#265 TFTC #3: Hypertension Update, Sarcoidosis, Seizures

April 2, 2021 | By Matthew Watto, MD

Recap our top pearls from recent shows on hypertension, sarcoidosis, and seizure. It’s Tales from the Curbside #3(TFTC #3)!, our monthly series providing a rapid review of recent Curbsiders episodes.

Note: No CME for this mini-episode but visit curbsiders.vcuhealth.org to claim credit for #254, #256, and #257. 

Episodes | Subscribe | Spotify | Swag! | Top Picks | Mailing List | thecurbsiders@gmail.com | Free CME!

Credits

• Written, Produced and Hosted by: Matthew Watto MD, FACP; Paul Williams MD, FACP  
• Infographics by: Beth Garbitelli and Edison Jyang
• Cover Art: Edison Jyang
• Editor: Matthew Watto MD (written materials); Clair Morgan of nodderly.com

Show Segments

• Intro, disclaimer
• Hypertension update
• Sarcoidosis
• Seizures
• Outro

Tales from the Curbside Top Pearls

Click the links below for full show notes.

Episode #254 – HTN Update with Dr Wanpen Vongpatanasin 

Produced by Deb Gorth with graphic by Edison Jyang

HTN Pearl 1 (BP goals, monitoring)

BP goals boil down to the “acceptable” and the “ideal” typically <140/90 and <130/80. Dr Vongpatanasin recommends using validatebp.org to find a BP cuff. Arm > wrist cuff. Check twice daily for 7 days to confirm the diagnosis. She recommends that patients average multiple readings (e.g. 2-3 readings in a row spaced by 1 min) each time they check.

HTN Pearl 2 (Spironolactone)

Caution spironolactone in men (sexual side effects and gynecomastia, dec libido, ED).

HTN Pearl 3 (Office vs Home BP)

Home BP readings tend to be lower than office readings, especially for in-office readings above 130/80. Remember that masked hypertension (normal clinic BP, but high home BP) and white coat hypertension (normal home BP and high clinic BP) both confer some cardiovascular risk, though less than that of sustained hypertension (BP high in all settings).

HTN Pearl 4 (Combo pills)

Consider the combo pill! Dr. Vongpatanasin taught us that one large health system prescribes lisinopril-hctz 20-25 mg tabs and patients take half a tab, full tab, two tabs based on the severity of their hypertension. 

Episode #256 Sarcoidosis with Drs. Boltax and Scholand 

Produced by Deb Gorth with graphic by Edison Jyang

Sarcoidosis Pearl 1 (Diagnosis)

We often find it incidentally when imaging asymptomatic patients. Sarcoidosis should be considered in patients with a history of multiple courses of antibiotics for non-resolving infections. Also, consider it in the patient with a history of unexplained syncope and palpitations. ACE levels are not a useful test for the diagnosis of sarcoidosis due to poor sensitivity and specificity.

“The diagnosis of sarcoidosis is arbitrarily made when the statistical likelihood of alternative diagnoses becomes too small to warrant further investigation”

Dr. Jonathan Boltax

Sarcoidosis Pearl 2 (Workup)

Initial workup: Full history and physical plus a CXR, full PFTs, eye exam, EKG, and bone labs (alk phos, 25-OH vitamin D, 1,25-OH vitamin D, and Calcium). Consider a high-resolution CT scan of the chest. Further testing may include Cardiac MRI or a full-body PET scan. 

Sarcoidosis Pearl 3 (Steroids)

Steroids are often started at a dose of 20-40 mg daily and tapered over months. Dr. Boltax notes that some patients come off steroids entirely. Others require maintenance doses with adjuvant immunomodulators added if patients cannot get below 10 mg prednisone daily. Consider pneumocystis prophylaxis for patients on at least 30 mg of prednisone for more than 30 days. 

Episode #257 Seizure Basics with Dr Sara Dawit 

Produced by Beth Garbs Garbitelli and Paul Williams

Seizure Pearl 1 (The RRT)

In a rapid response for the patient having a seizure, don’t put something in their mouth! Lay them on their side. Move them away from harmful objects. Time the seizure. Mind your ABCs. Call 911. Video the event if possible. 

Graphic by Beth Garbitelli

Seizure Pearl 2 (Precautions)

Counsel patients about seizure precautions: Avoid ladders. Always have supervision around water. Consider an epilepsy safe pillow. No driving for 3-6 months or when seizures uncontrolled. Common triggers include: poor sleep, alcohol use, and drugs (antibiotics, tramadol, bupropion). 

Graphic by Beth Garbitelli

Seizure Pearl 3 (Primary Care)

Monitor for medication side effects with routine labs (including drug levels annually) and vitamin D levels for patients on antiepileptic drugs (AEDs) that are inducers of cytochrome p450. Be ever mindful of comorbid mood disorders (approx. 20-50% prevalence). Patients with seizures are 3.5 to 5.8 times more likely to die from suicide.

Goal

Listeners will review tops pearls from recent curbsiders episodes

Learning objectives

After listening to this episode listeners will…

1. Accurately measure blood pressure and determine treatment goals for hypertension
2. Recognize the common features of sarcoidosis and order appropriate diagnostic testing for both initial diagnosis and monitoring
3. Identify patients with possible seizure and perform the appropriate initial diagnostic and management steps.

Disclosures

Drs. Watto and Williams report no relevant financial disclosures. 

Citation

Watto MF, Williams PN. “#265 TFTC #3: Hypertension Update, Sarcoidosis, Seizures”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list Final publishing date March 31, 2021.