You are seeing for the first time a 45-year-old female patient of your partner. A review of the patient’s medical record shows that her systolic blood pressure was greater than 140 mm Hg at both of her last clinic appointments. Her medical history is significant only for diabetes mellitus. Her blood pressure today is 164/92. What is the best next step in her blood pressure management?
Hypertension is defined as elevated blood pressure on two or more separate readings. In a patient with stage 1 HTN and no other cardiac risk factors, consideration may be given to a therapeutic trial of diet and lifestyle modification. This patient, however, has diabetes mellitus. Both the American Diabetes Association and JNC-7 recommend a target blood pressure of 130/80 or lower in patients with diabetes. It is unlikely that the patient will be able to reach target blood pressure with diet and lifestyle modification alone, although these interventions will be important adjunct therapies. The JNC-7 recommends a thiazide diuretic as initial therapy for most patients with hypertension. Patients with diabetes and hypertension, however, benefit more from an ACE inhibitor, especially if they have signs of renal damage (elevated creatinine or proteinuria). There is no contraindication to the use of calcium-channel blockers, but their increased expense without increased benefit would prevent answer d from being correct. Evidence of end-organ damage, such as left ventricular hypertrophy on an echocardiogram, is unlikely to change your initial management.
A 67-year-old man presents to your clinic to establish primary care; he is asymptomatic. He has a history of hypertension for which he takes hydrochlorothiazide. His father had a myocardial infarction at age 62. The patient smoked until 5 years ago, but has been abstinent from tobacco since then. His blood pressure in the office today is 132/78. Aside from being overweight, the remainder of the physical examination is unremarkable. Which of the following preventive health interventions would be most appropriately offered to him today?
The U.S. Preventive Services Task Force recommends that all men between the ages of 65 and 75 with any history of smoking undergo one-time screening for abdominal aortic aneurysm (AAA). There is no evidence that screening carotid ultrasonography (ie, in the patient without cerebrovascular symptoms or carotid bruits) or treadmill testing are beneficial to the patient. Although lipoprotein(a) and homocysteine levels have some predictive value in assessing CAD risk, their measurement is not recommended by the USPS Task Force.
A 68-year-old man complains of pain in his calves while walking. He notes bilateral foot pain, which awakens him at night. His blood pressure is 117/68. Physical examination reveals diminished bilateral lower extremity pulses. An ankle:brachial index measures 0.6. The patient’s current medications include aspirin and hydrochlorothiazide. Which of the following is the best initial management plan for this patient’s complaint?
This patient has symptomatic peripheral arterial disease (PAD). Initial intervention should focus on lifestyle modification, most notably smoking cessation. Claudication can be improved by a graduated exercise regimen. Cilostazol, a phosphodiesterase inhibitor, improves exercise tolerance. In addition, patients with PAD usually have underlying coronary disease. Aggressive risk factor modification (especially lipid and blood pressure control) may decrease the risk of their chief cause of death, which is coronary artery disease. Calcium-channel blockers have not been shown to improve exercise tolerance, and there is no role for systemic anticoagulation in patients with PAD. Invasive interventions (angioplasty, surgery) are typically reserved for patients who have failed medical therapy or have critical ischemia. Arteriography would likely be needed before invasive intervention is attempted.
A 70-year-old man with a history of mild chronic kidney disease, diabetes mellitus, and CHF is admitted to your inpatient service with decreased urine output, weakness, and shortness of breath. He takes several medications but cannot remember their names. Labs tests are pending; his ECG is shown below.
Based on the information available, what is the best initial step in management?
The patient’s ECG findings are most consistent with hyperkalemia. Additional ECG findings may include prolongation of the PR interval and QRS interval. Further electrical deterioration may lead to QRS widening and development of a sine wave. Ventricular fibrillation and asystole are potential terminal consequences. The patient’s diabetes mellitus and kidney disease are predisposing factors; ACE inhibitors, beta-blockers, and spironolactone can increase the serum potassium. Hyperkalemia less than 7.5 mEq/L usually does not result in fatal arrhythmias, but evidence of hyperkalemia on an ECG should prompt rapid intervention. Calcium gluconate is commonly administered to decrease membrane excitability. Its effects begin within 5 to 10 minutes and last up to 1 hour. There are no contraindications to calcium in this patient. Insulin causes K + to shift into the intracellular space and decreases serum potassium concentration. In euglycemic patients, a combination of insulin and glucose is typically administered concomitantly to decrease the risk of hypoglycemia. In hyperglycemic patients insulin alone should be given. In our patient, however, labs are still pending. It would be prudent to check a blood sugar before administering insulin. Sodium bicarbonate therapy also will shift K + into the cells. Patients with severe kidney disease or hypervolemic states, such as CHF, may not tolerate alkalinization or the associated sodium load. Ideally, the serum bicarbonate and creatinine should be checked before intravenous sodium bicarbonate is administered. Each of the above therapies only shifts K + into the cells. Attention must then be given to removing excess K + from the body. Sodium polystyrene sulfonate (Kayexalate) is a cation exchange resin that binds K + in the GI tract and decreases serum K + . The delayed onset of action of this drug prevents this from being the best initial intervention. Diuretic therapy (eg, furosemide) or hemodialysis can decrease total body K + . Depending on the patient’s kidney function and volume status, these may be considered, but they too take hours to work and should not take the place of immediate therapy. There is no role for hypertonic saline in the management of hyperkalemia.
You are called by a surgical colleague to evaluate a 54-year-old woman with ECG abnormalities 1 day after a subtotal thyroidectomy for a toxic multinodular goiter. Her only medication is fentanyl for postoperative pain control. The patient denies any history of syncope and has no family history of sudden cardiac death. Physical examination is unremarkable except for a clean postoperative incision at the base of the neck. Her ECG is reproduced below.
What is the best next step in evaluation and management of this patient?
The patient has a prolonged QT interval; her QTc is approximately 520 milliseconds (normal 450 milliseconds or less, although it may be slightly longer in women). As a general rule of thumb, a QT interval less than half of the RR interval should not raise alarm. Her recent thyroid surgery suggests hypocalcemia resulting from parathyroid damage. Besides hypocalcemia, toxins, hypothermia, and many medications may also lead to QT prolongation. Prolonged QT can cause torsade de pointes, a life-threatening ventricular arrhythmia. Magnesium may be used in the therapy of torsades, but this patient has not developed arrhythmia. Subarachnoid hemorrhage may lead to prolongation of the QT interval, and in the correct clinical setting a noncontrast CT scan of the head may be appropriate. This patient has no evidence of intracranial bleeding. There are several congenital QT prolongation syndromes, with Romano-Ward syndrome being most common. RomanoWard is characterized by prolonged QT and congenital deafness, and there may be a family history of sudden cardiac death. Formal auditory testing would be unlikely to expose congenital deafness not discovered during routine patient interaction. Simple reassurance would not be appropriate, as potential hypocalcemia would remain undiagnosed.