doc_clotaire
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A 83 yo woman has her BP checked in the shopping mall . During the test , the nurse asks her if she has had any headache during the past few months and the woman say yes . The nurse advises her to see her doctor . She calls her doctor 's office and he is out of town . She becomes nervous and decides not to wait for his return . She comes to you because you are the doctor covering for hers . She presents with a BP of 185/85 mm Hg . BP assesments are repeated during the next three visits scheduled over the next 3 months and persistently elevated pressures are noted .
What is the most appropriate step in this patient 's management ?
a ) follow up for repeat BP visit in 1 month
b ) initiation of nonpharmacologic approach to BP management
c ) initiation of diuretic therapy
d ) initiation of diretic therapy and ACE inhibitor therapy
e ) 24 hour BP monitoring
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| Doc750
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B
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| aaroho
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C
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| doc_clotaire
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Please explain !
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| Doc750
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after three seperate readings of HTN, go for lifestyle changes to control BP. (ie weight loss, exersize, salt restriction, alcohol reduction). If that fails then your going for a diuretic, unless pt has other co-morbid conditions in which case you'll consider, CCB, BB, ACEI, etc)
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| DrVirgo
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For HTN, we usually try lifestyle modifications first
This woman has >180 Systolic BP!!! thats severe HTN, (maybe htn-emergency?) plus it was already confirmed 3 times... lifestyle modifications probably wouldn't help much.
-treat now. I guess start with C)diuretic therapy.
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| Doc750
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this pt has a high systolic, but a normal diastolic.
classification are as follows
High normal BP 130-139/85-89
HTN- >140/>90
Stage 1: Mild HTN 140-159/90-99
Stage II: Moderate HTN 160-179/100-109
Stage III: Severe HTN 180-209/110-119
Stage IV: Very Severe (malig) >210/>120
**Note: If one measurement is normal and the other elevated, the higher category of either measurement is usually used to determine severity. For example, if systolic pressure is 165 (moderate) and diastolic is 92 (mild), the patient would still be diagnosed with moderate hypertension. It should be strongly noted that a high systolic pressure compared to a normal or low diastolic pressure should be a major focus of concern in most adults
so I guess you guys are right, you gotta tx.
Edited by Doc750 on 10/25/07 - 02:08 PM
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| DrVirgo
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Non pharmacologic lifestyle modifications are good for mild and moderate HTN.
Severe HTN -start immediate drug therapy (if diastoilc >100)
Patients with >160/100 --> start on two meds as initial therapy.
(not sure if this means Systolic "AND" Diastolic or Systolic "OR" Diastolic)
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| mjl1717
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DrVirgo wrote:
Non pharmacologic lifestyle modifications are good for mild and moderate HTN.
Severe HTN -start immediate drug therapy (if diastoilc >100)
Patients with >160/100 --> start on two meds as initial therapy.
(not sure if this means Systolic "AND" Diastolic or Systolic "OR" Diastolic)
treat with diuretec answer -c--(HCTZ) the HTN is severe!!
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| Ivonne
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| RitaM
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Guys HCTZ is such a weak diuretic.The patient can develop a stroke by the time it takes effect.
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| DrVirgo
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RitaM wrote:
Guys HCTZ is such a weak diuretic.The patient can develop a stroke by the time it takes effect.
Ok, if thats the case and we know:
Patients with >160/100 --> start on two meds as initial therapy.
Then I say
d ) initiation of diretic therapy and ACE inhibitor therapy --should be right thing to do.
Answer please? 
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| titly
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this is isolated systolic hypertension and it has to be treated pharmacologically. so u give diuretics and ACE inhibitors. dats D.
u hv to take care during the management not to reduce the diastolic BP below 70 to avoid hypoperfusion. isolated sys HTN is supposed to be difficult to treat.
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| RitaM
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Yes for Dr.Virgo: I think giving HCTZ and ACEI would be the right choice.As I have done that many atimes in the Neuro ICU.
for Dr.Titly:Please refer to uptodate management of stroke.The systolic should not go below 40 of the systolic before the treatment is initiated.If I am not wrong i.e if systolic is 185 never try to go below 145 as that can cause an ischemic stroke.
Chow guys
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| titly
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ya u r rite abt the systolic pressure. i hv mentioned abt the reduction in diastolic pressure. according to wat i hv read the diastolic pressure should not be reduced below 70mmhg whn u give antihypertensives. u hv to take special care abt this since in isolated systolic HTN we already hv a normal diastolic pressure.
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| genbot
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The answer is D
that is u give both a diuretic and an ACEI
The reason is simple this is Stage II hypertension according to JNC 7 and according to their recommendations treatment needs to be started with two agents preferably including a diuretic.
Stage II hypertension means either systolic BP > 160 OR diastolic > 100
A couple more things...
Anyone developing hypertension after age 55 is to be evaluated for secondary HTN.
And in the elderly Calcium channel blockers are preferred over ACEI because of their poorer response to these agents, unless of course they have a compelling indications such as diabetic nephropathy/post myocardial infarction.
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| doc_clotaire
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ANSWER : C
The patient has isolated systolic hypertension--Start with dietary modification and diuretic.
Diuretics as initial therapy have been shown to decrease incidence of stroke , fatal MI and overall mortality in this agre group
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| DrVirgo
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Hi, I actually thought C at first too but then changed to D after I looked it up because Kaplan says:
Patients with >160/100 --> start on two meds as initial therapy. (is this for BOTH systolic and diastolic values??)
Any more thoughts or ideas about this doc_clotaire or anyone?
doc_clotaire wrote:
ANSWER : C
The patient has isolated systolic hypertension--Start with dietary modification and diuretic.
Diuretics as initial therapy have been shown to decrease incidence of stroke , fatal MI and overall mortality in this agre group
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| doc_clotaire
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Her diastolic is fine dude
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| DrVirgo
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Ok, thanks.
So only start on TWO drugs if BOTH Systolic is over 160 AND Diastolic is over 100?
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| docnikki
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I read that we always start with one drug and after giving the drug in FULL doeses if BP still not controlled we add the 2nd. so its C.
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