Transcript Why we need a management group/commission for hypertension in

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HYPERTENSION :SHMS
GUIDELINE
Prof. Sulaiman Al-Shammari
Department of Family & Community Medicine , College of
Medicine King Saud University , Riyadh, Saudi Arabia
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Why Should We be Interested in Hypertension?
1.High prevalence of HTN & preHTN & poor control
2.Lacking Public and professional awareness
3.Open market for all possible drugs
4.Public misconceptions Re HTN, Rx & herbs
5.Many professionals “schools” with diverse traditions
6.HTN not adequately recognized as life-long risk for
CRF, Stroke and MI
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auth
region year
Prev
%
% Aware/
Or contr
Abo
alfotoh
SouthWest
1996
11
Contr
20
Saeed
Riyadh
1996
13
Awareness
Synnowo
Gasim
1996(94)
22-26
AlNuzha
Nationwide
1998
20.4
sys
27
?
?
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Prevalence, Awareness, Treatment and Control of
High Blood Pressure in the US Adult NHANES
II
%
1976-80
III
(Phase 1)
1988-91
III
(Phase 2)
1991-94
KSA
1999-00
Prevalence
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20.2
19.8
18
20%
Awareness
51.0
71.2
68.4
70
27%?
Treated
31.4
53.6
53.6
59
?
Controlled
9.9
27.2
27.4
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20%?
Burt V et al, Hypertension 1996 & Unpublished data NHLBI (NHANES III, Phase 2)
JNC-VII 2003
Hazmi 2001; Kalanta 2001; Warsy 1999; Wahid Saeed 1996& Al-Nozha 1997
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Prevalence in some countries
Country
Prev %
Contr %
USA
18
34
Canada
22
16
Egypt
26
8
China
14
3
6
Worldwide
Worldwide
20% of adults
Worldwide
50% over 60 years
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SHMS Clinical Guideline
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Classification

Normal < 120/ < 80
 Prehypertension 120-139/80-89
 Hypertension ; stage -1 : 140-159/90-99
 Hypertension ; stage -2 : > 160+/ 100 +
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Aims of Clinical Evaluation

Accurate Measurement of BP to establish
the diagnosis of Hypertension.
 Look for other risk factors.
 Assess for Co morbidities.
 Look for Target Organ Damage or
associated clinical conditions.
 Be alert for clues of secondary cause.
– Thorough history, physical exam & simple
tests.
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History-1

General medical history; allergies,
surgeries,…etc.
 Hypertension: duration , medications.
 Personal history of DM, Dyslipidemia,
CAD.
 Family history of hypertension, CAD,
Dyslipidemia, DM.
 Style of living: occupation, smoking,
activities, eating habits.
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History-2

Palpitations ,sweating, tremors; pheo.
 Weight gain; cushings, hypothyroid.
 Weight loss; hyperthyroid, DM, pheo.
 Renal stones; Hyperparathyroidism, PKD.
 Symptoms of TOD related to organ.
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History-3

Drug history :
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NSAID.
Steroids; oral contraceptive pill, corticosteroids.
Nasal decongestants-ephedrine.
Appetite Supressants-phenylpropanolamine.
Street drugs; cocaine.
Tricyclic antidepressants.
Erythropoietin.
Cyclosporine and Tacrolimus.
Alcohol.
Drug withdrawal; Clonidine, Beta-blockers.
Licorice.
Herbs ( dietary supplements).
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Measurement of BP-1
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A diagnosis of HTN is made on multiple
(3)measurement made on several occasions.
Five minutes rest before measurement.
Patient position-sitting, standing if Elderly, DM,
autonomic disturbance.
Appropriate cuff size.
Calibrated & validated device.
No exertion or smoking before measurement.
Two readings.
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Measurement of BP-2

Methods of BP measurements :
– Clinic or office BP measurements.
– Self BP measurements.
– Ambulatory BP measurements.
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Examination-1
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General medical examination.
BP; at the first visit, in both arms, if discrepancy
think of Coarctation, dissection. FU visit check BP
in the higher arm.
BP in lower limb; discrepancy suggests
Coarctation.
Pulse; at first visit, compare R & L arm, any
radiafemoral delay.
Weight, Height, BMI, Waist Circumference.
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Examination-2

Neck; raised JVP.
 Heart ; displaced apex, normal sounds,
added sounds, murmur.
 Lung ; check for any rales or wheezes.
 Abdomen; masses, striae .
 Lower limbs; swellings, trophic changes,
pulses.
 Fundus examination.
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Examination-3

Moon face, buffalo hump; Cushing.
 Hirsutism; Cushing.
 Bruits; carotid or abdominal.
 Exophthalmus; hyperthyroid.
 Café au lait spots, neurofibromatosis; pheo.
 Goitre.
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Risk Factors -1

Levels of SBP and DBP.
 Dyslipidemia :TC >250 mg/dl(6.5 mmol/L),
LDL C>155 mg/dl(4 mmol/L), HDLC < 40
mg/dl(1mmol/L) in men,< 1.3 mmol/L in
women.
 DM.
 Smoking.
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Risk Factors -2

Age (men >55, women > 65).
 Family history of Premature CVD (men <
55 women < 65).
 Obesity (BMI 30 + kg/m2)-abdominal
obesity( WC -M>102 cm, F>88 cm)
 CRP >1 mg/dl
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Target Organ Damage-1

Ultrasound or radiological evidence of
atherosclerotic plaque.
 Heart ; LVH.
 Proteinuria or raised plasma creatinine.
 Retinal arteries narrowing .
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Associated Clinical Conditions
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Cerebrovascular Disease (ischemic stroke,
cerebral hemorrhage, TIA).
Heart disease; MI, angina, Coronary
vascularization, CHF.
Renal disease; Cr. Men 1.34-1.6 mg/dl, women
1.25-1.45 mg/dl.
Vascular Disease (PAD, Dissecting aneurysm).
Advanced retinopathy; hemorrhage, exudates,
papilledema.
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Secondary Causes
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Chronic kidney disease.
Renovascular disease.
Primary aldosteronism.
Pheochromocytoma.
Cushing’s syndrome and steroid therapy.
Coarctation of aorta.
Thyroid or parathyroid disease.
Drug therapy.
Sleep apnea.
Alcohol
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Clues to Secondary Causes of
HTN

Age of onset.
 Poor response to therapy.
 Significant Target organ Damage.
 No family history of Hypertension.
 Examinations clues.
 Laboratory tests
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Laboratory Investigation

Urine analysis.
 CBC.-hematocrit.
 Blood chemistry; electrolytes, sugar, lipids,
creatinine.
 Electrocardiogram.
 Optional; urine albumin creatinine ratio,
CRP.
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Risk Stratification
normal
SBP120 139 or DBP
80-89
high normal
SBP140 159 or DBP
90-99
Stage 1
SBP160 179 or DBP
100-109
Stage 2
SBP180 - or
DBP
110
Stage 3
no risk
factors
average
average
Low
added
Moderate
added
High
added
1-2 risk
factors
except DM
Low
added
Low
added
Moderate
added
Moderate
added
Very high
added
3 or
more,TOD,
DM
Moderate
added
High
added
High
added
High
added
Very high
added
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BP levels
Risk
factors,
TOD,
ACC
SBP<120 &
DBP <80
Management Plan
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Establish Good patient Doctor relationship.
Educate patient & family on the consequences of
hypertension.
Encourage Self monitoring.
BP goal.
Non pharmacological therapy.
Pharmacological therapy.
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Life Style Modification

Stop smoking.
 Lose weight if overweight.
 No alcohol intake.
 Reduce sodium intake to 110 mmol/day (2.4 g
sodium or 6 g sodium chloride).
 Maintain adequate dietary potassium, calcium, and
magnesium intake.

Healthy diet; High in fresh fruits, vegetables and low fat
dairy products, low in saturated fat.
 Regular physical activity: optimum 30-45 minutes of
moderate cardiorespiratory activity 3-5/week or more 30
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Statins
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PRIMARY PREVENTION
1) Total cholesterol > 5 mmol/l,
2) < 70 Y., and
3) 10 Y. CHD-R > 30%.
 SECONDARY PREVENTION
1) Total cholesterol > 5 mmol/l,
2) < 75 Y., and
3) CV complication: – (Coronary Heart Diseases, Peripheral Vascular Diseases, Non-
hemorrhagic CerebroVascular Diseases, or Atherosclerotic
renovascular diseases.)
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Antiplatelet Therapy
only when BP control has been achieved
For Primary Prevention:
 Hypertensive patients above the age of 50 years
and at high or very high absolute cardiovascular
risk, or
 Hypertensive patients with moderate increase in
serum creatinine > 1.3 mg/dl i.e. > 107 mmol/L.
For Secondary Prevention:
 Patients with post MI, ischemic stroke,
angioplasty, or coronary bypass
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When you need to question
compliance
When the treatment response is judged inadequate,
the patient can be asked about compliance. If
the patient reports less than complete compliance, the
clinician can proceed with compliance interventions.
If the patient reports full compliance, problems with
the treatment itself can be considered along with
application of more sophisticated methods of measuring
compliance.
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Forms of Non-compliance
 Not
having the prescription filled,
 Taking the incorrect dose,
 Taking the medication at the wrong
time,
 Not taking one or more doses,
 Stopping the medication too soon,
 Relying on herbal meds
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How/Can we measure?
1• Pharmacological measures ( concentrations of
drugs or using biological markers integrated into
the tablets) (difficult)
2• Clinical measures: a) evaluation of promptness
for appointments or b) the use of questionnaires
c) or taking the amount of side effects into
account)
3• Physical measures ( pill counting )
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Recommendations for Improving compliance
using a multi-faceted approach

Understanding the reasons for these forms of non-compliance is of key importance
to the successful development of potential programs and their implementation
- Simplify medication regimens to once daily dosing
– Tailor pill-taking to fit patients’ daily habits
– Encourage greater patient responsibility/autonomy in monitoring their BP management
(including monitoring)
– Coordinate with worksite health care givers to improve monitoring of adherence with
pharmacological and lifestyle modification prescriptions
– Educate patients and educate/involve patients’ families about their disease/treatment
regimens
– Minimize side-effects, make taking it more appealing
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High standard educated and motivated health care providers,
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Indications for specialist
referral
1.Urgent treatment needed
2.Possible underlying cause
3.Therapeutic problems
4.Special situations
Other Indications
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Hypertension &Ramadan
“Based on the scarce available data, the
following recommendations can be reasonably
made”
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medical advice before fasting in order to adjust their medications, if
needed.
management should be individualized in fasting patients.
emphasize compliance with non-pharmacological and
pharmacological measures.
Diuretics are better avoided, especially in hot climates or to be
administered in the early evening.
emergency should be treated appropriately regardless of fasting.
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Many questions are awaiting answers.
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Hypertension in the Elderly

Hypertension occurs in more than half of
individuals aged 65 are HTN & poor control
 Follow same Rx principles outlined for the general
care of hypertension
 Lower initial drug doses may be indicated to avoid
symptoms
 Standard doses and multiple drugs are needed in
the majority of older people to reach appropriate
BP targets
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Hypertension in Pregnancy

Chronic hypertension
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Preeclampsia-eclampsia: preeclampsia occur in 23%; and eclampsia in 5-6/10,000 pregnancies that
progress beyond 20 weeks.
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Preeclampsia Superimposed upon chronic
hypertension or Renal Disease
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Gestational hypertension (only during pregnancy):
occur in 8-10% of nulliparous women
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Transient hypertension (only after pregnancy)
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Treatment during pregnancy

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Shared care with obstetrician for proper evaluation
Lifestyle changes: restrict activity and exercise during
pregnancy.
 Weight reduction is not recommended.
 Limit Sodium intake.
 Methyldopa and  ß-blockers can be used. Be ware of
the possible growth restriction
 An alternative would be nifedipine
 Diuretic are not usually used in pregnancy
 ACEI and ARBare contraindicated. If a patient becomes
pregnant while on these agents, she should have her
medication changed.
 The “cure” for preeclampsia is delivery
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Anticonvulsive Therapy
Breast Feeding
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All antihypertensives studied have been found in breast milk.
Long-term neonatal effects have not been studied.
Methyldopa as a first-line oral agent is reasonable unless
contraindicated, and then labetolol may become first-line therapy.
If the patient has renal disease, then calcium channel blockers are
the drugs of choice.
ACE inhibitors and angiotensin II receptor antagonists should not
be used due to neonatal renal effects.
Diuretics may decrease milk production.
Certain beta blockers are concentrated in breast milk (atenolol
and metoprolol), while others are not (labetolol and propranolol).
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Hypertension and the Pill

Oral contraception usually shifts the blood pressure
moderately upwards, but hypertension appears in
less than 5% of women (1% to 2%).
 Stopping OC is an effective antihypertensive
intervention in a clinical setting.
 keeping careful check on women taking these pills.
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‫المملكة العربية السعودية‬
‫‪kingdom of Saudi Arabia‬‬
‫'‪Saudi Commission of Health Specialties‬الهيئة السعودية للتخصصات الصحية‬
‫‪Saudi Hypertension Management Society‬الجمعية السعودية لرعاية ضغط الدم‬
‫)‪(SHMS‬‬
‫ندعوكم لإلنظمام إلى الجمعية كعضو‬
‫علما أن رسوم العضوية السنوية ‪ 200‬لاير ‪.‬‬
‫لمزيد من المعلومات يرجى االتصال‪:‬‬
‫‪http://www.saudi-hypertension.org‬الموقع اإللكتروني للجمعية ‪:‬‬
‫‪main@saudi-hypertension-org‬البريد اإللكتروني للجمعية ‪:‬‬
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