Essential Topics for Internal Medicine Resident Lectures
Hypertension Management: Evidence-Based Updates
Target blood pressure <130/80 mmHg for most patients with diabetes, with intensive targets (<120 mmHg systolic) providing additional cardiovascular benefit in high-risk populations. 1, 2
Blood Pressure Targets and Evidence
The 2017 ACC/AHA guidelines redefined hypertension as ≥130/80 mmHg, based primarily on the SPRINT trial demonstrating 25% reduction in cardiovascular events and 27% reduction in mortality with intensive systolic targets (<120 mmHg). 1, 2
For patients with diabetes specifically, the ADVANCE trial showed that achieving mean SBP/DBP of 136/73 mmHg reduced major cardiovascular events by 9%, cardiovascular death by 18%, and all-cause mortality by 14% compared to 141.6/75.2 mmHg. 1
The STEP trial in elderly patients (60-80 years, including those with diabetes) demonstrated that targeting SBP <130 mmHg versus <150 mmHg reduced composite cardiovascular outcomes by 26% and cardiovascular death by 28%. 1
The 2024 ESC guidelines introduced a simplified three-tier BP categorization: non-elevated (<120/70 mmHg), elevated (120-139/70-89 mmHg), and hypertension (≥140/90 mmHg), with treatment targets of 120-129 mmHg systolic for most adults. 2
Measurement and Diagnosis Essentials
Accurate BP measurement is foundational—use proper technique with appropriate cuff size, patient seated with back supported, feet flat, arm at heart level, after 5 minutes of rest. 1, 2
Utilize ambulatory BP monitoring or home BP monitoring to identify white coat hypertension (elevated office BP but normal out-of-office readings) and masked hypertension (normal office BP but elevated out-of-office readings). 1
Screen for secondary causes in patients with resistant hypertension: chronic kidney disease, renovascular disease, primary aldosteronism, pheochromocytoma, Cushing's syndrome, coarctation of the aorta, and obstructive sleep apnea. 1
Pharmacologic Management Algorithm
Initiate ACE inhibitors or ARBs as first-line therapy in patients with diabetes and hypertension, particularly those with albuminuria or chronic kidney disease. 1, 3
For patients with compelling indications (post-MI, heart failure with reduced ejection fraction), use β-blockers for at least 3 years post-MI in those with preserved left ventricular function. 1
Thiazide-like diuretics (chlorthalidone, indapamide) are preferred over hydrochlorothiazide for superior cardiovascular outcomes. 1
Combination therapy is typically required—the ADVANCE trial used fixed-dose perindopril/indapamide combination with significant mortality benefit. 1
Critical Pitfalls to Avoid
Clinical inertia—failure to titrate medications when BP remains above goal is a major barrier to control. Use decision support systems (electronic or paper-based algorithms) to prompt treatment intensification. 1
Do not discontinue antihypertensive therapy abruptly in pregnant patients—the CHAP trial demonstrated that treating to <140/90 mmHg in pregnancy with chronic hypertension improved outcomes without fetal harm. 1
More lenient targets (systolic 130-139 mmHg) are appropriate for very elderly patients (≥85 years), those with frailty, or symptomatic orthostatic hypotension. 2
Type 2 Diabetes: Cardiovascular and Renal Protection
SGLT2 inhibitors and GLP-1 receptor agonists should be prioritized in patients with type 2 diabetes and established cardiovascular disease or high cardiovascular risk, independent of glycemic control needs. 1
SGLT2 Inhibitors: Cardiovascular and Renal Benefits
The EMPA-REG OUTCOME trial demonstrated that empagliflozin reduced cardiovascular death, with particular benefit in patients with established cardiovascular disease (99% of trial participants had CVD). 1
The combined CANVAS/CANVAS-R trials showed canagliflozin reduced the composite outcome of cardiovascular death, MI, or stroke (HR 0.86,95% CI 0.75-0.97) in patients with mean age 63 years, 66% with prior CVD. 1
SGLT2 inhibitors provide additive renoprotection in diabetic patients with proteinuria >300 mg/g, regardless of glycemic control status—add to ACE inhibitor/ARB therapy for synergistic benefit. 3
Monitor for increased risk of lower-limb amputation with canagliflozin (HR 1.97,95% CI 1.41-2.75 in CANVAS program). 1
GLP-1 Receptor Agonists: Cardiovascular Outcomes
Consider liraglutide, semaglutide, or dulaglutide in diabetic patients with CVD or very high/high cardiovascular risk to reduce cardiovascular events and mortality. 3
These agents provide cardiovascular benefit beyond glycemic control and promote weight loss, addressing multiple metabolic risk factors simultaneously. 1
Comprehensive Risk Factor Management
Target LDL-C <55 mg/dL (<1.4 mmol/L) with ≥50% reduction from baseline in type 2 diabetes patients at very high cardiovascular risk using statin therapy as first-line. 3
Use ACE inhibitors or ARBs in all diabetic patients with hypertension or diabetic kidney disease—these agents reduce cardiovascular outcomes and slow CKD progression. 1
Finerenone (a non-steroidal mineralocorticoid receptor antagonist) should be considered in type 2 diabetes patients with CKD to reduce cardiovascular outcomes and CKD progression risk. 1
Lifestyle Intervention Framework
Prescribe at least 150 minutes per week of moderate-intensity aerobic plus resistance activity—emphasize that any amount of physical activity provides benefit. 4
Ensure adequate sleep (7-9 hours nightly) to improve insulin sensitivity and reduce inflammation. 4
Restrict dietary sodium to <2.0 g/day, which is synergistic with ACE inhibitor/ARB therapy and essential for BP control. 3
Limit alcohol consumption to ≤1 drink per day for women and ≤2 drinks per day for men. 4
Monitoring Parameters
Regularly assess BMI, waist circumference, blood pressure, lipid profiles, hemoglobin A1c, and kidney function (eGFR, urine albumin-to-creatinine ratio). 4
Screen for sleep disorders (particularly obstructive sleep apnea), which worsen insulin resistance, hypertension, hyperglycemia, and dyslipidemia. 4
Use non-invasive tests like FIB-4 to assess for liver involvement (NAFLD/NASH), with appropriate hepatology referral for intermediate to high-risk fibrosis. 4
Chronic Kidney Disease: Proteinuria and Hypertension Management
Initiate ACE inhibitor or ARB as first-line therapy and uptitrate to maximum tolerated dose (not just to BP control) in all patients with proteinuria ≥1 g/day, targeting proteinuria reduction to <1 g/day. 3
Diagnostic Workup and Risk Stratification
Quantify proteinuria using spot urine protein-to-creatinine ratio or 24-hour urine collection to establish baseline severity. 3
Measure baseline serum creatinine and eGFR to assess renal function, and evaluate for secondary causes (diabetes, autoimmune disease, multiple myeloma). 3
Assess cardiovascular risk factors including lipid panel and hemoglobin A1c if diabetic—CKD patients are at very high cardiovascular risk. 3
Pharmacologic Treatment Algorithm
Target systolic blood pressure <120 mmHg in most patients with proteinuria, using ACE inhibitor or ARB as foundation regardless of baseline BP. 3
Accept up to 30% increase in serum creatinine after starting ACE inhibitor/ARB—this is an expected hemodynamic effect indicating appropriate glomerular pressure reduction. 3
Check labs every 2-4 weeks initially: serum creatinine, eGFR, potassium, and urine protein-to-creatinine ratio. 3
Add-On Therapy for Inadequate Response
Add thiazide-like diuretic (or loop diuretic if eGFR <30 mL/min/1.73m²) for volume overload or resistant hypertension. 3
Add low-dose spironolactone or eplerenone for resistant proteinuria despite maximized ACE inhibitor/ARB and diuretic—provides additional antiproteinuric effect. 3
Add SGLT2 inhibitor (empagliflozin, canagliflozin, or dapagliflozin) in diabetic patients with proteinuria >300 mg/g for additive renoprotection and cardiovascular benefit. 3
Treatment Targets and Monitoring
Target proteinuria reduction of ≥25% by 3 months, ≥50% by 6 months, aiming for absolute proteinuria <1 g/day or at least 30-50% reduction from baseline. 3
Dietary sodium restriction to <2.0 g/day is mandatory and synergistic with ACE inhibitor/ARB therapy—non-negotiable for optimal proteinuria reduction. 3
CKD and Venous Thromboembolism Risk
All severities of kidney disease increase VTE risk: mild-to-moderate CKD confers 1.3-2-fold increased risk, end-stage renal disease 2.3-fold increased risk, and nephrotic syndrome up to 23-fold increased risk within first 3 months of diagnosis. 5, 6, 7
The association persists even with microalbuminuria and remains elevated for >5 years, particularly in nephrotic syndrome and glomerulonephritis. 7
Mechanisms include hemostatic derangements with procoagulant activity, platelet dysfunction, endothelial dysfunction, and inflammation. 5, 6
Venous Thromboembolism: Treatment in Special Populations
Rivaroxaban is FDA-approved for treatment of DVT and PE, with dosing adjustments required for renal impairment—use with caution in CKD and avoid in severe renal impairment (CrCl <30 mL/min for DVT/PE treatment). 8
Rivaroxaban Dosing for VTE Treatment
Standard DVT/PE treatment: 15 mg twice daily for 21 days, then 20 mg once daily for continued treatment and reduction of recurrent VTE risk. 8
Renal dosing considerations: rivaroxaban requires dose adjustment in renal impairment due to significant renal elimination. 8
Premature discontinuation increases thrombotic event risk—counsel patients on importance of adherence and do not stop without alternative anticoagulation plan. 8
Critical Safety Considerations
Spinal/epidural hematoma risk with neuraxial anesthesia or spinal puncture—delay rivaroxaban dosing appropriately and monitor for neurologic impairment. 8
Bleeding risk is increased—avoid in patients with active pathological bleeding and use caution with concomitant antiplatelet agents or NSAIDs. 8
Avoid concomitant use with combined P-gp and strong CYP3A4 inhibitors (e.g., ketoconazole, ritonavir) or inducers (e.g., rifampin, phenytoin). 8
VTE Risk in CKD Patients
Proteinuria itself is an independent VTE risk factor—the association is present even for microalbuminuria and increases with severity of proteinuria. 5, 6
Risk is highest within first 3 months after CKD diagnosis but remains elevated long-term, particularly in nephrotic syndrome (adjusted OR 2.89,95% CI 2.26-3.69). 7
Consider VTE prophylaxis in hospitalized CKD patients, especially those with nephrotic-range proteinuria, acute kidney injury, or recent kidney transplant. 5, 7
Emerging Infectious Diseases: Preparedness Framework
Core Competencies for Residents
Maintain updated knowledge of local and global infectious disease surveillance through CDC, WHO, and state health department resources. 1
Understand principles of infection control, isolation precautions, and personal protective equipment use for emerging pathogens with pandemic potential. 1
Recognize clinical presentations of re-emerging infections (tuberculosis, measles) and novel pathogens, with low threshold for infectious disease consultation. 1
Practical Approach to Suspected Emerging Infections
Obtain detailed travel history (including layovers), animal exposures, sick contacts, and occupational exposures in all patients with fever or systemic illness. 1
Implement appropriate isolation precautions immediately based on clinical syndrome (respiratory, contact, airborne) before definitive diagnosis. 1
Coordinate with infection prevention, infectious disease specialists, and public health authorities for suspected reportable diseases. 1
Patient Education and Adherence Strategies
Adopt an attitude of empathetic reinforcement—provide positive feedback for BP and behavioral improvements, and schedule more frequent appointments for patients not achieving goals. 1
Effective Communication Techniques
Assess patient's understanding and acceptance of their diagnosis, discussing concerns and clarifying misunderstandings at each visit. 1
Tell patients their BP reading and provide written documentation—come to agreement on goal BP and ask patients to rate (1-10) their likelihood of adhering to treatment. 1
Provide specific written information about lifestyle modifications including diet, physical activity, and medication regimens using standard brochures when available. 1
Overcoming Barriers to Adherence
Anticipate adherence problems in young men and consider non-adherence as a cause of resistant hypertension or sudden loss of BP control. 1
Encourage patients to bring all medications (prescription, over-the-counter, complementary) to each visit for medication reconciliation. 1, 4
Ask specifically about pain medication use (NSAIDs can elevate BP and interfere with antihypertensive efficacy). 1
Recognize and appropriately manage depression and psychiatric illness, which significantly impair treatment adherence. 1
Multidisciplinary Care Coordination
Refer patients with diabetes to certified diabetes care and education specialists (CDCES) when available to improve disease management and reduce complications. 4
Use shared decision-making when initiating pharmacological treatments, considering patient priorities to improve adherence and outcomes. 4
Organize care delivery systems with decision support prompts to advance therapy when goals are not achieved, reducing clinical inertia. 1