The Curbsiders Outstanding Hypertension Minicourse With Additional Resources On Other Outstanding Podcasts

In this post, I list the Curbsiders hypertension posts that I reviewed today. They are outstanding and grouped together make up what I like to call a minicourse.

Here are the podcasts I reviewed today:

  • #254 Hypertension Update with Dr. Wanpen Vongpatanasin
    • Transcript: 254-Hypertension Update
    • “Listen as our esteemed guest Dr. Wanpen Vongpatanasin, @DrWanpen (UT Southwestern) discusses the nitty-gritty of blood pressure monitoring and hypertension treatment. We review the thresholds for HTN diagnosis and how to accurately measure blood pressure levels at home and in the office. Dr Vongpatanasin shares the latest guideline recommendations for first line pharmaceutical therapies as well as her pearls about how to treat special populations.”
    • Gorth DJ, Valdez I, Vongpatanasin W., Williams PN, Brigham SK, Watto MF. “#253 Hypertension Update with Dr. Wanpen Vongpatanasin”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list Final publishing date February 1, 2021.
  • #321 Hypertension FAQ: Common Outpatient Cases with Dr. Jordy Cohen
    • “Master common hypertension scenarios in the clinic! Our guest Dr. Jordy Cohen (@jordy_bc) will lead us through the FAQs of outpatient hypertension management, including making a diagnosis of hypertension, managing blood pressure in patients with chronic kidney disease, working up refractory hypertension, and more.”
    • Gandhi MM, Cohen J, Williams PN, Watto MF. “#321 Hypertension FAQ: Common Outpatient Cases.” The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list February 14, 2021.
    • “Given that standardized ideal office blood pressure measurements (which our research trials are based on) are so rarely actually achieved in practice, the USPSTF now recommends out-of-office home blood pressure checks to confirm a diagnosis of hypertension with Grade A evidence (USPSTF guidelines).”
    • “Of course, obtaining reliable home measurements hinges on educating patients about the proper steps in taking their blood pressure. Dr. Cohen suggests the infographics on targetBP.org  as good patient-friendly educational tools. Patients should be instructed to obtain a validated device, ideally, one listed on www.validateBP.org.”
    • “With regards to the number of blood pressure measurements needed to reliably estimate home blood pressure, Bello, 2018 indicated that a minimum of 3 days of morning and evening measurements was sufficient. Over those three days, Dr. Cohen recommends that patients obtain two consecutive readings in the morning (before their AM medications and before their morning coffee), and two consecutive readings in the evening about 12 hours later (before their PM medications.)”
    • Initial blood pressure regimen: Single agent vs. combination therapy
      • “There is a growing body of literature in support of low-dose combination therapy as opposed to monotherapy for initial blood pressure management (Salaam et al, 2019).
      • Dr. Cohen’s preferred combination therapy for initial treatment: low-dose calcium channel blocker (ex: 2.5 mg amlodipine) + ARB (ex: 10 mg olmesartan). “
      • Counseling patients on the teratogenicity of ACEis/ARBs and the need for birth control while on these medications is important prior to initiation.”
      • “ACE inhibitors and race: Dr. Cohen favors ARBs as first-line in blood pressure management regardless of a patient’s race.  .   .  She notes that Black patients have been shown to have higher rates of cough/angioedema from ACE inhibitors (Miller et al, 2008Brown et al, 1996Elliot 1996), and all patients are at risk for these side effects making ARBs an attractive first-line over ACE inhibitors for everyone.”
    • Thiazides
      • Dosing: For hydrochlorothiazide, Dr. Cohen recommends a starting dose of 25 mg (she notes that 12.5 mg, which is a commonly used starting dose, is actually much too low!) For chlorthalidone, Dr. Cohen recommends a starting dose of 12.5 mg daily. Unfortunately, the 25 mg pill is small and difficult to break in half, though she tells patients that it is okay if they can’t break it precisely in half given that chlorthalidone has such a long half life. Alternately, other providers have advocated for starting patients on one 25 mg pill of chlorthalidone every other day based on its long half life.”
    • Gandhi MM, Cohen J, Williams PN, Watto MF. “#321 Hypertension FAQ: Common Outpatient Cases.” The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list February 14, 2021.
  • #386 Primary Aldosteronism, MRAs, and Renovascular Hypertension: NephMadness Pod Crawl 2023
    • Download the Transcript
    • “We demystify primary aldosteronism, MRAs (mineralocorticoid receptor antagonists), non-steroidal MRAs, and how to recognize and treat renovascular hypertension with nephrologist/hypertension expert, Dr. Matt Luther (@DrJMLuther) as part of the NephMadness  PodCrawl 2023.
    • Watto MF, Luther JM, Williams PN. “#386 Primary Aldosteronism, MRAs, and Renovascular Hypertension: NephMadness Pod Crawl 2023”. The Curbsiders Internal Medicine Podcast. https://thecurbsiders.com/episode-list Final publishing date March 20, 2023.
      1. Primary aldosteronism (PA) is common! Test all patients with hypertension at least once for primary aldosteronism with early morning aldosterone and renin.
      2. PA suspected? Check EKG for LVH +/- repolarization abnormalities, proteinuria/albuminuria & creatinine trends; assess for glomerulonephritis, and excess cortisol production.
      3. Aldosterone excess causes renal hyperfiltration, and treatment with MRA or adrenalectomy often results in “unmasking” renal dysfunction, so expect an initial decline in eGFR!
      4. Both primary aldosteronism and renovascular hypertension confer an increased risk for cardiac and renal disease, so aggressive medical management is warranted!
      5. Renin will become elevated when spironolactone (or eplerenone) reach appropriate doses, so titrate them accordingly.
      6. We must be selective about who we work-up for renovascular hypertension because revascularization is not more effective than medical therapy in most patients.
      7. Renovascular hypertension should first be treated with standard blood pressure medications and cardiovascular risk reduction.
      8. Serial imaging can be pursued if renovascular disease is suspected because renal atrophy can occur over the course of several months and sometimes the initial read is inaccurate.Top Pearls *Please see The Endocrine Society For guidelines on diagnosis and treatment in Adrenal Health and Disease
  • #390 Resistant Hypertension
    • Download the Transcript
    • “Tackle resistant hypertension. Learn when it is pseudo resistant hypertension, and how to treat this pesky condition when it is true resistant hypertension. Dr. Jordy Cohen (@jordy_bc) leads us through her approach to keeping the BP where it should be (University of Pennsylvania).”
    • Gorth DJ, Cohen J, Williams PN, Watto MF. “390 Resistant Hypertension”. The Curbsiders Internal Medicine Podcast. thecurbsiders.com/category/curbsiders-podcast Final publishing 17th April, 2023.
    • Resistant Hypertension Pearls
      • Hypertension is a systolic blood pressure (BP) ≥ 130mm Hg and/or a diastolic BP ≥ 80 mmHg (2017 ACC/AHA Guidelines)
      • Citalopram is useful in lowering blood pressure in patients with comorbid treatment resistant hypertension and anxiety (Fu et al 2015).
      • Have a low threshold for adding a third agent in a patient who is still hypertensive despite already being on two antihypertensive agents. Using multiple antihypertensive agents targeting different pathways at a lower dose can achieve blood pressure control with fewer side effects (Bennett et al 2017).
      • A patient has resistant hypertension when they are on the optimally tolerated doses of three first line antihypertensive agents and still have a blood pressure above goal. (Carey et al 2018).
      • An accurate blood pressure is an average of 3 readings using an automated device taken after the patient has rested for 5 minutes, and has their feet flat on the floor, back supported, and their bare arm supported at about the level of their heart (2017 ACC/AHA Guidelines).
      • Dr Cohen suggests that we address nonadherence by partnering with patients using phrases like “are there any side effects that I can help you with?”
      • Fixed dose combination pills can be a tool to fight against nonadherence (Parati et al 2021).
      • If certain chemotherapeutic agents (e.g., VEGF-inhibitors, TKIs) are being held, the antihypertensive agents may also need to be dose-reduced or held while closely monitoring blood pressure to avoid dangerous hypotension (Cohen et al 2023).

This entry was posted in Cribsiders, Curbsiders, Hypertension, Podcasts. Bookmark the permalink.