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Hypertension

Rationale

As many as 50 million Americans have elevated blood pressure (systolic pressure 140 mmHg or greater and/or diastolic blood pressure 90 mmHg or greater) or are taking antihypertensive medication. Nonfatal and fatal cardiovascular disease (CVD)- including coronary heart disease (CHD) and stroke- as well as renal disease, increase progressively with higher levels of both systolic (SBP) and diastolic (DBP) blood pressure levels. These relationships are strong, continuous, independent, predictive and etiologically significant, and indicate that reduction of blood pressure reduces these risks.

Prerequisites

Prior knowledge, skills and attitudes acquired during the pre-clinical (basic science) years should include:

  1. Pathogenesis and pathophysiology of hypertension
  2. Epidemiology and risk factors of hypertension
  3. Pharmacological management of acute and chronic hypertension
  4. Ability to elicit a medical history and perform a complete physical exam
  5. Understand the behavioral issues by sex, race, culture, and age that relate to the management and treatment of hypertension

Specific Learning Objectives

  1. Knowledge: Students should be able to define and describe:
    1. identify the etiologies and relative prevalence of primary and secondary
      hypertension
    2. define hypertensive urgency and emergency, citing examples of both
    3. describe signs and symptoms of the following presenting disorders associated with secondary hypertension:
      1. polycystic kidneys
      2. renovascular hypertension
      3. Cushing’s disease or syndrome
      4. pheochromocytoma
    4. define and describe the manifestations of target-organ disease due to hypertension
    5. define the classification of blood pressure (systolic blood pressure (SBP), diastolic blood pressure (DBP)) for all age 18 or older (young adult, middle age, and the elderly)
    6. describe basic approaches to the pharmacological management of acute and chronic hypertension, including the physiologic basis and scientific evidence supporting these approaches, and causes for lack of responsiveness to therapy
    7. describe the prevention strategies for reducing hypertension (including lifestyle factors, dietary intake of sodium, weight, and exercise level), and explain the physiologic basis and/or scientific evidence supporting each strategy
    8. describe steps in a critical pathway for management of patients with a hypertensive emergency
  2. Skills: Students should demonstrate specific skills including:
    1. history-taking skills: Students should be able to obtain, document and present an age-appropriate medical history, that differentiates among etiologies of disease including:
      1. duration and levels of elevated blood pressure
      2. history of symptoms of cardiovascular, cerebrovascular, or renal disease; diabetes; dyslipidemia; or gout
      3. history of symptoms suggesting secondary hypertension (see knowledge section, A:3)
      4. history of weight gain, leisure-time physical activities, smoking or other tobacco use
      5. family history of high blood pressure, premature CHD, stroke, CVD, diabetes mellitus and dyslipidemia
      6. psychosocial and environmental factors that may elevate blood pressure (family situation, employment status, working conditions, education level)
      7. dietary assessment including sodium intake, alcohol use and intake of saturated fat and cholesterol
      8. results and side effects of previous antihypertensive therapy
      9. use of commonly prescribed, over-the -counter, and illicit medications that may raise blood pressure or interfere with the effectiveness of antihypertensive medications
    2. physical exam skills: Students should be able to perform a physical exam to establish the diagnosis and severity of disease, including:
      1. blood pressure measurements to detect and confirm the presence of high blood pressure
      2. examination of the fundus for arteriolar narrowing, arteriovenous nicking, hemorrhages, exudates or papilledema
      3. neck for carotid bruits, distended veins or an enlarged thyroid gland
      4. heart for increased rate, increased size, precordial heave, clicks, murmurs, arrhythmias, and third(S3) and fourth (S4) sounds
      5. abdomen for bruits, enlarged kidneys, masses, and abnormal aortic pulsation
      6. extremities for diminished, delayed, or absent peripheral arterial pulsations, bruits, and edema
      7. peripheral pulses specifically femoral arterial pulses
      8. body habitus, looking for changes associated with secondary hypertension
      9. peripheral and central nervous system for ischemic changes
    3. differential diagnosis: Generate a prioritized differential diagnosis recognizing specific history and physical exam findings that suggest a specific etiology.
    4. laboratory interpretation: Students should be able to recommend and interpret diagnostic and laboratory tests, both prior to and after initiating treatment based on the differential diagnosis, including consideration of test cost and performance characteristics as well as patient preferences
      1. laboratory and diagnostic tests should include, when appropriate:
        • urinalysis
        • complete blood count
        • blood glucose (fasting if possible)
        • potassium
        • calcium
        • creatinine
        • uric acid
        • cholesterol, HDL, LDL, and triglycerides
        • electrocardiography
    5. communication skills: Students should be able to:
      1. communicate the diagnosis, treatment plan and prognosis of the disease to patients and their families, taking into account the patient’s knowledge of hypertension and his/her preferences regarding treatment options
      2. educate patients about hypertension risk factors, taking into account:
        • demographics
        • concomitant diseases and therapies
        • quality of life
        • physiologic and biochemical measurements
        • economic considerations
    6. basic procedural skills: Skills that students should be able to perform:
      1. urinalysis (dipstick and microscopic)
      2. EKG
    7. management skills: Students should develop an appropriate evaluation and treatment plan for patients with:
      1. acute and chronic hypertension
      2. primary hypertension
      3. secondary hypertension
      4. students should be able to access and utilize appropriate information systems and resources to help delineate issues related to hypertension.
      5. students should be able to prescribe preventive strategies to diminish hypertension, including:
        • weight reduction
        • moderation of alcohol intake
        • regular physical activity
        • reduction of sodium intake
        • increase in potassium intake
        • smoking cessation
  3. Attitudes and Professional Behaviors: Students should be able to:
    1. appreciate the importance of patient preferences and compliance with management plans for those with hypertension
    2. appreciate the importance of preventive strategies may diminish need for medications
    3. appreciate the importance of complications secondary to drug administration, to which the geriatric population in particular may be more prone