Transcript 6A - Blood pressure control in primary health care Jūratė Klumbienė

Blood pressure control
in primary health care
WORKSHOP
Jurate Klumbiene
Kaunas University of Medicine, Kaunas, Lithuania
Workshop agenda
• Presentation of a patient case in which the patient has
hypertension
• Identification of the patient’s problems and CVD risk
(individual exercise and plenary discussion)
• Designing a treatment plan (group work):
– Non-pharmacological measures
– Treatment goals, pharmacological therapy
– Measures to ensure compliance
• Presentation of the plans and discussion (plenary
presentation)
CASE: Alexander is a 56-year-old driver who schedules a visit as part of
a regular health examination.

History:
–
no significant past medical history, no medicine prescriptions
–
a regular smoker (20cig/day since 25 years old)
–
drinks a couple bottles of beer a night and "a bit more on the weekend”
–
no family history of CVD
• Physical examination:
• Blood pressure (BP) 146/94 (repeated BP – 144/92, 148/98)
• Pulse rate 76, regular
• Weight - 102 kg, height – 178 cm
• Waist circumference – 110 cm
• The remainder of the physical examination was unremarkable
 Laboratory investigations
 No abnormalities
Task for each participant
• Identify the patient’s problems and assess
CVD risk.
• Use ESH/ESC categorical stratification of
cardiovascular risk.
Plenary discussion
• The patient’s problems and CVD
risk
Tasks for group work
1) Non-pharmacological treatment
2) Treatment goals and
pharmacological therapy
3) The measures to ensure
compliance
CLASSIFICATION OF BP LEVELS
(European Society of Hypertension and Cardiology, 2007)
CATEGORIES
Systolic BP Diastolic BP
Optimal BP
< 120
and/or <80
Normal BP
120-129
and/or 80-84
High-normal BP
130-139
and/or 85-89
Grade1 hypertension (mild)
140-159
and/or 90-99
Grade2 hypertension (moderate)
160-179
and/or 100-109
Grade3 hypertension (severe)
>180
and/or >110
Isolate systolic hypertension
>140
and
<90
Stratification of CVD Risk (2007 Guidelines for the management of
arterial hypertension, ESH and ESC)
Other risk
factors, OD or
disease
Normal BP
No other risk
factors
Average
risk
1-2 risk
factors
High normal
BP
Grade 1 HT
Grade 2 HT
Grade 3 HT
Average
risk
Low
added risk
Moderate
added risk
High
added risk
Low
added risk
Low
added risk
Moderate
added risk
Moderate
added risk
Very high
added risk
3 or more risk
factors, MS,
OD or
diabetes
Moderate
added risk
High added
risk
High added
risk
High added
risk
Very high
added risk
Established
CVD or renal
disease
Very high
added risk
Very high
added risk
Very high
added risk
Very high
added risk
Very high
added risk
BP: blood pressure; CVD: cardiovascular; HT: hypertension. Low, moderate, high, very high risk refers to 10 year risk of a CVD
fatal or non-fatal event. The term “added” indicates that in all categories risk is greater than average. OD: subclinical organ
damage; MS: metabolic syndrome.
Presentation of the treatment plans
and discussion
Summary
• Blood pressure control
TREATMENT GOALS
 To achieve a maximum reduction in the long-term total risk of
cardiovascular morbidity and mortality (the treatment of all reversible
risk factors identified, including smoking, dyslipidaemia or diabetes and
the appropriate management of associated clinical conditions, as well
as treatment of high blood pressure per se).
 Blood pressure, both systolic and diastolic, should be lowered in all
hypertensive patients:
 At least below 140/90 mmHg.
 It may prudent to recommend lowering blood pressure to values
within the range 130-139/80-85 mm Hg (Reappraisal of
European guidelines on hypertension management, 2009).
TREATMENT STRATEGIES
 Lifestyle measures (non-pharmacological treatment)
should be instituted whenever appropriate in all patients,
including subjects with high normal blood pressure and
patients who require drug treatment.
 The purpose of non-pharmacological treatment is to
lower blood pressure, to control other risk factors and
clinical conditions and to reduce the number and doses
of antihypertensive drugs which might be subsequently
used.
Initiation of antihypertensive treatment (ESH/ESC, 2007)
Other risk
factors, OD or
disease
High normal BP
Grade 1 HT
Grade 2 HT
Grade 3 HT
No BP
intervention
Lifestyle changes
for several
months then
drug treatment if
BP uncontrolled
Lifestyle changes
for several weeks
then drug
treatment if BP
uncontrolled
Lifestyle
changes +
immediate
drug
treatment
1-2 risk factors Lifestyle changes
Lifestyle
changes
Lifestyle changes
for several weeks
then drug
treatment if BP
uncontrolled
Lifestyle changes
for several weeks
then drug
treatment if BP
uncontrolled
Lifestyle
changes +
immediate
drug
treatment
3 or more risk
factors, MS,
Lifestyle changes
OD or diabetes
Lifestyle
changes and
consider drug
treatment
Diabetes
Lifestyle changes
Lifestyle
changes + drug
treatment
Lifestyle changes
+ drug treatment
Lifestyle
changes +
immediate
drug
treatment
Lifestyle changes
+ immediate
drug treatment
Lifestyle
changes +
immediate drug
treatment
Lifestyle changes
+ immediate
drug treatment
Lifestyle
changes +
immediate
drug
treatment
No other risk
factors
Established
CVD or renal
disease
Normal BP
No BP
intervention
Lifestyle changes
+ drug treatment
Lifestyle changes
+ immediate
drug treatment