Hypertension: JNC 8 Guidelines

The eighth version (hence JNC 8) of these guidelines, they may be revised soon after the results of the SPRINT trial come out, but we ain't there yet. Here's a breakdown:

• Make sure to check the blood pressure properly AKA two different visits. Try lifestyle modifications first (diet, exercise, no smoking/drinking).
• If they have CKD, start on an ACE inhibitor or ARB.
• If they are BLACK, start them on a thiazide, or calcium-channel blocker (alone or in combo).
• All other patients start on thiazide diuretic, calcium-channel blocker, ACE inhibitor, or ARB.
• Goal should be set to < 140/90. If OVER 60 YEARS OLD, set goal to < 150/90.
• GOAL NOT REACHED? Try increasing the dosage of a single medication or combining medications, with regard to cost and side effects. If that doesn't work, try adding beta blockers or aldosterone antagonists.
• If the patient is PREGNANT, use labetalol, nifedipine, or methyl-dopa.

Statin Therapy: ACC/AHA guidelines

The 2013 guidelines make it very clear who should be receiving statin therapy for high cholesterol. There are 4 conditions to consider:

• Atherosclerotic cardiovascular disease (ASCVD)? Start a statin.
• LDL-C > 190mg/dL? Start a statin.
• LDL-C of 70-189mg/dl...but the patient is diabetic and 40-75 years old? Start a statin.
• None of the above criteria...but the 10 year ASCVD risk score is above 7.5%? Start a statin.

You can find the ASCVD easily accessible risk calculator here. There is also a downloadable app.

Diabetes: AACE/ACE Guidelines

Diabetes is a little more complex, mainly because of the variety of treatment options available for use. Fortunately the endocrinologists know how to make a killer powerpoint which you can download from the link above, or get directly from here. Below is a very summarized explanation.

• Set an HbA1c goal: < 6.5% if patient has no other illnesses and is at low risk of hypoglycemia, otherwise set the goal > 6.5%.
• If HbA1c < 7.5%, start on metformin (preferred), GLP-1 agonist, SGLT-2 inhibitor, or DPP-4 inhibitor.
• If HbA1c > 7.5%, start on metformin PLUS a GLP-1 agonist, SGLT-2 inhibitor, or DPP-4 inhibitor.
• If HbA1c > 9.0% but not symptomatic, start on dual or triple therapy as above.
• If HbA1c > 9.0% AND SYMPTOMS ARE PRESENT, start on insulin plus/minus other agents.
• Re-assess every 3 months to see if at HbA1c goal. If concerned about side effects, check the powerpoint for a great color-coded chart.

Stage C Heart Failure: AHA Guidelines

Heart failure is also complex, mostly because it can be defined by limitations of physical activity (NYHA classes I-IV) and risk/presence of treatable heart failure (AHA stages A-D). The guidelines presented below are for treatment of patients who are diagnosed with heart failure and have some degree of symptoms and physical limitations. The data referenced below can be found on page 60 of the PDF.

• ALL PATIENTS should be started on a beta blocker PLUS ACE inhibitor or ARB.
• If the patient (CLass II-IV) has VOLUME OVERLOAD, add a loop diuretic.
• If the patient (Class III-IV) is BLACK, add hydralazine and nitrates.
• If the patient has GFR > 30mL/min and K+ < 5mEq/dL, add an aldosterone antagonist.

Acute MI Management

The AHA and AAFP have a couple resources on what to do when a patient presents with symptoms of an MI. The list below comes from one of my preceptors, an Emergency Medicine physician.

• Oyxgen
• Sublingual Nitroglycerin
• Beta-Blockers
• Morphine
• Aspirin (325mg)
• Atorvastatin 80mg
• Anti-Platelet Agents (clopidogrel, ticagrelor, prasugrel)
• Heparin

Subacute MI Management: AAFP Guidelines

After stabilization in the hospital, patients who have had an MI get a whole boatload of medications to try to prevent future MIs. Here's a few that the patient should be taking.

• Every patient should be on aspirin.
• Anti-platelet agents (clopidogrel, ticagrelor) are synergistic with aspirin.
• Beta-blockers decrease work of heart, preventing decreased myocardial perfusion, also useful for heart failure.
• ACE inhibitor and ARBs decreases afterload, and also assist with proper myocardium remodeling (otherwise weaker scar tissues forms).
• Since the patient obviously has Atherosclerotic Cardiovascular Disease (ASCVD), they need a statin.
• Certain patients may also require nitroglycerin, aldosterone blockers, and PPIs

Post-Stroke Management: AAFP Guidelines

Most strokes are caused by ischemia secondary to thrombi or emboli. Therefore, in the majority of cases, prophylaxis consists of anti-coagulation.

• Patients should receives either aspirin plus/minus dipyridamole OR clopidogrel, but not aspirin PLUS clopidogrel.
• Warfarin should not be used unless the patient has a history of atrial fibrillation.
• Treat hypertension, diabetes, and hyperlipidemia. Also have the patient make lifestyle improvements.

Immunizations: CDC Guidelines

Vaccine schedules depend on the age of the patient and any comorbidities that might be present. Here, I'll break down the necessary vaccinations by comorbidity. Fortunately the CDC has put out some great color-coded infographics, which you can find at the link above.

• If the patient is pregnant, DO NOT GIVE MMR, zoster, or varicella as they are live vaccines and can cause infections in the fetus.
• Give HiB and PCV 13 (then PCV 23) to patients with weak immune systems. Give HIV+ patients, regardless of CD4 count, PCV 13 (then PCV 23), meningococcal, and HBV. Do not give MMR, zoster, or varicella to patients with weak immune systems or CD4 counts < 200 (> 200 is okay).
• If the patient is missing their spleen, give PCV 13 (then PCV 23), meningococcal, and HiB vaccines, to cover encapsulated organisms that might causes sepsis in a asplenic setting. Also give zoster.
• If the patient has CKD, give PCV 13 then PCV 23, and HBV. And zoster.
• If the patient has liver disease, heart disease, or diabetes, give PCV 23 alone (no PCV 13). Also give HBV for diabetics, and HAV/HBV for liver disease patients. You should also give zoster.
• If the patient is 60+ but otherwise healthy, give the zoster vaccine. If 65+, also give PCV 13 then PCV 23.
• Everyone should get a flu shot annually, and a TDaP once in adulthood then a booster every 10 years.