HYPERTENSION PROTOCOL: INITIAL VISIT
- RATIONALE
- This protocol will assist in the differentiation between essential hypertension and renal artery stenosis to aid in the identification of patients in need of referral to nephrology to prevent further renal damage from an unidentified renal artery stenosis. The design of the protocol for UTI encompasses these principles.
- SYMPTOMS
- HYPERTENSION
- Blood pressure >140/90 mmHg
- Other possible subjective symptoms
- Headache
- Visual changes
- Dyspnea
- Chest pain
- Sensory or motor deficit
- RENAL ARTERY STENOSIS
- Onset of hypertension age >55 years or <30 years
- History of accelerated, malignant, or resistant hypertension
- HYPERTENSION
- History of unexplained kidney dysfunction
- History of multivessel coronary artery disease
- History of other peripheral vascular disease
- Abdominal bruit
- Sudden or unexplained recurrent pulmonary edema
- Other possible factors
- Absence of family history of hypertension
- Other bruits
- History of acute kidney injury after administration of ACE inhibitor or angiotensin II receptor antagonist (ARB)
- HISTORY
- Continue with the treatment of hypertension but consult supervising physician if the patient has:
- History of accelerated, malignant, or resistant hypertension
- History of unexplained kidney dysfunction
- Continue with the treatment of hypertension but consult supervising physician if the patient has:
- History of multivessel coronary artery disease
- History of other peripheral vascular disease
- Abdominal bruit
- Sudden or unexplained recurrent pulmonary edema
- PHYSICAL EXAM
- Perform the following examinations:
- Vital Signs (blood pressure, pulse)
- Auscultation for bruits (carotid, abdominal, and femoral)
- Perform the following examinations:
- Palpation of thyroid
- Cardiac
- Respiratory
- Lower extremities for edema and pulses
- Neurological
- Consult supervising physician if findings of:
- Abdominal bruit
- Another bruit
- LAB TESTS
- Metabolic panel
- Cholesterol
- Blood sugar
- Metabolic panel
- Uric acid level
- Glomerular filtration rate
- Consult the supervising physician if:
- GFR indicates chronic kidney disease (CKD) or renal failure
- PHARMACOLOGICAL TREATMENT
- List the hypertension drug classifications and examples you would prescribe in order of treatment according to clinical practice guidelines without consideration of race or ethnicity: (Provide generic names for examples. Doses are not needed or required.)
| Drug Category/ Classification | Example 1 | Example 2 | Example 3 | Example 4 |
| Thiazide Diuretics | Hydrochlorothiazide | chlorthalidone | indapamide | Metolazone |
| ACE Inhibitors | Captopril | Enalapril | Lisinopril | Ramipril |
| ARBs | Losartan | Valsartan | Telmisartan | Candesartan |
| Calcium Channel Blockers | Nimodipine | Amlodipine | Verapamil | Nicardipine |
- 1st line pharmacological treatment if warranted in a non-African American patient after a thiazide diuretic has been given and no compelling contraindications/comorbidities are identified: (Choose a generic drug from the drug class you would like to prescribe to either add to existing treatment or replace a thiazide.)
- Drug: Angiotensin-Converting Enzyme Inhibitor (ACEI) – Lisinopril
- Dose: Dosage can vary depending on the patient’s specific condition and blood pressure response, but a common starting dose is 10 mg once daily.
- Route: Oral (tablet)
- Frequency: Once daily, preferably in the morning.
- Instructions to provide patient: Take the medication at the same time every day. It can be taken with or without food.
- Caution/Precautions: Inform the healthcare provider of any signs of allergic reactions (e.g., rash, itching, swelling), as well as any persistent cough or other adverse effects.
- Using a source such as GoodRX, what is an estimated cost of this drug for a 30-day supply? $4.00 to $12.03
- What patient education is needed for this drug? – Explain to the patient that Lisinopril is used to treat high blood pressure and may help prevent certain heart-related conditions. – Instruct the patient to take the medication as prescribed by their healthcare provider, preferably at the same time each day, and not to skip doses. – Advise the patient to follow a healthy lifestyle, including a balanced diet low in sodium, regular exercise, and stress management, to complement the effects of the medication. – Inform the patient that Lisinopril may cause dizziness or lightheadedness, especially during the first few days of starting the medication, and to get up slowly from a sitting or lying position to minimize this side effect. – Educate the patient about the potential side effects of Lisinopril, such as a dry, persistent cough, and to promptly report any unusual or severe side effects to their healthcare provider. – Emphasize the importance of regular follow-up appointments to monitor blood pressure and assess the effectiveness of the medication.
- 1st line pharmacological treatment if warranted in an African American patient after a thiazide diuretic has been given and no compelling contraindications/comorbidities are identified: (Choose a generic drug from the drug class you would like to prescribe to either add to existing treatment or replace a thiazide.)
- Drug: Calcium Channel Blocker (CCB) – Amlodipine
- Dose: Dosage can vary depending on the patient’s specific condition and blood pressure response, but a common starting dose is 5 mg once daily.
- Route: Oral/P.O
- Frequency: Once daily, preferably at the same time each day.
- Instructions to provide patient: Take the medication as prescribed by their healthcare provider, with or without food.
- Caution/Precautions: Instruct the patient to avoid sudden discontinuation of the medication and to notify their healthcare provider if they experience any unusual or severe side effects.
- Using a source such as GoodRX, what is the estimated cost of this drug for a 30-day supply? $5.45 – $20.40
- What patient education is needed for this drug? – Tell the patient that Amlodipine is prescribed to lower blood pressure and may reduce the risk of developing cardiovascular disease. – Tell the patient to take the medicine regularly and at the same time each day as directed by their doctor. – Encourage the patient to supplement the medication’s benefits by adopting a healthy lifestyle, which includes eating a balanced diet low in salt, engaging in regular exercise, and managing stress. – Patients using Amlodipine should be warned that the drug might cause them to feel dizzy or lightheaded, particularly after getting out of a sitting or laying posture. – Instruct the patient to contact their doctor immediately if they have any serious or unexpected adverse effects after taking Amlodipine, such as swelling in their ankles or feet. – Regular follow-up consultations to check blood pressure and evaluate the medication’s efficacy should be emphasized.
- When should ACEIs be used in African Americans according to the course textbook? Include a citation with matching references in the reference section.
- ACE inhibitors may be considered for African American patients diagnosed with hypertensive nephrosclerosis.
- ACE inhibitors may be considered for African American patients whose blood pressure is not stable with a single antihypertensive drug.
- ACE inhibitors may be considered for African American patients with type 1 diabetes and proteinuria.
- Prescribe statin therapy according to the prescription table which follows:
| High-Intensity Therapy | Moderate-Intensity Therapy | Low-Intensity Therapy |
| Daily dose lowers LDL-C on average by ≥ 50% | Daily dose lowers LDL-C on average by 30% to < 50% | Daily dose lowers LDL-C on average by < 30% |
| Drug/Dose 1: Atorvastatin 40-80 mg Drug/Dose 2: Rosuvastatin 20-40 mg | Drug/Dose 1: Atorvastatin 10-20 mg Drug/Dose 2:Rosuvastatin 5-10 mg Drug/Dose 3:Simvastatin 20-40 mg Drug/Dose 4:Pravastatin 40-80 mg Drug/Dose 5:Fluvastatin 40 mg | Drug/Dose 1: Simvastatin 10 mg Drug/Dose 2:Pravastatin 10-20 mg Drug/Dose 3:Lovastatin 20 mg |
| What patient education is needed when prescribing statins? Consider any patient counseling points and adverse effects they may need to be aware of or report if experienced. | Advise the patient to take statins at the same time every day as suggested by their doctor. Instruct the patient to report any side effects, such as muscular discomfort or weakness, to their doctor. To enhance statin treatment, advise the patient to eat a balanced diet, exercise regularly, and avoid smoking and alcohol. Stress the need of frequent follow-up sessions to evaluate cholesterol levels and drug efficacy and safety. Inform the patient that statins may interact with other drugs. Remind the patient that statin medication is long-term and should not be stopped without medical advice. | |
TREATMENT MONITORING
How long until a follow-up appointment should be done with the patient?
The scheduling of the subsequent appointment with the patient ought to be predicated upon the precise treatment regimen and the unique requirements of the individual. In accordance with customary practice, it is customary to arrange a subsequent appointment within a span of 4 to 6 weeks subsequent to the commencement or modification of medication. Subsequently, it is advisable to schedule periodic appointments as necessary, with the intention of evaluating the efficacy of the treatment and attending to any apprehensions that may arise. Monitoring needs for blood pressure medication prescribed: (Include physical assessments as well as lab/diagnostics as applicable. If not applicable, enter N/A to show you find it not applicable.)-
- Physical Assessments:
- Labs/Diagnostics:
- Monitoring needs for statin medication prescribed: (Include physical assessments as well as lab/diagnostics as applicable. If not applicable, enter N/A to show you find it not applicable.)
- Physical Assessments:
- Labs/Diagnostics: