Hyperstention. Conclusion

Start with a low dose diuretic or a beta blocker, they are equally effective as the new more expensive agents, they are known to provide important benefits to patient’s. I f you want to use long acting calcium channel blockers, there is evidence in the elderly that they are beneficial, it appears as though African Americans and the elderly are more responsive to diuretics so if you have patient’s in that category, a diuretic is the first drug, the contraindications to diuretics are only allergies and gout, and contraindications to beta blockers are listed there. If the patient has diabetes, heart failure or heart attack, refer the patient and I am sure you would all feel comfortable doing that. This is an alga rhythm that the JNC recommends, I won’t go through it, it is in your hand out, it basically says start with a diuretic, if that doesn’t work, you might switch to a beta blocker, or add, if you started with diuretics you can add a beta blocker and if that doesn’t work, then it’s time to refer the patient.

Followup care once drugs are initiated, one to two months, figure out if the patient is still taking the medicine, whether it’s making him sick, take their blood pressure when standing up to make sure they are not going to fall down in the bathroom and break their hip from hypotension. The lab tests you need to get are small in diuretics, basically it’s basic chemistry panel and calcium because diuretics on rare occasions can elevate calcium and see the patient every two months, once their blood pressure is controlled, you can see them annually. These drug diuretics are very safe and are very effective. There is a list of patient education issues, I can’t over emphasize this enough, if the patient doesn’t know why they are taking medicine, they will stop, because when they saw you, they didn’t feel their blood pressure and there weren’t sick, and now you are asking them to take pills and to do laboratory tests, you need to tell them that the reason to do this is so that they won’t be looking after their grandchildren paralyzed on the left side of their body with a stroke, it’s preventative care.

If you can’t counsel the patient or choose not to, get your nurse to do it. Therapy is life long for hypertension. It is the very rare patient who will get skinny and come off medicines. It happens but it’s rare. Some patient’s think I finished the bottle of my medicine and now I’m okay. Well if you didn’t tell the patient that it’s refillable on a p.r.n. basis for the rest of their lives, they wont’ know that.

Indications for referral. You can refer if you don’t feel comfortable treating at all but if you feel comfortable treating stage I hypertension with diuretic therapy, I would encourage you to do that. The patient has severe hypertension, end organ disease or some other important medical disease, it is reasonable to refer that patient to a general internist or cardiologist. If they have some evidence of secondary causes, or if you have tired a diuretic and/or a beta blocker and you don’t have their blood pressure below 140 and comfortably below 90, then it is a reasonable thing to refer that patient to somebody who is a little bit more comfortable using the large number of medications which we have for the treatment of hypertension.

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