General medicine Pearls

Hypertension (post SPRINT)

Definition: normal <120/80, elevated BP <130/80, Stage 1 <140/90, Stage 2 >139/89 (take readings properly - 2 readings , 2 occasions, 1 minute apart: sit quietly 5 minutes off phone, with both feet on the floor, note highest: automated without doctor, home monitoring with calibrated cuff checked twice a year - 2 before meds and 2 in afternoon after medications, ambulatory ie. not manually by the physician)

Why important?: sBP>140 is risk factor for vascular disease (CVA, AMI, ESRF)

If need more than two medications: work player-coach relationship

Targets: <150/90 (strong) or

<140/90 (ACP evidence) or <130/80 (after SPRINT ACC/AHA consensus): if >60 for secondary prevention (prior CVA, AMI, CKD but no improved mortality or if high risk (non diabetic 10 year ASCVD risk >10% -  and diabetic) (SPRINT NNT63 5.2% vs 6.8% with >50% on 3 agents BP 120 vs 136: strict target not for everyone; ACCORD 2010 no CV outcomes): <140/90 (if already on 2 agents) or <130/80 (balance against high pill burden, impaired perfusion eg. AKI/cognition

First line:

non-pharmacological: exercise, diet, EtoH, weight loss
Single agent: if stage I, two agents if average >20/10 above target.

thiazide (CTD>HCT), CCB, ACE, ARB

CKDIII or CKDI/T2DM with microalbumin (>300mg/d, mg/g alb/Cr): ARB/ACE; HFrEF: Betablocker (avoid CCB), HFpEF+volume overload: diuretics then ACE/ARBs/BB

CKD