be more beneficial than meds first.

Additionally, allowing the PT. some initial personal responsibility for the outcome might improve future drug protocol adherance.

I'M NO PUSHER:rolleyes:

[rd100]

Bad Question. All Are First Line Drgs For The Mangement Of Htn. None Are Incorrect And The Comorbidites Should Dictate Treatment In Their Absence Any One Of These Drugs Can Be Used They Are all 1st Line .

Diuretics And Bb are The Only Two Shown To Decrease Mortality From Htn In Teh Absence Of Other Comorbidities.

Diuretics Are The Most Synergistic Of The 4 Mentioned And This Is The best Answer - Hctz.

regards

richard

[teratos]

Here is a summary of the JNC-7 guidelines

http://www.nhlbi.nih.gov/guidelines/hypertension/phycard.pdf

[teratos]

I would use an ACE-I or thiazide first line. There was a recent study where ACE/CCB (amlodipine) combination was found to be the best at reducing morbidity and mortality. Unfortunately, the name of the trial eludes me at the moment.

Beta-blockers are losing favor as a first-line treatment.
Log In Problems (http://www.medscape.com/viewarticle/542689_2)
Beta Blockers Are Less Effective Than Other Drugs For First-line Treatment Of High Blood Pressure (http://www.sciencedaily.com/releases/2007/01/070124072648.htm)
I still use them sometimes in combination with a diuretic in people with relatively fast pulse rates. These folks tend to respond well to bets-blockers since their BP issues are likely to be catecholamine related.

ACE-I/ARB's have been shown to significantly reduce morbidity and mortality even in people without co-morbids.

This guy in the OP question....as said above.....lifestyle mods. He can have 3-6 months to lose weight/exercise/change his diet. Better to keep people off drugs if you can help it......

[lifeAgift]

Bad Question. All Are First Line Drgs For The Mangement Of Htn. None Are Incorrect And The Comorbidites Should Dictate Treatment In Their Absence Any One Of These Drugs Can Be Used They Are all 1st Line .

Diuretics And Bb are The Only Two Shown To Decrease Mortality From Htn In Teh Absence Of Other Comorbidities.

Diuretics Are The Most Synergistic Of The 4 Mentioned And This Is The best Answer - Hctz.

regards

richard


Yeah but then you need a K+ supplement or else your sodium/ potassium pump will be out of wack.

1st line treatment is no better than placebo if behavior/lifestyle/ environmental changes aren't made.

You just end up with a patient who needs more scripts later to manage kidney damage, thyroid issues, insulin uptake.

It becomes a vicious cycle with real preventive medicine being the most efficacious and cost effective 1st line response in Pts. under 40

[teratos]

Yeah but then you need a K+ supplement or else your sodium/ potassium pump will be out of wack.

1st line treatment is no better than placebo if behavior/lifestyle/ environmental changes aren't made.

You just end up with a patient who needs more scripts later to manage kidney damage, thyroid issues, insulin uptake.

It becomes a vicious cycle with real preventive medicine being the most efficacious and cost effective 1st line response in Pts. under 40

Rarely do you need a K+ supplement with HCTZ. You can always change to dyazide (HCTZ/triamterene). First line treatment IS better than placebo even without lifestyle mods...of course, the optimum treatment includes lifestyle modifications. You can always use an ARB, which has been shown to be reno-protective, and also reduce insulin resistance (valstartan in particular). I am not sure where they thyroid issues come in to play :confused:

[rd100]

Again 150 / 95 deserves treatment and investigation. THis man is young 2nd cause should be ruled out in so far as management it is not wrong to treat 150/95,nor is it wrong to f/u qmonthly with life style mod.. More info is need for a definitve answer.

ie.

Low TSH in a patient with a history of status epilepticus presents w bp 150/95 now what do you use ? to control bp acutely or do you want to wait, treat the thyroid and than f/u bp (this is the wrong answer !) so now what do you do ? how about if bp wa 180/90 is management the same ? or what if bp is 185/100 is mangement the same ? Say yes BC YOU WANT TO PASS STEP II ! SO WHAT IS THE FIRST LINE TREATMENT?

[lifeAgift]

Rarely do you need a K+ supplement with HCTZ. You can always change to dyazide (HCTZ/triamterene). First line treatment IS better than placebo even without lifestyle mods...of course, the optimum treatment includes lifestyle modifications. You can always use an ARB, which has been shown to be reno-protective, and also reduce insulin resistance (valstartan in particular). I am not sure where they thyroid issues come in to play :confused:

That's just it western medicine doesn't treat the whole person!!!


The thyroid is always impacted as well as the liver and the kidney's ....ALWAYS!!!!

Health conditions rarely occur in isolation, rarely!

Every individual that I've ever provided nutritional counseling for that is taking HCTZ has had a Potassium deficiency!!! I'm talking dozens of folks over a five year period not just a handful!!!

"Certain medications can accelerate the removal of potassium from the body; including thiazide diuretics, such as hydrochlorothiazide; loop diuretics, such as furosemide; as well as various laxatives. The antifungal amphotericin B has also been associated with hypokalemia. "

"Potassium, sodium, and lithium are alkaline minerals which are involved in the cellular pumps which regulate the transport of water and nutrients through the cell walls. There is evidence that a potassium deficiency can cause the cells to fill with water leading to an overall edema in the body. It's possible that edema of the brain cells from potassium deficiency may be involved in chronic headaches. It's also possible that potassium deficiency is responsible for the rapid increase in body weight seen in thyroid patients. "

"Potassium--an electrolyte mineral located in body fluids. Potassium balances the acid/alkaline system, transmits electrical signals between cells and nerves, and enhances athletic performance. It works with sodium to regulate the body's water balance, and is necessary for heart health against hypertension and stroke, (people who take high blood pressure medication are vulnerable to potassium deficiency), muscle function, energy storage, nerve stability, and enzyme and hormone production."

[rd100]

i appreciate your reply but step two is a "Western medicine exam"! Intresting point , but good way not to pass step II

[teratos]

OK. So our experiences don't differ so much. I put a lot of people on HCTZ, either alone or in combination with something else. I check potassium levels fairly often, and find a problem maybe 10-20% of the time. So that't probably 100+ people per year. Interestingly, race and sex are a factor in who is at risk. In terms of treatment of hypertension, it is a very important aspect of maintaining adequate kidney function. 1/3 of the people on dialysis are there as a direct result of their hypertension. Essential hypertension is probably the most common problem seen in the general population. Early on, it is seen by itself. It can be a sign that these people are on a course to develop multiple metabolic problems including (but not limited to) diabetes and dyslipidemia ....the "metabolic syndrome". We can council until we are blue in the face. Some of us do. People just don't want to leave McDonald'd behind, and won't exercise, or quit smoking. What a load of crap about western medicine not treating the "whole person". Most of us in primary care do our best to guide our patients in leading the healthiest lives they can. Most of it is their doing.

That being said, there is an enormous amount of data that goes into making these guidelines. There is no question that controlling blood pressure, cholesterol, blood sugar, thyroid disease with our evil western medicines reduces morbidity and mortality. With every new-onset diabetic I see, I give them the same lecture.....85% of people who have diabetes type 2 for less than 5 years WILL NOT have diabetes if they acheive a normal weight. I spend a lot of time going over diet, exercise etc. You know how many actually do it?

That's just it western medicine doesn't treat the whole person!!!


The thyroid is always impacted as well as the liver and the kidney's ....ALWAYS!!!!

Health conditions rarely occur in isolation, rarely!

Every individual that I've ever provided nutritional counseling for that is taking HCTZ has had a Potassium deficiency!!! I'm talking dozens of folks over a five year period not just a handful!!!

"Certain medications (http://en.wikipedia.org/wiki/Medication) can accelerate the removal of potassium from the body; including thiazide diuretics (http://en.wikipedia.org/wiki/Thiazide_diuretic), such as hydrochlorothiazide (http://en.wikipedia.org/wiki/Hydrochlorothiazide); loop diuretics (http://en.wikipedia.org/wiki/Loop_diuretic), such as furosemide (http://en.wikipedia.org/wiki/Furosemide); as well as various laxatives (http://en.wikipedia.org/wiki/Laxative). The antifungal amphotericin B (http://en.wikipedia.org/wiki/Amphotericin_B) has also been associated with hypokalemia. "

"Potassium, sodium, and lithium are alkaline minerals which are involved in the cellular pumps which regulate the transport of water and nutrients through the cell walls. There is evidence that a potassium deficiency can cause the cells to fill with water leading to an overall edema in the body. It's possible that edema of the brain cells from potassium deficiency may be involved in chronic headaches. It's also possible that potassium deficiency is responsible for the rapid increase in body weight seen in thyroid patients. "

"Potassium--an electrolyte mineral located in body fluids. Potassium balances the acid/alkaline system, transmits electrical signals between cells and nerves, and enhances athletic performance. It works with sodium to regulate the body's water balance, and is necessary for heart health against hypertension and stroke, (people who take high blood pressure medication are vulnerable to potassium deficiency), muscle function, energy storage, nerve stability, and enzyme and hormone production."

[teratos]

Again 150 / 95 deserves treatment and investigation. THis man is young 2nd cause should be ruled out in so far as management it is not wrong to treat 150/95,nor is it wrong to f/u qmonthly with life style mod.. More info is need for a definitve answer.

ie.

Low TSH in a patient with a history of status epilepticus presents w bp 150/95 now what do you use ? to control bp acutely or do you want to wait, treat the thyroid and than f/u bp (this is the wrong answer !) so now what do you do ? how about if bp wa 180/90 is management the same ? or what if bp is 185/100 is mangement the same ? Say yes BC YOU WANT TO PASS STEP II ! SO WHAT IS THE FIRST LINE TREATMENT?

There are several right answers. You could use lifestyle mods, HCTZ, ACE, CCB, etc. and still be right. This is unlikely to be a board question because you can't nail down 1 right answer. 180.90, 185/100...those you should treat the first time you see them. I would use either a combination ACE/HCTZ, or amlodipine/ACE combination, as you will not likely acheive goal with a single agent.

he kid with 150/90 does warrant some invstigation. BMP, UA. That should be sufficient initially. I don't think I would go for urine VMA or plasma free metanephrines right off the bat. A good history and physical is very important. You may get your answer there. G

[the_punisher]

Q) 34 yo white man, HTN: 150/95. No other diseases. (not mention primary or secondary HTN). What drug you should prescribe to him:

1.b-blocker
2.ACE I
3.Diuretics
4.Ca blocker

This is from ghost files


A= 4


I am quite sure: ca Ch blocker should do just fine. Ace could have been, but the scenario does not ask for such.

Hello IMG SURVIVOR and MDXRS22,

I think the answer is 3 .What do you think?


ok so from what i've learned and understood, most african americans ( blacks ) and hispanics have high BP because of high salt intake leading to a high "STROKE VOLUME".... so in these pt. loop diuretic would be good... loops are also first line for "congestive heart failure or volume over-load conditions". this patient is neither black nor is there any history of volume overload. actually there is no history at all... except white male

i would go with CCB or B-blocker... because from what i've learned and understood, stress is the most common cause of HTN in whites which increases HR... this pt. is a white male and middle age.

now one last thing that i also learned is the most common cause of HTN in elderly is atherosclerosis... so TPR would be increased... if it was an ELDERLY male, then the answer option would me a dilator of some sort...