1. Hypertension
Presentation: Most are not symptomatic, Occipital Headaches, headache on awakening in am,
blurry vision,
Assessment:
... [Show More] Asymptomatic
Occipital headache
Blurry vision
Headache upon wakening
Look for AV nicking
LVH
Exam:
Carotid bruits
Abdominal bruits
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:
Secondary hypertension
Pregnant
Pregnancy induced hypertension
Hollier: page 622
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
Xanthomata (lipid deposits around the eyes)
Corneal Arcus prior to age 50 years (white iris), normal
Angina
Bruits
MI
Stroke
Diagnostics:
Fasting/nonfasting lipid profile (total cholesterol, LDL, and HDL minimally
affected by eating)
Glucose,
UA and creatinine (for detection of nephrotic syndrome which can induce
dyslipidemia),
TSH (for detection of hypothyroidism)
Diagnosis: Pt with LDL >= 190mg/dL
Non-pharmacologic Management:
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:
o Atorvastatin 40 or 80 mg daily
o Rosuvastatin 20 or 40 mg daily
Moderate risk:
o Atorvastatin 10 or 20 mg daily
o (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 [Show Less]