C is a year-old black American woman with a 7-year history of hypertension first diagnosed during her last pregnancy. Her family history is positive for hypertension, with her mother dying at 56 years of age from hypertension-related cardiovascular disease CVD. In addition, both her maternal and paternal grandparents had CVD. At physician visit one, Ms.
Luerding, MD Presentation R. Other medical problems include obesity and hypothyroidism. He has a history of heavy alcohol use but quit drinking alcohol 2 years ago. There is no retinopathy or thyromegaly. There is no clinical evidence of congestive heart failure or peripheral vascular disease.
Questions Does this patient have renal disease? Should his blood pressure be treated? What treatment strategy should be used? Commentary Diabetic nephropathy is a clinical syndrome characterized by albuminuria, hypertension, and progressive renal insufficiency. Early detection and treatment of albuminuria is essential in diabetes.
Many organizations, including the American Diabetes Association, recommend regular screening for microalbuminuria. Type 1 diabetic patients should be screened 5 years after diagnosis of diabetes and after puberty. People with type 2 diabetes should be screened from the time of diagnosis, since many type 2 diabetic patients have had undiagnosed disease for some time.
If the initial screening is negative, then annual screenings are indicated. Newer methods, such as Micral-Test II test strips Boehringer Mannheim, Mannheim, Germanypermit reliable semiquantitative determination of microalbuminuria and can be used in the office for dipstick screening of diabetic patients.
Transient elevations in urinary albumin excretion may be associated with marked hyperglycemia, acute febrile illness, exercise, hypertension, heart failure, and urinary tract infection.
If the initial test is elevated, these and other potential causes of renal disease should be considered and ruled out. Because there is also marked day-to-day variability in urinary albumin excretion, a positive test should be confirmed on a subsequent occasion before designating a patient as having persistent microalbuminuria.
Patients identified with persistent microalbuminuria should be aggressively treated both with respect to glycemic and blood pressure control.
The treatment of choice for hypertensive diabetic patients with or without microalbuminuria remains angiotensin-converting enzyme ACE inhibitors. Only captopril Capoten is approved for the treatment of diabetic nephropathy, but all ACE inhibitors appear to be effective.
Fosinopril Monopril has a dual route of elimination and therefore may have an advantage over other ACE inhibitors, particularly when used for patients with renal insufficiency or failure.
Once started, renoprotective therapy should be continued indefinitely. ACE inhibitors have been shown to prevent or slow the progression from microalbuminuria to overt nephropathy.
Studies have also shown that the renoprotective effects of ACE inhibitors go beyond those expected from blood pressure reduction by itself. Additionally, the renoprotective effects apply to both normotensive and hypertensive patients with microalbuminuria. Therefore, the indication for ACE inhibition can be persistent microalbuminuria, regardless of blood pressure.
Discontinuing therapy will result in a recurrence of microalbuminuria. In addition to aggressively managing blood pressure, attempts need to be made toward lifestyle modifications. These include meticulous control of blood glucose, seeking counseling to stop smoking, maintaining optimal body weight, following an appropriate diet, and exercising regularly.
Clinical Pearls Screen diabetic patients for microalbuminuria. Relationships among diabetes, microalbuminuria, and ACE inhibition. J Cardiovasc Pharmacol 32 Suppl 2:Case Studies in Managgging Hypertension: Defining the Barriers to Control David Feldman, MD, PhD, FACC, FAHA *Hypothetical case based on a typical patient expected to present in clinical practice.
6 Three reviews of 50 observational studies found the risk of CV disease was lowered in those who were physically active. Clinical case scenarios for primary care Clinical case scenario 1: Mary Presentation Mary is 38 years old.
She is attending for a routine appointment about her contraception, for which she uses a diaphragm. Medical history. Clinical Management and Treatment Decisions Case study, American Journal of Hypertension, Volume 11, Issue S8, 1 may be different for black American and white individuals.
10–12 Some studies indicate that effective treatment of hypertension in black Americans results in a decrease in the incidence of CVD to a level that is similar to.
1 Case Studies in Managgging Hypertension: Defining the Barriers to Control David Feldman, MD, PhD, FACC, FAHA Director of Heart Failure and CardiacDirector of Heart Failure and Cardiac. Randomized clinical trials are the backbone of evi-dence-based medicine.
Large epidemiologic studies (Framingham, National Health and Nutrition Examina-tion Survey [NHANES]) and many clinical trials have Case Studies in .
Introduction. Case studies are an invaluable record of the clinical practices of a profession. While case studies cannot provide specific guidance for the management of successive patients, they are a record of clinical interactions which help us to frame questions for more rigorously designed clinical studies.