You know that abnormal blood pressure is a component of many disease conditions that will be covered on the Physician Assistant Exam. Hypertension is the term for high blood pressure, and it’s an epidemic in the United States. Blood pressure is useful for assessing health, too. That’s why along with temperature, heart rate, and respiratory rate, blood pressure is called a vital sign.
Hypertension is called the “silent killer” because it’s a significant risk factor for coronary artery disease (CAD) and stroke, and it’s also the second leading cause of kidney disease, right behind diabetes mellitus. In fact, CAD and diabetes often coexist.
The Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC) cites four blood pressure categories. Below, you will see the numbers from the JNC’s seventh report. If you haven’t memorized these before, now is a good time.
The blood pressure categories list or numbers, not and numbers. If the systolic and diastolic blood pressure are in different ranges, the patient goes in the higher range. For example, if someone has a blood pressure of 130/98 mmHg, he or she has Stage 1 hypertension, even though the systolic blood pressure is in the range of prehypertension. The elevated diastolic blood pressure marks it as Stage 1 hypertension.
| Category | Systolic (mmHg) | Diastolic (mmHg) |
|---|---|---|
| Normal (desirable) | 90–119 | 60–79 |
| Prehypertension | 120–139 | 80–89 |
| Stage 1 hypertension | 140–159 | 90–99 |
| Stage 2 hypertension | 160 or greater | 100 or greater |
You need a minimum of three elevated readings to establish a diagnosis of hypertension. You may get these readings from several office visits; however, many people also measure their blood pressure at home. The gold standard for diagnosis is actually ambulatory blood pressure monitoring — it should be used way more than it’s prescribed.
You’re evaluating a 65-year-old man at his annual physical. On examination, you get a blood pressure reading of 158/90 mmHg. Blood pressure measurements similar to this have been obtained on prior office visits and at his home. Which of the following would you prescribe?
(A) Lisinopril (Zestril)
(B) Metoprolol (Lopressor)
(C) Hydrochlorothiazide (HCTZ)
(D) Clonidine (Catapres)
(E) Terazosin (Hytrin)
The correct answer is Choice (A). This question asks what you’d pick first-line for someone coming into your office for hypertension. When Rich was in medical school, the first-line medications were lisinopril or hydrochlorothiazide.
Choice (A), lisinopril, is first-line, because ACE inhibitors like lisinopril do so much above and beyond lowering blood pressure. They’re heart protective. They help improve mortality in the setting of congestive heart failure, and they help lower proteinuria in someone with diabetic nephropathy.
What’s a second-line med? Well, based on the ON-TARGET trial, it’s amlodipine (Norvasc), which is more of a vasodilator. Third-line is Choice (C), hydrochlorothiazide (HCTZ). Choices (B) and (D) are used later on and in specific instances. Choice (B), metroprolol, is used with someone after a myocardial infarction when the person has an indication of heart failure in the treatment.
Choice (D), clonidine, is used when other medications don’t work. Side effects of clonidine include dry mouth, lethargy, and hypotension. Choice (E), terazosin, is used in someone who has both benign prostatic hyperplasia (BPH) and problems with high blood pressure.