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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2866_Библиотеки_им_академика_М_И_Перельмана.pdf
326
ABPM: Ambulatory Blood Pressure Monitoring
J. Barmecha
HYPERTENSION
Continue Lifestyle Modification
Continue Lifestyle
Start Pharmacological Agents
MASKED HYPERTENSION
pharmacological agents
ASCVD Risk for starting
Modifications Assess for
progression
hypertension or
ELEVATED BP
to detect Masked
Lifestyle modification
Annual ABPM /HBPM3
Organ Damage (HMOD)
Hypertension - Mediated
Raised Office Based Blood Pressure (BP)
YES
YES
Lifestyle Modification
WHITE COAT HYPERTENSION
> 130 / 80 mmHg
or
HBPM
DAYTIME ABPM
< 130 / 80 mmHg
Annual ABPM or HBPM
NO
NO
HYPERTENSION
Lifestyle Modification
pharmacological agent (s)
HBPM: Home Blood Pressure Monitoring
Assess for ASCVD risk for starting
F . Algorithm and detection of elevated BP, masked, and white coat hypertension based on office BP, HBPM,
and ABPM
Refractory or Resistant Hypertension: Management Algorithm
Chapter 16. Hypertension
327
Refractory or Resistant Hypertension
Refractory or resistant hypertension is defined as a blood
pressure of at least 140/90mmHg or at least 130/80mmHg in
patients with diabetes or renal disease (i.e., with a creatinine
level of more than 1.5mg/dL or urinary protein excretion of
more than 300mg over a 24-h period), despite adherence to
treatment with full doses of at least three antihypertensive
medications, including a diuretic [13].
In order to diagnose refractory hypertension, various factors that needs to be considered are secondary causes of
hypertension (Table16.8), improper blood pressure measurement, volume overload, competing substances, obesity, nonadherence to treatment, inadequate doses or inappropriate
combinations of medications, alcohol consumption, and other
substances (Table16.6).
Establishing a diagnosis - Blood pressure >140/90 or 130/80 mm Hg in patients with diabetes or
chronic kidney disease and patient prescribed 3 or more antihypertensive medications at optimal doses,
including a diuretic
Is patient adherent with prescribed regimen? Obtain home, work, or ambulatory blood pressure readings
to exclude white coat effect or masked hypertension (exclude pseudoresistance)
Identify and Modify Lifestyle Factors: Obesity, Physical inactivity, Excessive alcohol consumption, high
salt low fiber diet. NSAIDS, Sympathomimetics (diet pills, decongestants), Stimulants, Oral
contraceptives or other drugs need to be evaluated and discontinued.
Evaluate Secondary Causes of Hypertension - Obstructive sleep apnea, Primary Aldosteronism, Chronic
kidney disease, Renal artery stenosis, Pheochromocytoma, Cushing’s syndrome & Coarctation of Aorta
Pharmacologic Treatment - Maximize diuretic therapy, including possible addition of mineralocorticoid
receptor antagonist, Combine agents with different mechanisms of action, Use loop diuretics in patients
with chronic kidney disease and/or patients receiving potent vasodilators (e.g. Minoxidil)
Refer to appropriate specialist for known or suspected secondary cause(s) of hypertension or refer to
hypertension specialist if blood pressure remains uncontrolled after 6 months of treatment
328
J. Barmecha
T . Classication of hypertension in adults
Primary (essential benign or idiopathic)
Secondary
Renal
Parenchymal diseases
Vascular (renal artery stenosis)
Tumors (renin producing)
Adrenal
Cushing’s disease
Primary aldosteronism
Pheochromocytoma
Endocrine
Hypothyroidism
Hyperthyroidism
Acromegaly
Carcinoid tumors
Vascular
Coarctation of aorta
Aortic regurgitation
Medications
Oral contraceptives
Erythropoietin
NSAIDS
Corticosteroids
Cyclosporine
Chapter 16. Hypertension
T . (continued)
Miscellaneous
Pregnancy
Perioperative period
Alcohol withdrawal
Obstructive sleep apnea
Caffeine
Nicotine
329
Role ofDigital Health inHypertension
Digital health innovations for hypertension include blood
pressure sensors (cuffless monitors), smartphone-enabled
upper arm blood pressure monitors, mobile applications, and
remote monitoring technologies. Wearable trackers have the
potential to improve hypertension control and medication
adherence through real-time capture of clinical data, better
connectivity with health care providers and medication
reminder alerts. With increasing emphasis on home and
ambulatory blood pressure monitoring to confirm hypertension prior to treatment, such devices also can help improve
the diagnostic and treatment paradigm.
For wider adoption, device manufacturers and clinical
researchers should collaborate on the development of clinical
trials and evidence based guidelines for better clinical outcomes associated with emerging technologies.
Clinical Pearls
• Hypertension in its early stages is an asymptomatic pro-
cess and has no clinical manifestations.
• Hypertension is preventable and an independent risk fac-
tor for end organ damage: myocardial infraction, stroke,
heart failure, retinopathy, peripheral arterial disease, and
end-stage renal disease (hypertension-mediated organ
damage―HMOD).
330
J. Barmecha
• Social determinants and behavioral factors play an impor-
tant role in the development of hypertension and its
related complications.
• Lifestyle management including diet and physical activity
are an integral part of blood pressure control along with
pharmacological interventions.
• Adequate screening and control of blood pressure is an
important clinical quality measure.
Don’t Miss This!
• Hypertension can be either isolated systolic or diastolic or
both systolic and diastolic.
• Secondary causes of hypertension should be assessed in
patients with resistant hypertension.
• Ambulatory blood pressure monitoring (ABPM) is a use-
ful tool in the management of hypertension.
• All antihypertensive medications have serious side
effects especially ACE inhibitors, ARBs (angiotensin
receptor blocker), and renin inhibitors that can cause
fetal abnormalities and should be avoided in women of
childbearing age.
• While prescribing pharmacological agents, one should
consider associated medical illnesses and patient’s prefer-
ences including cost of the medications.
References
1. Centers for Disease Control and Prevention, National Center
for Health Statistics. National health and nutrition examination
survey (NHANES) public use data files. https://www.cdc.gov/
nchs/nhanes/. Accessed 21 Nov 2021.
2. Virani SS, et al. Heart disease and stroke statistics (2021):
a report from the American Heart Association. Circulation.
2021;143:e254–e74.
3. Kaplan N, Victor RG. Kaplan’s clinical hypertension. 11th ed;
2015.
4. Whelton PK, etal. 2018 guideline for the prevention, detection,
evaluation, and Management of High Blood Pressure in adults:
Chapter 16. Hypertension
a report of the American College of Cardiology/American
Heart Association task force on clinical practice guidelines.
Hypertension. 2018;71(19):e127–248.
5. Unger T, et al. International Society of Hypertension
Global Hypertension Practice Guidelines. Hypertension.
2020;2020(75):1334–57.
6. https://www.mdcalc.com/framingham- risk- score- hard- coronary-
heart- disease. Accessed 27 Dec 2021.
7. Jones DW, etal. Management of Stage 1 hypertension in adults
with a low 10-year risk for cardiovascular disease: filling a
guidance gap: a scientific statement from the American Heart
Association. Hypertension. 2021;77:e58–67.
8. Eckel RH, Ard JD, etal. 2013 AHA/ACC guideline on lifestyle
management to reduce cardiovascular risk: a report of the
American College of Cardiology/American Heart Association
task force on practice guidelines. Circulation. 2014;129(25 Suppl
2):S76–99. Erratum in Circulation. 2015 Jan 27;131 (4):e326
9. www.dashforhealth.com. Accessed 27 Dec 2021.
10. James PA, Oparil S, Carter BL, etal. 2014 evidence-based guideline for the management of high blood pressure in adults: report
from the panel members appointed to the eighth joint National
Committee (JNC 8) [published correction appears in JAMA.
2014;311(17):1809]. JAMA. 2014;311(5):507–20.
11. Pickering TG, Shimbo D, Haas D. Ambulatory blood-pressure
monitoring. N Engl J Med. 2006;2006(354):2368–74.
12. https://www.validatebp.org. Accessed 20 Dec 2021.
13. Moser M, Setaro JF.Resistant or difficult–to–control hypertension. N Engl J Med. 2016;2006(355):385–92.
331
Chapter 17
Chest Pain
AdarshKatamreddy
Chest Pain
Chest pain is a common clinical presentation encountered in
the outpatient setting [1]. A systematic approach is required
for timely diagnosis and management. The etiology for chest
pain ranges from benign to potentially life-threatening causes
[2]. Early identification of life-threatening causes and triaging
to a higher level of care from an office setting is vital. In this
chapter, we will review essential history, physical exam, and
diagnosis strategies in the ambulatory setting. Chest pain is
anxiety provoking in patients. Therefore, in addition to making the diagnosis, alleviating the patient’s anxiety for benign
causes of chest pain is essential.
History
Eliciting an accurate history is a crucial first step in making
an accurate diagnosis. Using an open-ended style of questioning gives important clues about the underlying etiology. “Can
A. Katamreddy (*)
Internal Medicine, Jacobi Medical Center/Albert Einstein College
of Medicine, Bronx, NY, USA
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2022
E. Sydney et al. (eds.), Handbook of Outpatient Medicine,
https://doi.org/10.1007/978-3-031-15353-2_17
333
334
A. Katamreddy
you tell me more about the pain?” should be the first question. Then, teasing out further details regarding the onset,
duration, precipitating factors, character, radiation, association with food, exertion, respiration, any history of similar
pain, and the relation of pain to the movement of the upper
extremities and neck are significant to note. After trying
open-ended questioning, close-ended questions can be used
to further clarify the diagnosis.
Past medical history of cardiovascular risk factors including diabetes, hypertension, hyperlipidemia, chronic inflammatory conditions, and surgical history of cardiac procedures
increases the likelihood of coronary artery disease. In addition, smoking and cocaine use history and family history of
cardiac disease should also be reviewed.
Physical Exam
Blood pressure, heart rate, temperature, and respiratory rate
provide crucial diagnostic information. Jugular venous distention, examination of bilateral pulses, cardiopulmonary
auscultation, and assessment of pedal edema are important.
Inspection of the skin of the chest, palpation of the chest wall
for tenderness, and active movements of the neck and both
upper extremities should be performed based on the elicited
history.
Differential Diagnosis
The causes can be broadly divided into:
1. Cardiac chest pain (Fig.17. 1 )
2. Non-cardiac chest pain (Fig.1 7. 2 )
The clinical features of various chest pain presentations
are presented below.
Chapter 17. Chest Pain
Cardiac Chest
pain
335
Acute
Acute coronary
syndrome
ST elevantion MI
Non ST elevation
MI
Unstable angina
Acute
pericarditis
F . Cardiac chest pain causes
Chronic/ episodic
Aortic stenosis
Chronic
pericarditis
Chronic stable
angina
Mitral valve
prolapse
336
A. Katamreddy
F . Noncardiac chest pain
causes
Non cardiac Chest
Potentially life
threating
Aortic dissection
Pneumothorax
Pulmonary
embolism
Esophageal rupture
pain
Potentially non life
threating
Herpes zoster
Muscular chest pain
Cervical angina
Rib fracture
Pleurtic chest pain
Gastroesophageal
reflux disease
Esophageal spasm
Costochondritis