Hypertension

An 83-year-old woman is hospitalized for treatment of deep venous thrombosisin her left leg. She underwent left hip replacement surgery 2 months earlier.At that time, mild anemia (hemoglobin level, 10 g/dL) was noted, and iron therapywas initiated. An iron panel obtained shortly after the hip surgery revealeda serum iron level of 80 μg/dL, a transferrin level of 360 mg/dL, and a ferritinlevel of 50 ng/mL.

Issues of when and whom to screen for various diseases and conditions have longbeen sources of controversy. The amount of information about screening tests canbe overwhelming, and the costs of the latest preventive technology can be daunting.To provide an evidence base for decision making in one source for busy clinicians,Dr Snow has compiled key previously published reviews of the data behind the latestUS Preventive Services Task Force (USPSTF) screening recommendations fortype 2 diabetes, postmenopausal osteoporosis, breast cancer, colorectal cancer, andprostate cancer. Also included are reviews of the evidence concerning chemoprophylaxisof cardiovascular disease (with aspirin and with hormone replacementtherapy) as well as reviews of the latest data on screening for hypertension and depression,which were specially commissioned for this volume. The reviews containguidelines on which patients to screen and address the issue of screening frequency-in terms of both optimum patient care and maximum cost-effectiveness. Inaddition, a list of key points that summarize important “take-home” messages precedeeach review. The book also contains a valuable introduction (“How to ThinkAbout Screening” by David M. Eddy, MD, PhD) and a concise guide to 25 preventiveservices.

My patient-an 84-year-old woman with hypertension-presented with itchingand blistering of 3 days’ duration on her right foot (Figure).

Q:Should hypertensive patients be discouraged from participating inmoderate to vigorous exercise?A:On the contrary, most patients with sustained hypertension should bestrongly encouraged to exercise regularly at moderate to vigorous levels.Randomized controlled clinical trials have demonstrated that increasedphysical activity can lower blood pressure (BP) and delay or prevent the developmentof hypertension and thus the need for antihypertensive medication.1In addition, physical activity can help reduce cardiovascular risk factors by improvinglipid profiles and reducing weight and blood glucose levels. In elderlypersons, exercise is associated with improvements in osteoporosis, depression,and physical functioning, as well as an enhanced sense of well-being.

Cataracts areone of themost importantcauses ofreversibleblindness in elderly persons.1 A recent report thatpredicts a surge in cataractincidence has heightenedawareness of the importanceof proper timing andtechniques for cataract extraction.The study, authoredby the Eye DiseasesPrevalence ResearchGroup, estimated that thenumber of Americans withcataracts will increase byapproximately 50% in thenext 20 years as the populationages.2 Cataracts werethe leading cause of low vision(less than 20/40 bestcorrected visual acuity inthe better-seeing eye)among whites, blacks, andHispanics.

The FDA has approved injectable Acetadote (acetylcysteine)from Cumberland Pharmaceuticals Incto prevent or lessen liver damage resulting from an overdoseof acetaminophen. According to the FDA, unintentionalacetaminophen overdose is responsible for 100deaths and 56,000 emergency department visits per year.

Is treatment recommended for high-normalblood pressure (BP)-say, 135/88 mm Hg-ina postmenopausal woman?

We chose to present this case to readersbecause the patient’s neurologicexamination was normal and her presentationthus appeared benign.

I have read that mental confusion and paranoia may be potential side effects ofcertain angiotensin-converting enzyme (ACE) inhibitors.

A 67-year-old man complainsof abdominal distention and bouts ofdiarrhea with intermittent constipation.These symptoms have beenpresent for weeks but recently havebecome more severe. The patienthas not seen blood in his stool. Hedenies fever, travel to a foreign country,and recent trauma. He has hypertension,which is well controlledwith calcium channel blockers.

For several weeks, a 68-year-old man has had painful blisterson his hands that crusted as they healed. The patienthas diabetes mellitus, hypertension, and chronic renalfailure, for which he is undergoing hemodialysis. His longtermmedications include a hypoglycemic agent and adiuretic.

A 62-year-old woman was found on thefloor of her bathroom at home with herwheelchair partially on top of her.She was unresponsive except to painfulstimulus.

What is the risk of dementia in patients who have had an ischemic stroke?

In this compact clinical guide, the author presents detailed prescribing advice forall types of cardiac patients. The first chapters are devoted to the principal classesof cardiac drugs: β-blockers, angiotensin-converting enzyme inhibitors, angiotensinII receptor blockers, calcium antagonists, and diuretics. These chapterscover such topics as indications, contraindications, adverse effects, interactions,dosages, differences between the available agents in a given class, and how tochoose the most appropriate agent from a class for a particular patient. Chapterson the management of the various cardiac disorders-hypertension, angina, acutemyocardial infarction, heart failure, arrhythmias, cardiac arrest, infective endocarditis,and hyperlipidemia-comprise the core of the book. There are also chapterson antiplatelet agents, anticoagulants, and thrombin inhibitors; and the use ofcardiac drugs during pregnancy and lactation. The sixth edition features a newchapter on recent clinical trials, new American Heart Association cardiac arresttreatment algorithms, current hypertension management guidelines, and expandeddrug administration and dosage tables. Numerous tables, charts, algorithms,and graphs accompany the text.

A 49-year-old man complains of sharp pain in the medial left ankle that begansuddenly 3 nights earlier, waking him up. That night he also felt feverish anddiaphoretic, but those symptoms have subsided. The pain is present whenhe moves the ankle or when a shoe compresses the area. No other joints areinvolved. He denies trauma to the ankle or foot.

In his Hypertension Q&A, “When Snoring Has More OminousConsequences Than a Sleepless Spouse” (CONSULTANT,October 2003, page 1410), Dr Donald Vidt suggestsseveral questions that a physician can ask patients to screenfor obstructive sleep apnea (OSA).

A number of my patients have very high high-density lipoprotein cholesterol (HDL-C)levels as well as elevated total cholesterol and low-density lipoprotein cholesterol(LDL-C) levels. One such patient is a nonsmoking middle-aged woman whose weightand blood pressure are normal.

For 2 days, a 49-year-old man with hypertension and hypercholesterolemiahas experienced light-headedness and fatigue.Based on the presenting ECG, what is the most likely cause of hissymptoms?A. Accelerated junctional rhythm.B. First-degree atrioventricular (AV) block.C. Mobitz type I (Wenckebach) second-degree AV block.D. Mobitz type II second-degree AV block.E. Third-degree AV block (complete heart block).

For over 25 years, NSAIDs have been used to treat a variety of pain syndromesand inflammatory diseases. More than 50 million Americanstake these drugs. Unfortunately, control of pain and inflammation is notachieved without an associated cost-namely, GI complications and, to a lesserextent, nephrotoxicity.In an attempt to reduce drug-related toxicity, a new class of selectiveNSAIDs-the COX-2 inhibitors-was introduced in 1999. These selectiveNSAIDs are as effective as and pose less risk of gastric toxicity than nonselectiveNSAIDs.1,2The COX-2 inhibitors are thought to reduce end-organ injury, such as GIulceration, by sparing homeostatic or “constitutive” COX-1 enzyme function.1,2 Incontrast, therapeutic effects result from the inhibition of the “inducible” COX-2enzyme.1,2 Such drug effects target the production of proinflammatory prostaglandinsby COX-2 without interrupting normal cell function mediated by COX-1.2,3

A 66-year-old woman presents tothe emergency department(ED) with exertional dyspnea, generalizedweakness, and orthostaticdizziness; the symptoms startedabout 1 week earlier and have progressedinsidiously. The patient alsoreports diaphoresis and nausea withoutvomiting. She has no chest pain,palpitations, cough, or hemoptysis;she has not had a recent respiratorytract infection. While she is waitingto be admitted, she has an episode ofsyncope.

A painful scalp eruption of 4 days’duration brings an 81-year-old man toyour office. He has taken a lipid-loweringagent and an antihypertensivefor years but has not started any newmedications recently. One week earlier,he had a haircut. He denies recenttrauma to the scalp.

I recently diagnosed type 2 diabetes mellitus in a 33-year-old man who has no diabeticsymptoms, proteinuria, or evidence of nephropathy. His blood pressure is low(100/60 mm Hg).

A 55-year-old constructionworker who spends a gooddeal of time outdoors has had occasionalblurred vision and an irritatedeyelid for several days. He has wellcontrolleddiabetes and hypertension.Which of these conditions doyou suspect?

In his article, “Subclinical Hypothyroidism: When to Treat, When to Watch?”(CONSULTANT, April 1, 2004, page 533), Dr Vahab Fatourechi notes that thereis some evidence that subclinical hypothyroidism has adverse effects on cardiovascularfunction that may contribute to left ventricular systolic dysfunction with effort.

For 3 days, a 42-year-old man has had episodic dullchest pain. The anterior precordial and retrosternalpain intensifies with inspiration and movement. He has nohistory of recent viral infection, hypertension, coronaryartery disease, cardiac surgery, diabetes mellitus, or hyperlipidemia.There is no family history of cardiovasculardisease.

A 38-year-old overweight woman presents with an asymptomatic rash ofat least 2 months’ duration that had not responded to a combinationcorticosteroid/antifungal agent. She has mild hypertension and type 2 diabetesmellitus that is being managed with diet and exercise. She is otherwisehealthy.

Intermittent, worsening confusion recently developed inan 82-year-old man. His daughter brings him to the officefor evaluation.

A 64-year-old woman complainsof neck fullness that has increased inthe last few months. She has occasionaldyspnea but denies fever, cough, andhemoptysis. Hypertension is well-controlledwith propranolol.

To demonstrate to hypertensive patientsthe effect of high blood pressureon the heart, have them wrap onehand around a partially inflated sphygmomanometercuff and close thevalve.

Long-standing chorioretinal scarring in both eyes didnot affect a 67-year-old woman’s vision. The scars wereroundish, irregular, and yellowish white with interior pigmentation(A and B).