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| Hypertension Pearls for the Seasoned PA |
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by Ben Taylor, PA-C, PhD - December 6, 2011
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Hypertension is commonly encountered by PAs during their day-to-day visits with patients. Yet despite the prevalence of this condition, many PAs still appear to be unfamiliar with the initial treatment and subsequent management of this common disorder. Early recognition and intervention is important in slowing the progression to chronic kidney disease and preventing its complications. The evidence-based pearls in described here will help all PA’s avoid common pitfalls in the recognition and treatment of this disorder and guide their decision on when to refer their patients to a specialist.
1- Never make a significant decision on treatment based on one reading, and make sure the cuff actually fits correctly. Take it manually if need be. Ensure the patient is not sitting on the exam table with legs dangling off. They need to be in a chair with both feet flat on the floor.
2- Asymptomatic patients do not need rapid correction of BP. They have likely been at this level for a long time and autoregulation has likely caused compensatory changes in circulation, and if you drop it too fast it will cause decreased cerebral perfusion. Allow the baroreceptors to reset themselves. Recheck your patients in 4-6 weeks after starting a new drug regimen.
3- Recommend all high BP readings for a recheck sooner than later. If they are in your clinic, make them sit there and recheck the BP before they leave to ensure there is some reduction in the BP.
4- Avoid old school nifedipine as a fast fix to reduce BP in the office (or emergency setting as it is unreliable and dangerous in many ways to include stroke, fetal distress, blood-vessel blockage, heart attack, severe low blood pressure and death.
5- Screen blood pressure (BP) in adults annually since BP rises with increasing age.
6- Encourage patients with prehypertension to engage in lifestyle changes to reduce risk of proceeding to hypertension to include:
a. Lose extra pounds and watch their waistline
b. Exercise regularly
c. Eat a healthy diet
d. Reduce sodium in their diet
e. Limit the amount of alcohol they drink
f. Avoid tobacco products and secondhand smoke
g. Cut back on caffeine
h. Reduce stress in their life
i. Monitor their blood pressure at home and make regular doctor's appointments
j. Get support from family and friends
7- Explain to patients that blood pressure control reduces cardiovascular risks over a lifetime.
8- Once hypertension is diagnosed, take aggressive action to reduce blood pressure to include lifestyle modifications for all patients, as appropriate.
9- Use thiazide-type diuretics, alone or in combination with other agents as first line therapy. Choose other agents based on evidence for reduction of mortality and morbidity. These agents include (in alphabetical order): angiotensin-converting enzyme inhibitors (ACEIs), angiotensin II receptor blockers (ARBs), beta-blockers, and long-acting calcium channel blockers.
10- Strongly consider starting therapy with a combination of 2 drugs for patients with Stage 2 hypertension (BP ≥160 or ≥100).
11- Target blood pressure goals appropriately for each patient and titrate therapy to achieve that goal through:
a. Informing patients about their blood pressure (BP) goal
b. Following-up closely until goal achieved
c. Adjusting medication as necessary at each visit
d. Keeping the medication regimen as simple as possible
e. Educating and involving patients in their care plan
f. Using ancillary staff and available programs (to include pharmaceutical reps) to support and help in reaching their target goal.
12- In your workup of secondary hypertension, consider primary hyperaldosteronism and/or the presence of an adrenal tumor, which is more common than generally appreciated.
13- When managing hypertension in pregnancy, the antihypertensive agent with the largest quantity of data regarding fetal safety is methyldopa, which has been used during pregnancy since the 1960s. Labetalol, a combined alpha- and beta-receptor blocker, is often recommended as another first-line or second-line therapy for hypertension in pregnancy. Long-acting calcium-channel blockers also appear to be safe in pregnancy, although experience is more limited than with labetalol. Angiotensin-converting-enzyme inhibitors and angiotensin-receptor blockers are contraindicated in pregnancy.
14- Refer immediately to Cardiology if the patient has signs of:
a. Accelerated (malignant) hypertension (blood pressure more than 180/110 mmHg with signs of papilloedema and/or retinal hemorrhage).
b. Suspected phaeochromocytoma (possible signs include labile or postural hypotension, headache, palpitation, pallor and diaphoresis).
15- Consider referral if:
a. The patient has unusual signs and symptoms.
b. The patient has signs or symptoms suggesting a secondary cause.
c. The patient’s management depends critically on the accurate estimation of their blood pressure.
d. The patient has symptoms of postural hypotension, or a fall in systolic blood pressure when standing of 20 mmHg or more.
Utilize these pearls to help protect your patients and avoid visiting deposition central.
Practicing in cardiology for 18 years, Ben treats patients at the Medical College of GA Emergency Department in Augusta and the Edgefield, SC-based Peachtree Family Practice. He is the Vice President of the Association of Family Practice Physician Assistants and Past President of the Georgia Association of Physician Assistants (GAPA). Ben has worked in multiple emergency rooms across the country over the past 20 years and teaches EKGs to providers at the Medical College of GA on a recurring basis. He has mentored and precepted PA students for the past 15 years and was named PA of the Year in 2010 from the Georgia Society. He lectures across the country and has authored parts of the cardiology section of the PA certification exam. Ben consistently ranks among top rated speakers and keeps the audience “in stitches” with his humor and entertaining style.
Ben will be speaking at the upcoming DMGCME conferences in Las Vegas and Walt Disney World. Come prepared to learn and to be entertained!
The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.
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| maravarpac@hotmail.com (MI) |
on 09 Dec 2011 at 7:20 pm |
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| Great easy-to-remember practical pointers to live/practice by. |
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