A 55-year-old man with diabetes mellitus presents to his cardiologist with a blood pressure of 165/95 mmHg. According to the JNC (Joint National Committee) 8 guidelines, what is his target blood pressure measurement?
Stage 2, 130/80 mmHg. The most recent JNC 8 guidelines recommend that patients with diabetes have blood pressure goal of less than 140/90 mmHg based on the large ACCORD-BP (Action to Control Cardiovascular Risk in Diabetes — Blood–Pressure-lowering arm) study. The new guideline makes no distinction between patients with CKD or diabetes mellitus with no or with otherwise uncomplicated hypertension in patients less than 60 years of age. The most controversial aspect of the new guideline involves patients >60 years whose treatment goal is now <150/90 mmHg if they have no CKD or diabetes mellitus.
What is the mechanism of action of the antihypertensive medication aliskiren?
Direct renin inhibitor. Aliskiren is a direct renin inhibitor. The renin enzyme controls the rate-limiting step in the generation of angiotensin II. Aliskiren reaches peak concentration in 2 to 4 hours with a half-life of 24 to 36 hours. It is 50% protein bound. Diarrhea is the most common side effect occurring in up to 9.5% of patients. A dose of 150 mg daily will decrease systolic blood pressure on average 12.5 mmHg with a further 2.7 mmHg decrease when the dose is increased to 300 mg PO daily as compared with placebo. Aliskiren has been shown to have similar blood pressure-lowering effects when compared with thiazide diuretics as well as ACEIs. However, to date there are limited data on the effect of aliskiren on hypertensioninduced end-organ damage and clinical outcomes.
A 35-year-old woman with no past medical history, not receiving oral contraceptives, and with a family history of hypertension presents with a gradual increase in blood pressure over the past few years. Today in clinic her blood pressure is 155/95 mmHg.
What is the most appropriate next step?
Patient has essential hypertension; start thiazide diuretic. The patient likely has essential hypertension. The age of onset is typically between the early 20s to the late 50s. The presence of a family history of hypertension, the mild elevation in blood pressure, and the gradual onset make the diagnosis of essential hypertension more likely. First-line therapy in this individual, assuming she is not trying to become pregnant, is the use of a thiazide diuretic. Reevaluation in 1 year would not be appropriate, given the long- term complications associated with uncontrolled hypertension. A repeat evaluation in a few weeks is not necessary, given the documented hypertension over the past few years. The presence of unilateral renal artery stenosis from vascular hyperplasia is a possibility; however, the clinical history is most consistent with essential hypertension.
A 68-year-old man with coronary artery disease, hypertension, diabetes mellitus, and stage II hypertension presents for routine follow-up in the cardiology clinic. His blood pressure is 180/100 mmHg. He is compliant with all his medications and is currently on hydrochlorothiazide, lisinopril, metoprolol, amlodipine, and isosorbide mononitrate. He recently has had two episodes of noncardiogenic pulmonary edema in the setting of an ejection fraction of 55% with no evidence of diastolic dysfunction.
What is the most appropriate next step in the management of his hypertension?
Renal MRI. The distinction between essential hypertension and secondary causes is critical in the management of a patient with long-standing hypertension that is difficult to control. In this scenario, the inability to control the patient’s blood pressure with multiple medications increases the pretest probability of a secondary etiology. In this individual, the presence of multiple cardiac risk factors, along with repeat episodes of noncardiogenic pulmonary edema, suggests the diagnosis of bilateral renal artery stenosis. Addition of further antihypertensive medications would be indicated, but not prior to initiating a workup for renal artery stenosis. A renal MRI would be the most appropriate of the mentioned answers.
A 44-year-old woman had a blood pressure of 115/75 mmHg a few years ago. She now has a blood pressure of 155/75 mmHg, which was confirmed on a repeat visit. How much has her risk for cardiovascular disease increased?
Twofold. Increasing blood pressure beginning at 115/75 mmHg is noted to be a risk factor for stroke, heart failure, and myocardial infarction. For every 20 mmHg increase in systolic blood pressure and for every 10 mmHg in diastolic blood pressure, there is a twofold increase in the risk of cardiovascular disease. For the above patient, her risk of cardiovascular disease has increased by twofold.
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