HTN Interventions

A 56-year-old man with a 10-year history of hypertension presents for a primary care visit, stating he has not taken his high blood pressure medicines, a calcium channel blocker, angiotensin-converting enzyme inhibitor, and thiazide diuretic for the last three months due to, quote, running out of medication and not getting to the pharmacy, close quote. Today's blood pressure is 192 over 120, and he's without complaint, denying shortness of breath, chest pain, or visual changes. He states, "I just came in today for a visit since I ran out of high blood pressure refills. I need to get back to work in a half an hour." His physical exam shows no acute distress, grade one hypertensive retinopathy, and S4 heart sound. His neck veins are within normal limit, chest is clear, no peripheral edema with a resting heart rate of 73. Respiratory rate 16, 12 lead ECG is within normal limits. His BMI is 33. 

Which of the following is the next best step in the patient's care?

A. Administer in-office oral clonidine and reassess blood pressure in 1 hour. 

B. Activate EMS with prompt transfer to emergency department

C. Restart prior blood pressure medications with follow-up within the next month

D. Advise restricting dietary sodium and weight loss to help with BP control. 

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Transcript

Voiceover: Welcome to NP Certification Q&A presented by Fitzgerald Health Education Associates. This podcast is for NP students studying to pass their NP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Expert Fitzgerald faculty clinicians share their knowledge and experience to help you dissect the anatomy of a test question so you can better understand how to arrive at the correct test answer. So, if you're ready, let's jump right in.

Margaret Fitzgerald: A 56-year-old man with a 10-year history of hypertension presents for a primary care visit, stating he's not taken his high blood pressure medicines, a calcium channel blocker, angiotensin-converting enzyme inhibitor, and thiazide diuretic for the last 3 months due to “running out of medication and not getting to the pharmacy”. Today's blood pressure is 192 over 120 and he's without complaint denying shortness of breath, chest pain, or visual changes. He states, “I just came in today for a visit since I ran out of high blood pressure refills. I need to get back to work in a half an hour.” His physical exam shows no acute distress, grade one hypertensive retinopathy, an S4 heart sound. His neck veins are within normal limit. Chest is clear. No peripheral edema with a resting heart rate of 73. Respiratory rate 16. 12 lead ECG is within normal MI limits. His BMI is 33. 

Which of the following is the next best step in the patient's care? 

A. Administer in-office oral clonidine and reassess his blood pressure in 1 hour.

B. Activate EMS with prompt transfer to emergency department. 

C. Restart prior blood pressure medicine with follow-up within the next month. 

D. Advise on restricting sodium intake and weight loss to help with blood pressure control. 

The correct answer is C. Restart prior blood pressure medicines with follow-up within the next month. 

Where do you start with a question like this? Of course, as we always do, consider what kind of a question it is. Given the patient's history includes significant hypertension along with medicine non-adherence, we need to consider the next steps in his care. This is a plan/intervention question. 

In a recent podcast, I outlined the clinical condition of severe asymptomatic hypertension, formerly known as hypertensive urgency, where the blood pressure is really very elevated, but the patient is without signs and symptoms of accelerated hypertensive target organ dysfunction. The clinical scenario in asymptomatic marketkedly elevated blood pressure is where what we see in this question. 

So that was our first part. We had to appreciate that this person has, yes, a marketkedly elevated blood pressure, but we've got a really clear reason for it. He stopped taking his three meds uh 3 months ago. and who this is a extraordinarily common clinical scenario and there's a term that's not used so much to describe high blood pressure anymore but years ago it was very commonly used and high blood pressure was called the silent killer and um I I think we should start using that term again to be perfectly honest with you because high blood pressure is really asymptomatic. There's an adage in treating people with high blood pressure is it's very hard to make an asymptomatic person feel better. 

Think about that for a minute. So, we've got a guy FYI, he's on a quick break from work and he would like you to move this visit right along because he needs to get back to work. Um he feels fine but his blood pressure is through the roof and that is why this condition is called asymptomatic elevated blood pressure. Okay, that's why it's called that because he's totally without symptoms. 

Okay, who is the classic person with this? Just like this person, patient who's had high blood pressure for a number of years, usually on at least three and sometimes four meds to control the blood pressure, which tells me the blood pressure has his was quite elevated when he first went on meds. And then the person simply runs out of medication or stops taking the advised medications. And then that person will uh present to the clinical setting feeling well often candidly pushed by a loved one that says you know you're not taking a blood pressure medicine you need to make sure you do that something along those lines. Um on physical exam in severe um asymptomatic hypertension there are no alarm findings i.e. No high-grade hypertensive retinopathy like grade three or grade four. No visual changes like black spots in the visual field which are very common in grade three and grade four. Uh hypertensive retinopathy because he's bleeding in the back of the eye, no shortness of breath, no chest pain, no S3 heart sound, which I'll remind you is a sound of systolic dysfunction, no neck vein distension. 

All of these findings that I just listed are common with hypertensive emergency where there is evidence of hypertensive TOD. In this scenario, we're given a normal physical exam with some minor changes, including the S4 heart sound, something that's consistent with diastolic dysfunction and quite common after a number of months of elevated blood pressure, and grade one hypertensive retinopathy, low grade hypertensive retinopathy where there's no visual changes, no permanent findings. In other words, both of those abnormalities on his physical exam today are, shall we say, acceptable with this clinical scenario, and they'll both resolve once the blood pressure's been normalized for a period of time. 

So, let's get back to the issue at hand. Taking a look at what we have in this clinical scenario. A 56-year-old man with a 10-year history of hypertension presents for primary care visit states he's not been taking his high blood pressure medicines which include a calcium channel blocker angiotensin converting enzyme inhibitor and thiazide diuretic for the last 3 months due to “running out of the medication and not getting to the pharmacy.” Today his blood pressure is 192 over 120 and he's without complaint denying shortness of breath, chest pain or visual changes. He states, "I just came in today for a visit since I ran out of blood pressure refills. I need to get back to work in a half an hour." His physical exam re um reveals he is in no acute distress. He has grade one hypertensive retinopathy, an S4 heart sound. Neck veins are within normal limits. Chest is clear. No peripheral edema with a resting heart rate of 73. Respiratory rate is 16. 12 lead ECG is within normal limits. His BMI is 33. Which of the following is the next best step in the patient's care? 

A. Administer in-office oral clonidine and reassess blood pressure in 1 hour. This is a common practice but is incorrect. Whether the diagnosis is severe asymptomatic hypertension or hypertensive emergency, the AHACC hypertension guidelines are abundantly clear on this. Do not use short acting anti-hypertensive meds in any setting under any circumstances. One rationale is here given that he has no evidence of accelerated hypertensive to there's no emergency situation where his blood pressure needs to be brought down quickly. In addition, remember if you're sitting for the family or the adult ger primary care exam, you should anticipate that almost every question, if not every question, the clinical setting will be in a primary care office. It is a relatively uncontrolled setting. bringing down his blood pressure rapidly can pose a risk for an acute cerebrovascular or cardiovascular event. Clearly, that is dangerous. And if you're thinking, well, that must be a newer recommendation because we're not that many that much time away from a major overhaul in the hypertension guidelines from ACC and AHA. Um, this actually was mentioned in JNC8 and I'm pretty sure the publication date of JNC8 was 2017. So this is not a new recommendation, but you will see clinicians who have been in practice for a while and aren't aware of the newer evidence and the newer guidelines will still be giving short acting anti-hypertensive meds in office to try to urgently lower blood pressure should not be done. 

B. Activate EMS with prompt transfer to the emergency department. This is also incorrect. Would it be correct if this person had hypertensive emergency? Yes, it would be. But this person has asymptomatic marketkedly elevated blood pressure. He should not be referred to the emergency department or hospitalized. It is not a life-threatening situation. And indeed, even though you're looking at this person and saying, "Oh, blood pressure is so high. It's giving me a headache." Um, it is amazing how well these folks do. It is. And that is one reason why there is no advice on urgently lowering blood pressure. 

Um, option C, restart blood pressure medications with follow-up in the next month. This is of course the correct answer. Patients with asymptomatic marketkedly elevated blood pressure aka formerly known as hypertensive urgency, um should be treated by reinstituting their previously taken anti-hypertensive meds and then making sure you schedule a follow-up. uh practice guidelines from ACC and AHA. Practice guidelines from ACC AHA advise that if you start a new blood pressure medicine, tweak a dose, anything like that, that the blood pressure is rechecked within about a month. In other words, give the med some time to work. And given how complicated this situation potentially is, I would not defer to simply a nursing visit to have his blood pressure elevated. I'd want to see him um back like that. Indeed, to be honest with you, a lot of times what I try to do is get patients like this back in a couple of weeks, but I do that not to ensure their blood pressure is down in an acceptable range, but it is more because no doubt I've done some blood work. Um, no doubt I want to make sure the patient actually restarted their high blood pressure medicines. So, I'm trying to see them for a closer clinical follow-up in part to check on adherence as much as anything else. But I actually wouldn't expect his blood pressure to come down all that much in just two weeks. Probably will take more like the full month. 

And I will say part of the plan of care today is investigating with the patient as to why the medication was not refilled. Did they have difficulty getting to the pharmacy? Was there a large co-pay that got in the way of picking up the med? How did the patient feel while on the med? Were there intolerable adverse effects that made the patient discontinue the medication? This is as important a part of high blood pressure care as prescribing the correct medicine. And by the way, you'll notice in the question it said he was on a calcium channel blocker, an angiotensin receptor blocker and a thiazide diuretic. It is not uncommon on boards for the meds not to be mentioned as a particular agent but simply referred to as a drug class. So what you need to be able to do is then interpret in your noggin what examples of those meds would be. So quickly calcium channel blocker most commonly used would be Amlodipine any of the Sertin drugs and thiazide diuretic either hydrochloride or chlortalidone.

Option D. Advise restricting sodium intake and uh weight loss to help with BP control. Now, here here's a really good example of a question that clearly has two correct answers. This man has a BMI of 33. Okay. Would his blood pressure be easier to control if his BMI was lower? You bet it would be. Um, cutting back. So, but but is that something that's going to happen overnight? No. That's going to take a number of months uh perhaps even years of working with him on. and uh it will also require his buy in to alter diet, physical activity etc. The other part is sodium intake restricting it even in people who have very high dietary sodium intakes doesn't lower their blood pressure all that much. It's not going to take him out of the 190 plus over 120 range. So yes, you would advise about sodium contact. you would advise about um working on achieving a healthier BMI and any of the other lifestyle modifications that are important to the treatment of high blood pressure. And again, I would never ever discourage a patient from making wise lifestyle changes or the nurse practitioner from having that dialogue with the patient. But which is going to work faster? Getting him back on his meds or talking to him about lifestyle modification? It's really clear in this situation. Option C, getting him back on his meds is the best answer. The best answer. And D is not incorrect, but it is not the best answer. 

Key takeaway: Knowing the difference between asymptomatic marketkedly elevated blood pressure and hypertensive emergency is key to safe practice. While there's a good deal of overlap between the two conditions, the clinical presentation and treatment are quite different.

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