Hi, this is Ginger Biesbrach and today we're going to talk about hypertension and hyperlipidemia. First, let's talk about screening recommendations for hypertension. So, the U.S. Preventive Services Task Force back in 2015 gave us several guidelines. The first one was every adult greater than or equal to 40 years old needs to be screened annually. Annually for those adults that are at risk for high blood pressure, overweight, obese, or African-American, regardless of their age. Annually for adults with blood pressure 130 to 139, over 85 to 89 millimeters of mercury. So again, not related to age if they fall in this category. For those that are 18 to 40 that don't have any of the above risk factors, it's every three to five years. And remember, hypertension is a leading contributor to mortality. So, we talk a lot about it being the silent killer, mi-stroke vascular disease. And persistent hypertension can develop into target organ damage. We call it end organ damage, including aortic disease, microvascular disease, heart disease, kidneys, retina, and of course, central nervous systems such as stroke. So, what do our guidelines tell us as far as classification? We had some new guidelines come out in 2017. And basically, trying to keep it simple. So, elevated blood pressure is now anything greater than 120 to 129, less than 80. Back in the day, we used to have a couple different definitions depending on if you were diabetic or not, they got rid of that. Anything greater than 129 over 80 would be considered elevated blood pressure. Stage one hypertension is 130 to 139 over 80 to 89. And this is in either systolic or diastolic. And then, our target blood pressure for all adults is now less than 130 over 80. So again, I mentioned it's silent killer, often has no symptoms. If it does have symptoms, you know, headache, necturia, some vision changes. Certainly, elevated blood pressure readings is consistent with hypertension. Other signs that you might see a transient S3 or S4 gallop on cardiovascular exam, especially if you've got some hypertensive cardiomyopathy or heart failure type symptoms. Displaced PMI when long-term and you have that hypertrophy, that left ventricular hypertrophy has developed, dependent edema and chronic disease. If you're doing a retinal exam, you might see flame hemorrhages or fluffy exudate. Renal bruise on your abdominal exam, that would be consistent with renal artery stenosis. And then a systolic murmur if you have aortic stenosis. You could have a diffuse injury, chest wall heave if you have significant left ventricular hypertrophy. So again, if you look at these physical exam findings, they're really related to that end organ damage, not so much related to the actual blood pressure reading. So what do our guidelines tell us? A few pearls around management. So again, those ACC AHA 2017 guidelines suggest that adults with untreated systolic blood pressure greater than 130 but less than 160 or greater than 80 diastolic but less than 100 use a daytime ambulatory blood pressure monitoring to rule out white coat syndrome. So give them a little bit of a benefit of the doubt and send them home with an ambulatory blood pressure monitor. And adults with untreated systolic pressure 120 to 129 or diastolic 75 to 79, the same recommendation is reasonable. So again, you've got borderline numbers. Are they typically higher when they're home? So you're welcome to go ahead and do that ambulatory blood pressure monitoring again. And adults with hypertension screen for primary aldosteronism when any of the following are present. And I will tell you, I've had some very difficult to treat hypertensions or hypertensives and found out within the workup they ended up with primary aldosteronism. And if you don't treat that, you will never get that blood pressure down to where you need it. So these are the times when you begin to look for that. Resistant hypertension, just as I mentioned, they're failing medical management. Hypokalemia, so get that CHEM 7, see what their potassium is. An incidentally discovered adrenal mass, go back and look at their CT scans or any of their old imaging if they've had any of that done in the past. Family history of an early onset hypertension and then stroke at a young age less than 40. So what about management? So two or more antihypertensive medications are recommended to achieve a blood pressure less than 130 over 80. So don't be afraid to add the second med or even the third med. And I will tell you, you will get pushback from some of your patients. My own mother struggles with the thought of having to be on one, let alone two. That what we fail to maybe not educate our patients about is that when we utilize blood pressure meds, they often target or their mechanism of action is different. And sometimes it takes two different mechanism of actions or two different targets in order to really get that pressure down. And then also remember that your blood pressure medications of choice are driven by comorbidities. So you might use an ACE inhibitor and ARB if they're diabetic or have chronic kidney disease. You might use a beta blocker if they have cardiovascular disease. So your choice also has to do with their other comorbidities. I'm not going to go through all of this today, but we've got our hypertension JNC8 recommendations. And I think they did a really nice job of going through the drug classes and giving you some agents of choice, as well as some additional comments. Also gave you some good comorbidities and talked about when different classes are associated or should be used with those comorbidities. All right, let's transition to hyperlipidemic management. So 10 key points from the Multisocietal 2018 Hyperlipidemia Guidelines. Number one, all individuals, you need to emphasize a heart-healthy lifestyle across the life course. You're not doing them any good if you just start them on a med without giving them lifestyle education. In patients with atherosclerotic heart disease, reduce the LDL-C with high-intensity statins or maximally tolerated statins to decrease that risk. And I'm going to talk about what's high-intensity versus medium versus low in a moment. In every high-risk coronary artery disease or atherosclerotic cardiovascular disease, use an LDL-C threshold of 70. We've had this number for a long time, that threshold of 70 to consider addition of non-statins to statins. So if you can't get that LDL lower than 70, you need to think about adding another medication as outlined here. In patients with severe primary hypercholesterolemia, an LDL-C greater than or equal to 190, you need to use high-intensity statin therapy whether or not they have atherosclerotic disease or not. And then in patients that are 40 to 75 with diabetes and an LDL greater than 70, start that moderate-intensity statin. Again, if they don't necessarily have coronary disease, you're still at higher risk with their diabetes and use that moderate-intensity statin. In addition, adults 40 to 75 with primary atherosclerotic disease prevention, so it's primary prevention, have a clinician-patient risk discussion before starting statin therapy, so risk versus benefit. In adults 40 to 75 without diabetes and with an LDL greater than or equal to 70, at a 10-year atherosclerotic risk of greater than or equal to 7.5%, start a moderate-intensity statin if the discussion of treatment options favors the statin therapy. As above, if the atherosclerotic CV disease is 5 just below 20%, risk-enhancing factors favor initiation of statin therapy. And then if that risk is greater than or equal to 7.5 to 19.9, if a decision about statin therapy is still uncertain, so the patient isn't really there yet, consider measuring a calcium score, a CT calcium score. And then assess adherence and percentage response to LDL-C lowering medications and lifestyle changes with repeat lipid measurements 4 to 12 weeks after, so 1 to 3 months, and repeat it every 3 to 12 months as needed. So again, monitor that lipid panel or lipid profile to make sure that you're getting the benefits and the improvement that you're looking for. Again, 10 different rules here or guidelines. This is one of those. Go ahead and print it out and hang it up somewhere because you've got a lot of different scenarios here to think about. I talked about the high, moderate, or low-intensity statin therapies. You'll see that right here. The high-intensity, you really only have two choices, atorvastatin 80 or risuvastatin 40. And then the moderate, you've got a few more choices, and then you can kind of see the low. So that ends today's video. I hope that was helpful. Again, just try to pull out some of those pearls from your readings, and I appreciate your engagement, and certainly let us know if you have any questions. Thank you.

screening recommendations

hypertension management

hyperlipidemia management

blood pressure classification

statin therapy