HTN Findings

A 56 year old man with a 10 year history of hypertension presents for a primary care visit, stating he's not taking his hypertension med, a calcium channel blocker, an angiotensin converting enzyme inhibitor, and a thiazide diuretic for the past three months due to  "running out of the medication and not getting to the pharmacy." Today, his blood pressure is 192 over 120 and he has no complaint, denying shortness of breath, chest pain or visual changes. He states, "I just came in today for a visit since I ran out of my blood pressure refills. I need to get back to work in a half an hour." When considering the diagnosis of asymptomatic markedly elevated blood pressure, the clinician would predict his physical exam is normal with the exception of which of the following.

A. S4 heart sound

B. Grade 3 HTN retinopathy

C. Neck vein distension

D. Murmur of aortic regurgitation

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Transcript

Voiceover: Welcome to NP Certification Q&A presented by Fitzgerald Health Education Associates. This podcast is for NP students studying to pass their NP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Leading NP expert Dr. Margaret Fitzgerald shares her knowledge and experience to help you dissect the anatomy of a test question so you can better understand how to arrive at the correct test answer. So, if you're ready, let's jump right in.

Margaret Fitzgerald: A 56-year-old man with a 10-year history of hypertension presents for a primary care visit, stating he's not taken his hypertension med, a calcium channel blocker, an angiotensin converting enzyme inhibitor, and a thiazide diuretic for the past 3 months due to “running out of the medication and not getting to the pharmacy”. Today his blood pressure is 192 over 120 and he has no complaint denying shortness of breath, chest pain or visual changes. He states, "I just came in today for a visit since I ran out of my blood pressure refills. I need to get back to work in a half an hour." When considering the diagnosis of asymptomatic markedly elevated blood pressure, the clinician would predict his physical exam is normal with the exception of which of the following? 

A. An S4 heart sound

B. Grade three HTN retinopathy

C. Neck vein distension 

D. Murmur of aortic regurgitation 

The correct answer is A. S4 heart sound. 

Where should you start? First determine what kind of a question this is given that we're being asked for an anticipated components of the patient's clinical presentation in physical exam. This is an assessment question. A bit of background information. Patient has a 10-year history of hypertension and he admits to non-adherence to a three drug regimen. As a result, patients blood pressure is really quite markedly elevated. At the same time, the patient is without signs or symptoms of problematically markedly elevated blood pressure. This condition is actually known as asymptomatic markedly elevated blood pressure by the latest terminology from the American College of Cardiology and the American Heart Association hypertension guidelines. It was formerly known as hypertensive urgency. If you go back to like JNC8 and the earlier hypertension guidelines, additional terms for the same condition including what agency has generated their guidelines is severe hypertension without evidence of acute target organ injury. Another term is markedly elevated blood pressure without acute end organ damage. If you ask me which one of these terms I think will come up on boards, I would think it'd be the asymptomatic markedly elevated blood pressure. But what I want you to appreciate is all three of those different terms are saying the exact same thing. The blood pressure is very high, but there is no acute emergency. 

Asymptomatic markedly elevated blood pressure is defined just as it says. The blood pressure is significantly elevated but the person is otherwise stable without acute or impending hypertensive target organ dysfunction or TOD. Now remember also hypertensive TOD gets another name with these newer guidelines called hypertensive mediated organ damage or HMOD. 

The lack of TOD in this scenario, keeping in mind the primary organs that hypertension targets are the brain, the eye, the heart, and the kidney, is reflected in the fact that the patient denies chest pain, shortness of breath, visual changes, and his physical exam is within acceptable parameters with the with just one abnormal finding, and I'll get into that in a moment. Typically in this severe asymptomatic hypertension the this is the history we have. It is a patient with a history of high blood pressure. They've been on generally a three or four med regimen because their blood pressure can be very high. So they need lots of meds to keep it in control and they've stopped their meds or they are intermittently adherent to their hypertensive medication regimen. Obviously, this is part of the patient's current history. 

In this situation, physical exam, as I mentioned, all normal with just one small exception. And he feels well and oh, by the way, could you move things along because he's on break from work. And if you think, oh, this couldn't possibly happen in primary care, welcome to my world. I see patients like this on a regular basis. And of course, the boards aren't going to get into this. I'm not going to get into this in the answer to the question here, but what I try to do with folks like this is always, always, always reinforce, call in and ask for a gap refill on your medication till you can get into see us next. Never go without your high blood pressure medicine. Right? And you know, I've seen people with blood pressures this high and sometimes I've thought, well, I think that even drove my blood pressure up a bit. But what is our role as clinicians to apply best evidence and not push the panic button. 

One reason the term hypertensive urgency has been discarded is it does imply that you need to do something urgently, right? And the newer terminology helps set the stage that this commonly encountered situation doesn't require extreme urgent intervention. By the way, I'll cover the intervention of this condition in a future podcast. So, keeping all of this in mind, let's revisit the question and the possible responses. And oh, by the way, I just want to throw in one more comment. Why aren't we trying to urgently bring down his blood pressure today? Because there's no evidence that he, in the short term, is at acute risk for a cardiovascular or cerebrovascular event that's been very well demonstrated in many different studies.

So, back to the question. A 56-year-old man with a 10-year history of hypertension presents for a primary care visit, stating he's not taken his hypertension meds, which include a calcium channel blocker, angiotensin converting enzyme inhibitor, and thiazide diuretic for the past 3 months due to “running out of medication and not getting to the pharmacy”. Today's BP is 192 over 120 and he's without complaint, denying shortness of breath, chest pain, or visual changes. He states, quote, "I just came in today for a visit since I ran out of my high blood pressure refills. I need to get back to work in about a half an hour." When considering the diagnosis of asymptomatic markedly elevated blood pressure, the clinician would predict his physical exam is normal with the exception of which of the following findings? 

A. S4 heart sound. This is the correct answer. And this condition with severe asymptomatic hypertension and S4 heart sound is actually an anticipated finding. If you recall, the S4 heart sound is a sound of long-standing diastolic dysfunction but likely in the absence of systolic dysfunction and usually the person with an S4 heart sound has preserved cardiac output. 

How does this develop? It develops be in this person due to the chronically elevated blood pressure. And another way to think of it is if you pick up the S4 heart sound on a person whose blood pressure is elevated in office and they say, "Oh, don't worry about it. Today's Thursday. I just skipped my high blood pressure medicines yesterday because I ran out." Uh, probably not. Probably what happened is their blood pressure is up today. They've got an S4 heart sound because they ran out of their blood pressure medicine. Maybe three weeks ago, four weeks ago. In other words, it takes a number of days to weeks to months of elevated blood pressure before the S4 heart sound develops. 

We’re told that he's been off his high blood pressure medicines for a number of months and again requires three meds for control. So, we know his blood pressure has been up for a while. Is the S4 now a permanent finding? No. Once he's back on his blood pressure medicines and his BP is within acceptable range, the heart workload and stress is improved and the S4 heart sound will go away. It probably will take a few weeks of high blood pressure control before that happens. 

Option B, grade three HTN retinopathy. This is incorrect because grade three HTN retinopathy findings including bleeding in the back of the eye, retinal hemorrhages as well as severe vasoconstriction. The other part of this is the person with grade three hypertensive retinopathy because they're looking through blood that's in the back of their eye will usually report black spots in the visual field that are new. This is an example of a high-grade hypertensive retinopathy. And if coupled with the highly elevated blood pressure here, this would constitute HTN emergency. But we're told his physical exam is okay except for the S4 hearts out. So, the fact that we're told this physical exam is unremarkable that implies that he does not have hyper uh high-grade HTN retinopathy. So, grade three HTN retinopathy clearly a pathologic condition and a aside from the visual changes that we expect to be reported the patient would also likely have some cardiac symptoms and I'll expand on that with the next answer choice. 

C, neck vein distension. Obviously, this is also incorrect given that one of the hypertensive TODS is the heart. Neck vein distension usually noted in heart failure is often seen with hypertensive emergency but not with asymptomatic markedly elevated blood pressure. Aside from the pathologic finding, the person with neck vein distension would usually be reporting shortness of breath and/or chest pain. Um, tachypnea, tachycardia would be common as well. Additional findings would likely include crackles in the lung field and any other findings that are common in heart failure. 

D. Murmur of mitral regurg. Clearly, this is incorrect. The murmur of mitral regurg caused by the failure of the aortic valves to close properly is heard during distally or between S2 and the next S1. A variety of clinical conditions can result in this murmur including rheumatic heart disease, tertiary syphilis. It's not something that we're going to see in asymptomatic markedly elevated blood pressure um or in HTN emergency as well.

Key takeaways asymptomatic markedly elevated blood pressure is a common condition noted in primary and urgent care. Knowing how to differentiate urgency and emergency is key to safe and effective practice. I'll review the treatment of this condition in another podcast.

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