CORE: Hypertension / Hyperlipidemia
Hypertension:
Goal: Understand risk factors, diagnosis, and management of hypertension
Objectives:
What are risk factors for hypertension?
Discuss diagnosis and different levels of hypertension
Discuss management of hypertension, including medication and lifestyle factors
Discuss ongoing management and monitoring of patients on hypertensive medications
Build HTN management resources in Epic including dotphrases and dashboard links
Patient Hi Beepee is a 45 yo male with no past medical history who presents for a routine physical at the insistence of his wife. He has no specific concerns today. Before you go into the exam room, your MA comes to tell you that he needs a blood pressure recheck because his blood pressure was 144/92 on initial reading and 148/94 on repeat check.
Does Hi Beepee have hypertension? Why or why not?
You discuss Hi Beepee’s elevated BP with him. He reports he has never been told that his blood pressure is elevated. You proceed with the rest of the visit. Patient denies any known underlying medical conditions. He has never had surgery. He is not taking any medications. He denies use of any illicit substances. He drinks 2-3 beers most nights and drinks 2 Mountain Dews daily. He does not do any regular physical activity. His BMI is 31.
What are the risk factors for hypertension?
What lifestyle modifications should you recommend for X? For each lifestyle intervention, how much do you expect this to lower his blood pressure?
You have him work on lifestyle modification and plan to see him back in the clinic in 3 months. In 3 months he returns for an office visit. BP is 144/90, BMI is now 30.
Does Hi Beepee have hypertension? If so, what stage? What are the various stages for hypertension?
What is your goal blood pressure for this patient? For other patient demographics?
What are the first line medications classes (3-4) for treatment of hypertension? For each class discuss:
Sources to review:
JNC8 (with management algorithm)
2017 HTN guideline
SPRINT trial
UConnect ambulatory HTN guidelines
Hyperlipidemia
Goal: Understand how to assess cardiac risk and diagnose and treat dyslipidemia
Objectives:
How do you calculate a 10 year ASCVD?
What are the different ASCVD risk categories?
What are common and uncommon side effects of statin therapy?
Understand risk enhancing factors beyond ASCVD risk level that can help guide management
Understand who is an appropriate candidate for coronary artery calcium scoring as well as how to interpret the results
Carl Esterol is a 53 year old male who presents for an annual physical. He completed pre-visit labs, which included an A1c (5.3) and a fasting lipid panel (Total cholesterol 243, Triglycerides 201, HDL 36, LDL 170).
What additional information do you need in order to decide if Carl needs medication to lower his cholesterol? What medical history would qualify Carl for medical therapy regardless?
Assume Carl is a white man without a history of diabetes or HTN. He does not smoke. BP today is 134/82. He has no family history of premature CAD. What is his 10 year ASCVD? How would you classify his 10 year ASCVD risk (ie low, borderline, intermediate, high)? What are the classification criteria for other ASCVD risk categories?
What nonpharmacologic and pharmacologic options would you recommend for Carl as next steps in management of his hyperlipidemia?
What are common side effects associated with statin therapy?
Imagine Carl is resistant to the idea of starting a statin. What else might you want to know about Carl in order to better understand his personal risk for ASCVD (beyond what the calculator tells you) to determine how hard you should push for a statin? Are there other lab tests or imaging studies that might be helpful in guiding this decision?
In what populations might coronary artery calcium measurements be useful?
Carl’s CAC score is 5. Should he be started on a statin?
When should you recheck lipids?
Sources to review:
2019 lipid guidelines