hypertension famco

7/29/2019 Hypertension Famco

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Hypertension

Musleh Al Musalhi


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Case

Mr. M is 45 years old. He is attending for a job

check-up.

Mr. M first clinic blood pressure measurement

was 158/94 mmHg.

What further history you need?


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History

history should extract the following information:

Risk factors for hypertension

Extent of target organ damage Assessment of patients cardiovascular risk

status

Exclusion of secondary causes of hypertension


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Risk Factors

Non-modifiable

Age

Gender

Family History Ethnicity

Modifiable

Alcohol

Cigarette Smoking

Diabetes Mellitus

Elevated serum lipids

Excess Na+ in diet

Obesity

Sedentary Lifestyle

Socioeconomic

Stress


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Target Organ Damage

Heart

Left ventricular hypertrophy

Angina or prior myocardial infarction

Prior coronary revascularization

Heart failure

Brain

Stroke or transient ischemic attack

Chronic kidney disease

Peripheral arterial disease

Retinopathy


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Identifiable

Causes of Hypertension

Sleep apnea

Drug-induced or related causes

Chronic kidney disease Primary aldosteronism

Renovascular disease

Chronic steroid therapy and Cushings syndrome Pheochromocytoma

Coarctation of the aorta

Thyroid or parathyroid disease


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Mr. M history

From his records you notice that Mr. M bloodpressure has increased since her last check.

He is not doing any regular exercise and doesnt

taking care of his diet. He does not smoke and has no notable medical

history.

His father had HTN for more than 20 yrs.

What is next?


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Physical Examination

Height: 178 cm

Weight: 96 kg

BMI: 30.3

BP: 148/90

Heart rate: 76

Chest: Clear

Heart: Regular rhythm, no gallops or murmurs

audible Abdomen: soft, no bruits or organomegaly

Fundoscopy : Normal


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So, What investigations must be

done??


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Laboratory Tests

Electrocardiogram

Urinalysis

Blood glucose, and hematocrit

Serum potassium, creatinine, or the corresponding

estimated GFR, and calcium

Lipid profile

Measurement of urinary albumin excretion oralbumin/creatinine ratio


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Blood Pressure Classification

Normal 100

BP Classification SBP mmHg DBP mmHg

The Seventh Report of the Joint National

Committee on Prevention, Detection, Evaluation,

and Treatment of High Blood Pressure (JNC 7) ,

2003


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Blood Pressure Classification

Stage 1 hypertension:

Clinic blood pressure (BP) is 140/90 mmHg or higher and

ABPM or HBPM average is 135/85 mmHg or higher.

Stage 2 hypertension:

Clinic BP 160/100 mmHg is or higher and

ABPM or HBPM daytime average is 150/95 mmHg orhigher.

Severe hypertension:

Clinic BP is 180 mmHg or higher or

Clinic diastolic BP is 110 mmHg or higher.

NICE clinical guideline 127 -2011Hypertension: clinical management of primary hypertension in adults


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If the clinic blood pressure is 140/90 mmHg orhigher, offer ambulatory blood pressure monitoring

(ABPM) to confirm the diagnosis of hypertension.

Diagnosis

NICE clinical guideline 127 -2011

Hypertension: clinical management of primary hypertension in adults


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When using the following to confirm diagnosis, ensure:ABPM:

at least two measurements per hour during the

persons usual waking hours, average of at least 14measurements to confirm diagnosis

HBPM: two consecutive seated measurements, at least 1

minute apart blood pressure is recorded twice a day for at least

4 days and preferably for a week measurements on the first day are discarded

average value of all remaining is used.

Diagnosis


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NICE clinical guideline 127

August 2011

Hypertension: clinical management

of primary hypertension in adultshttp://pathways.nice.org.uk/pathways/hypertension/hypert

ension-overview
http://pathways.nice.org.uk/pathways/hypertension/hypertension-overviewhttp://pathways.nice.org.uk/pathways/hypertension/hypertension-overviewhttp://pathways.nice.org.uk/pathways/hypertension/hypertension-overviewhttp://pathways.nice.org.uk/pathways/hypertension/hypertension-overviewhttp://pathways.nice.org.uk/pathways/hypertension/hypertension-overviewhttp://pathways.nice.org.uk/pathways/hypertension/hypertension-overview


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Guideline summary


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Lifestyle Modifications

Dietary modifications and exercise

Low calorie diets have modest effect on BP inoverweight individuals (avg. 5-6 mm Hg).

Aerobic exercise (brisk walking, jogging, or cycling)for 30-60 min., 3-5 times/week, had small effecton BP (2-3 mm Hg).

Relaxation therapies

These activities (stress management, meditation,cognitive therapy, muscle relaxation) reduce byaverage of 3-4 mm Hg.


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Lifestyle Modifications

Limit alcohol consumption

Excessive alcohol consumption is associated withraised blood pressure, poorer CV and hepatic health.

Reducing alcohol can lower BP 3-4 mm Hg. Limiting excessive consumption of coffee/caffeine

(small benefit).

Limit dietary sodium intake

< 6 g/day, modest reduction of 2-3 mm Hg.

Encourage smoking cessation (reduce risk ofCV/pulmonary disease).


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Initiating Treatment

Offer antihypertensive drug treatment to

people aged under 80 years with Stage 1

hypertension who have one or more of the

following:

Target organ damage, established cardiovascular

disease, renal disease, diabetes, and 10-year CV

risk equivalent to 20% or greater. Offer antihypertensive drug treatment to

people of any age with stage 2 hypertension.


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Initiating Treatment

For people aged under 40 years with stage 1

hypertension and no evidence of target organ

damage, CV disease, renal disease or diabetes,

consider specialist evaluation of secondarycauses of hypertension and more detailed

assessment of potential target organ damage.


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Anti-hypertension drugsAdverse effectsContraindicationsEg.Group

Dry cough

HypotensionRenal impairment

Pregnancy

Renovasculardisease

Lisinopril

Captopril

ACE-I

Hypotension

Renal impairmentPregnancyRenovasculardisease

Losartan

Valsartan

ARB


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Adverse

effectsContraindicationsEg.Group

Loop diuretics(Not used for

hypertension)

Diuretics

Hypokalemia

RashErectile

impotense

Hyperglysemia

HypokalemiaGoutHydrochlorothiazide

Indapamide*

Thiazide

diuretics

Renal

impairmentInhibit

excretion of

lithium

Renal insufficiencyAmiloride

Triamiloride

Potassium-

sparing diuretics&

spironolactone

AdverseContraindicationsEgGroup


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Adverse


Asthma & COPD

2nd or 3rd degree heart block

Acute or unstable heart failure

In combination with CCB

Atenolol

Labetolol

CarvedilolB- blockers

Adverse


Flushing

Headache

Peripheral

oedema

Pregnancy & breast feedingAmlodipineNifedipineDihydropyridinesCCB

Pregnancy & breast feeding


DilitazemBenzthiazep

ines

HypotensionPregnancy & breast feeding


In combination with B

blockers

VerapamilPhenyalkylamines


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Drug combinations in hypertension with

comorbiditiesRecommended drugCompelling indication

CCBARBACE-iBBDiureticsDMARBACE-iChronic kidney disease

ACE-iDiureticsRecurrent strokeARBACE-iBBDiureticsHeart failure

ACE-iBBPost MICCBBBStable angina

Methyldopa or hydralazineLactation


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Blood Pressure Goals

People aged < 80 years with treatedhypertension: 80 years with treatedhypertension:


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Comparing NICE with JNC7 (U.S.):

Diagnosis NICE

Hypertension signaled

from clinic reading

(>140/90 mm Hg).

Officially diagnosedusing Ambulatory

Blood Pressure

Monitoring (>135/85

mm Hg)

JNC 7 (U.S.) Mainly based on office

BP reading (>140/90)

Ambulatory or Home

Blood PressureMonitoring mainly

used for self-

monitoring.


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Comparing NICE with JNC7: Initiation

of Medication Therapy NICE: Stage 1 (>135/85mmHg

Ambulatory or Home BP) Offer antihypertensive to

patients under 80 years ifthe patient has: Target

organ damage, establishedcardiovascular disease,renal disease, diabetes, and10-year CV risk equivalentto 20% or greater.

Stage 2 (150/95 mmHgABPM). Offer antihypertensive

therapy to patients of anyage with Stage 2hypertension

JNC7: After attempt of lifestyle

modifications to lower BP,if still not at goal: Stage 1: diuretic or

medication for compelling

indication Stage 2: diuretic +

additional medicationconsidering compellingindication.


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Comparing NICE with JNC7 (U.S.): First

Medication Therapy Used. NICE:

< 55 years: ACE

inhibitor or ARB

> 55 years: Calcium

Channel Blocker

If CCB not tolerated or

contraindicated, use

diuretic.

JNC 7: Thiazide diuretic for

most

Unless diuretic cannot

be used or ifcompelling indication

requires use of another

class of

antihypertensive.


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Comparing NICE with JNC7: Additional

medication treatment NICE: Step 2: ACEi/ARB +

Calcium Channel Blocker

Step 3: ACEi/ARB +Calcium Channel Blocker +

diuretic Step 4: add

spironolactone if K < 4.5mmol/L or increase dosesof diuretic if K > 4.5

mmol/L. Also can add alpha blocker

or beta blocker

JNC 7: Stage 2 (>160/100

mmHg):

Thiazide diuretic + ACEi orARB or CCB or BB.


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National NCD screening program

Made for those above the age of 40.

Screen for hypertension, diabetes, chronic

kidney disease, hypercholestrolemia and

obesity.


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Assessment Confirm whether or not blood pressure is

elevated.

Presence of target organ damage (e.g. LVH,

hypertensive retinopathy, increased

albumin:creatinine ratio).

Evaluate the persons cardiovascular risk.

Consider possibility of secondary causes for

the hypertension.


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CVD risk assessmentAllow clinicians to predict the likelihood of patients developing coronary or

cardiovascular disease using lifestyle and clinical markers.

1. Established cardiovascular disease or high cardiovascular disease risk states (e.g.

diabetes or CKD).

2. By calculation of their 10 year CVD risk estimate.

Four major areas:

Coronary heart disease.

Cerebrovascular disease.

Peripheral artery disease.

Aortic atherosclerosis and thoracic or abdominal aortic

aneurysm.


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Why this risk models assessment is important for patient with

Hypertension?

Address a patient's overall profile of risk rather than

treat one risk factor in isolation.

An individual with a number of modest risk factors

may be at greater risk of developing cardiovascular

disease than an individual with one high risk factor.


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How to assess?

Different assessment models. Identify risk factors.

Estimate an individual's risk over the next tenyears using:

A. Gender.B. Age.

C. Diabetic status.

D. Smoking status.

E. Total serum cholesterol (TC), high density lipoprotein cholesterol (HDL-C).

F. Blood pressure.

Charts, Graphs or Computer programmes.

QRISK 2 & framingham.


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Case:

A 56 year old male, diagnosed with hypertension 7

years back on a combination drugs.He presents to emergency department with

headache & shortness of breath of one hourduration.

On examination: BP: 250/145 mmHg, finecrepitation detected bilaterally.

Q. diagnosis?

Hypertensive emergency


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Hypertensive emergencies & urgenciesHypertensive emergencies: sudden increase in

systolic & diastolic BP associated with acutetarget-organ damage that require immediatemanagement in hospital sitting. Accelerated hypertension: recent significant increase over

baseline BP that is associated with target organ damage (exceptpapilledema).

Malignant hypertension: .. Papilledema must present.

Hypertensive urgencies: severe elevation in BPwithout acute target-organ dysfunction ordamage.


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EmergencyUrgency>220/140>220/120BP Shortness of breath

Chest pain

Nocturia Dysarthria

Weakness

Altered consciousness

Severe headache

Or

Asymptomatic

Symptoms

Encephalopathy

Pulmonary edema Cerebrovascular accident

Renal insufficiency

Cardiac ischemia

Clinical cardiovascular

disease present but stableExamination

Baseline lab tests

IV line

Monitor BPObserve 3-6 hours

Lower BP with short acting

oral agent:Captopril, Clonidine,

Labetalol, Prazocin

Adjust current therapy

Therapy

Immediate admission toArrange follow-up Plan

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