2 Didactic Day 2
Theresa McHale: Adolescent Health
Case
Theresa McHale is a 15 year old female who comes to see you because she missed her period. Menarche occurred 4 years ago, she has no significant past medical history, and she takes no medications. She’s sexually active with a 17 year-old senior boy in her high school and says they use condoms. Her boyfriend is leaving to go to college next year and her grades have been down. Her parents had been fighting a lot recently and her father has been threatening to move out of the house. She is living with her mother Jill McHale, her brother Patrick McHale and her dad Brian McHale.
Physical Examination Findings:
Weight = 98 pounds. Height = 5’2”
Questions to Consider
- What additional history do you want to obtain from Theresa?
- What laboratory tests do you want to order?
- What is the most likely cause of her secondary amenorrhea?
The patient requests that you and she determine appropriate birth control in addition to condoms, and that you prescribe it without disclosing any information to her mother.
- Would you prescribe contraception? Do you have legal consent for treatment?
- Would you honor her request of confidentiality?
Learning Objectives
By the end of the session, the active participant will be able to:
- Identify adolescent risk factors and develop clinical strategies to screen for them.
- Describe clinical interventions for the prevention of teen pregnancy and STIs.
- Summarize medico-legal issues regarding medical care of adolescents, including confidentiality.
The Adolescent Interview
Useful questions when talking to adolescents – getting into teens’ HEADS
| HOME | Who lives with you at home? How do you get along with family members? Do you feel safe at home? (If teen lives with one parent) How often do you see the parent who does not live with you? What do you do together? What types of responsibilities do you have at home? What would you like to change about your family if you could? |
| EDUCATION | What grade are you in? At what school? What kind of grades do you make? What is your favorite class? What is your least favorite class? Do you have any particular goals for college or a career? |
| ACTIVITIES | What do you do for fun? What do you and your friends do outside of school? What kind of activities, organizations, or clubs do you participate in? What kind of exercise or organized sports do you do? Have you ever been injured in sports? How much screen time do you have daily? (computer, TV, video games) |
| DRUGS | Do you smoke cigarettes or use chewing tobacco? Do you drink alcohol? What is the most you have ever had to drink at one time? Have you ever done anything you later regretted after drinking? Have you ever tried other drugs? What type, and how often? Have you ever been in a car when the driver was impaired from alcohol or drugs? Have your friends ever tried to pressure you to do things that you don’t want to do? How did you handle that? |
| SEX | Is there anyone special in your life? Do you date or go out? With only one person or a lot of people? Do you have any concerns or questions about sex? Are you sexually active, or have you been in the past? With men, women, or both? Have you ever had sexually transmitted infection? Do you use any kind of birth control? What kind? Do you use condoms? Every time, or just sometimes? Has anyone ever touched you in a way you didn’t like? Forced you to have sex? |
| EMOTIONAL HEALTH | How do you cope with stress? What do you do to make yourself feel better when you are down or blue? Who do you talk to when you are upset or sad? Have you felt depressed in the past two weeks? Do you feel you have decreased interest in activities that you usually enjoy? |
Required Reading: Adolescent Health Care, Confidentiality
Required Reading: Consent to Reproductive Health Services by Young People
Tom Lee: Child with a Cough
Case
Tom Lee is a 7 year old male who comes in with his mother Brenda Lee. Tom had a persistent dry cough for several months despite three courses of antibiotics.
Questions to Consider
- What additional information do you want?
- What are the most important components of the physical exam of this patient?
- What labs/studies are indicated?
- What treatment would you initiate?
Learning Objectives
- Develop a differential diagnosis for chronic cough.
- List treatment strategies for the most common causes of chronic cough.
- Address traditional medical practices in a culturally competent way.
Required Reading: Chronic Cough (in children & adults)
Optional Resource: Asthma Care: Quick Reference
Brenda Lee: “Cold”
Case
Brenda Lee is a 31 year old female. Over the telephone, she explains that she has had a cough productive of thick yellow sputum for four days. She feels tired and achy and requests that you call in a Z-pak because that’s what your partner called in for her last year and it worked.
Questions to Consider
- What additional history is needed?
- Should this patient be prescribed antibiotics over the phone?
- Does this patient need to be seen in the office?
- What is the best way to manage this patient?
Learning Objectives
By the end of the session, active participants will be able to:
- Elicit an adequate history to evaluate a young healthy patient with a cough.
- Describe evidence-based management of bronchitis.
- Identify the indications and contraindications for prescribing antibiotics.
- Use shared decision making to develop a plan of care that is acceptable to the patient.
- Educate patients on the dangers of inappropriate antibiotic use in a way that preserves an alliance with the patient.
Required Reading: Treatment of the Common Cold
Mobile Medicard: URI
Ashley O’Brien: Immunizations
Case
Ashley O’Brien is an 18-month-old baby coming to you for a well-child check. She was born at a birthing center with the help of a midwife. Her mother, Peggy O’Brien, had a healthy pregnancy and a normal vaginal delivery at term without any complications.
Her parents have many concerns about the 18 month vaccines.
Weight: 75th percentile
Length: 50th percentile
Head Circumference: 65th percentile
Questions to Consider
- What history is needed?
- How can you discuss immunizations with this parent while preserving your doctor-patient relationship?
- What role does evidence-based medicine have in your discussion?
- How will you manage this case?
Learning Objectives
By the end of the session, the active participant will be able to:
- Develop strategies for discussing immunizations with parents.
- Use cultural humility and non-judgmental discussion approaches.
- Practice shared decision making.
Mobile Medicard: Immunization Handouts
Antonio Santiago: Diabetes Mellitus
Examples
Antonio Santiago is a 55 year old man who was diagnosed a decade ago with type 2 diabetes. His wife Marta loves to cook, especially rice dishes and delicious baked goods. Antonio’s BMI is 38 and his last A1c was 7.9.
Family History: His father Carlos died of stroke at age 84. His mother Margarita is alive at age 81; she also has type 2 diabetes. He has two older brothers: Diego, 61, has hypertension, and Juan, 57, has no diagnoses.
Questions to Consider
- What tests would you order (if any)?
- What are the most important interventions and treatments?
- What are the goals of care?
Learning Objectives
By the end of the session, the active participant will be able to:
- Use the Rule of 3’s framework for managing type 2 diabetes.
- Describe the macrovascular and microvascular complications of diabetes and name the interventions or tests appropriate for preventing or managing each.
- List the numeric benchmarks for type 2 diabetes care.
- Apply the most updated lipid guidelines.
Diabetes Mellitus: The Rule of Three’s
A model to Facilitate Comprehensive Care for Patients with Type 2 Diabetes Mellitus
| Micro-Vascular Complications | Blood Sugar Control | Macro-Vascular Complications |
| 1. EYES (Retinopathy)
Annual visit with Ophthamologist |
1. HEMOGLOBIN A1C
Check every 3-6 months |
1. HYPERTENSION
Systolic BP <140 |
| 2. KIDNEYS (Nephropathy)
Annual screen for Microalbuminuria |
2. LIFESTYLE
Nutrition |
2. LIPIDS
Follow 2013 AHA/ACC Guideline |
| 3. FEET (Neuropathy)
Patient Education: Foot Care |
3. MEDICATIONS
Metformin First-Line |
3. CAD/CVA Prevention
Smoking Cessation, Nutrition, Activity |
Created by Wayne Altman, MD (Tufts Family Medicine)
Required Reading: Diabetes Mellitus
Required Reading: Type 2 Diabetes Therapies: A STEPS Approach
Required Reading: Oral Medications
Contraception
By the end of the session, active participants will be able to:
- List all of the major contraceptive options.
- Compare and contrast the risks and benefits of each contraceptive option for particular patient situations.
- Describe the major contraindications to using each option.
Resource: Reproductive Access Project
Especially helpful sections of the above resource:
- Your Birth Control Choices Fact Sheet
- Medical Eligibility Criteria
Andrea Pena: Maternity Care
Case 1
Andrea Pena is a 34 yo F, G1P1, s/p 1 vaginal delivery in 2003, with a history of chronic hypertension and generalized anxiety disorder. She presents to your office for hypertension follow up. She has stopped her previous anti-hypertensive. She is only using condoms for contraception currently with a new partner. She is undecided about whether having another baby is a good idea, especially because of her health issues, and how soon she should start trying to conceive if she wants to have a baby.
She is a non smoker and works as a house cleaner.
Her vitals are: T 98 BP 154/92, P75, Wt 190lbs Ht 5’4”, BMI 32.6
Questions to Consider: Case 1
How would you approach this visit? Please outline a plan for antihypertensives, contraception options as well as pre-conception counseling.
List her assessment and plan is a problem-based outline.
Case 2
Andrea Pena is a 34 year old G2P1 who presents at 6 weeks by last menstrual period (LMP) to your office wondering if she could be pregnant because she missed her period. She would be excited to be pregnancy. History of uncomplicated NSVD in 2003.
She has past medical history of essential hypertension which is well controlled on labetalol 200mg BID, and generalized anxiety disorder for which she has been sporadically engaged in psychotherapy. Non smoker, works as a house cleaner.
Her vitals: T 98, BP 129/80, P75, Wt 190lbs, Ht 5’4”, BMI 32.6
Urine HCG: Positive.
Questions to Consider: Case 2
Andrea will come back for her official prenatal intake the following week where full blood/urine testing will be done, but for today please address the patient’s questions in a problem-based fashion:
- What extra risks are present and testing is indicated because of her obesity and hypertension?
- What do you recommend for her anxiety? In particular, consider a medication if she starts having more panic attacks which she had in her previous pregnancy.
- Finally, she also hasn’t been sleeping well and wonders how much coffee would be safe for her to drink so she can get through her workday.
Case 3
Andrea Pena is a 34 yo Brazilian female, G2P1 at 28 wks gestation currently. 1 prior vaginal delivery in 2003 which was uncomplicated. She has chronic hypertension, which is well-controlled on labetalol, and generalized anxiety disorder, for which she sees a therapist occasionally and is taking low dose sertraline 25mg/day. Her pre-pregnancy BMI was 32lbs. She has only gained 8lbs so far in pregnancy and is feeling well.
She has some questions about the third trimester. She is worried about the delivery because she gets extremely anxious when she has pain and is asking about whether a primary C-section could be a good option for her. She also worries about pre-eclampsia and is asking any ways to monitor for this or even prevent it. Finally, she wants to know if it’s safe to fly to Arizona for a brief vacation.
Questions to Consider: Case 3
Please outline a problem-based plan for her including routine testing for her at this gestational age, counseling regarding mode of delivery, prevention/surveillance for pre-eclampsia, and whether travel is safe for her.
Case 4
Andrea Pena is a 34 yo G2P2 comes in 5 weeks postpartum after a successful NSVD with her baby Sofia to the office for the baby’s 1 month well child check and also wants to add-on a sick visit for herself She has a history of hypertension which is controlled with labetalol 200mg BID, she has anxiety for which she is taking sertraline 25mg daily and she has continued her prenatal vitamins.
She is breastfeeding exclusively but she still struggles sometimes with nipple soreness, the baby is terribly fussy and her husband is working a lot and is not so helpful. She seems exhausted and overwhelmed. Now on top of this, she has a bad cold (headache, stuffy nose and cough) and she wonders what medications are safe for her to take for her cold while breastfeeding. She also has heard about some over the counter remedies for colic for her baby and wonders which could be safe or effective.
Her vitals are: T99.5, BP 135/89, P99, Wt 205lbs O2 98% Ht 5’4” BMI 35
Questions to Consider: Case 4
Please outline a problem-based plan for her to address her cold symptoms, lactation struggles and questions about colic remedies. Address her mental health issues and hypertension, and if there is time think of a good birth control plan for her.
Learning Objectives
- Describe the approach to a prenatal visit at various gestational ages
- Identify key prenatal tests and interventions
- Name the important components of a postpartum visit
Prenatal Care Map
Used with permission from Boston University
| Physician | Patient Education | |
| INTAKE | History
Demographic information Medical history- update problem list History since last LMP Family history Obstetric history Genetic risk assessment Psychosocial assessment Substance use assessment Physical Send GC/Chlamydia Send pap if indicated Plan Labs: Type and screen, CBC, RPR, HIV, HepBsAg, urine culture. If not previously documented: Rubella Ab, CF screen or other genetic disorder, Hg electrophoresis, Varicella Ab, G6PD, TSH (optional) Additional labs: 1 hour glucola if high risk
Baseline HELLP labs if PHx pre-eclampsia or chronic HTN
TB assessment- place PPD if high risk Review immunizations with specific documentation of Tdap status of patient and anticipated newborn caregivers Order US for dating if indicated Send for first trimester testing (11-13wks) Prenatal vitamins prescription Offer Genetic Counseling if high risk (>35y @ delivery, FHx genetic abnormality etc.) Refer to MFM for high risk condition Review with Case Manager PRN Nutrition counseling Financial counseling Update Problem list and plans |
Orientation to System-What to expect at prenatal visits
First trimester tests Changes in body (months 1-3) Fetal development Safety in pregnancy Smoking cessation/Alcohol & drug addiction HIV risks First trimester warning signs Depression/anxiety Domestic violence Facts about breastfeeding |
| 12 TO 16 | Give first dose of Hepatitis B vaccine to high risk women who are HbsAg and HbsAb negative
Offer flu shot (indicated any trimester during flu season) CXR if PPD positive, no prior CXR Schedule appointment with nutritionist/WIC, if needed and not done previously Schedule appoint w/ Social Worker if needed |
Anatomy of pregnancy
Exercise/Nutrition/Weight gain Making love during pregnancy Second trimester testing |
| 15 TO 20 | Offer quad screen (if first trimester testing not done)
Offer MSAFP only if first trimester testing done Update genetic screening plan Give 2nd dose of Hepatitis B vaccine to high risk women (one month after first dose) Ultrasound for anatomy |
Changes in body (months 4-6)
Fetal development Breastfeeding-Getting Started |
| 20 TO 24 | Reassess adverse health behaviors, psychosocial risks, and financial status
Childbirth education referral |
Warning signs-signs of preterm labor (PTL)/pre-eclampsia
Depression/anxiety |
| 24 TO 28 | Reassess adverse health behaviors, psychosocial risks, and financial status
Nutrition counseling Ensure that patient is scheduled for childbirth classes and stress the importance of attendingOffer doula referral Refer to OB or fellowship trained FM if prior c/s to discuss TOLAC vs. C/S Diabetic screen (one hour Glucola), 3 hour GTT if glucola >140 Rhogam if indicated (Antibody screen should be drawn prior to Rhogam, but no need to wait for results) |
Breastfeeding-Infant cues/positions/frequency |
| 28 TO 32 | Tubal consent form signed (if indicated). Fax signed copy to L&D, give another copy to patient
Repeat CBC. Give Fe if anemic (hct <32) and follow Administer Tdap each pregnancy (CDC recommendation: optimal 27-36w EGA) |
Changes in body (months 7-9)
Warning signs/ signs of pre-eclampsia/PTL Fetal development/fetal movement Getting ready for baby/car seat/choosing baby’s doctor/circumcision/sibling care Breastfeeding-Common questions/Pumping Third trimester tests |
| 36 TO 40 | Reassess adverse health behaviors, psychosocial risks, and financial status
GC/chlamydia, RPR (if high risk) Check HIV, document if pt declines Check genital GBS culture 35-37w (unless GBS bacteruria this preg or previous infant with GBS disease). If high risk PCN allergy check clindamycin/ erythromycin susceptibility testing Give 3rd dose of Hepatitis B vaccine to high risk women (six months after dose) Prescribe anticipated postpartum prescriptions |
Changes in body after birth
Postpartum blues/depression Family planning Infant care |
| 40 | Rhogam (if >12 wks since last injection; Send Ab screen prior to Rhogam)
Discuss post dates management (options for monitoring vs. IOL) Check cervix if scheduling induction Call L&D to schedule postdates induction between 41-42 wks. |
Discuss induction indications and methods |
| 41 | Birth control method
Start biweekly NST/AFI at 41 wks |
Family Planning
Appointments with appropriate preventive service providers |
| Post-Partum |
Review discharge summary, update outpatient chart Screen for PP depression (2 step then Edinburgh) DM screening if h/o GDM Update all immunizations: finish HPV series if age appropriate |
Smoking cessation
Weight loss Exercise Healthy diet Breastfeeding issues Depression Birth control and inter-pregnancy interval |
Required Reading: Routine Prenatal Screening Tests
Required Reading: Prenatal Care
Required Reading: Postpartum Care
Resource: LactMed (database on medication safety during lactation)
Resource: ZipMilk (resources for breastfeeding support & links to local lactation consultants)
Resource: Centering (group prenatal care)
Resource: Perinatology (perinatal care)
Kathleen McHale: Menopause
Case
Kathleen McHale is a 51 year old female. She came in today for a physical exam. She has not seen a doctor for a long time. She explains that she has been too busy worrying about her husband Richard and her kids to take care of herself. Lately however, she has been waking up in the middle of the night hot and sweaty for no reason and is concerned enough to come to the doctor.
Questions to Consider
- What additional history do you want?
- What labs/studies are indicated?
- To what do you attribute her nighttime symptoms?
- What are her treatment options?
- How would you counsel this patient on hormone replacement therapy?
Learning Objectives
By the end of the session, active participants will be able to:
- Describe how to evaluate and treat menstrual changes in a peri-menopausal woman.
- Demonstrate skills in counseling patients on the risks and benefits of HRT.
Required Reading: Hormone Replacement Therapy ( Executive Summary (2 pages) only; the rest is optional)
Required Reading: Treatment for Menopausal Symptoms
Optional Resource: Natural Medicines in the Clinical Management of Menopausal Symptoms
Jill McHale, part II: IPV
Case
Jill returns for a follow-up visit, after being diagnosed 2 months ago with depression. She thinks that the medication you prescribed is helping but still feels stressed, and definitely appears so. Jill is with her husband Brian (also your patient). You are aware that Brian is also in a relationship with one of your other patients Julia Santiago. When you politely ask Brian how he is doing, he replies, “fine, if I could be at work instead of having to drive Jill around to all her appointments.”
Questions to Consider
- What is the best way to continue the interview about Jill’s depression?
- What primary issues will you address?
- How will you deal with the anger displayed by her husband?
Learning Objectives
By the end of the session, the active participant will be able to:
- Define the prevalence of Intimate Partner Violence in the United States
- Identify common presentations in patients suffering from Intimate Partner Violence.
- Describe some of the reasons people stay in violent relationships.
- Appropriately screen and interview a patient about domestic violence.
- Demonstrate the ability to facilitate a safety plan for a victim of Intimate Partner Violence.
Required Reading: Intimate Partner Violence
Required Reading: Power & Control
Resource: https://www.casamyrna.org
Hypertension
Learning Objectives
- Describe proper blood pressure measurement technique
- Identify the blood pressure goals recommended by JNC-8
- Choose appropriate blood pressure medications
- Describe side effects of common antihypertensive agents
Required Reading: Management of Hypertension
JNC 8 (January 2014)
- Goal <140/90 for <60 yo
- Goal <150/90 for 60 yo and older
- Lifestyle modification still first line
- DM2 and Chronic Kidney Disease (CKD) –> Goal is <140/90 for all ages
- Thiazides, CCBs, ACEis (ARB if cough) first line
(exception: ACEis/ARBs not first line in AA patients) - Beta-blockers now considered second line
- Do not use ACEi and ARB together
- Use ACEi (ARB if cough) first line if CKD (DM2 no longer specified here)
Prepared by Wayne Altman, MD, FAAFP (Tufts Family Medicine)
Hypertension: JNC – 8 (2014) vs AHA/ACC (2017)
In 2014, The Eighth Joint National Committee released evidence-based guidelines for the management of high blood pressure in adults, including treatment thresholds, target BP goals, and specific medications. These were more robust, evidence-based evidence based guidelines that expanded on the predominantly, expert consensus-based guidelines of JNC-7, released 10 years prior. A major change in JNC-8 was the shift to more permissive (higher) blood pressure goals. A major contributor to this decision was the ACCORD BP 1 trial which failed to show statistically significant morbidity and mortality benefits for diabetics when they were treated with stricter blood pressure goals. A summary of JNC-8 recommendations can be found in the Tufts Mobile Medicards.2
In 2017, the American Heart Association and the American College of Cardiology released another set of hypertension guidelines that proposed new hypertension definitions, and advised stricter blood pressure control due to the mortality benefits seen from the SPRINT trial (published in 2015 after JNC 8)3. These guidelines focused on stricter treatment thresholds, lower target BP goals, called for more accurate blood pressure monitoring, and highlighted the need for lifestyle changes. Earlier this year, the American Academy of Family Physicians criticized the AHA/ACC guidelines for disproportionately weighing the SPRINT trial and not considering the totality of evidence. The AAFP announced that they would not be adopting these guidelines and would continue to endorse JNC-8.4
Why did stricter BP control have a mortality benefit in SPRINT but not ACCORD BP? ACCORD BP was about half the size of SPRINT and therefore may have been insufficiently powered. On the other hand SPRINT was stopped early due to the mortality benefit seen between the two groups, yet truncated RCTs can be associated with an overestimation of effect size.5 In SPRINT, the significant benefit was in rates of heart failure and all cause cardiovascular mortality, but there was no difference in rates of stroke, myocardial infarction, and acute coronary syndrome.
Guidelines from abroad:
- European Society of Hypertension/European Society of Cardiology 2014 guidelines recommend blood pressure goal of <140/90 in all patients unless over 80 yo in which case they recommend <150/90 is suggested, (Diabetes: recommend DBP <85)
- Canada’s 2017 guidelines released on the diagnosis, management and treatment of hypertension emphasized the importance of accurate BP measurement and established a threshold for hypertension as >135/85 or >130/80 with diabetes.
So where do we go from here? Can we reach a general consensus on how to define hypertension and how to manage patients with hypertension?
| JNC-8 (2014) | AHA/ACC Guidelines (2017-2018) | |
| Methodology | Initial systematic review of RCTs from 1996 to 2013, with subsequent review of RCT evidence and recommendations based on standardized protocols | Disproportionate weight to the SPRINT trial, an RCT assessing standard vs. strict blood pressure treatment goals |
| Definitions | Normal: <120/<80 Pre-hypertension: 120-139/80-89 Stage 1: 140-159/90-99 Stage 2: >160/>100 |
Normal: <120/80 Elevated: SBP 120-129 Stage 1: 130-139/80-89 Stage 2: >140/>90 |
| Thresholds for initiating treatment | >60 yo: >150/90
<60 yo or comorbid conditions (DM, CKD): >140/90 |
>130 SBP or >80 DBP if history of CVD or >10% ASCVD risk
>140/90 if no clinical CVD and <10% ASCVD risk |
| Treatment Goals | <140/90 if <60 yo or comorbid conditions (DM, CKD); (Grade E recommendation)
<150/90 if >60 yo (Grade A recommendation) |
<130/80 |
| Medication Selection | Non-African American: Thiazide, ACEi/ARB, or CCB
African-American: Thiazide or CCB |
Non-African American: Thiazide, ACEi/ARB, or CCB
African-American:Thiazide or CCB |
| Treatment Algorithm | Start 1 med → follow up 1 mo. → add med or increase does if not at goal BP | 1 med for stage 1 2 meds for stage 2 with different mechanism of action |
| The Numbers | ACCORD BP N=4733 2632 intensive BP control 2371 less intensiveNo sig difference in nonfatal MI, nonfatal stroke, CV deathNNT non fatal stroke 476/yr Fatal Stroke 588/yrNNH: Adverse Events attributable to BP meds 49 |
From SPRINT N=9,361 4678 targeted SBP at <120 4683 targeted SBP at 135-139NNT primary outcome (1st MI, stroke, CHF or death) 63NNH (adverse events possibly or definitely related to intervention) 45 |
| Pitfalls | Based primarily on data prior to 2013; limited data prior to 2013 that assessed the long term sequelae of overtreatment. | New definition increases number of Americans with hypertension from 72 million to 103 million (32–>46% of US adults) Chair of SPRINT trial was also Chair of the AHA/ACC guidelines |
Conclusions
While much of the focus has been on the definitions of hypertension and thresholds for treatment, there is a good amount of overlap between the ACA/AHA and JNC 8 guidelines:
- The ACA/AHA and JNC-8 guidelines both recognize that lifestyle modifications (DASH diet, weight loss, exercise, smoking cessation) are first line and are paramount for reducing morbidity and mortality associated with elevated BP. These interventions do not carry any of the risks associated with medications.
- Proper measurement of blood pressure (appropriate cuff size, pt seated in a chair with feet on floor and back support, no talking by patient or person measuring BP) is vital. The SPRINT trial identifies a possible variation of 20 points on SBP related to improper measurement.
- Ambulatory blood pressure monitoring may be helpful in circumventing white coat hypertension and placing patients on unnecessary medications. The Canadian guidelines incorporate ambulatory monitoring into their initial diagnosis of hypertension.
- Medication management for Non-African American patients should feature Thiazides ACEis, ARBs, and CCBs. African American patients should be prescribed Thiazides and CCBs as ACEi/ARBs have been shown to have reduced efficacy in lowering blood pressure in AA patients.
As for how to deal with the differences in blood pressure guidelines, it is necessary to account for the different demographics of the patients in both trials. SPRINT (2017) enrolled patients who were at high risk for cardiovascular events, therefore the risks and benefits associated with treatment regimens in SPRINT are most applicable to patients with CV disease or high risk for CV disease, and not as applicable for patients who are at lower risk for cardiovascular disease or who are frailer.
So high-risk patients (ASCVD>10%), diabetics and non-frail older adults may benefit from lower BP targets per the ACC/AHA Guidelines. In particular, patients with heart failure may benefit significantly from intensive blood pressure control. Healthy adults (<65 with no evidence of cardiovascular disease) with elevated blood pressure would likely benefit most from focusing on lifestyle modifications and initiation of medication at a threshold of 140/90 as the risk-benefit ratio is much more narrow in this population.
Patients with limited mobility (e.g. frail elderly) would benefit from more conservative BP targets, independent of their comorbidities because the risk of falls and acute kidney injury may outweigh the benefits of stricter blood pressure control.
Ultimately, there is not a one-size fits all approach and the treatment of hypertension represents another opportunity to engage our patients in shared decision-making.
—
Braidie Campbell M19, C. Dan Early M19, Wayne Altman MD
References:
1. The ACCORD Study Group, et al. Effects of intensive blood-pressure control in type 2 diabetes mellitus. N Engl J Med. 2010;362:1575–85
2. Tufts Mobile Medicards: http://tusk.tufts.edu/mobi/view/content/Medical/3052/1741982
3. The SPRINT research Group. A randomized trial of intensive versus standard blood-pressure control. N Engl J Med. 2015;373(22):2103–16
4. Chris Crawford. “AAFP decides not to endorse AHA/ACC Hypertension Guideline- continues to endorse JNC-8 guidelines” https://www.aafp.org/news/health-of-the-public/20171212notendorseaha-accgdlne.html
5. Bassler D, Briel M, Montori VM, et al. Stopping Randomized Trials Early for Benefit and Estimation of Treatment Effects Systematic Review and Meta-regression Analysis. JAMA. 2010;303(12):1180–1187. doi:10.1001/jama.2010.310
6. Munter, Paul, et al. “Potential US Population Impact of the 2017 ACC/AHA High Blood Pressure Guideline.” Circulation, vol. 137, no. 2, 2017, pp. 109-118., doi: 10.1161/circulationaha.117.032582.