Elderly, Kidney Disease, and Pregnancy - Hypertension (Part III)

In the final episode of our hypertension series, Taylor  and Dr. Gallagher discuss the causes of high blood pressure and management in special populations.

Share your reactions and questions with us at  Speak Pipe . We might feature you on a future episode!

=== Outline ===
1. Introduction
2. Chapter 1: Causes of Primary Hypertension
3. Chapter 2: Secondary Hypertension
4. Chapter 3: Treating Hypertension in Special Populations
6. Conclusion

=== Learning Points ===

1. About 90% of patients with hypertension experience primary hypertension. About 10% of patients with hypertension experience secondary hypertension due to an underlying disease or interfering medication. Causes of secondary hypertension can include pheochromocytoma, renal artery stenosis, CKD, primary hyperaldosteronism, fibromuscular dysplasia, and obstructive sleep apnea.
2. Workup for diagnosing the cause of hypertension should include a detailed history and a focused physical exam. Basic labs should include assessment for acute nephritis (e.g. hematuria, pyuria, or proteinuria), lipid panel, and A1C to screen for type 2 diabetes. 
3. “Hypertensive urgency” is differentiated from forms of hypertensive emergency by the absence of hypertensive end organ damage. Distinguishing between the two conditions is key for determining the therapeutic goal for blood pressure.
4. Patients who are elderly, pregnant, may become pregnant, or have chronic kidney disease require special attention and management of their hypertension.

=== Our Expert(s) ===

Benjamin Gallagher, MD, FACP is an Assistant Professor of Clinical Medicine (General Medicine) at Yale School of Medicine.

=== References ===

de la Sierra A, Segura J, Banegas JR, Gorostidi M, de la Cruz JJ, Armario P, Oliveras A, Ruilope LM. Clinical features of 8295 patients with resistant hypertension classified on the basis of ambulatory blood pressure monitoring. Hypertension. 2011 May;57(5):898-902. doi: 10.1161/HYPERTENSIONAHA.110.168948. Epub 2011 Mar 28. PMID: 21444835.

Anderson TS, Jing B, Auerbach A, et al. Clinical Outcomes After Intensifying Antihypertensive Medication Regimens Among Older Adults at Hospital Discharge. JAMA Intern Med. 2019;179(11):1528–1536. doi:10.1001/jamainternmed.2019.3007

=== About Us ===

The Primary Care Pearls (PCP) Podcast is created in collaboration with faculty, residents, and students from the Department of Internal Medicine at the Yale School of Medicine. The project aims to create accessible and informative podcasts about core primary care topics centered around real patient stories.

Hosts: Josh Onyango, Maisie Orsillo
Producers: Helen Cai, Kevin Wheelock, Danish Zaidi
Logo and name: Eva Zimmerman
Theme music and Editing: Josh Onyango
Other background music: Coma Media, Defekt_Maschine, Chris Haugen, Unicorn Heads, and Slynk.

Instagram: @pcpearls
Twitter: @PCarePearls
Listen on most podcast platforms: linktr.ee/pcpearls

Transcript

Introduction

[00:00:00] Maisie: Hi, I'm Maio. Orci one of your hosts for this episode. Welcome to primary care pearls. A podcast made by learners for learners today. We're concluding our conversation about hyper tensions. 

[00:00:13] Taylor: So that's why we have to do like different tests on you because it is. For someone your age and, like where you're at in life and like you're like healthy otherwise so it was kinda, it was like a, not funny conversation that I had with both of them separately too, but they were both just they seemed a little like nervous almost to tell me that they were like, we don't know why this is happening.

[00:00:35] Maisie: During our discussion today, we'll be joined by Taylor. 

[00:00:38] Taylor: hi, my name is Taylor. I am a patient at the hypertension clinic at Yale. 

[00:00:44] Maisie: We'll learn more about her experience with receiving a diagnosis of hypertension. We'll also be joined by Dr. Ben Gallagher, a faculty expert from the Yale school of medicine, 

[00:00:55] Gallagher: Ben Gallagher, I am a general internist. I also work at the Yale school of medicine and I primarily work in the outpatient setting in a primary care clinic in new Haven where a lot of the internal medicine residents at Yale also practice. And I have a special interest in hypertension, both in diagnosis and management.

[00:01:14] Maisie: and also by our resident interviewer from the Yale school of medicine, Dr. Kevin Wheelock 

[00:01:19] Kevin: My name is Kevin Wheelock. I'm a second year internal medicine residents at the Yale school of medicine.

[00:01:26] Maisie: and our medical student interviewer Helen Cai 

[00:01:29] Helen: hello, my name is Helen and I'm a first-year medical student here at the Yale school of medicine.

[00:01:34] Maisie: Our discussion today will be the final part of a three part series where we will focus on causes of secondary hypertension, how to manage hypertensive, urgency, and emergency, and how to treat hypertension in special populations.

[00:01:49] I'm a second year primary care internal medicine resident at Yale, and I'll be your co-host for today's episode. 

[00:01:55] Josh: And my name is Dr. Joshua Onyango I'm a third year, primary care internal medicine, resident at Yale. And I'll also be co-hosting this episode. Before we get started, please know that this content is made to be for learning and entertainment purposes only, and should not be used to serve as medical advice. If you are a loved one, is suffering from anything discussed in today's episode, please be sure to discuss it with a medical expert now onto the 

[00:02:22] So believe it or not. Maisie We've reached the final episode in our hypertension series and we've covered so much ground over the last two episode. Could you kind of remind me a little bit about what we've talked about so far. 

[00:02:35] Maisie: Definitely. In our first episode, we spent time getting to know Taylor and Dr. Gallagher guided us through the importance of getting the correct blood pressure measurements. Then in our second episode, we learned about establishing blood pressure treatment goals for patients and different considerations to make when initiating pharmacotherapy. 

[00:02:54] Josh: Okay. Thanks for that reminder. I think I'm feeling more ready to jump into this episode now. but one question I still have is once we diagnose and start treating hypertension. I mean, is that it? Do we ever need to find out why someone developed hypertension in the first place? Is that important? 

[00:03:11] Maisie: You know, that's a great question. Josh. Let's hear what Dr. Gallagher has to say about that. 

Chapter 1: Causes of Primary Hypertension

[00:03:16] Gallagher: So in the vast majority of cases, about 90% of the time, patients will have what we call. Primary hypertension. We used to be called essential hypertension. Um, The term essential hypertension came from the notion in the 20th century that was prevalent in the medical community, that it was essential or necessary for blood pressure to increase as people aged because of the hardening of the arteries and the increased systemic vascular resistance as a result of that that you needed to have a higher blood pressure in order to perfuse your end organs.

[00:03:50] So that's where the term essential hypertension but came from, but basically essential primary hypertension is another word for idiopathic hypertension. We don't there's not an underlying disease that's causing it. And it's a very commonly encountered issue uh, that we find, especially as people get.

[00:04:04] There are certain risk factors for essential hypertension that can make people more or less likely to get it as they get older. Age, as I mentioned is the primary risk factor, but being overweight or obese having a high salt diet, a family history of hypertension and a sedentary lifestyle are all things that are more likely to make people develop primary hypertension, especially as they age.

[00:04:28] So in the other 10% of people will have a type of secondary hypertension, meaning that there's a certain underlying disease or an interfering medication that's causing them to have hypertension where otherwise they would not have an elevated blood pressure.

[00:04:44] Helen: what was Dr. Gallagher's response to that on your visit with him? 

[00:04:47] Taylor: So he, him and Dr. Heuer had like immediately gotten together on it. Because I'd seen him too, and they both had the same reaction.

[00:04:56] They were like, look. Basically, you know, 32 years old, you're not like morbidly obese or anything. Like you do things like active wise. Like I'm not like going to the gym every day, but like I'm not sitting all day either. Like you're generally healthy. I there's something that's gotta be wrong here and we're gonna figure it out.

[00:05:16] They're like give us some time and we will figure it out.

[00:05:19] Helen: and when he finally met Dr. Gallagher, Dr. Hewitt how did they explain what was going on? 

[00:05:24] Taylor: Not that I shouldn't say they didn't explain it to me, but they were like, we don't really know like why this is happening. So that's why we have to do like different tests on you because it is. For someone your age and, like where you're at in life and like you're like healthy otherwise so it was kinda, it was like a, not funny conversation that I had with both of them separately too, but they were both just they seemed a little like nervous almost to tell me that they were like, we don't know why this is happening. So we are going to have to like, it's going to take some time

[00:05:53] it's probably from a hereditary thing. I don't think I said this before. My grandmother also, my dad's mother has high blood pressure.

[00:05:59] Maisie: Huh. You know, come to think of it. It is odd to have Taylor who's so young and without many risk factors, develop hypertension, you know, I'm curious to hear how Dr. Gallagher would go about the initial investigation, uh, to see if there's any underlying disease that might be contributing to her high blood pressure.

[00:06:17] Kevin: What's the next thing that you want to do with with someone after you make the diagnosis of hypertension?

[00:06:22] Gallagher: Yeah. So at that initial visit or the first few visits where you're either doing multiple measurements in the office or reviewing their home measurements you really want to do a focus history and physical and some basic labs that will help you both make the contextualize, the diagnosis potentially find causes of secondary hypertension and then get information that will help you make a treatment plan.

[00:06:47] That's going to be most efficacious for the patients. The history and physical really is focused on potential underlying causes of hypertension. So for example, people who come to you and they're have a moon, face, cheese, and easy bruising and a dorsal, cervical fat pad, that's pretty rare, but that person might have Cushing's disease.

[00:07:11] Um, you want to ask them about their family history because again, that's a risk factor. You want to talk about their diet and the level of physical activity. You also want to get a sense both by history and exam of end organ damage. So related to hypertension. So is this the person who just went for a routine eye exam and they have some retinopathy.

[00:07:33] Or they went to the emergency room when they did an EKG and they found that they had left ventricular hypertrophy or they're having symptoms that might be related to hypertension. Like they have a bubbly urine, and you find that they now have nephrotic range, proteinuria. Those are all things that you can pick up on the history and the exam.

[00:07:51] And then you also want to um, look survey them and interview them and ask them about um, comorbid conditions that could influence your treatment, whether it be, whether that that's, because they're going, those conditions will tip you toward a more aggressive blood pressure target, or use certain medications that will have benefits in those diseases or the opposite, medicines that you want to avoid because of certain comorbid conditions that they have.

[00:08:18] So that's the history and physical, then you want to do some basic labs to help you understand those same things, looking at their renal function, looking at their, your analysis to see if they have proteinuria or a lot of hematuria or pyuria that might suggest that they have an acute nephritis, which again, would be pretty rare.

[00:08:37] But these are all basic tests that you can do. Um, Checking an A1C to screen them for diabetes, checking their lipid panel, because both of those kinds of fit factor into many of the validated atherosclerotic cardiovascular risk calculators, that will help you determine among people who do not have specific high risk conditions, who are the higher risk people that merit a more aggressive blood pressure treatment. And so that's what you want to, get from your history, physical and the labs and the first visit.

[00:09:06] Josh: Okay. That was really helpful. So it sounds like to begin our investigation, like in most other cases, it's always helpful to start with a detailed history and physical and maybe some initial, basic lab tests, that include a urinalysis. 

[00:09:20] Maisie: Right. And in Taylor's case, it seemed many of the basic investigations were pretty unrevealing. So when there might be a suspicion for secondary hypertension, as opposed to primary hypertension in a young patient like Taylor, let's see how Dr. Gallagher approaches that.

Chapter 2: Secondary Hypertension

[00:09:35] Kevin: We've been talking about primary, um, or as assembles a essential hypertension know, want to talk now more about that 10% of patients that fall into their secondary hypertension category. Um, Talk to us about when you're suspicious that someone might have.

[00:09:53] know, An under, like a underlying identifiable etiology to their hypertension and what are some ways that you can suss that out and make the diagnosis?

[00:10:02] Gallagher: Yeah, sure. I think I alluded to this earlier, that there are certain underlying diseases that have um, historical or a physical exam or laboratory findings that would suggest that the patient has them. And so even in someone with uncomplicated primary hypertension, with those features, you might want to screen for something like that.

[00:10:23] So we talked about the Cushing wide features, the spells of high blood pressure with headaches and palpitations might make you think of a pheochromocytoma, a older patient who smokes and has other, a known occlusive vascular disease might, you might want to screen them for. Renal artery stenosis, especially if you hear a brewery or you've known from their imaging, that they have asymmetrical, kidney size, those kinds of things.

[00:10:48] Otherwise we tend to wait until someone has what we call resistant hypertension before we screen for some of the more common causes of secondary hypertension, because among those with resistant hypertension, the number of people have secondary hypertension is higher than in the general hypertensive population.

[00:11:07] So what we mean when we say resistant hypertension is a blood pressure that is still above goal. Despite patient taking three medications one of which is a diuretic and those medications have to be taken at maximally tolerated doses.

[00:11:24] So the unpack that for a moment we talked in the a little while ago about each of the three first-line classes being equivalent as monotherapy. There's some debate about what's the most effective two drug regimen. And then we think that using all three of them in combination is what's preferred when you need three drugs.

[00:11:43] The fourth drug, fifth drug, et cetera, it gets more complicated, but we think that if you need to be on three agents, that most likely you should be on an ACE inhibitor or an ARB, a calcium channel blocker and some type of diuretic, usually a thiazide diuretic. You may have other comorbid conditions that would push you toward using a different type of medication.

[00:12:04] Like a beta blocker, if you have heart failure, atrial fibrillation. But otherwise it's probably going to be one of each of the three first-line medications and importantly, those need to be taken at the maximally tolerated doses. And in particular, the diuretic is one that is often under dose.

[00:12:21] And in getting people to goal, we generally recommend pushing the diuretic as much as you can, even in the absence of clinical volume overload until you get, patient feeling dizzy or having acute kidney injury or something like that. Um, And in people who are thought to have resistant hypertension and we call that group a parent resistant hypertension you need to make sure that they're on an appropriate regimen.

[00:12:44] Like I mentioned, you need to make sure that the blood pressure you're getting in the office is being appropriately measured. And it's ideal to confirm that the blood pressure is uncontrolled. By out of office monitoring because about a third or more of these patients will be found to have white coat effect.

[00:13:03] And so they are not resistant when you measure their blood pressure at home, but their blood pressure in the office is still above their goal. So that's pretty common in this population and then medication adherence is key. So by definition, these patients are already taking several medications.

[00:13:20] They tend to be older and more comorbid. And so they may be taking other medications too, for their other conditions. And inherence tends to not be that good. And we talked earlier about how you might assess for that and improve adherence over time. But there are some studies that have been done in kind of patients who are referred to a hypertension specialist for resistant hypertension.

[00:13:41] Where they're able to measure adherence by blood or urine tests, which are generally not available clinically and find that the adherence rates are really low, including patients who have no detectable drug in their system of any of the three or four drugs that they're taking. And so taking yourself through that process is important to ruling out the other interfering factors that might make someone have a parent resistant hypertension without having true resistant hypertension, but people who are truly resistant deserve a basic workup for some of the most common causes of secondary hypertension.

[00:14:19] Maisie: So to quickly recap, Dr. Gallagher mentioned a few conditions that can be associated with secondary hypertension, Cushing syndrome, Pheochromocytoma uh, or renal artery stenosis in patients with risk factors for coronary artery disease. 

[00:14:35] Josh: Gotcha. And it seems that we should worry. about These syndromes, particularly if the patient also has other symptoms that are suggestive of the diseases you mentioned, but I guess there are times when we would still worry about some underlying secondary hypertension, especially when a patient has resistant hypertension, which is officially defined by blood pressure that's still above goal. Despite a patient being on three medications at maximally tolerated doses with one of them being a diuretic. 

[00:15:04] Maisie: Yeah. And sometimes trying to pursue further investigations might be pretty benign for us as physicians, but we should be mindful of what our patients are going through during this time, as the testing can become pretty inconvenient.

[00:15:17] Helen: What were some of the initial tests and first steps in that relationship?

[00:15:21] Taylor: I had so many blood tests. I did a couple of different kidney things and I don't know what they were called. We did a. I don't know what it's called the 24 hour urine collection test. The most recent one I ended up not actually doing, they wanted me to do, they thought there was maybe like too much of a steroid in my body. And after I was like, it was like months and months, honestly, of going through just like random tests.

[00:15:45] And I was like, I can't, I don't know. Everything also, by the way, that all the testing that I did, like basically I'd get the results and they'd be like, I hate to say it, but I kinda am happy to see that all of these are fine. They basically both told me that they didn't think that's what it was. And they were like, we could try it if you want. And I was like, I'm just going to hold off for now. So it was just a couple months of I felt like I was there like every week again, great people.

[00:16:09] Not that it was like horrible, but it was just like a lot of time that I was like going in the morning before work. I was getting into the work late and it's fine. But after awhile I was like, all right, let me. I'm not dying right now, so let's let's just take a break from this. 

[00:16:21] Kevin: So let let's say that you you've done your diligence at this point and, you know, having good home blood pressure monitoring readings are good in office readings and you're um, you're confident that the person's, know, adhering their, to their medications and they're on the max doses that, can, they can tolerate are, which are, I guess, clinically appropriate doses as well Um, how do you start to approach working this person up further?

[00:16:48] Gallagher: barring any clinical features that make you think of a specific cause you want to focus on the secondary causes that are most common in this population. And so those tend to be CKD chronic kidney disease, primary hyperaldosteronism, renal, artery stenosis, and obstructive sleep apnea.

[00:17:09] Now a C K D at this point is usually not surprising because you've done lab work and know that they have renal insufficiency. Primary hyperaldosteronism is pretty common and not always, or even a majority of the time causing hypokalemia and. It's worth screening people for that. And I'm not going to go into the details.

[00:17:26] Obstructive sleep apnea does have a strong association with hypertension. It's not clear exactly what the mechanism is and the studies that have treated sleep apnea with positive airway pressure, as a means of lowering blood pressure have been mixed. And the reason for that may be that both the hypertension and the OSA have a third proximal cause so that treating the OSA per se, would not affect the blood pressure.

[00:17:56] You need to address the approximate cost. And there's some thought that that cause may be volume overload and that fat cells uh, make aldosterone. And so that may is probably what's driving association between obesity. And hypertension. And if there's fluid retention in the pharyngeal organs that cause airway obstruction that may also be causing OSA.

[00:18:20] And so treating the OSA may not affect the hypertension, but treating the volume overload by giving them a higher dose diuretic or giving them an aldosterone, antagonist may help both problems. And the last one that I'll mention is renal artery stenosis. This is more well, the most common type is due to atherosclerosis, and that seemed more in people who are older and smoke and have other cardiovascular risk factors. In the younger women fibromuscular dysplasia, which is vascular inherited vascular disorder of the renal arteries causes a different type of stenosis and both of these cause hypertension by causing relative hypoperfusion of the kidneys, which then activates their rent, an angiotensin aldosterone system and causes fluid retention and hypertension.

[00:19:08] During the reason I bring this one up um, for a special mention is that you want to think about it, any test, that diagnostic tests that you do, how the result is going to change your management. And it's not clear based on many studies that have been done that ameliorating renal artery stenosis in particular atherosclerotic minorities.

[00:19:26] You notice this with stenting or angioplasty actually. Help us reduce blood pressure. And it seems like the problem in many cases is number one, you already missed the boat. That by the time you diagnose it, the kidney has been ischemic for too long for reprofusion to affect your blood pressure. And the second thing is that even in people with macrovascular, large artery stenosis, that downstream of that, there's also a smaller arteries that are blocked off and opening the big water is not necessarily going to help open the small ones downstream of that.

[00:20:01] And so screening for renal artery stenosis may AME or not be helpful. And I would reserve that only in people in whom you would actually consider revascularizing. If you were to find mule artists who notices the vast majority is patients will respond to medical therapy. Most of them can still tolerate brass inhibition, despite what you've learned about the med school, about that causing AKI and flash pulmonary edema, most patients can still tolerate it.

[00:20:28] Maisie: If you recall, during our first episode, we got an introduction to Taylor's story. When she was incidentally found to have very elevated blood pressures, let's take another listen to her experience and then discuss how we can think about patients with, in her words, alarmingly high blood pressure. 

[00:20:45] Taylor: your blood pressure is like alarmingly high and they're like, we're gonna They checked it like three times already. And like before they had said anything and I knew something was up. Cause it was weird. Since she's I'm going to have someone else come in, are you okay with that?

[00:20:57] I was like, yeah, of course, whatever. And they're like, are you nervous? I'm like, no, not at all. And they like kept asking me like, are you like, did something happen at work today? And I'm like, I don't know, like what are we getting at right now? So the second person that came in, they checked it and then they all looked at each other like eyes like extremely wide and walked out of the room.

[00:21:17] And I still was I don't like, I feel fine, nothing's wrong, whatever. And they come back with someone else and they check it again. And they're like, so do you have anybody with you? And I'm like, no. And they're like you shouldn't have to call someone because we really think you should maybe go to the emergency room.

[00:21:32] And I'm like, I'm sorry, what? Like why? And they like showing me my blood pressure and I'm like, I don't know what this means. What is this supposed to be? What does that mean? And they're like you're like really high risk for having a stroke. What are you talking about? Anyway, I was like, I'm not going to go the hospital.

[00:21:45] Gallagher: so the kind of dangerous own blood pressures. Generally speaking are systolic that's over 180 and a diastolic that's over one 10 or a one 20. And so patients with that blood pressure if they have no symptoms of hypertensive end organ damage, I that's called a hypertensive urgency. Whereas if they do have symptoms or signs or evidence of hypertensive end organ damage, And acute EMI or an aortic dissection or a stroke injury, that's a hypertensive emergency.

[00:22:21] And so assessing out which of those that it is in the clinic office is a little bit challenging. They're based on your history and your physical and some basic tests like an EKG and maybe some labs you can tell whether they have end organ damage. Let's assume that there is no evidence of end organ damage because as a name implies with hypertensive urgency or emergency, that person needs to be hospitalized and have their blood pressure lowered rapidly in order to prevent worsening of that end organ damage.

[00:22:50] Whereas people who have only hypertensive urgency. You want to lower the blood pressure more slowly and in particular, because likely that blood pressure has been elevated for a while and their end organs have gotten used to that blood pressure. And by lowering it by more than say, 25% in the first 24 hours, you may actually cause end organ hypoperfusion and have problems as a result of that.

[00:23:13] So most of what you're going to see is going to be hypertensive urgency, I'll say at the outset that there is accumulating data that hypertensive urgency may not be a clinically important entity in the sense that in studies, where you look at patients with hypertensive urgency that were sent home and managed as an outpatient versus sent to the emergency room, there's no short term difference in cardiovascular outcomes or mortality.

[00:23:46] So. The patients with hypertensive urgency may not really benefit from being evaluated in the ER or hospitalized because they can be managed as and so it may be that a hypertensive urgency is just as severe manifestation of uncontrolled hypertension. And you often see this in patients with a new diagnosis who were asymptomatic and they went to their dentist's office say, and their blood pressure was really high.

[00:24:13] And everyone got really nervous or people who are no deaf hypertension and are non adherent to their medications. And so their blood pressure gets high over time. And that's what you see when you find when you intercept them with the healthcare encounter. So again I tend those blood pressures do alarm me um, but there's probably hypertensive urgencies in my clinic every Right. And we tend not to send them all to the ER because of that fact that they mostly can be managed with close outpatient followup and either starting Denovo or resumption of previous medications. 

[00:24:50] And I'll say emergency room, they're pretty good at not overreacting to this in my experience. Um, and there's some movement toward renaming hypertension or hypertensive urgency as severe asymptomatic hypertension. And what I see them often doing in the ER, is either giving them their home meds and seeing what happens to their blood pressure over a few hours or starting them on something Denovo and seeing what their blood pressure does.

[00:25:21] But I believe there are even ER, guidelines that suggest for these patients. To not even start treating them in less, you're not sure they can get appropriate outpatient Follow-up in a reasonable amount of time. And again, that's all motivated by these data that it may not really be a condition that carries excess short-term risks.

[00:25:41] Kevin: are you more aggressive in these people in making medication adjustments? Assuming I think that's assuming that you have any level of confidence that they're adhering to the medications that they're on. know, How do you think about making med changes with those patients? 

[00:25:56] Gallagher: Yeah. I think you want to follow up with them closely. You want to make sure that they have access to medications very soon, either ones that you're starting or ones that you're restarting, otherwise you should be using the same first-line medications that you would be using for anybody.

[00:26:11] You know, By definition, these are people that are going to be well above their blood pressure goal. And so using combination therapy at the outset is probably a good idea. you know, there are some clinics that stock short acting, blood pressure medicines, like oral Clonidine or captive Priscilla beta wall, and put people in a room with for a couple hours after giving them one of these medicines and seeing if their blood pressure comes down. 

[00:26:34] Taylor: anyway, so I went to the ER that. I didn't love going to the ER, I'll be honest. Who likes that? Of course, but the thing that I didn't like about it, and I know it makes sense for an ER, but they're obviously just looking for a quick fix to make you so like you can go home, obviously.

[00:26:49] They, don't not that they don't care about you, but it's not that same relationship that you have with I have one now with Dr. Gallagher and our RQI where they actually seem to care. 

[00:26:58] Gallagher: Like you mentioned, that may be treating the healthcare professionals more so than the patient. and some people even just sitting in a room, dark, quiet room for half an hour, their blood pressure will come down significantly. So both of those things are just proving to you that their blood pressure can come down.

[00:27:16] And it's not just getting higher and higher. But, most of those short acting medicines are not the ones that are going to be dosing people in the longterm. And so I tend to just send people home and ask them to come back after taking their, whatever medications they're prescribing for a week or so. 

[00:27:33] Josh: So in Taylor's case, she ended up going to the ER to get help managing her elevated blood pressure, which is obviously a very different setting than your typical setting where most primary care providers are, um, in the clinic or in the outpatient space. 

[00:27:49] Maisie: Exactly. And, you know, Josh, that actually does bring up some challenges. We might, manage or even think about blood pressure in the hospital, in a way that's very different from, how we think about it in the clinic setting. So let's listen in on Dr. Wheelock and Dr. Gallagher's conversation on this distinction.

[00:28:05] Kevin: as you mentioned before, he knows residents in internal medicine were very heavy inpatient. And I think when you're taking care of people, inpatient and they have these really high blood pressures and are asymptomatic, it's easier to watch it. Um, and Yeah, maybe make sure that they actually took their med, you know, when they came in that day, um, and, or increase the dose of their home meds essentially while they're there. But because we do less outpatient there's. I think there's less comfort, you know, and having someone like that, the in clinics

[00:28:40] Gallagher: So, if you were in the hospital and you got a page from a nurse that that was the patient's blood pressure, think that the environment of the hospital kind of conditions you to just like react to every provocation. And so the implied in that text from the nurse, the blood pressure is 180 over 200, 120, is that you're supposed to do something about it, right?

[00:29:01] Whether or not that's really, what's the evidence-based thing to do. The, there, there are data now. I think some of it came from the VA looking at um, non-cardiovascular admissions and patients who had their blood pressure. Regimen, either intensify or had a new Medicaid, a new regimen starting inpatient.

[00:29:23] And these are people who are admitted for, biliary, colic and pneumonia and whatever. And those people in the short term actually have an increase in adverse outcomes because the hospital environment is so different. And I also do wonder about how much does the true blood pressure deviate how different is their true blood pressure from what you're actually getting.

[00:29:45] When there, you know, there's like alarms and bells going on all the time and they're in the pain and things like that. And so you may do more harm than good by, uptake. I remember as a resident, like every day, increasing someone's blood pressure medicine when they're admitted for a totally unrelated reason and expecting that, that, they're going to.

[00:30:05] I have him as, uh, as much of a risk, a significant response over one day. Um, And making those changes on a daily basis, it really, it was just like something to do and learn how to use the medicines. But I think it's not really going to help patients in the longterm. And then even the medicines that you use in patients are different than I, it's not infrequent that I see a patient discharged from the hospital with a blood pressure regimen of libido law, Clonidine and hydralazine with none of the first-line meds, because oh, that's what they were using short acting is in the hospital.

[00:30:34] So that's what we're gonna discharge them on. And that's totally different from what we use in the outpatient. So I think there's something to be said for or I have concerns about the kind of increasingly bright line between inpatient and outpatient practice in internal medicine. Whereas people who practice in ones where people practice in one setting Tend not to practice in the other setting. Because there are conditions like hypertension and diabetes for that matter. and then others that, where the management is so different, inpatient and outpatient, that when you're making a transition from one to the other, you need to know how that's going to change.

[00:31:11] Maisie: Okay. So I don't know about you, Josh, but I totally feel this challenge as a resident. I can't tell you how many times I've gotten the overnight page about a patient who has elevated blood pressures and, you know, it was checked again and it was still elevated to systolics 180 S one 90 S uh, but the patient may otherwise feel fine. And from what Dr. Gallagher is saying, it seems like there may actually not be a lot of utility in trying to lower the blood pressure urgently, unless we believe it's leading to immediate harm.

[00:31:40] Josh: That's right. Maisie and unless someone is in true hypertensive emergency blood pressure lowering, at least from what Dr. Gallagher is saying, it seems to be best relegated to the outpatient world and in the clinic with careful consideration for those transition plans that are made as a patient is leaving the hospital setting, to go into the outpatient world.

Chapter 3: Treating Hypertension in Special Populations

[00:31:59] Maisie: All right. So keeping all of this in mind, uh, let's take a look at special populations starting with pregnant individuals or patients who could become.

[00:32:11] Taylor: oddly enough, one of my, like very good friends about a year and a half ago, like basically same thing happened to her. Out of nowhere just had high blood pressure. It went away when she got pregnant. But it was like really random.

[00:32:24] I forget what she was on. She stopped it pretty recently. Like I said, she got pregnant. It like randomly went away, but We had tested like basically all the same different medications we had all the same testing done. And one of the ones though that I forgot, I just don't remember. It's called now. Didn't work for me. Like at all I feel like I'd barely reacted to, it was the one that worked really well for.

[00:32:45] So I was kind of weird cause I feel like, obviously I know our bodies are very different, but we're very similar people and just like in how we live our lives. So I was like a little surprised. I know it's like a stupid thing cause why would that really matter? But I just assumed oh, that's what worked for her. And then I tried it and I'm like, oh no, that didn't work for me. 

[00:33:04] Kevin: one, sub population we haven't covered is pregnancy. 

[00:33:07] Um, so in patients who are pregnant uh, talk to us about how you manage blood pressure in that group, because know, many of the meds that we normally use, aren't aren't able to be used in those patients. So how do you approach that? 

[00:33:22] Gallagher: So I do not have a lot of patients who are currently pregnant in whom I am the one primarily managing their hypertension that usually is done by the OB GYN and maternal fetal medicine. There are different kinds of blood pressure um, cutoffs and targets that?

[00:33:37] are different for a high pregnancy compared to non-pregnant women.

[00:33:41] And so that's worth familiarizing yourself with, and then there's this distinction between patients who had pre pregnancy hypertension versus hypertension develops during pregnancy. But I do see a lot of women who are reproductive age in whom this consideration um, is needs to come into play to determine how to treat them.

[00:34:02] For and I have to say that I didn't think about this too much until I finished the residency and started practicing primarily as an outpatient, because you don't take care of a lot of pregnant or potentially pregnant patients in residency when you're mainly doing inpatient medicine, most the ones who are actively pregnant, usually go to the OB service, right?

[00:34:23] A lot of the patients that you take care of in the hospital, even the women are tend to be older and less likely to be pregnant because they may have gone through menopause, tend to, it's unlikely that people become pregnant in the hospital. I'm not saying it's never happened. I haven't seen it. you know, When you started doing a lot of outpatient medicine, you see a lot of women who are premenopausal and, they may have chronic conditions and I, and.

[00:34:45] My internal medicine training did not teach me to be cognizant of that as much as I think it should have. So with few exceptions, know, when I have a reproductive age woman that I'm seeing, I basically treat them as if they could be getting pregnant at any moment, unless they are taking a, highly reliable means of contraception like a a IUD or a subdermal implant or they're coming frequently to get the, on schedule to get their depo shots, or they take their birth control pills every day.

[00:35:18] Or they've had a hysterectomy or they've had their tubes tied. And so if they are going to be taking medications that are not safe in pregnancy I counsel them very strongly that if something changes you're not sexually active in. But you might become that in the future, or you're not trying to get pregnant now, but you may want to try to have a baby later on.

[00:36:12] You have to let me know before you continue taking this medication, if that changes. Um, so all that haven't been said the medications that are safe to use in women who maybe come pregnant or currently pregnant or breastfeeding are the calcium channel blockers and specifically nifedipine um, law and hydralazine, which is not ideal because of the frequency of dosing.

[00:36:38] And another one is alpha methyldopa, which I don't think I've ever prescribed to anyone. And there are others that we think are probably safe based on limited data. But I would say that my Filipina and labetalol are the ones that I fall back on most often the ones that are. Really avoid are the RAs inhibitors.

[00:36:59] And I think because labetalol is dosed either two or three times a day, I tend to use my fed pain first. And it's very similar in side effects and efficacy to the other dihydropyridine calcium channel blockers. And so there's um, there's really no reason not to use it for women who are reproductive age. 

[00:37:22] Josh: So to recap in this population, it's important to first distinguish that the patient has chronic hypertension or hypertension related to their pregnancy, which could be separate entities. And in addition to this, there are certain medications Such as ACE inhibitors and ARBs that we should avoid, in pregnant individuals or individuals who could become pregnant as they can affect the growing fetus.

[00:37:49] Maisie: So patients with chronic kidney disease or other forms of renal insufficiency can also require special management.

[00:37:56] Kevin: focusing on patients with chronic kidney disease. A very common uh, subset our, of our primary care population, particularly in our patients that we're treating for hypertension. How does that affect the medication choices that you would use in The presence of CKD.

[00:38:14] Gallagher: Yeah. So when people with CKD or not anyone with CKD dialysis or not in dialysis volume retention is a huge driver of hypertension. And so making sure that they are really pushing the diuretic again, to the point of them? feeling precinct couple are developing AKI is what you need to do in order to get their blood pressure under control.

[00:38:36] Um, And we tend to be of cautious about that um, because we don't like when their numbers change, but if they're creating goes from 3.0 to 3.5 and their blood pressure is much better, they're probably going to be better off in the long-term, taking a higher dose of the diuretic people with CKD and proteinuria.

[00:38:54] Um, There is a renal benefit in terms of preventing worsening of The CKD and developing a stage renal disease to RAs inhibition with either an ACE inhibitor or an angiotensin receptor blocker. And I highlight that it's people with significant proteinuria, not necessarily people with CKD, without proteinuria or people with a small degree of proteinuria.

[00:39:17] And also add to that people who are diabetic, who have no proteinuria or very minimal proteinuria, there is not as clear of a renal benefit there to rest inhibition. And so ACE inhibitors and ARBs are one of those first line classes that's good to use. But I have a lot of residents coming to me that want to use ACEs and ARBs and people with diabetes and or CKD

[00:39:38] As their primary treatment. And there may not be that much special benefit unless they have significant amounts of proteinuria. 

[00:39:44] managing hypertension in patients on dialysis is. Big challenge and instances of something that we don't get too involved in primary care. But again, volume is a big factor and because most patients over time will become and uric, you can't really use the diarrhetics to manage their volume. And so they rely on three times a week, most likely haemodialysis to manage their volume. And the problem is that is really hard to, it's really hard to maintain a dry weight, dialyzing people that way.

[00:40:16] In Europe, for example, they are much more restrictive on who gets dialysis, but you get dialysis five times a week and for shorter sessions, and that is much more effective at keeping people at a steady state and in the U S peritoneal dialysis is a little bit more effective at maintaining you bulemia over the course of the week.

[00:40:34] So what you have when you get three times a week haemodialysis is that, especially after you've waited the first day of the week, when you've waited for three days, you try as you might to uh, reduce fluid intake and reduce salt, you're going to have weight gain. And then they, you only have that one shot, that Monday to get all that weight off.

[00:40:52] And it's hard to do, there's limited resources, limited time, right? A lot of patients when they, know, have two-inch intradialytic a. Could use extra dialysis, but they don't get it cause there's no time or money for that. And so people's driveway tends to go up and up and up over time.

[00:41:08] And it's in the the dialysis centers will generally just redefine the dry weight as whatever you can get them down to at the end of a session, not what their true dry weight is. And you sometimes see this to get to the point where they just show up in the hospital with a pulmonary edema because, um, they just got tipped over the edge.

[00:41:26] And what those people really need is to be dialyzed down to their true dry weight, and then try to maintain it as best as they can. So volume management is going to be a big component and it's not that much for you to do um, are certain medications you may want to pay attention to whether they're dialyzer able or not, because um, you may want to switch to a similar medicine that is not feasible or to dose the one that isn't is dialyzed double until after dialysis and the days when they get dialysis then, you have to be careful with renally acting medications, although there's not really any brass and it comes up a lot with harass and ambition.

[00:42:00] There's no creatanine or level or GFR at which you cannot use RAs inhibition. You just have to be careful. Um, So people with assets still can take ACE inhibitors and ARBs. And even though they may not be acting on the kidney that much anymore, they are a very effective vasodilators. And so it's it's still helpful.

[00:42:19] But in the law, I tend not to get too involved in adjusting medications with dialysis patients because I'm operating in a vacuum, the dialysis you're, you have blood pressure. On one day we talked about and, non CKD patients that there's a lot of variability from day to day in blood pressure, but with the ALS patients even more, because it matters a great deal, whether it's their pre dialysis day or their post dialysis day, and you don't have that information right.

[00:42:44] What is their blood pressure when they show up for a session, what is it throughout the session? And at the end of the session, because there are patients who also become hypotensive during dialysis. And so if you don't know that, and when they see you on their day before dialysis, their blood pressure is high.

[00:43:01] If you're now making them their blood pressure too low by adding medications or adjusting their medications. Now they show up at dialysis and they're they can't be dialyzed or ultra filtered appropriately because their blood pressure is getting too low. And what does that happen over time? They just accumulate more fluid and blood pressure goes up.

[00:43:18] So I tend to leave this to the nephrologists because I feel like I'm not I'm flying blind. I don't have enough information to really make educated decisions, but it is a very challenging problem to manage.

[00:43:29] Taylor: I had a friend come over last week, showed me my like drawer, looking for a brush and she's Jesus, what do you like 90? Like, yeah, I know. 

[00:43:36] Maisie: Okay. So obviously our patient isn't 90, but she does bring up a good point. Many of our patients with hypertension tend to be elderly. It's important that we keep in mind, physiologic changes associated with aging, that change what an individual's ideal blood pressure actually is.

[00:43:54] Kevin: in my practice, you know, at the VA I'm taking care of a much older population um, than a lot of other people in primary care. And one thing that comes up a lot with blood pressure management, especially as we add new agents or titrate existing agents is people going too far, you know, in the other direction and having , orthostasis or even falls.

[00:44:18] Um, I'm curious how, when you have an individual patient in front of you, especially someone who's older those people also can gain more benefit from controlling their blood pressure cause they tend to have a much higher baseline cardiovascular risk know, balancing that versus know, the potential harms of titrating medications.

[00:44:35] Gallagher: Yeah. So have two comments about that. One is that, most recent data that we have from an RCT, looking at hypertension, the elderly is from sprint, which had a, I think a subgroup of people that were 75 or older that were heavily enriched. But I think even among those group, most of the patients were less than 80.

[00:44:55] So when people who you know, 85 90, we really are operating with have that much data. But, overall in sprint, in the uh, higher more in the lower target group um, there were higher incidences of things like falls and electrolyte, abnormalities and AKI. But the number of injurious falls leading to fractures and things like that were not higher.

[00:45:19] And the overall benefit was still in the direction of favoring uh, more aggressive treatment. Every patient obviously is different than, so you do want to screen for orthostasis and or symptoms of that before you start to be really aggressive with people who are older older patients, and also take more medications.

[00:45:38] And so the burden and complexity of the regimen is something that you want to keep in mind when you are adding or uptight trading medications. So so That's the first point. The second point is that it's about diastolic blood pressure. So I told you in the beginning that the term essential hypertension comes from the fact that sock blood pressure increases as you age as the arteries harden.

[00:46:01] And so there's more resistance to. Blood flow in systally, but in diastole, the blood uh, the arteries are less elastic. And so the elastic recall of the arteries is lower. And so your diastolic blood pressure tends to get lower as you age. So as you get, as you age, it's August going up the dialogue peaks around middle age and then goes down.

[00:46:20] So your post pressure widens, as you get older and older, now your end organs don't see systolic or diastolic, they see immune or to a pressure, which is more heavily influenced by your diastolic blood pressure because you spend two thirds of your life in diastole. Right. And so there's a concern that.

[00:46:38] And also blood pressure, lowering medications, lower, both the systolic and diastolic. So you got an old diddly person whose blood pressure is say, one 50 over 60, what do you do with that? You're going to lower their systolic and they may get benefit from that. But maybe their diastolic blood pressure will then get too low.

[00:46:56] And your mean, arterial pressure will then be lower than what your end organs are used to. And then you start having things like poor mentation or syncope or acute kidney injury, et cetera. And another consideration is that the coronary arteries are perfused in diastole. And so they're more heavily influenced in terms of their blood flow by diastolic blood pressure.

[00:47:18] So we don't really know what is a kind of minimum diastolic blood pressure, but we think maybe around 60 is where you want to start to be careful. So that's another mitigating factor in trying to do. Elderly patients with with high blood pressure is to keep an eye on the diastolic blood pressure.

[00:47:35] Kevin: so I guess to summarize for your first point know, certainly we always want to be mindful about adverse events, but, um, at least in trial data, the the adverse events for people who had more um, intensive blood pressure control was a higher, but not necessarily dramatically higher.

[00:47:52] And and in terms of falls, things like fractures, which are, of course what we really care about fractures and bleeding, you know, it sounds like it was actually not not higher which is really good to know. And then, know, on the other end, thinking about when you do have, that more elderly population, and you're talking about titrating up a medication, keeping an eye on that diastolic blood pressure as being something that's really helpful.

Outro

[00:48:14] Josh: Wow. So thinking back to our very first conversation. We talked a lot about getting at this number in relation to blood pressure and how often that's the main thing we're using really to gauge how effective our treatment 

[00:48:28] Maisie: yeah. But even though it does feel like we're just treating a number in hypertension through this series, we've learned that there are so many other complexities to keep in mind. 

[00:48:38] Josh: Right. From contextualizing the blood pressure, depending on how well it was measured, 

[00:48:43] Maisie: gauging how concerned we should be when a patient's blood pressure is really high and whether they might need to be in an inpatient setting for hypertensive emergency 

[00:48:52] Josh: thinking about whether there might be an explanation for someone's high blood pressure, like secondary hypertension, especially if their blood pressure is resistant to pharmacologic management, in which case we would call it resistant hypertension. 

[00:49:05] Maisie: And finally we wanna think about who we're treating and whether that warrants a change in how we think about that particular patient's blood pressure management. 

[00:49:15] So, you know, Josh, I learned a ton from, from this series. I think we so commonly encounter hypertension in the primary care clinic, and there is so much, Complexity to it. It's, it's not so simple We wanna talk with patients about how their lives are impacted by living with high blood pressure, you know, hearing from Taylor, this is just one of thousands of patient experiences 

[00:49:40] so let's just, do a quick recap and go through some key takeaways that I took away from today's episode, and I hope you will too. 

[00:49:49] Most of our patients, high blood pressure will be due to essential hypertension, but it's important to have our S spy senses tuned to situations when we should suspect secondary causes to patients, hypertension, and what tests we could use to further evaluate.

[00:50:05] Resistant hypertension is defined as a blood pressure, still above goal. Despite patients taking three medications, one of which is a diuretic before we label patients with this diagnosis, it's important to ensure our blood pressure measurements are accurate and that the patient has been adhering to their treatment regimen.

[00:50:25] When patients come to the clinic with alarmingly high blood pressures, it's okay to keep our cool and try to distinguish whether the patient is having a true hypertensive emergency keeping in mind that if they are not, their blood pressure can be managed in the outpatient setting without the expense and time associated with an ed visit.

[00:50:45] Lastly, it's important to keep in mind, special populations, such as patients who are, or could become pregnant patients with kidney disease and elderly patients as their blood pressure management often differs from individuals in the average population. 

[00:51:02] Josh: Thanks for that Maisie well, this not only concludes our episode for today, but also our three part hypertension series. We hope you enjoyed. it. we'd like to thank our patient Taylor, Dr. Kevin Wheelock, who served as our resident interviewer and Dr. Ben Gallagher, who served as our faculty expert and provided peer review for the project

[00:51:21] special thanks to our producers, Madison swallow, Augusta Loco, Helens, and me Dr. Josh Onyango as well as our faculty advisor and Dr. Katie, Gillon be sure to follow us at PC pearls on Instagram, Where you can expect to get sneak, peeks, additional learning content and the most up to date details on show release times would also appreciate it.

[00:51:43] If you shared this episode with friends or colleagues who might have an interest in the health condition we discussed today. Thanks again for joining us farewell from all of us at the primary care pearls podcast. And we'll catch you in the next. One 

[00:51:57] And we'll catch you in the next. One Peace 

[00:52:04] Maisie: Amazing. 

[00:52:05] Josh: Yay. 

[00:52:05] Maisie: Yay. 

[00:52:06]