High Cholesterol and High Blood Pressure Management
Student Doctor Jocelyn Lee
DO/MPH Candidate2015
Touro Univeristy-CA Student Run Health Clinic
AFT III (Adult Treatment Panel III) for Cholesterol Management in Adult
Screening and Treatment Plan for Cholesterol:
Step 1: Determine lipoprotein levels
Step 2: Identify high risk (CHD & equivalents) ******
Step 3: Determine other major risk factors******
Step 4: 2+ risk factors assess 10 year risk
Step 5: Determine risk category
Step 6: Initiate therapeutic lifestyle change******
Step 7: Consider adding drug if LDL not at goal
Step 8: Identify metabolic syndrome and treat******
Step 9: Treat elevated triglycerides & non-HDL
******= can be assessed at Student Run Health Clinic
AFT and HTN protocol activated if initial triage BP is >120/80
Step 2Identify high risks
1. Symptomatic carotid artery disease
2. Peripheral arterial disease: ankle/brachial index < .9 (measure systolic blood pressure of
ankle and brachial artery)
ABI
PAD
0.95-1.20
Normal
< 0.90
Significant
< 0.40*
Severe usually
manifests as rest
pain or ulceration
3. Abdominal aortic aneurysm
4. Diabetes Mellitus
Step 3-detremine other major risk factor
1. Age (male > 45 yrs, female> 55 yrs)
2. BP > 140/90 mm/Hg
3. HDL < 40 mg/dl in male; < 50 female
4. Family history of premature CHD
High Cholesterol and High Blood Pressure Management
Touro University-CA Student Run Health Clinic
Family History: Important in Early Risk of CHD
Most early CV events occur in families with a positive history of CV disease
– Odds are worse when family members present at younger age or multiple
relatives are involved
– Sibling history may be more strongly associated with risk than parental history
14% of general US population has a family history of premature CHD
These families with a history of premature CHD account for 72% of new cases of
premature CHD
Step 6: Recommend TLC Diet
• Diet to consist of 25-35% calories as fat with < 7% as saturated fat and cholesterol <
200 mg/day plus consider increasing viscous (soluble) fiber (10-25 g/d) and plant
stanols/sterols (2 g/d)
• Weight management
• Increased physical activity talk to your doctor before starting exercise
Notes: plant sterols are naturally occurring compounds that compete with body’s
cholesterol for absorption; they are in vegetables oils, nuts, rice and soy milk,
pomegranate and dark chocolate. Supplements forma are also available.
Step 8: identify Metabolic syndrome:
1. abdominal obesity (waist circumference >40 inches in men or >35 inches in women),
2. glucose intolerance (fasting glucose >110 mg/dL),
3. BP >130/85 mmHg,
4. high triglycerides (>150mg/dL)
5. low HDL (<40 mg/dL in men or <50 mg/dL in women).
If patient fit 3 out of 5 it is diagnostic of metabolic syndrome
High Cholesterol and High Blood Pressure Management
Touro University-CA Student Run Health Clinic
TREATMENT of Metabolic Syndrome:
Intensive lifestyle modification should be pursued in all individuals with the metabolic
syndrome, and appropriate drug therapy should be instituted for each of its components as
indicated.
Hypertension Management:
Risk Factors for cardiovascular risk:
High Cholesterol and High Blood Pressure Management
Touro University-CA Student Run Health Clinic
Notes:
Family history of premature cardiovascular disease definition:
(First degree relative: parents or siblings: men under age 55 or women under age 65)
Most common organ damage: ischemic heart disease
Classification of Hypertension
The classification is based on the average of two or more properly measured seated BP
readings on each of two or more office visits. In contrast to the classification provided in the
JNC 6 report, a new category designated prehypertension has been added, and stages 2 and 3
hypertension have been combined. Patients with prehypertension are at increased risk for
progression to hypertension; those in the 130–139/80–89 mmHg BP range are at twice the risk
to develop hypertension as those with lower values.
Evaluation:
1-assesses lifestyle and identify CV risk factors
2-to reveal identifiable causes of high BP
3-assess target organ damage
High Cholesterol and High Blood Pressure Management
Touro University-CA Student Run Health Clinic
HTN goal:
140/90-general
130/80-HTN with compelling indication (history of heart failure, chronic renal disease or
diabetes)
Acurrate BP measurement:
The auscultatory method of BP measurement with a properly calibrated and validated
instrument should be used. Persons should be seated quietly for at least 5 minutes in a chair
(rather than on an exam table), with feet on the floor, and arm supported at heart level.
Measurement of BP in the standing position is indicated periodically, especially in those at risk
for postural hypotension. An appropriate-sized cuff (cuff bladder encircling at least 80 percent
of the arm) should be used to ensure accuracy. At least two measurements should be made.
Hypertensive Emergencies and Urgencies
Hypertensive emergencies are severe elevations in BP, often higher than 220/140 mm Hg,
complicated by clinical evidence of progressive target organ dysfunction. These patients require
High Cholesterol and High Blood Pressure Management
Touro University-CA Student Run Health Clinic
immediate admission and BP reduction (not necessarily to normal ranges) to prevent or limit
further target organ damage. Examples include hypertensive encephalopathy, intracranial
hemorrhage, acute myocardial infarction, acute left ventricular failure with pulmonary edema,
dissecting aneurysm, acute renal failure, and eclampsia of pregnancy. Immediate admission to a
monitored unit and parenteral antihypertensive therapy are indicated. It is the clinical state of
the patient—in particular, the degree of and/or progression of target organ damage—–that
defines a hypertensive emergency and not the absolute level of blood pressure.
Severe hypertension (urgencies) are marked elevations of BP, usually higher than 180/110 mm
Hg. Evidence of target organ damage is often present, but nonprogressive and manifesting
symptoms may include headache, shortness of breath, and pedal edema. Management in the
emergency department (ED) with oral agents is suitable, depending on the individual's
presentation, and follow-up within 24 to 72 hours is recommended. In many cases, with blood
pressure higher than 180/110 mm Hg, patients present without clinical symptoms and have no
clinical evidence of target organ damage. If untreated, they may be initiated on a two-drug
regimen or an existing treatment regimen may be modified. Emotional distress or
nonadherence with prior treatment are often at fault. These patients do not require BP
reduction to normal and, after brief observation in the emergency room, can be discharged,
with follow-up scheduled within 3 to 7 days.
High Cholesterol and High Blood Pressure Management
Touro University-CA Student Run Health Clinic
High Cholesterol and High Blood Pressure Management
Touro University-CA Student Run Health Clinic
Note: Compelling indication= history of heart failure, renal disease and diabetes
High Cholesterol and High Blood Pressure Management
Touro University-CA Student Run Health Clinic
Note: 1 teaspoon is 6 gram of NaCI
References:
Guidelines are available at
http://www.nhlbi.nih.gov/guidelines/current.htm
Hypertension information adapted from:
U.S. Dept of Health and Human Services. National High Blood Pressure Education Program. Seventh
Report of Joint National Committee on Prevention, Detection, Evaluation and Treatment on High Blood
Pressure (JNC7 Express)
High Cholesterol information adapted from Dean Michael Clearfield’s lecture PowerPoints-- Intro and
Group Cases coronary heart diseases
High Cholesterol and High Blood Pressure Management
Touro University-CA Student Run Health Clinic
Hypertensive crisis information adapted from:
http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/nephrology/hyperte
nsive-crises/#cesec1