MICHIGAN HYPERTENSION CORE CURRICULUM Education modules for training and updating physicians and other health professionals in hypertension detection, treatment and control Developed by the Hypertension Expert Group A Partnership of the National Kidney Foundation of Michigan and the Michigan Department of Community Health 2010 Michigan Hypertension Core Curriculum 2010 Developed by the Hypertension Expert Group A Partnership of the National Kidney Foundation of Michigan and the Michigan Department of Community Health 2 Hypertension Core Curriculum NKFM & MDCH 3 Acknowledgements Hypertension Expert Workgroup Committee April 2010 Ziad Arabi, MD, Senior Staff Physician, Internal Medicine/Hospitalist Medicine, Henry Ford Hospital, Certified Physician Specialist in Clinical Hypertension* Dear Colleague: Aaref Badshah, MD, Chief Medical Resident, Department of Internal Medicine Saint Joseph Mercy-Oakland Hospital * In 2005, the Michigan Department of Community Health (MDCH) and the National Kidney Foundation of Michigan (NKFM) convened a group of hypertension experts to identify strategies that will improve Jason I Biederman DO, FACOI FASN, Hypertension Nephrology Associates, PC* blood pressure control in Michigan. Participants included physicians from across Michigan specializing Joseph Blount, MD, MPH, FACP, Medical Director, OmniCare Health Plan, Detroit, MI in clinical hypertension, leaders in academic research of hypertension and related disorders, and Mark Britton, MD, PhD, Center of Urban and African-American Health Executive Committee, Wayne representatives of key health care organizations that are addressing this condition that afflicts over 70 State University School of medicine, Wayne State University* million U.S. adults. The Hypertension Expert Group has focused on approaches to reduce the burden of kidney and cardiovascular diseases through more effective blood pressure treatment strategies. Paul Dake, MD, Family Medicine Residency Program Faculty McLaren Hospital In an effort to improve hypertension control, the group developed educational programs on blood Benjamin Diaczok, MD, FACP, Program Director, Department of Internal Medicine, St. Joseph Mercy pressure management, diagnosis and treatment standards. The Expert Group has now turned their Oakland Hospital* attention toward strengthening academic programs for health care providers in the area of clinical Mark D Faber MD, FACP, Program Director, Division of Nephrology and Hypertension hypertension. It was suggested that while all universities and training programs have curricula focused Henry Ford Hospital, Clinical Associate Professor, Wayne State University* on cardiovascular diseases, considerable variability exists on how each approaches the diagnosis and treatment of hypertension, in part because hypertension has not been the domain of any single medical John M. Flack, MD, MPH, FAHA, FACP, Professor of Medicine and Physiology Chair and Chief, Division of Translational Research and Clinical Epidemiology subspecialty. Department of Internal Medicine, Wayne State University, Specialist in Chief for Internal Medicine, Thus, our goal was to develop a state-wide core curriculum designed to serve as a comprehensive Detroit Medical Center* Editor in Chief guide for updating clinical knowledge of hypertension and related disorders. This core curriculum Arthur Franke, PhD, National Kidney Foundation of Michigan, Ann Arbor, MI would ensure that trainees are adequately educated, focused on a basic understanding of pressure- related vascular pathophysiology and target-organ injury/dysfunction, optimal therapeutic strategies, Crystal R. Gardner-Martin, MD, Hypertension Nephrology Associates, PC* and the most recent authoritative evidence-based guidelines and practice standards developed and Patricia Heiler, MPH, CHES Michigan Department of Community Health, promulgated by hypertension experts. The curriculum will be updated periodically and should continue to Cardiovascular Health Section serve as a readily available current source for training. Khaled Ismail MD, Hypertension Nephrology Associates, PC* Diane Levine, MD, FACP, Associate Professor of Medicine, Vice Chair for Education Sincerely, Department of Internal Medicine, Wayne State University Michael Misuraca DO, Hypertension Nephrology Associates, PC* Samar A. Nasser, PA-C, MPH, Division of Translational Research and Clinical Epidemiology, Department of Internal Medicine, Wayne State University* John Flack, MD, MPH Sandra Waddell, RN, BSN Chair, HTN Expert Committee Project Manager, HTN Expert Committee Silas P. Norman, MD, Assistant Professor of Medicine, Division of Nephrology Section of Transplantation, University of Michigan* Wayne State University National Kidney Foundation of Michigan 4 Hypertension Core Curriculum NKFM & MDCH 5 Acknowledgements Kevin L. Piggott, MD, MPH, FAAFP Preventive Medicine Resident, University of Michigan School of Produced April 2010 Public Health and Family Physician* Permission is granted for the reproduction of this publication provided that the reproductions contain Rosalind M. Peters, PhD, RN, Associate Professor, College of Nursing, Wayne State University* appropriate reference to the source. William Repaskey, MD, Internal Medicine Hospitalist, University of Michigan Hospitals, Ann Arbor, MI* Made possible in part by funding from the Michigan Department of Community Health, Division of Chronic Disease and Injury Control, Cardiovascular Health, Nutrition and Physical Activity Section. Robert R. Ross, PA-C, Affiliate Professor, U of D Mercy PA Program Thank you to the National Kidney Foundation of Michigan’s Scientific Advisory Board. for their review Robert D. Safian, MD, Director, Cardiac and Vascular Intervention Director, Cardiovascular Fellowship and input of the Hypertension Core Curriculum. Training Program, Department of Cardiovascular Medicine, William Beaumont Hospital* Thank you to Sheila Jackson at the National Kidney Foundation of Michigan for assisting with the Ankur Sandhu MD, Nephrology and Critical Care Fellow, Henry Ford Hospital* design and formatting of the Hypertension Core Curriculum. Kiran Saraiya DO, Hypertension Nephrology Associates, PC* Linda Smith-Wheelock, ACSW, Chief Operating Officer, National Kidney Foundation of MI Hani Al-Sharif MD, Nephrology Fellow, Henry Ford Hospital* Susan P Steigerwalt MD, FACP, Director, Hypertension clinic SCSP; Member, Division of Nephrology and Hypertension, St John Hospital and Medical Center, Detroit, MI and Providence Hospital, Southfield, MI, ASH Clinical Hypertension Specialist* Radhika Thalla MD, Nephrology Consultants P.C, William Beaumont Hospital, Royal Oak, MI* Velma Theisen, MSN, RN, Manager, Heart Disease and Stroke Prevention Unit Cardiovascular Health, Nutrition and Physical Activity Section, Michigan Department of Community Health* Joel M Topf, MD, Chief of Nephrology, St Clair Specialty Physicians , Director of the Chronic Kidney Disease Clinic, St John Hospital and Medical Center* Sandra Waddell, RN, BSN National Kidney Foundation of Michigan, Ann Arbor , MI Steven A Yarows, MD, Chelsea Internal Medicine, Michigan Hypertension Center, IHA, Adjunct Professor of Internal Medicine, Cardiovascular Division, University of Michigan Health System* Jerry Yee, MD, Henry Ford Hospital, Nephrology * Denotes contributing author 6 Hypertension Core Curriculum NKFM & MDCH 7 Table of Contents Blood Pressure Measurement........ pp. 10 Hypertension Management Controversies Low Diastolic Blood Pressure Should Prevent Antihypertensive Drug Therapy of Systolic Essential Hypertension Hypertension (J-Curve Debate)........pp. 271 Primary Hypertension........ pp. 18 Use of Dihydropyridine Calcium Antagonists in Chronic Kidney Disease........pp. 274 Physiological Determinants of Blood Pressure.........pp. 24 Special Populations Case Studies........pp. 276 Intro for special populations........pp. 39 1. A hypertensive patient taking multiple antihypertensive medications with poor BP control without an Chronic Kidney Disease........pp. 40 appropriate diuretic prescribed. Elderly........pp. 50 2. A well controlled hypertensive patient with refractory hypokalemia despite replacement Diabetes........pp. 56 3. A hypertensive patient with diabetes who is taking a diuretic and the steps that can be taken to Obesity........pp. 64 minimize or prevent diuretic induced hyperglycemia. African Americans........pp. 71 4. Hypertensive patient with CKD with poorly controlled BP control experiencing a significant elevation Hispanics........pp.83 in creatinine when BP is lowered below his goal BP. 5. A hypertensive patient who is being treated with multiple antihypertensive drugs who has significant Secondary Hypertension orthostatic hypotension. Obstructive Sleep Apnea........pp. 87 Pheochromocytoma........pp. 90 6. A hypertensive patient with truly resistant hypertension. Polycystic Ovary Syndrome........pp. 96 7. A hypertensive patient with CKD and heavy proteinuria. Primary aldosteronism........pp.98 8. A hypertensive patient with CKD, and proper use of diuretics appropriate to level of renal function. Renal Artery Stenosis........pp. 106 9. Ms. LN returns 2 weeks after addition of an ACE-I and diuretic, and lab results reveal a reduction in EGFR. What may be the cause of the reduction in renal function, and how would you handle? Prevention 10. Ms. LN returns 4 weeks after addition of an ACE-I and diuretic, and is symptomatic. What may be Public Health Approaches........pp. 145 causing these symptoms, and how would you handle? Pervasive Hypertension