Hypertension

[See Resistant/Secondary Hypertention]
Terminology sBP dBP  
Normal < 120 < 80  
Pre-hypertension 120-139 80-89  
Hypertension stage 1 140-159 90-99  
Hypertension stage 2 ≥ 160 ≥ 100  
Hypertensive Crisis
(malignant Hypertension)
≥ 180 ≥ 110 NO
end-organ injury
Hypertensive Emergency ≥ 180 ≥ 110 PLUS
End-organ damage

JAMA 2014 Guideline

Risk Factors

Risk factors
  • Cigarette smoking
  • Obesity (body mass index ≥ 30 kg/m2)
  • Family history of cardiovascular disease: women < 65 yr or men < 55 yr
  • Dyslipidemia
  • Diabetes mellitus
  • Very sedentary lifestyle
  • Age > 55 yr (men) or > 65 yrs (women)
  • Men or postmenopausal women

End-organ damage

  • Heart disease
    • Left ventricular hypertrophy
    • Coronary artery disease
    • Congestive heart failure
  • Stroke or transient ischemic attack
  • Nephropathy (microalbuminuria or creatinine clearance < 60 mL/min)
  • Peripheral vascular disease
  • Retinopathy

Drugs that cause high BP

Medications/Herbs that cause elevated BP (Stop if possible)
  • Anabolic steroids and corticosteroids,
  • bevacizumab
  • bromocriptine
  • bupropion (wellbutrin)
  • buspirone
  • clozapine
  • cyclosporine
  • darbepoetin
  • ephedra
  • epoetin-alpha
  • estrogens [OCP]
  • fludrocortisone
  • MAOIs
  • Metoclopramide [Reglan]
  • Nicotine
  • NSAIDs
  • Phentermine
  • Pseudoephedrine
  • sibutramine
  • sorafenib
  • sunitinib
  • sympathomimetics
  • Tacrolimus, and venlafaxine;
  • Herbs:
    • aniseed
    • bayberry
    • blue cohosh
    • capsaicin
    • ephedra
    • gentian
    • ginger
    • ginseng
    • guarana
    • licorice
    • ma huang
    • Pau d'Arco
    • parsley
    • St. John's wort
       

Conditions that cause High BP

Clinical conditions that cause high bp in hospitalized pt
Important to exclude and address these causes of blood pressure elevation:
  • Pain
  • Anxiety
  • Alcohol/drug withdrawal
  • Elevated intracranial pressure
  • Renal failure
  • Excess sodium administration (watch IV fluids)
  • Excessive bladder or bowel distension.

Initial Workup

  • Blood work:
    • CBC, BMP, calcium, fasting lipid, and renal panels
  • Other studies:
    • Urinalysis, ECG, eye exam, and a CXR if signs of CHF
  • Eval for secondary HTN if:
    • Onset < 30 yr or > 60 yr
    • Accelerated, resistant, or paroxysmal HTN
    • Abnormal UA or ↑ creatinine
    • Unprovoked ↓ K or ↑ Ca
    • Cushing syndrome
    • Abdominal mass/bruit

Treatment

ED Management

Drip
  1. Cardene Drip - Parenteral CCB, good initial choice, 5 mg/hour, titrate q 3 minutes, max 15 mg/hour.
    DO NOT USE P.O. Cardene (it's useless).
    • ↓ cerebral vasospasm, and therefore is a good for stroke syndromes.
       
  2. Nitroglycerine Drip - Good for cardiac hypertensive states, 10-20 mcg/min, increase 10-20 q 3min until desired effect max 100-200
 
IV
  1. ACEI
    • Enalaprilat (Vasotec IV) 0.625 - 1.25 mg IV q6h; (MAX: 5mg IV q6h)
    • Enalapril (Vasotec PO) 2.5, 5, 10, 20 mg IV q6h (MAX: 5mg IV q6h),
  2. Beta-blockers: (DO NOT USE IF HTN 2nd TO CLONIDINE WITHDRAWAL)
    • labetalol 10-20mg IVP, then 40-80 mg IV q10min prn; infusion: 1-8 mg/min; Max 300mg IV.
    • Metoprolol 5 mg q 15 min x 3;
  3. Hydralazine 10-20mg IV q30min.
  4. Nitroprusside 0.5 - 5 mcg/kg/min;
    • Start: 0.25-0.3 mcg/kg/min IV, titrate to desired effect; MAX: 10 mcg/kg/min x 10 min.
    • Cerebral vasodilator, should be used carefully in stroke syndromes
    • monitor thiocyanate levels.
  5. Diltiazem 20 mg → 5-15 mg/hr
 
PO
  1. Clonidine 0.2 mg x 1 then 0.1 mg q1h x 6;
    • 0.1 - 0.3 mg po TID, may incr. by 0.1 mg/day qwk; max: 2.4 mg/day.
      Taper dose over 2-4 days to D/C.
  2. Captopril 25 mg q1h x 4
  3. Minoxidil 10-40 mg PO qd or q12h (Max: 100mg qd, Half-life: 4.5 hr)
  4. Labetalol 200-400 mg q2-3h; or
  5. Nifedipine XL 30 mg x 1
 
Paste
  1. Nitro paste: Nitro-Bid 2% oint 0.5-2 inch topical q4-6h

 

Drug Effects:
Drug BP Pulse Comments
Labetolol α1-, β-Adrenergic blocker
Much more β-blockade than α-blockade
Effective as single agent
Clonidine ↔, ↓↑ Centrally acting α2-agonists, central sympathetic outflow.
Application: hypertension, especially with renal disease (no decrease in blood flow to kidney).
HCTZ ↔, ↓  
Vasotec ↔, ↓  
Hydralazine ↔,↑ Direct arteriolar vasodilator (watch for reflex tachycardia)
Nitroglycerin (reflex response) Venous >> arteriolar dilation
Verapamil, diltiazem conduction velocity, ERP, PR interval.
Used in prevention of nodal arrhythmias (e.g., SVT)
Nicardipene ↔, ↓ Calcium channel blocker
Peripheral vascular resistance
Cerebral vasospasm (good for stroke syndromes)
Phentolamine Pure α-blocker
Orthostatic hypotension, Vomiting, Diarrhea, flushing, wheezing.
 

Lifestyle modification

  • Weight reduction (aiming for BMI < 25 kg/m2): decreases SBP 5-20 mmHg
  • <2 drinks of alcohol/d (men) and ≤1 drink/d (women): decreases SBP 2-4 mmHg
  • Aerobic exercise (≥30 min/d ≥ 4 d/wk): decreases SBP 4-9 mmHg
  • <2.3 g sodium/d: decreases SBP 2-8 mmHg
  • Diet: Dietary Approaches to Stop Hypertension (DASH) diet (↓ SBP 8-14 mmHg); adequate potassium, magnesium, calcium; low saturated fat, high fiber, and low cholesterol
  • Smoking cessation.

 

Initial Drug Therapy

Initial drug therapy
  • BP goals:

    • DM, CAD, or CKD:  ≤ 140/90 
    • Proteinuria > 1 g/d:  ≤ 125/75
  •  Initial therapy in patients with no compelling indications for specific drug classes

    • Thiazides (drug of choice for most patients if creatinine < 2 mg/dL or CrCl > 35 mL/min/1.73 m2), despite the small increased risk in new-onset diabetes.
    • JNC-8 Guideline:
      In the general non-black population, including those with diabetes, initial treatment should include: A thiazide-type diuretic or
      CCB, or
      ACEI, or
      ARB
      In the general black population, including those with diabetes, initial treatment should include: A thiazide-type diuretic or
      CCB
      • In the population > 18 years with CKD, initial (or addon) treatment should include: ACEI or ARB to improve kidney outcomes.
      Do not use an ACEI and an ARB together in the same patient.
      The main objective of hypertension treatment is to attain and maintain goal BP Add and titrate as necessary to meet this objective
      ASH/ISH Recommendations:
      • In patients > 18 years initiate treatment at BP > 140/90
      • In patients > 80 years initiate treatment at BP > 150/90
      • Non-black < 60 ACEI or ARB
      • Non-black > 60 CCB or thiazide
      • Black CCB or thiazide
      • If initial BP > 160/100 initiate with 2 drugs
      – CCB or thiazide plus ACEI or ARB
    • ACEI:
      • If a bump in Cr < 30% after initiating Tx -->  Recheck Cr in 1 week --> if Cr Stable & BP controlled = Cont' AECI
      • Slight rise in creatinine serves as an indirect indicator that intraglomerular (IG) pressure has been reduced.
      • ACEI/ARB also dilate efferent arteriole, exaggerating decline in IG pressure. = GOOD THING
      • If creatinine increases by > 30%, agent should be discontinued and other causes of renal dysfunction should be evaluated.
    • Thiazide Diuretics:
      • Reduce excretion of:
        – Calcium (may slow bone demineralization)
        – Uric acid (increasing likelihood of gout)
        – Lithium (increasing risk of lithium toxicity)
      • Increase excretion of:
        – Potassium (average decrease of 0.3-0.4 mmol/L; dietary salt restriction can minimize thiazide-induced K loss)
        – Magnesium (complicates correction of hypo-K)
      • Typically considered ineffective when GFR < 30-40 mL/min
        – Exception is metolazone, which is not useful as monotherapy but improves diuresis when used in conjunction with loop diuretic.
      • All biochemical adverse effects such as hypokalemia, hyponatremia, hyperuricemia, insulin resistance, and visceral fat accumulation are dose dependent and become clinically more significant with daily doses exceeding 25 mg.
      • An additional concern is the risk of sudden cardiac death that has been shown to increase in a dose dependent fashion with HCTZ doses exceeding 25 mg daily.
    • β-blockers not the best monotherapy for HTN if no compelling indications
    • Stage 2 hypertension usually requires at least 2 drugs
  • Drugs for Resistant Hypertension
    • Definition:
      • Persistent HTN despite 3 drugs
    • Treatment options:
      • – Typically inadequate diuresis
        – Move to loop diuretic
        – Add spironolactonem OR Chlorthalidone
        – Consider vasodilating β-blocker (carvedilol, labetalol, nebivolol)
        – Consider clonidine, hydralazine, α-blocker
  • [Resistant/Secondary HTN]
Compelling indications
Indication Diuretic BB ACEI ARB CCB Aldo-antag
Heart failure  
Post-MI      
High coronary disease risk    
Diabetes  
Chronic kidney disease        
Recurrent stroke
prevention
       

 

Indication Drug of Choice
Diabetes with proteinuria ACEI*, ARB*
Verapamil, or diltiazem
Congestive heart failure ACEI*, ARB*
b-blockers
diuretics
AA
Diastolic dysfunction b-blocker
verapamil, diltiazem
thiazides
ACEI*
Isolated systolic hypertension Thiazides,
Dihydropyridine CCB,
b-blocker
ACEI*
Nitrates
Post-myocardial infarction b-blocker
ACEI*
AA
Angina b-blocker
calcium channel blocker
Atrial fibrillation b-blocker
Verapamil, or diltiazem
Dyslipidemia ACEI, b-blocker,
thiazides
Essential tremor b-blocker
Hyperthyroidism b-blocker
Migraine b-blocker
Verapamil, or diltiazem
Osteoporosis Thiazides
Pregnancy Methyldopa
Hydralazine
Labetalol
Benign prostatic hyperplasia α1-blockers in combination with other agents
Erectile dysfunction ACEI, ARB
CCB
Renal insufficiency ACEI* or ARB*
Cerebrovascular disease Thiazides,
ACEI, ARB
Amlodipine
Obstructive sleep apnea CPAP therapy
AA
Thiazides
CCB
-- at bedtime
African American race Thiazides (1st line)
CCB
ACEI*
Aortic dissection Labetalol (b-blocker)
Diltiazem
Refractory hypertension Minoxidil & loop diuretic & b-blocker or CCB
AA = Alpha Agonist = Clonidine, Methyldopa.


 

HTN Urgency
 (>180/110 WITHOUT end-organ damage)

  • Need to exclude chronic, poorly controlled hypertension (outpatient management)
  • Oral agents titrated to effect:
    • Clonidine 0.2 mg x 1 then 0.1 mg q1h x 6;
    • Captopril 25 mg q1h x 4;
    • Labetalol 200-400 mg q2-3h; or
    • Nifedipine XL 30 mg x 1
  • IV agents if pt NPO:
    • Metoprolol 5 mg q 15 min x 3;
    • Labetalol 20-40 mg q 10-15 min (max 300 mg/d);
    • Hydralazine 5-10 mg q 30 min;
    • Enalaprilat 1.25 mg q6h;
    • Diltiazem 20 mg → 5-15 mg/hr

HTN Emergency
(>180/110 WITH end-organ damage)

  • Defined by end-organ damage, e.g., encephalopathy, renal dysfunction, CHF, Cardiac ischemia, decreased placental perfusion
  • dBP > 120 mmHg but BP can be as low as 160/100 (e.g., pregnant woman, drug reaction in young adult)

Treatment

  1. Cardene Drip - Parenteral CCB, good initial choice, 5 mg/hour, titrate q 3 minutes, max 15 mg/hour.
    DO NOT USE P.O. Cardene (it's useless).
    • ↓ cerebral vasospasm, and therefore is a good for stroke syndromes.
       
  2. Nitroglycerine Drip - Good for cardiac hypertensive states, 10-20 mcg/min, increase 10-20 q 3min until desired effect max 100-200
  3. Oral agents titrated to effect:
    • Clonidine 0.2 mg x 1 then 0.1 mg q1h x 6;
    • Captopril 25 mg q1h x 4;
    • Labetalol 200-400 mg q2-3h; or
    • Nifedipine XL 30 mg x 1
  4. IV agents if pt NPO:
    • Metoprolol 5 mg q 15 min x 3;
    • Labetalol 20-40 mg q 10-15 min (max 300 mg/d);
    • Hydralazine 5-10 mg q 30 min;
    • Enalaprilat 1.25 mg q6h;
    • Diltiazem 20 mg → 5-15 mg/hr

 

Tx By Scenario

Clincal Scenario Goal of Tx 1st line Rx Comments
Hypertensive Encephalopathy 20-25% reduction in MAP over 2-3hr (but keep dBP>100 mmHg) -Nitroprusside 3-4 mcg/kg/minIV (max 10mcg/kg/min x 10min)
-Fenoldopam 0.025-0.3 mcg/kg/min IV, titrate by 0.05-0.1 mcg/kg/min q15min; (max: 1.6 mcg/kg/min); Short term use up to 48 hr
-Clevidipine 1-2 mg/h IV, double rate q90sec until near BP goal, then incr. by smaller increments q5-10min; (max: 32 mg/h, 500 mg/24h)
-Labetalol 20mg IV x1, may give 40-80mg IV q10min. (max: 300mg/total dose)
-Nicardipine 5 mg/h IV, incr. 2.5mg/h q5-15min prn (Max: 15mg/h)
Treatment may worsen neuro function.
Avoid Clonidine, bb (CNS effects)
Ischemic Stroke if BP ?220/120, lower 15-25% in first day -Labetalol 20mg IV x1, may give 40-80mg IV q10min. (max: 300mg/total dose)
-Nicardipine 5 mg/h IV, incr. 2.5mg/h q5-15min prn (Max: 15mg/h)
Nitropruside, Fenoldopam, NTG may incr. ICP.
Goal: 185/110 if thrombolytics
Intracerebral Hemorrhage Gradually reach 160/80
MAP < 110
CPP >60 w/ ICP monitor
or prestroke level
-Labetalol 20mg IV x1, may give 40-80mg IV q10min. (max: 300mg/total dose)
-Nitroprusside 3-4 mcg/kg/minIV (max 10mcg/kg/min x 10min)
-Nicardipine 5 mg/h IV, incr. 2.5mg/h q5-15min prn (Max: 15mg/h)
Monitor for worsening neuro function after lowering BP
Subarachnoid Hemorrhage same as intracranial hem. -Nimodipine 60mg PO/NGT q4h (to prevent spasm)
+/-
-Labetalol 20mg IV x1, may give 40-80mg IV q10min. (max: 300mg/total dose)
AVOID Nitropruside, Fenoldopam & NTG (incr. ICP)
Pulmonary Edema dBP <100 or resolution of Sx -Nitroprusside 3-4 mcg/kg/minIV (max 10mcg/kg/min x 10min)
+
-NTG 5mcg/min IV & incr. 5mcg/min q3-5min until response
+
-Lasix 40mg IV x1.
Avoid (-) ionotropes in LV dysfunction.
Search for myocardial ischemia. In CAD or PAD, seek RAS
MI or Unstable Angina dBP <100 or resolution os Sx NTG, BB.
Add SNP if dBP remain elevated
 
Aortic Dissection sBP 100-120 or MAP 80 (watch urine output) -Nitroprusside 3-4 mcg/kg/minIV (max 10mcg/kg/min x 10min)
or
-Clevidipine 1-2 mg/h IV, double rate q90sec until near BP goal, then incr. by smaller increments q5-10min; (max: 32 mg/h, 500 mg/24h)
or
-Fenoldopam 0.025-0.3 mcg/kg/min IV, titrate by 0.05-0.1 mcg/kg/min q15min; (max: 1.6 mcg/kg/min); Short term use up to 48 hr
PLUS
-Labetalol 20mg IV x1, may give 40-80mg IV q10min. (max: 300mg/total dose)
Decrease sp/dT, Avoid vasodilator drugs
Sympathomimetic Crisis:
[Cocaine, amphetamines, pheochromocytoma
MAOI reaction
bb or
Clonidine withdrawal]
dBP~ 100-105 (but <25% reduction in presenting BP) over 2-6h -Phentolamine (1st) 5mg IV/IM, then
-Labetalol 20mg IV x1, may give 40-80mg IV q10min. (max: 300mg/total dose)

Benzodiazapine:
- Ativan 1mg IV/IM for cocaine-like drugs.

Alt: NTG +/- CCB
Avoid BB or Labetolol alon (unopposed alpha stimulation)
Restart BB or Clonidine if withdrawing.
Pregnancy (eclampsia) dBP 90-105 or MAP < 126 -Hydralazine 10-20mg IV q30min
-Labetalol 20mg IV x1, may give 40-80mg IV q10min. (max: 300mg/total dose).
-Nifedipine10-20mg PO
PO: methyldopa.
Avoid: SNP, ACEI
Postoperative PreOp BP SNP, Labetolol, Diuretics Tx pain, Volume overload & decrease O2
Acute renal insufficiency sBP ~ 100-105 (but <25% reduction in presenting BP) Fenoldopam, CCB, BB, Clevidipine, Clonidine. Avoid diuretics. Maintain renal  blood floww
 

Causes of Secondary HTN

Features of secondary hypertension Possible etiologies Labs
Sudden onset of severe hypertension or newly diagnosed in those <30 yr or >60 yr Renal vascular disease or renal parenchymal disease (children) Renal US
(children)
Abnormal urinalysis Renal parenchymal/glomerular disease Renal US
Hypokalemia and ARR >66.9 ng/dL* Primary hyperaldosteronism (MCC) Aldosterone/renin ratio
Hypercalcemia Hyperparathyroidism PTH
Fine tremor, heat intolerance, ↓ TSH, ↑ fT4 Hyperthyroidism TSH, T3/T4
Paroxysmal severe HTN, palpitations, HA Pheochromocytoma 24-hour urine collection for catecholamines.
Metanephrines, normetanephrines, and creatinine.
Serum free metanephrines and normetanephrines.
Plasma catecholamines
Abdominal mass Polycystic kidney disease Renal US
Flank bruit Renal artery stenosis

– Age < 30: fibromuscular disease
– Age > 30: atherosclerotic disease
1st Tests To Order
serum creatinine
serum potassium
urinalysis and sediment evaluation
aldosterone-to-renin ratio (*Elevated renin level alone is NOT diagnostic)

Other Tests to Consider
duplex ultrasound
gadolinium-enhanced MR angiography
CT angiography
captopril radionuclide renal scan
conventional angiography
↑ glucose, striae, truncal obesity, etc. Cushing syndrome 1st Tests To Order
Urine pregnancy test.
Serum glucose.
late-night salivary cortisol.
1 mg overnight dexamethasone suppression test (morning cortisol >1.8 micrograms/dL).
24-hour urinary free cortisol (>50 micrograms/24 hour).
48-hour 2 mg (low-dose) dexamethasone suppression test (morning cortisol >1.8 micrograms/dL).

Other Tests to Consider
plasma dehydroepiandrosterone sulfate (DHEAS) level.
morning plasma ACTH (>20 picograms/mL indicates pituitary or ectopic etiology; <5 picograms/mL indicates adrenal etiology).
High-dose dexamethasone suppression test (positive test is defined as suppression of cortisol <50% of the baseline value).
pituitary MRI.
adrenal CT.
inferior petrosal sinus sampling.
CT of chest, abdomen, and pelvis.
MRI chest.
PET scan.
Octreotide scanning.
Resistant hypertension on three meds Renal vascular/parenchymal disease  
Markedly decreased femoral pulses Coarctation of aorta 1st Tests To Order
ECG
CXR
echocardiogram

Other Tests to Consider
CT angiography
magnetic resonance angiography
cardiac catheterization
Central obesity, loud snoring, daytime hypersomnolence, nonrestorative sleep Obstructive sleep apnea 1st Tests To Order
Polysomnography (PSG).
Portable multichannel sleep tests.
Awake fiberoptic endoscopy.

Emerging Tests
cine MRI
drug-induced sleep endoscopy (DISE)
cardiovascular and neurological tests
biochemical or genetic signatures and assays

 

MOA of Drugs

Mechanism Of Action of Anti-hypertensive Drugs
Diuretics
- Furosemide (preferred over thiazides if serum creatinine ≥ 2.5 mg/dL)

Negative inotropic
-   β-blockers
-   Verapamil
-   Diltiazem

Sympatholytics
-  β-blockers
-  Clonidine
-  Methyldopa
-  Guanethidine

Renin/angiotensin/aldosterone blockers
-  β-blockers
-  ARBs
-  ACEIs
-  Direct renin inhibitors
-  AAs

Vasodilators
-  Hydralazine
-  α1-blockers
-  Minoxidil
-  Dihydropyridine CCBs
-  Thiazides (creatinine < 2.5 mg/dL)
 
Drug Effects:
Drug BP Pulse Comments
Labetolol α1-, β-Adrenergic blocker
Much more β-blockade than α-blockade
Effective as single agent
Clonidine ↔, ↓↑ Centrally acting α2-agonists, central sympathetic outflow.
Application: hypertension, especially with renal disease (no decrease in blood flow to kidney).
HCTZ ↔, ↓  
Vasotec ↔, ↓  
Hydralazine ↔,↑ Direct arteriolar vasodilator (watch for reflex tachycardia)
Nitroglycerin (reflex response) Venous >> arteriolar dilation
Verapamil, diltiazem conduction velocity, ERP, PR interval.
Used in prevention of nodal arrhythmias (e.g., SVT)
Nicardipene ↔, ↓ Calcium channel blocker
Peripheral vascular resistance
Cerebral vasospasm (good for stroke syndromes)
Phentolamine Pure α-blocker
Orthostatic hypotension, Vomiting, Diarrhea, flushing, wheezing.

Admission Order:
Hypertensive Emergency

1. Admit to:

2. Diagnosis: Hypertensive emergencies

3. Condition:

4. Vital Signs: q30min until BP controlled, then q4h.

5. Activity: Bed rest

6. Nursing: Intra-arterial BP monitoring, daily weights, inputs and outputs.

7. Diet: Clear liquids.

8. IV Fluids: D5W at TKO.

9. Special Medications:

-Labetalol (Trandate, Normodyne) 20 mg IV bolus (0.25 mg/kg), then 20-80 mg boluses IV q10-15min, titrate to desired BP or continuous IV infusion of 1.0-2.0 mg/min, titrate to desired BP.

-Fenoldopam (Corlopam) 0.01mcg/kg/min IV infusion. Adjust dose by 0.025-0.05 mcg/kg/min q15min to max 0.3 mcg/kg/min. [10 mg in 250 mL D5W].

  -Nicardipine (Cardene IV) 5 mg/hr IV infusion, increase rate by 2.5 mg/hr every 15 min up to 15 mg/hr (25 mg in D5W 250 mL).
  -Esmolol (Brevibloc) 500 mcg/kg/min IV infusion for 1 minute, then 50 mcg/kg/min; titrate by 50 mcg/kg/min increments to 300 mcg/kg/min (2.5 gm in D5W 250 mL).
 
  -Phentolamine (pheochromocytoma), 5-10 mg IV, repeated as needed up to 20 mg.
 

10. Symptomatic Medications:

  - Acetaminophen (Tylenol) 325-650 mg PO q4-6h prn headache.
  - Zolpidem (Ambien) 5-10 mg qhs prn insomnia.
  - Docusate sodium (Colace) 100-200 mg PO qhs.
  - Zofran 4 mg IV q4h prn n/v.
 
- Famotidine (Pepcid) 20 mg IV/PO q12h  OR
  - Lansoprazole (Prevacid) 30 mg qd.

 

11. Extras: Portable CXR, ECG, echocardiogram.

12. Labs: CBC, CMP, UA with micro. TSH, free T3/T4, 24h urine for metanephrine. Plasma catecholamines, high sesitivity CRP, urine drug screen.

 


References:

JAMA 2003:289:2560; NEJM 2003;348:610; JAMA 2002;288:2981; J Clin Hypertension 2007;9:10; Circulation 2007;115:2761.