Transcript FAME HTN

Management
of
Hypertension
Introduction to Primary Care:
a course of the Center of Post Graduate Studies in FM
PO Box 27121 – Riyadh 11417
Tel: 4912326 – Fax: 4970847
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Objectives
 to discuss the importance of hypertension in FP
 to describe the recommendations for screening of
hypertension.
 to describe current guideline recommendations on
the diagnosis of hypertension
 to describe the complications of hypertension
content
 Epidemiology
 Definition of hypertension
 Types of hypertension
 Evaluation of hypertensive patient
History &physical examination
Laboratory tests
 Accurate BP Measurement
 White Coat Hypertension
Epidemiology
 About 1/3 of middle aged patients have
hypertension
 About
½ of elderly patients
have
hypertension.
 Responsible for 12% of deaths worldwide.
 5-6% reduction in diastolic blood pressure
over 5 years reduces risk of CVA by 35-40%
and IHD by 20-25%
Proportion of deaths attributable to leading risk factors
worldwide (2000)
High mortality, developing region
Lower mortality, developing region
Developed region
0
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2
3
4
5
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Attributable Mortality
(In millions; total 55,861,000)
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8
World Health Report 2003
Of the 10 leading global disease burden risk factors
– High blood pressure
– High cholesterol
– Obesity
– Physical inactivity
– Insufficient consumption of fruits and
vegetables
– Smoking
Important Points:
 Hypertension is the most common treatable risk
factor for cardiovascular disease in patients over
50 years.
 Only 70% are aware they have HTN
 Of those aware of their HTN, only 50% are being
treated.
 Only 25% of all hypertensive patients have their
BP under control.
 HTN is a risk factor for coronary artery disease
(CAD), congestive heart failure (CHF), stroke, and
renal failure.
JNC VII
Definition
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




Persistent elevation
SBP ≥140 mmHg
And OR
DBP ≥90 mmHg\
Several occassions
Three readings proper technique/cuff on 3
separate occasions over at least 4-6 weeks
 Days-weeks (level-complication-end organ
damage)
 Not on anti hypertensive medications.
Recommendation for follow up
Initial blood pressure ,mmHg
Systolic Diastolic Follow up recommendation
<130
<85
Recheck in 2 years
130139
85-89
Recheck in 1 years
140159
90-99
Confirm within 2 months
160179
100-109
Evaluate or refer to source of care within 1
month
>=180
>=110
Evaluate or refer to source of care
immediately within 1week depending on the
clinical situation
Types of hypertension
 Primary (“essential”) 95% of cases
 Secondary 5% of cases
Stage of
hypertensio
n:
Cardiovascular
risk factors
Secondary causes
Target
organ
damage
Associated
clinical
condition
ACCs
EVALUATION OF HYPERTENSIVE
PATIENT
Blood Pressure Classification
SBP mmHg*
DBP mmHg
Lifestyle
Modification
Drug
Therapy**
<120
and <80
Encourage
No
Prehypertension
120-139
or 80-89
Yes
No
Stage 1
Hypertension
140-159
or 90-99
Yes
Single
Agent
Stage 2
Hypertension
≥ 160
or ≥ 100
Yes
Combo
BP Classification
Normal
*Treatment determined by highest BP category; **Consider treatment for compelling
indications regardless of BP
JNC 7 Express. JAMA. 2003 Sep 10; 290(10):1314
Cardiovascular Risk Factors
 Hypertension (levels of SBP&DBP)
 Smoking
 Obesity (body mass index≥30kg/m2 )
 Physical inactivity
 Dyslipidema (total cholesterol >250mg/dl i.e
>6.5mmol/l,LDL-C155mg/dl
i.e4.0mmol/l,HDL-C <40mg/dl i.e<1.0mmol/l)
 DM*
*Considered as coronary heart disease
equivalent
Cardiovascular Risk Factors-contd
 Microalbuminuria or estimated
GFR<60ml/min
 Age (older than 55for men,65 for
women)
 Family history of premature
cardiovascular disease (men under age
55,women under age 65)
 C-reactive protein ≥1mg/dl
Secondary Causes:
ABCDE mnemonic
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
Apnea (OSA)
Aldosteronism (hyperaldosteronism)
Bruits (renal artery stenosis)
Bad Kidneys (intrinsic kidney disease)
Catecholamines
Coarctation
Cushing’s Syndrome
ABCDE mnemonic
 Drugs (stimulants, OCPs, NSAIDS)
 Diet (high Na/low K, Mg, Ca)
 Erythropoietin: elevated EPO in COPD or
 renal failure or exogenous use for anemia
 Endocrine: Thyroid/Parathyroid, pregnacy,
pheochromocytoma, acromegaly
Associated clinical condition ACCs
 Cerebrovascular disease : ischemic
stroke, cerebral hemorrhage, or TIA.
 Heart disease : MI, angina, coronary
revascularization, or CHF.
 Renal disease : diabetic nephropathy or
renal failure  creatinine ,men > 1.6
mg/dl (133umol/l) women > 1.45 mg/dl
(124 umol/l )
 Vascular disease: (dissecting aneurysm
or symptomatic arterial disease.
 Advanced hypertensive retinopathy
White Coat Hypertension
 20-30% of Apparently Resistant
Hypertension May be due to “WhiteCoat Hypertension”
 Patients with WCH have an increased
risk of CV events and often have some
degree of end organ damage
 Use home or ambulatory monitoring to
sort out
Home and Ambulatory BP Monitoring
(ABPM)
 Often lower than office readings
 Useful to “calibrate” home monitors
 Nocturnal Dip (10-20% fall during the
night) is physiologically important
(Dippers vs. Non-Dippers)
 Can identify “windows of poor control”
or windows of low BP and correlate with
perceived symptoms
Checking blood pressure at home
 Some monitors are inaccurate and are
not calibrated.
 Wrist monitors are not usually accurate.
 Can give multiple recordings and help in
the management of white coat
hypertension.
 Involves patient in the management.
 Results should be factored up by 10/5.
Routine Laboratory Tests
Investigation of all patients with hypertension
1. Urinalysis
2. Complete blood count
3. Blood chemistry (potassium, sodium and creatinine)
4. Fasting glucose
5. Fasting total cholesterol and high density lipoprotein cholesterol
(HDL), low density lipoprotein cholesterol (LDL), triglycerides
6. Standard 12-leads ECG
Optional Laboratory Tests
Investigation for specific patient subgroups
• For those with diabetes or renal disease: assess
urinary protein excretion, since lower blood
pressure targets are appropriate if proteinuria is
present.
• Other secondary forms of hypertension require
specific testing.
What do labs mean?
 CBC: Look for elevated Hb/HCT
 Chem7: Look for low K, elevated
Bun/Cr,
 elevated Ca. Calc GFR
 U/A: Look for protein/blood
 Alb:Cr ratio: Look for microscopic
albumin
 FLP: Look for abnormal lipids
 EKG: Look for LVH, CAD, arrhythmia
Lifestyle Recommendations for Prevention of
Hypertension for NON-Hypertensive
Individuals.
1. Healthy diet:
High in fresh fruits, vegetables and low fat diary
products, low in saturated fat and salt.
2. Restriction of salt intake to less than 100
mmol/day in individuals considered saltsensitive
3. Maintenance of ideal body weight (BMI 18.524.9 kg/m2)
Lifestyle Recommendations for Prevention of
Hypertension for NON-Hypertensive
Individuals.
4. Waist Circumference
< 102 cm for men
< 88 cm for women
5. Regular physical activity:
accumulation of 30-60 minutes of moderate
intensity dynamic exercise 3-5/week at least
4/week
6. Smoke free environment
7. Abstinence from alcohol
True or False
• For persons over age 50, DBP is more
important than SBP as CVD risk factor.
False
• For persons over age 50, SBP is a more
important than DBP as CVD risk factor.
True or False
• Those people whose BP is classified as
prehypertensive should be initially treated
with lifestyle modification from the time
they are identified.
True
• Those people whose BP is classified as
prehypertensive should be initially treated
with lifestyle modification from the time
they are identified.
Normal blood pressure is defined in JNC
7 as:
1. <120/<70
2. <120/<80
3. 120-139/80-89
4. 140-159/90-99
5. ≥160/ ≥100
Which of the following is incorrect for the proper
measurement of BP in the office setting?
1.
2.
3.
4.
5.
Persons should be seated for at least 5
minutes resting before taking the BP
BP should be taken with the patient sitting
on exam table with the arm relaxed in their
lap
At least 2 measurements should be made
SBP is the point at which the first of two or
more sounds is heard
DBP is the point before the disappearance
of sound (phase 5)
THANKS