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Hypertension in a 35-year-old man
« on: /November/ 10, 2005, 04:10:57 PM »

A 35-year-old man presented with with elevated blood pressure (188/112, seated) at a yearly physical exam. Previous exams noted blood pressures of 160/94 and 158/92. On questioning, he admitted episodes about twice a month of apprehension, severe headache, perspiration, rapid heartbeat, and facial pallor. These episodes had an abrupt onset and lasted 10-15 minutes.

Physical Exam
30 min after the initial blood pressure measurement, the seated blood pressure was 178/110 with a heart rate of 90. The blood pressure after 3 min of standing was 152/94 with a heart rate of 112. The optic fundi showed moderately narrowed arterioles with no hemorrhages or exudates.

Initial lab studies
Routine hematology and chemistry studies were within the reference ranges and a chest film and EKG were essentially normal.


How would you assess this patient's presentation?

First,this is a relatively young patient presenting with severe hypertension. He has several additional findings that are consistent with catecholamine excess:
1.A rapid heart rate
2.Narrowing of the vessels of the optic fundi (indicative of vasoconstriction)
3.A significant drop in blood pressure (but remaining hypertensive) on standing? why?

Catecholamine-mediated vasoconstriction is one of the mechanisms that helps maintain blood pressure on standing. This patient may be so vasoconstricted at rest that the circulatory system has trouble compensating for changes in position, thus the blood pressure drops when he stands up.

Second, the patient reports periodic episodes that suggest bursts of catecholamine release. In a patient of this age with this history, a catecholamine-producing tumor is a serious consideration.

---> A 24-hour urine specimen was collected for analysis of catecholamines and catecholamine metabolites. Plasma catecholamines were also assayed.

? ? ?? ?? ? ? ? ? ? ? ? ? ? ?? ? ? ? ? ? ? ? ? ?? ? ?? ? ??Patient? ? ? ?Reference
Norepinephrine, Free (24 hr U)? ? ? ? ? ? ? 1800 ug? ? ? ?15 - 80
Epinephrine, Free (24 hr U)? ? ? ? ? ? ? ? ? ?100 ug? ? ? ? 0 - 20
Vanillylmandelic acid (VMA, 24 hr U)? ? ?? 12.5 mg? ? ? ? ?2 - 7
Metanephrines (24 hr U)? ? ? ? ? ? ? ? ? ? ? ?2.5 mg? ? ? ? ? <1.0

Catecholamines (P)
? ? Norepinephrine? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ?2500 pg/ml? 174 - 624
? ? Epinephrine? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ?85 pg/ml? ? 0 - 114
? ?
(U = urine, P = plasma)

What do you see in these labs?

- Urinary catecholamines and catecholamine metabolites are all elevated.
- Plasma norepinephrine is markedly elevated, but epinephrine is within the normal range. (does it really matter?!)

>> Be aware that catecholamine secretion by pheochromocytomas is episodic, and different results might be obtained from a sample drawn half an hour later. The urinary free catecholamines are probably the best test for pheochromocytoma because they essentially measure output over time.

>>Note that more tests were done than were really needed for diagnosis in this case--the urinary free catecholamines alone would have been sufficient.

-A CT scan of the adrenals revealed an 8 cm mass on the left side.
-The patient was treated with alpha and beta blockers (catecholamine receptor blocking agents) for several weeks and had no further paroxysms during that time. His blood pressure declined to 110/78.
-He then underwent abdominal surgery with removal of 250 g pheochromocytoma.


It is important to make this diagnosis for several reasons.

1.This is a curable form of hypertension in relatively young people. If the tumor is removed and the hypertension is terminated before too long, they can be spared the vascular disease that accompanies long-term hypertension.
2.Furthermore, pheochromocytomas may metastasize after a period of time (about 10% do). Early recognition and removal can be curative of the tumor as well as the hypertension.

>>> In this patient, the elevated epinephrine in the urine indicated that the tumor was located in the adrenal medulla. Similar tumors may be located outside the adrenal gland. When they are, they are called extra-adrenal paragangliomas rather than pheochromocytomas, and they produce norepinephrine but not epinephrine.? ( so it really matters? ?Smiley? )


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Secondary hypertension
« Reply #1 on: /November/ 13, 2005, 07:58:55 AM »

We see a lot of cases of hypertension , management is simple (life style modification & medications) in most cases. Treatment in this case will be given forever (essential hypertension isn't curable). This is OK for essential hypertension (95% of cases) but what if there is a cause? and this is secondary hypertension , we must identify the cause and treat it , this will cure hypertension and will prevent complications from the cause.

Essential hypertension represents most of the cases (95%) , so when to suspect secondary hypertension then search for a cause later? (3 main points)
1. Hypertension starting at age >55 or <25. (age of onset of essential is 25-55).
2. Assosiated symptoms/ signs / lab suggestive of a secondry cause. (see below). Our patient here had symptoms of pheochromocytoma.
3. Hypertension refractory to treatment.

> (also the abrupt onset of severe hypertension is suggestive of secondry cause)

> If any one is present , suspect and exclude secondary hypertension. Use the simple approach below.

Harrison's manual says that the following investigations should be done in any case of hypertension as screening for a cause:

(1) serum creatinine, BUN, and urinalysis (renal parenchymal disease);
(2) serum K measured off diuretics (hypokalemia prompts workup for hyperaldosteronism or renal artery stenosis);
(3) CXR (rib notching or indentation of distal aortic arch in coarctation of the aorta); (4) ECG (LV hypertrophy suggests chronicity of hypertension);
(5) other useful screening blood tests include CBC, glucose, cholesterol, triglycerides, calcium, uric acid.

This is a hint about most common causes of secondary hypertension:

-RENAL ARTERY STENOSIS? ?Due either to atherosclerosis (older men) or fibromuscular dysplasia (young women). Presents with sudden onset of hypertension, refractory to usual antihypertensive therapy. Abdominal bruit often audible; mild hypokalemia due to activation of the renin-angiotensin-aldosterone system may be present.

-RENAL PARENCHYMAL DISEASE? ?Elevated serum creatinine and/or abnormal urinalysis, containing protein, cells, or casts.

-COARCTATION OF AORTA? ?Presents in children or young adults; constriction is usually present in aorta at origin of left subclavian artery. Exam shows diminished, delayed femoral pulsations; late systolic murmur loudest over the midback. CXR shows indentation of the aorta at the level of the coarctation and rib notching (due to development of collateral arterial flow).

-PHEOCHROMOCYTOMA? ?A catecholamine-secreting tumor, typically of the adrenal medulla, that presents as paroxysmal or sustained hypertension in young to middle-aged pts. Sudden episodes of headache, palpitations, and profuse diaphoresis are common. Associated findings include chronic weight loss, orthostatic hypotension, and impaired glucose tolerance. Pheochromocytomas may be localized to the bladder wall and may present with micturition- associated symptoms of catecholamine excess. Diagnosis is suggested by elevated urinary catecholamine metabolites in a 24-h urine collection; the tumor is then localized by CT scan or angiography.

-HYPERALDOSTERONISM? ?Due to aldosterone-secreting adenoma or bilateral adrenal hyperplasia. Should be suspected when hypokalemia is present in a hypertensive pt off diuretics

-OTHER CAUSES? ?Oral contraceptive usage, Cushing's and adrenogenital syndromes ,thyroid disease, hyperparathyroidism, and acromegaly.

This is a simple approach? to patient with suspected secondary hypertension:

A] History

Most pts are asymptomatic. Severe hypertension may lead to headache, epistaxis, or blurred vision.

Clues to Specific Forms of Secondary Hypertension? ?Use of birth control pills or glucocorticoids; paroxysms of headache, sweating, or tachycardia (pheochromocytoma); history of renal disease or abdominal traumas (renal hypertension).

B] Physical Examination

-Measure bp with appropriate-sized cuff (large cuff for large arm).
-Measure bp in both arms as well as a leg (to evaluate for coarctation).
-Signs of hypertension include retinal arteriolar changes (narrowing/nicking); left ventricular lift, loud A2, S4.
> Clues to secondary forms of hypertension include cushingoid appearance, thyromegaly, abdominal bruit (renal artery stenosis), delayed femoral pulses (coarctation of aorta).

C] Laboratory Workup

1. Screening Tests for Secondary? Huh

2. Further Workup? ?(Indicated for specific diagnoses if screening tests are abnormal or bp is refractory to antihypertensive therapy):

(1) renal artery stenosis: magnetic resonance angiography, captopril renogram, renal duplex ultrasound, digital subtraction angiography, renal arteriography, and measurement of renal vein renin;
(2) Cushing's syndrome: dexamethasone suppression test
(3) pheochromocytoma: 24-h urine collection for catecholamines, metanephrines, and vanillylmandelic acid;
(4) primary hyperaldosteronism: depressed plasma renin activity and hypersecretion of aldosterone, both of which fail to change with volume expansion;
(5) renal parenchymal disease (according to suspected condition)

« Last Edit: /November/ 30, 2005, 07:08:04 AM by dr_b.e.s.m » Logged
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« Reply #2 on: /November/ 13, 2005, 01:08:48 PM »

Pseudohypertension is a condition seen almost exclusively in the elderly population. It is the result of calcification and loss of elasticity of the peripheral arteries, which cause patients to have falsely high readings when blood pressure is measured with a cuff.

In 1892, Osler noted that such patients have a palpable radial pulse even when the cuff is inflated above the systolic pressure. This means of screening for pseudohypertension, referred to as the Osler maneuver, became widely advocated. However, studies have shown it to be unreliable in identifying patients with pseudohypertension, which seems to be a primarily diastolic phenomenon.

? In pseudohypertension, cuff measurements of blood pressure underestimate the systolic pressure and overestimate the diastolic pressure. Hence, even in patients with pseudohypertension, the mean arterial pressure measured by cuff usually correlates well with the mean arterial pressure measured intra-arterially.

Some preliminary data suggest that blood pressure measurements in the fingers are accurate in patients with pseudohypertension, because these arterioles are not as prone to atherosclerosis as the larger arteries, such as the brachial artery, which is used to auscultate the Korotkoff sounds .

Pseudohypertension should be suspected in patients with significantly elevated blood pressure readings in both clinical and home settings but no target-organ damage, or in patients who are taking medication and who have significant orthostasis and symptoms of dizziness despite high blood pressure readings.

As there are currently no reliable noninvasive screening measures available, intra-arterial monitoring may be necessary to make a definitive diagnosis.
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ISH !!
« Reply #3 on: /November/ 16, 2005, 06:43:34 AM »

A colleague asks your advice on management of blood pressure (170/70 mmHg) in a 78-year-old woman with a history of stroke. Elevated blood pressure measurements are repeatedly confirmed at examinations done by your colleague and by clinic nurses. The patient is asymptomatic.

This is a common condition , can you diagnose it ?!


Because this patient shows evidence of end organ damage caused by hypertension, she is unlikely to have "pseudohypertension," a condition in which a discrepancy exists between blood pressure measurements obtained using indirect methods (such as with a sphygmomanometer) and direct intraarterial measurements.

In addition, this patient is unlikely to have "white coat hypertension" (a condition commonly seen among older patients), because similar blood pressure readings were obtained by different clinical personnel.

This patient appears to have ISH.? [Isolated Systolic Hypertension] = Systolic blood pressure > 160 mmHg with diastolic blood pressure <90-95 mmHg (more usually <90 mm Hg).

Pathophysiology: Rigidity and loss of elasticity of large arteries due to aging +/ - atherosclerosis exaggerates the systolic peak in pressure and the lack of elastic recoil in diastole reduces diastolic pressure. This results in a wide pulse pressure and increasing impedance to left ventricular ejection, which leads to increasing hypertrophy (LVH) and increasing shear stress in arteries.
>> The circulation is increasingly sensitive to sodium and fluid loading, with exaggerated and more rapid diuresis in response.
(Very important in treatment)

Treatment of Isolated Systolic Hypertension in Older Adults

Several large randomized controlled trials have documented that treatment of ISH in older adults results in reduction in incidence of stroke, coronary heart disease events, and vascular causes of deaths. (so it must be treated , unlike the old concept saying that no need for treatment as it's a normal aging process) also don't say diastolic is more important and it's normal so no treatment , I read that systolic blood pressure is the most important determinant of cardiovascular risk in people > 50 years old , this is proved by studies! So it MUST be treated.


Generally Applicable Treatment Suggestion

1: Lifestyle Modification

Because this patient is currently asymptomatic and may be taking other medications, a reasonable initial approach is to advise nondrug lifestyle modifications to lower blood pressure. Recently, the Trial of Nonpharmacologic Interventions in the Elderly (TONE) Study showed that rigorous sodium restriction (ie, limiting sodium intake to 80 mEq/day, or 1.8 g of sodium/day) and weight reduction (by about 3.5 kg/week) eliminated both recurrent hypertension and medication use in 44% of obese elderly patients, compared with 16% of the control population at 30 months.

In contrast to younger patients, older subjects tend to have a greater decrease in blood pressure in response to sodium restriction, a response suggesting that hypertension in older patients has a clinically significant volume-dependent component.

In addition to sodium restriction, moderate and graded aerobic exercise, smoking cessation, and limited alcohol intake all have beneficial effects on blood pressure.

Nonsteroidal anti-inflammatory drugs (NSAIDs), commonly used by older adults, induce sodium retention and adversely affect blood pressure.

In contrast, postmenopausal hormone replacement therapy rarely influences resting blood pressure.

2: Medical Therapy

Several randomized controlled studies6 of elderly patients with ISH have shown that compared with placebo, medical treatment reduces rates of stroke, cardiovascular events, and cardiovascular mortality without causing major adverse effects.
- However, owing to diminished hepatic metabolism, reduced renal excretion, and decreased volume of distribution, elderly patients are more sensitive to medications than are younger patients.
- Moreover, incidence of orthostatic hypotension is higher in older patients because of autonomic dysfunction and enhanced venous pooling.

For these reasons, any antihypertensive medical therapy should be initiated cautiously, and the patient must be carefully monitored.

Which antihypertensives to use?

1- For ISH, small doses of diuretics (such as hydrochlorothiazide 12.5 mg a day) or fixed-dose combinations with a potassium-sparing diuretic may be sufficient. Hypokalemia should be avoided.
2- lternatively, long-acting dihydropyridine calcium channel blockers (eg, nifedipine, felodipine, or amlodipine) have been beneficial.
3- For patients with concurrent illness (eg, previous myocardial infarction, diabetes mellitus, or angina), beta- blockers, angiotensin-converting enzyme (ACE) inhibitors, or nitrates have been successfully used.

>> So the two main medications in ISH are D & C.? ?Diuretics & Calcium channel blockers .

Specific Treatment Suggestions in this patient

-A trial of sodium restriction may be attempted.
-She should be asked about NSAID use; if she is taking these drugs, she should stop or minimize the dose.
-If her blood pressure remains elevated despite sodium restriction, a small dose of hydrochlorothiazide (12.5 mg/day) or a fixed-dose combination with a potassium-sparing diuretic would be reasonable treatment. Care should be taken to avoid hypokalemia or thiazide-induced hyponatremia, to which elderly women in particular are prone.
-A long-acting dihydropyridine calcium channel blocker may be added later.

> Orthostatic hypotension must be avoided; therefore, to determine therapeutic effect, blood pressure should be measured with the patient standing instead of sitting.

> Because of this patient's history of stroke, treatment consisting of lipid management and low-dose aspirin therapy is advised.
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Essential hypertension - Guidelines
« Reply #4 on: /November/ 18, 2005, 03:47:41 PM »

You are in an out patient clinic and you see a lot of patients with essential hypertension.

How to manage?

Which drug to start with ? or life style modification is enough now?

What's life style modification?

What are the common mistakes while measuring blood pressure?

What's your target BP?

This patient has co morbidity , will this affect our drug choice?

When to shift to another drug? When to use combination?

These tables are simple guidelines for management of primary hypertension. Hope they are useful insha`allah.

* a.JPG (58.3 KB - downloaded 51 times.)
« Last Edit: /November/ 18, 2005, 03:50:08 PM by dr_b.e.s.m » Logged
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Essential hypertension - Guidelines
« Reply #5 on: /November/ 18, 2005, 03:52:25 PM »

Choice of anti hypertensive according to co morbidity:

* b.JPG (94.3 KB - downloaded 52 times.)
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Essential hypertension - Guidelines
« Reply #6 on: /November/ 18, 2005, 03:53:41 PM »

Flow chart:

* c.JPG (94.54 KB - downloaded 57 times.)
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Re: Hypertension in a 35-year-old man
« Reply #7 on: /November/ 30, 2005, 05:19:34 AM »

thanks for this useful information Wink
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Re: Hypertension in a 35-year-old man
« Reply #8 on: /November/ 30, 2005, 06:37:09 AM »

You are welcome , hard_way. Hope this info is really useful insha`allah.
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More about antihypertensive medications!
« Reply #9 on: /November/ 30, 2005, 07:04:41 AM »


1. Start with a low dose of an agent and, if blood pressure is not controlled, increase only moderately. [Except for those patients with severe hypertension (average diastolic blood pressure>130 mmHg), in whom intensive therapy with several agents simultaneously is usually required, most patients are treated initially with a single agent.]

2. Start with an agent that may also treat and/or not harm a coexisting condition.

3. Add a second agent from a different, complementary class if blood pressure is not controlled with a moderate dose of the first agent.? When used in combination, drugs are chosen for their different sites of action.

4. Start with an agent that the patient is likely to tolerate best; long-term compliance is related to tolerability and efficacy of the first agent used.

5. Use a diuretic when two agents are used, in nearly all cases.

6. Use thiazide diuretics only at low doses, i.e., 25 mg/d of hydrochlorothiazide or its equivalent, unless some pressing reason exists.

7. Use low-dose combination therapy when appropriate as initial therapy:

a. A diuretic with a beta blocker, ACE inhibitor, or angiotensin II antagonist;

b. A calcium channel blocker with an ACE inhibitor or a beta blocker

8. One or two agents will control blood pressure in 90% of hypertensive patients; to achieve a diastolic blood pressure of <90 mmHg in the HOTstudy, two agents were required in 70% of cases.

- If therapy with two drugs does not achieve blood pressure control, the primary agent should be increased to full dose, e.g., 100 mg of captopril or atenolol, 20 mg of enalapril, or 360 mg of diltiazem.

- If the blood pressure is still not controlled, then a detailed search for a secondary cause of hypertension, as outlined above, is indicated.

- If none is found, then a dietary assessment will often reveal a high sodium intake. With reduction in salt intake to 5 g/d or less, blood pressure is often controlled.

- If the blood pressure is still not controlled, then the primary agent should be switched, maintaining the thiazide. Caution should be used if anACEinhibitor was not the original agent, as administration of such an agent to a patient who is already taking a diuretic occasionally may lead to profound hypotension.

- If none of these changes produces better control of arterial pressure, then the combination of a calcium channel antagonist and an ACE inhibitor, or triple therapy, usually with a diuretic, ACE inhibitor, and hydralazine, may be effective.

- If the blood pressure is controlled, then a stepwise reduction in the dose and/or withdrawal of some of the agents should be carried out to determine the minimal therapeutic program that will maintain the blood pressure at 140/90 mmHg or less. Whether triple or quadruple drug therapy is warranted to lower blood pressure further is uncertain.

- Fewer than 5% of patients will still be hypertensive at this point. For these, one first should consider the reasons for therapeutic failure.

- If none can be identified, then one of the other agents, such as one of the vasodilators (e.g., hydralazine) or an antiadrenergic agent (e.g., prazosin or clonidine), should be added. If blood pressure is controlled, previous drugs are withdrawn sequentially to determine the minimal therapeutic program that will maintain a normal blood pressure.

>> While the recommendations outlined above are satisfactory for a large majority of patients, it is important to use a flexible approach, because individual patients may respond differently to individual drugs and drug combinations. For those patients requiring multiple drugs, once the appropriate combination has been found, the use of a single formulation with the appropriate combination of drugs may simplify the regimen and thereby increase compliance. Every effort should be made to reduce the number of times each day the patients must interrupt their schedules for the medication. Pharmacologic treatment of essential hypertension is usually lifelong, and since most patients are asymptomatic, compliance with a complex regimen may be a serious problem, particularly if the therapeutic regimen has a negative impact on the quality of the patient's life.
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« Reply #10 on: /November/ 30, 2005, 07:43:38 AM »

1. Diagnose hypertension (2 or more abnormal readings)

2. Exclude white coat hypertension & pseudohypertension

3. If possible, order creat, K, ECG, CXR.
4. Is there anything suggestive of secondry hypertension? If yes, proceed.

5. This is essential hypertesnion. Proceed.

By the way, we said that in order to diagnose hypertension , we need 2 or more abnormal readings. Can one reading be enough?

If very high (> 210/120) or if accompanied by target organ damage.

« Last Edit: /November/ 30, 2005, 01:26:47 PM by dr_b.e.s.m » Logged
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Hypertension - short cases.
« Reply #11 on: /February/ 14, 2006, 09:46:15 AM »

Hypertension - short cases.

There are short cases, we can try to apply the info I posted before in the management of the cases. It'll be like a simulation for the real practice, and you can imagine how many cases of hypertension you'll see everyday! The point is to that the management must be based on scientific basis.

Another point is that I don't have the answer of these cases, all what we can do is discussion as if they are real patients. I think it'll be interesting.



? All blood pressure readings presented in the case studies have been documented on at least two occasions and represent bona fide measurements sufficient to trigger intervention (when elevated)? ?

? Assume that attempts at nonpharmacologic intervention (dietary modifications, smoking cessation, weight loss, exercise, etc.) and other lifestyle modifications are being implemented concurrently with drug-based therapy.?

 ? In the case studies that follow, there may not always be a single preferable approach, and other options not discussed by the experts may also be appropriate.

? So as not to be confused, we can use this approach in every case:?


Case (1) :

A 36-year old white male, previously in good health, in two separate office visits, has a documented BP of 135/85.

Clinical Approach and Issues:

1-What are the options for initial management of his elevated blood pressure?

2-Should a single agent be employed for a blood pressure of this magnitude?

« Last Edit: /February/ 22, 2006, 06:33:28 AM by dr_b.e.s.m » Logged
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Re: Hypertension in a 35-year-old man
« Reply #12 on: /February/ 22, 2006, 07:14:11 AM »

A 36-year old white male, previously in good health, in two separate office visits, has a documented BP of 135/85.

First question is what's the diagnosis? is it hypertension? Which class? Or prehypertension? Or normal/ high normal?

This table will answer this question:

so the answer is : pre hypertension.

Next question: what to do for him?

Read these guidelines and let's see which one applies here:

"Prehypertension is defined as a BP of 120?139/80?89. In these patients with no more than one cardiovascular risk factor, excluding diabetes mellitus, and no target organ damage, BP can be followed for up to 6 months with nonpharmacologic therapy. If treatment is ineffective or the patient has evidence of end-organ damage or diabetes, or both, pharmacologic therapy should be initiated. Lifestyle modifications should be encouraged. "

So what do you think?

Is there target organ damage? Heart Diseases(LVH? Angina/prior MI? Heart Failure) ? Stroke or TIA ? Nephropathy ? Peripheral Arterial Disease ? Hypertensive Retinopathy.

Nothing mentioned? ?(and we can do the investigations we need to exclude any damage, eg. ECG, fundus exam, may be urine analysis).

How many cardiac risk factors? And what are the cardiac risk factors?

? Smoking
? Dyslipidemia
? Diabetes mellitus (considered a separate item anyway)
? Age > 60 years
? Gender:
? Men (he's male!)
? Postmenopausal women
? Family History:
? Women < age 65
? Men < age 55

Only one risk factor (being male!) and nothing else is mentioned, wanna order lipid profile? Go on, I think it's right.

What about DM? no (and here also we can order blood sugar lever to exclude it)

---->>? ? No DM , no organ damage , only one risk factor in a patient with pre hypertension so all what we need to do is non pharmacologic therapy + regular follow up for 6 months. If controlled then nothing more is needed, if still elevated then we should start pharmacologic therapy.

What's the nonpharmacologic therapy ?
? Quit smoking to reduce cardiovascular risk.
? Lose weight, if needed.
? Restrict sodium intake to no more than 2 Gms per day.
? Limit alcohol intake to no more than 1-2 drinks per day.
? Get at least 30-45 minutes of aerobic activity on most days.

Simply: smoking, weight loss, exercise, Na in diet.

This isn't an answer I already have, I just wrote it based on what I've read, so please if you have any comments, post them. Also if you have a different treatment plan, we'd like to know it.

« Last Edit: /February/ 22, 2006, 01:24:12 PM by dr_b.e.s.m » Logged
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Re: Hypertension in a 35-year-old man
« Reply #13 on: /March/ 21, 2006, 01:11:00 PM »

thank you dr baha  Wink,god bless you  Wink ,your topic is more than excellent Wink
plz is there diff ( ) border line and labile hypert,or they one thing?
is there is isolated diastolic hypert ?
thank u Smiley
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