Read Online Pocket Medicine: The Massachusetts General Hospital Handbook of Internal Medicine by Marc Sabatine - Free Book Online Page B
Authors: Marc Sabatine
Tags: Medical, Internal Medicine
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modifications (each ↓ SBP ~5 mmHg)
weight loss: goal BMI 18.5–24.9; aerobic exercise: ≥30 min exercise/d, ≥5 d/wk
diet: rich in fruits & vegetables, low in saturated & total fat (DASH, NEJM 2001;344:3)
sodium restriction: ≤2.4 g/d and ideally ≤1.5 g/d ( NEJM 2010;362:2102)
limit alcohol consumption: ≤2 drinks/d in men; ≤1 drink/d in women & lighter-wt Pts
• Pharmacologic options (if HTN or pre-HTN + diabetes or renal disease)
Pre-HTN : ARB prevents onset of HTN, no ↓ in clinical events ( NEJM 2006;354:1685)
HTN : choice of therapy controversial, concomitant disease and stage may help guide Rx
uncomplicated : thiazide if likely salt sensitive (eg, elderly, black, obese), o/w start w/ ACEI or CCB ( NEJM 2009;361:2153). bB not first line ( Lancet 2005;366:1545).
+ high-risk CAD : ACEI or ARB ( NEJM 2008;358:1547); ACEI + CCB superior to ACEI + thiazide ( NEJM 2008;359:2417) or bB + diuretic ( Lancet 2005;366:895)
+ angina : bB, CCB, nitrates
+ post-MI : ACEI, bB ± aldosterone antagonist (see “ACS”)
+ HF : ACEI/ARB, bB, diuretics, aldosterone antagonist (see “Heart Failure”)
+ 2 ° stroke prevention : ACEI ( Lancet 2001;358:1033); ? ARB ( NEJM 2008;359:1225) + diabetes mellitus : ACEI or ARB; can also consider diuretic, bB or CCB
+ chronic kidney disease : ACEI/ARB ( NEJM 1993;329:1456 & 2001;345:851 & 861)
• Tailoring therapy
if stage 1, start w/ monoRx; if not at goal, Δ to different class rather than adding 2nd agent
if stage 2, consider starting w/ combo (eg, ACEI + CCB; NEJM 2008;359:2417) as most will require ≥2 drugs; low–mod doses of 2 drugs generally preferred over max dose of 1 drug (b/c of dose-related AEs)
if resistant [= HTN despite ≥3 drugs (incl diuretic) at opt doses], consider noncompliance, volume overload, secondary causes; ? renal artery denervation ( Lancet 2010;376:1903)
• Secondary causes
Renovascular : control BP w/ diuretic + ACEI/ARB (watch for ↑ Cr w/ bilat. RAS) or CCB Atherosclerosis risk-factor modification: quit smoking, ↓ chol. If refractory HTN, recurrent flash pulm edema, worse CKD, consider revasc
For atherosclerosis: stenting ↓ restenosis vs. PTA alone, but no clear improvement in BP or renal function vs. med Rx ( NEJM 2009;361:1953; Annals 2009;150:840)
For FMD (usually more distal lesions): PTA ± bailout stenting
Renal parenchymal disease : salt and fluid restriction, ± diuretics
Endocrine etiologies : see “Adrenal Disorders”
• Pregnancy: methyldopa, labetalol, nifedipine, hydralazine; avoid diuretics; ACEI/ARB
HYPERTENSIVE CRISES
• Hypertensive emergency : ↑ BP → acute target-organ ischemia and damage
neurologic damage: encephalopathy, hemorrhagic or ischemic stroke, papilledema
cardiac damage: ACS, HF/pulmonary edema, aortic dissection
renal damage: proteinuria, hematuria, acute renal failure; scleroderma renal crisis
microangiopathic hemolytic anemia; preeclampsia-eclampsia
• Hypertensive urgency : SBP >180 or DBP >120 (?110) w/ min. or no target-organ damage Precipitants
• Progression of essential HTN ± medical noncompliance (esp. clonidine) or Δ in diet • Progression of renovascular disease; acute glomerulonephritis; scleroderma; preeclampsia • Endocrine: pheochromocytoma, Cushing’s
• Sympathomimetics: cocaine, amphetamines, MAO inhibitors + foods rich in tyramine • Cerebral injury (do not treat HTN in acute ischemic stroke unless Pt getting lysed, extreme
BP (>220/120), Ao dissection, active ischemia or HF ( Stroke 2003;34:1056)
Treatment ( Chest 2007;131:1949)
• Tailor goals to clinical context (eg, more rapid lowering for Ao dissection) • Emergency: ↓ MAP by ~25% in mins to 2 h w/ IV agents (may need arterial line for monitoring); goal DBP <110 w/in 2–6 h, as tolerated • Urgency: ↓ BP in hours using PO agents; goal normal BP in ~1–2 d • Watch UOP, Cr, mental status: may indicate a lower BP is not tolerated
AORTIC ANEURYSMS
Definitions
• True aneurysm (dilation of all 3 layers of aorta)
weight loss: goal BMI 18.5–24.9; aerobic exercise: ≥30 min exercise/d, ≥5 d/wk
diet: rich in fruits & vegetables, low in saturated & total fat (DASH, NEJM 2001;344:3)
sodium restriction: ≤2.4 g/d and ideally ≤1.5 g/d ( NEJM 2010;362:2102)
limit alcohol consumption: ≤2 drinks/d in men; ≤1 drink/d in women & lighter-wt Pts
• Pharmacologic options (if HTN or pre-HTN + diabetes or renal disease)
Pre-HTN : ARB prevents onset of HTN, no ↓ in clinical events ( NEJM 2006;354:1685)
HTN : choice of therapy controversial, concomitant disease and stage may help guide Rx
uncomplicated : thiazide if likely salt sensitive (eg, elderly, black, obese), o/w start w/ ACEI or CCB ( NEJM 2009;361:2153). bB not first line ( Lancet 2005;366:1545).
+ high-risk CAD : ACEI or ARB ( NEJM 2008;358:1547); ACEI + CCB superior to ACEI + thiazide ( NEJM 2008;359:2417) or bB + diuretic ( Lancet 2005;366:895)
+ angina : bB, CCB, nitrates
+ post-MI : ACEI, bB ± aldosterone antagonist (see “ACS”)
+ HF : ACEI/ARB, bB, diuretics, aldosterone antagonist (see “Heart Failure”)
+ 2 ° stroke prevention : ACEI ( Lancet 2001;358:1033); ? ARB ( NEJM 2008;359:1225) + diabetes mellitus : ACEI or ARB; can also consider diuretic, bB or CCB
+ chronic kidney disease : ACEI/ARB ( NEJM 1993;329:1456 & 2001;345:851 & 861)
• Tailoring therapy
if stage 1, start w/ monoRx; if not at goal, Δ to different class rather than adding 2nd agent
if stage 2, consider starting w/ combo (eg, ACEI + CCB; NEJM 2008;359:2417) as most will require ≥2 drugs; low–mod doses of 2 drugs generally preferred over max dose of 1 drug (b/c of dose-related AEs)
if resistant [= HTN despite ≥3 drugs (incl diuretic) at opt doses], consider noncompliance, volume overload, secondary causes; ? renal artery denervation ( Lancet 2010;376:1903)
• Secondary causes
Renovascular : control BP w/ diuretic + ACEI/ARB (watch for ↑ Cr w/ bilat. RAS) or CCB Atherosclerosis risk-factor modification: quit smoking, ↓ chol. If refractory HTN, recurrent flash pulm edema, worse CKD, consider revasc
For atherosclerosis: stenting ↓ restenosis vs. PTA alone, but no clear improvement in BP or renal function vs. med Rx ( NEJM 2009;361:1953; Annals 2009;150:840)
For FMD (usually more distal lesions): PTA ± bailout stenting
Renal parenchymal disease : salt and fluid restriction, ± diuretics
Endocrine etiologies : see “Adrenal Disorders”
• Pregnancy: methyldopa, labetalol, nifedipine, hydralazine; avoid diuretics; ACEI/ARB
HYPERTENSIVE CRISES
• Hypertensive emergency : ↑ BP → acute target-organ ischemia and damage
neurologic damage: encephalopathy, hemorrhagic or ischemic stroke, papilledema
cardiac damage: ACS, HF/pulmonary edema, aortic dissection
renal damage: proteinuria, hematuria, acute renal failure; scleroderma renal crisis
microangiopathic hemolytic anemia; preeclampsia-eclampsia
• Hypertensive urgency : SBP >180 or DBP >120 (?110) w/ min. or no target-organ damage Precipitants
• Progression of essential HTN ± medical noncompliance (esp. clonidine) or Δ in diet • Progression of renovascular disease; acute glomerulonephritis; scleroderma; preeclampsia • Endocrine: pheochromocytoma, Cushing’s
• Sympathomimetics: cocaine, amphetamines, MAO inhibitors + foods rich in tyramine • Cerebral injury (do not treat HTN in acute ischemic stroke unless Pt getting lysed, extreme
BP (>220/120), Ao dissection, active ischemia or HF ( Stroke 2003;34:1056)
Treatment ( Chest 2007;131:1949)
• Tailor goals to clinical context (eg, more rapid lowering for Ao dissection) • Emergency: ↓ MAP by ~25% in mins to 2 h w/ IV agents (may need arterial line for monitoring); goal DBP <110 w/in 2–6 h, as tolerated • Urgency: ↓ BP in hours using PO agents; goal normal BP in ~1–2 d • Watch UOP, Cr, mental status: may indicate a lower BP is not tolerated
AORTIC ANEURYSMS
Definitions
• True aneurysm (dilation of all 3 layers of aorta)
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