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1. Hypertension

Presentation: Most are not symptomatic, Occipital Headaches, headache on awakening in am, blurry vision,

Assessment:

0. Asymptomatic
1. Occipital headache
2. Blurry vision
3. Headache upon wakening
4. Look for AV nicking
5. LVH

Exam:

1. Carotid bruits
2. Abdominal bruits
3. Kidney bruits

Diagnostic studies: to look for secondary causes of HTN like target organ damage and establish

ASCVD risk: EKG, fasting lipid profile, fasting blood glucose, CBC, CMP (electrolyte, creatinine, & calcium levels), and urinalysis (checking for proteinuria).

Diagnosis: Measure BP 5 minutes apart. Average of 2 or more BP readings on two different visits at > 140/90 mm Hg start then can be diagnosed with HTN.

If Stage 1 (ASCVD <10%) then non-pharmacologic management only:

• First: Lifestyle modifications: diet and exercise 30 minutes aerobic exercise 5 days per week.
• Limit alcohol
• stop smoking
• stress management.
• DASH
• Medication compliance
• Reduce sodium intake
• Measure BP daily

If Stage 2 (ASCVD >10% and known CAD) initiate lifestyle + Pharmacologic

Management:

• Alone: hydrochlorothiazide (HCTZ) 25 mg/day (chlorthalidone is preferred over HCTZ)
• Alone: lisinopril 10mg/day complicated HTN first line
• Combo: thiazide + ACE or ARB
• Alternative CB (especially in isolated HTN seen mainly in older adults)
• Black population: thiazide + CCB is recommended first line

Follow up:

• 2-4weeks

Referral:

• Cardiology if EKG is abnormal

Differential:

1. Secondary hypertension
2. Pregnant
3. Pregnancy induced hypertension

Hollier: page 62

2. Hyperlipidemia

Etiology: may be familial, dietary, obesity, hypothyroid, renal disorders, thiazide or beta blocker use, alcohol and/or caffeine intake

Presentation: few physical findings

0. Xanthomata (lipid deposits around the eyes)
1. Corneal Arcus prior to age 50 years (white iris), normal
2. Angina
3. Bruits
4. MI
5. Stroke

Diagnostics:

1. Fasting/nonfasting lipid profile (total cholesterol, LDL, and HDL minimally affected by eating)
2. Glucose,
3. UA and creatinine (for detection of nephrotic syndrome which can induce dyslipidemia),
4. TSH (for detection of hypothyroidism)

Diagnosis: Pt with LDL >= 190mg/dL

Non-pharmacologic Management:

1. Lifestyle Modification; diet and exercise.

Pharmacologic Management

Those who benefit most from statin therapy include:

• hx of CVD or stroke,
• LDL 190 or greater,
• DM with LDL 70-189,
• no evidence of ASCVD or DM but have LDL 70-189 PLUS an estimated ASCVD risk of 7% or greater

• High risk:
  • Atorvastatin 40 or 80 mg daily
  • Rosuvastatin 20 or 40 mg daily
• Moderate risk:
  • Atorvastatin 10 or 20 mg daily
  • (other statin medications also listed in Hollier)
• If statins not tolerated, temporarily stop, decrease dose, and re-challenge with 2-3 statins of differing metabolic pathways and intensities.

Follow up:

• after initiating therapy, follow-up every 6-8 weeks until goal attained then every 6-12 months to evaluate compliance
• evaluate lipids every 5 years starting at age 20 if normal values obtained

Refer: Nutritionist

Differentials: consider secondary causes

• Hypothyroidism
• Pregnancy
• Diabetes
• Non-fasting state

Hollier: page 55