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A 58-year-old African American male presents for a routine physical. His blood pressure is measured as 162/94 mmHg. This reading is repeated after 5 minutes and found to be 158/92 mmHg. He reports occasional headaches but is otherwise asymptomatic. He has a BMI of 32, family history of hypertension, and works a high-stress job. What additional assessments should be performed to evaluate for target organ damage?
Answer: This patient requires a comprehensive evaluation including fundoscopic examination to assess for hypertensive retinopathy, cardiac assessment (ECG, possibly echocardiogram) to evaluate for left ventricular hypertrophy, laboratory tests (BUN/creatinine, urinalysis) to assess renal function, and neurological assessment. His stage 2 hypertension, combined with multiple risk factors (obesity, family history, race, stress), places him at high risk for complications.
| Medication Class | Primary Mechanism | Preferred Population | Major Side Effects | Key Considerations |
|---|---|---|---|---|
| Thiazide Diuretics | ↑ Na+ excretion, ↓ blood volume | African Americans, Elderly | Hypokalemia, hyperglycemia, hyperuricemia | Monitor electrolytes; most cost-effective |
| ACE Inhibitors | Block angiotensin II formation | Diabetes, CKD, HF, post-MI | Dry cough, angioedema, hyperkalemia | Contraindicated in pregnancy; monitor K+ and renal function |
| ARBs | Block angiotensin II receptors | Diabetes, CKD, ACE-I intolerance | Hyperkalemia, dizziness | Contraindicated in pregnancy; fewer side effects than ACE-I |
| CCBs | Block Ca2+ influx in smooth muscle | African Americans, Elderly | Peripheral edema, constipation, gingival hyperplasia | Dihydropyridines vs. non-dihydropyridines have different effects |
Never combine ACE inhibitors with ARBs as this dual RAAS blockade increases risk of hyperkalemia, hypotension, and acute kidney injury without providing additional benefit. Similarly, avoid combining potassium-sparing diuretics with ACE inhibitors or ARBs without careful monitoring of potassium levels and renal function.
ACE inhibitors and ARBs are contraindicated during pregnancy due to risk of fetal renal malformations, oligohydramnios, and fetal death. Women of childbearing age taking these medications must use reliable contraception and should be switched to safer alternatives (methyldopa, labetalol, nifedipine) if pregnancy occurs or is planned.
| Term | Definition | Clinical Significance | Management Approach |
|---|---|---|---|
| Primary (Essential) Hypertension | Elevated BP without identifiable cause (90-95% of cases) | Multifactorial etiology involving genetic and environmental factors | Lifestyle modifications plus pharmacotherapy based on comorbidities |
| Secondary Hypertension | Elevated BP due to identifiable underlying condition | Often presents with resistant hypertension or atypical features | Treat underlying cause (e.g., renal artery stenosis, pheochromocytoma) |
| White Coat Hypertension | Elevated BP in clinical settings but normal at home | Lower cardiovascular risk than sustained hypertension | Home BP monitoring, ambulatory BP monitoring, lifestyle changes |
| Masked Hypertension | Normal BP in clinical settings but elevated at home | Associated with increased cardiovascular risk | Home BP monitoring, ambulatory BP monitoring, treat as sustained HTN |
| Hypertensive Urgency | Severe BP elevation (>180/120) without acute target organ damage | Requires prompt but not emergency treatment | Oral medications, close follow-up within days |
| Hypertensive Emergency | Severe BP elevation with acute target organ damage | Life-threatening condition requiring immediate intervention | IV medications in ICU setting, gradual BP reduction |
| Medication Comparison | Key Differences | Side Effect Profiles | Clinical Considerations |
|---|---|---|---|
| ACE Inhibitors vs. ARBs | ACEIs block angiotensin II formation; ARBs block receptors | ACEIs cause dry cough (10-20%); ARBs rarely cause cough | Similar efficacy and indications; ARBs preferred if ACEI cough develops |
| Thiazide vs. Loop Diuretics | Thiazides act on distal tubule; loops on ascending loop of Henle | Both cause electrolyte imbalances; loops more potent diuresis | Thiazides preferred for HTN; loops for HF or CKD with GFR <30 |
| DHP vs. Non-DHP CCBs | DHPs (amlodipine) primarily affect vessels; non-DHPs affect heart | DHPs: peripheral edema; non-DHPs: bradycardia, constipation | Non-DHPs contraindicated with beta-blockers or heart failure |
| Cardioselective vs. Non-selective Beta-Blockers | Cardioselective (metoprolol) primarily affect β1 receptors | Non-selective can cause bronchospasm, mask hypoglycemia | Cardioselective preferred in diabetes, COPD, or asthma |
Angioedema (rare but serious)
Cough (dry, persistent, non-productive)
Elevated potassium (hyperkalemia)
Which patient should the nurse assess first?
Answer: C. The patient with BP 210/118 reporting visual changes and confusion shows signs of possible hypertensive emergency with neurological involvement requiring immediate assessment and intervention.
Alteration in mental status (confusion, lethargy, seizures)
Blurred vision or other visual disturbances
Chest pain or cardiac dysfunction (heart failure)
Dyspnea (pulmonary edema)
End-organ damage (renal failure, papilledema)
A 62-year-old patient with hypertension is prescribed lisinopril. Which assessment finding would warrant immediate notification of the provider?
Answer: C. Facial and lip swelling with difficulty swallowing indicates angioedema, a potentially life-threatening reaction to ACE inhibitors requiring immediate discontinuation and intervention.
A nurse is teaching a patient with newly diagnosed hypertension about the DASH diet. Which meal choice best reflects adherence to this diet?
Answer: B. Baked salmon with brown rice, steamed vegetables, and water aligns with DASH diet principles: lean protein, whole grains, vegetables, and low sodium.
A patient with hypertension is prescribed hydrochlorothiazide. Which laboratory value should the nurse monitor most closely?
Answer: A. Thiazide diuretics commonly cause hypokalemia, which can lead to cardiac arrhythmias and requires close monitoring.
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