Stage I HTN

[spicedmanna]

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Okay, I was doing questions in Kaplan's Step II Qbank and came across one dealing with Stage I HTN and it's treatment. In the question, the patient presented on her first visit with an elevated BP at Stage I level with no other comorbidities or risk factors. Two weeks later, the BP was assessed to be around the same range, therefore, the patient has Stage I HTN. That's obvious. The questions asks for the appropriate intervention. The JNC-7 and just about every book I've ever read on the topic says that the given patient should first do a trial of lifestyle changes, i.e., diet and exercise, before being placed on pharmacological therapy (which in this case, should be HCTZ). Thus, I chose the answer that indicated lifestyle changes only.

However, that was not the correct answer. Qbank says that the appropriate intervention should be diet, exercise, and thiazides. The explanation was of no help to clarify my question. Am I missing something here? I thought diet and exercise were almost always the first intervention in an outpatient setting, followed by one or two pharmacological agents, should the patient fail the trial. Did I somehow read the question incorrectly (for example, perhaps the question was really asking what appropriate interventions should be done at the Stage I level, not the first appropriate intervention), or perhaps missed some critical point in my numerous readings on the topic, or is Kaplan's answer incorrect?

Please help me understand what I might be missing. Thanks.

 

[cogwise]

Prehypertension: 120-129, 80-89. Rx is Lifestyle Modification.
Stage I HTN: 140-159, 90-99. Rx is LM + Drug therapy.
This could have been easily looked up in a book rather than posting it here.

 

[spicedmanna]

Prehypertension: 120-129, 80-89. Rx is Lifestyle Modification.
Stage I HTN: 140-159, 90-99. Rx is LM + Drug therapy.
This could have been easily looked up in a book rather than posting it here.

Thanks for answering, but before you start with the condescension, you might want to consider that I did extensive research and am at the end of my 3rd year. Your admonishment for me to look it up in a book doesn't seem appropriate. I already know the criteria and the therapy for hypertension. It's obvious to most everyone at this level. What got me all worked up is that I don't believe your answer is correct. If you look at the JNC-7 algorithm and many other resources, most say to start with a trial of lifestyle changes FIRST, followed by pharmacotherapy if the patient fails the trial, not a combination of lifestyle changes and pharmacotherapy as the initial treatment. According to the JNC-7 algorithm, as I read it, this includes Stages I and II. I am looking for an intelligent explanation to this question and how I am not correct in my analysis, not just a rehash of what I already know. Your answer doesn't clarify my concern at all.

Perhaps I am not stating my question correctly. What I am asking, stated another way, is why, for a patient with newly-diagnosed Stage I HTN with no other comorbidities or risk factors (except age), would you start out with lifestyle changes and pharmacotherapy instead of just lifestyle changes alone as the INITIAL intervention? Is that the standard these days? Anybody with HTN you just start off with pharmacotherapy without a trial of lifestyles changes first? If that is the case, I'd appreciate an up to date reference which cites that.

 

[Jonathan13180]

If you want the detailed, in depth explanation, I would look up the studies that were done, but that would be tedious and take too much of your time (for boards purposes)...From what I have found, when Type 1 HTN is diagnosed (not spurious elevations due to anxiety, stress, etc ) at that point Lifestyle modifications alone will not reduce the BP. In most people who have type I HTN, the process leading to their elevated bp (obesity, smoking, you name it) is far enough along that diet and exercising alone will not reduce it to a 'normal' level.

Hope that helps.

Thanks for answering, but before you start with the condescension, you might want to consider that I did extensive research and am at the end of my 3rd year. Your admonishment for me to look it up in a book doesn't seem appropriate. I already know the criteria and the therapy for hypertension. It's obvious to most everyone at this level. What got me all worked up is that I don't believe your answer is correct. If you look at the JNC-7 algorithm and many other resources, most say to start with a trial of lifestyle changes FIRST, followed by pharmacotherapy if the patient fails the trial, not a combination of lifestyle changes and pharmacotherapy as the initial treatment. According to the JNC-7 algorithm, as I read it, this includes Stages I and II. I am looking for an intelligent explanation to this question and how I am not correct in my analysis, not just a rehash of what I already know. Your answer doesn't clarify my concern at all.

Perhaps I am not stating my question correctly. What I am asking, stated another way, is why, for a patient with newly-diagnosed Stage I HTN with no other comorbidities or risk factors (except age), would you start out with lifestyle changes and pharmacotherapy instead of just lifestyle changes alone as the INITIAL intervention? Is that the standard these days? Anybody with HTN you just start off with pharmacotherapy without a trial of lifestyles changes first? If that is the case, I'd appreciate an up to date reference which cites that.

 

[cogwise]

You are confusing pre-HTN with stage I HTN. Stage I HTN you treat with drugs period. What, you are referring to is pre-HTN where the other compelling indications are taken into account to determine whether to initiate drug therapy or not.
Don't over analyze and look all over the medical literature, you will end up more confused than before. This is a simple distinction, now move on with other stuff. There is a lot of material on the test. Stop ruminating.

 

[spicedmanna]

You are confusing pre-HTN with stage I HTN. Stage I HTN you treat with drugs period. What, you are referring to is pre-HTN where the other compelling indications are taken into account to determine whether to initiate drug therapy or not.
Don't over analyze and look all over the medical literature, you will end up more confused than before. This is a simple distinction, now move on with other stuff. There is a lot of material on the test. Stop ruminating.

Yeah, I get the gist of what you are both are saying. I will stick with the basic rule that you use drugs period. I do have the tendency to over-analyze and read too much about topics. Thank you both. It's just that it was beaten into me by some academic physicians that you need to risk stratify patients and that you should consider lifestyle modification first before writing a script for meds. Yet, I know for a fact that in practice guidelines can be impractical and may not be followed exactly as recommended. With that in mind, most physicians that I have worked with usually do just give drugs as initial therapy.

 

[spicedmanna]

My fault. I guess I was confusing myself. Here is the quote from JNC-7 that corroborates what you are both saying:

This classification does not stratify hypertensive
individuals by the presence or absence of risk
factors or target organ damage in order to make
different treatment recommendations, should either
or both be present. JNC 7 suggests that all people
with hypertension (stages 1 and 2) be treated. The
treatment goal for individuals with hypertension
and no other compelling conditions is <140/90
mmHg (see Compelling Indications). The goal
for individuals with prehypertension and no
compelling indications is to lower BP to normal
levels with lifestyle changes, and prevent the progressive
rise in BP using the recommended lifestyle
modifications (see Lifestyle Modifications).

Okay, you are both right. I am looking far too deeply and confusing myself. Sorry for wasting forum space. *sigh* Back to the books.