Transcript Hypertension Cases

Hypertension
Family Medicine Specialist CME
October 15-17, 2012
Pakse
Objectives
• Review diagnosis and best treatments for
hypertension
• Explore opportunities to screen for
hypertension
• Review strategies for successful community
treatment of hypertension
Case number 1
• A 65 year old woman
who lives in Sekong
comes to the provincial
hospital because of
pneumonia. She has no
medical problems but
she is obese and her
diet is high in salt. You
treat her pneumonia
but notice that her
blood pressure is
150/100.
Discussion questions
• Does she have a diagnosis of hypertension?
• What will you counsel her?
• When will you see her again?
Diagnosis of Hypertension
• Visit 1: any patient with hypertensive crisis
• Visit 2: BP> 180/110 ; or BP>140/90 with
target organ damage, DM, or chronic kidney
disease
• Visit 3: BP>160/100
• Visit 4: BP>140/90
Target organ damage
• Cerebrovascular disease (stroke, TIA)
• Cardiac disease (myocardial infarction, heart
failure)
• Chronic renal disease
• Peripheral artery disease
Lifestyle counseling
Lifestyle goal
Estimated BP reduction
Increase physical activity
-4.9/-3.7 mmHg
Loose weight
Decrease alcohol use
-7.2/-5.9 mmHg (per 4.5 kg)
-3.9/-2.4 mmHg
Decrease salt in diet
-5.1/-2.7 mmHg
Decrease stress
-6.1/-4.3 mmHg
Stop smoking
Follow up
• If BP high in visit 1, follow-up within 1 month.
• If on lifestyle treatment alone, follow-up every
3-6 months, or every 1-2 months if very BP
high.
• If starting antihypertensives follow-up every 12 months to adjust medications until target BP
reached on two visits.
• When target BP reached, follow-up every 36months.
Case number 2
• The woman from
Sekong comes back to
your clinic for follow up
of her pneumonia. The
pneumonia is improved
but her blood pressure
today is 180/110. You
examine her and find no
evidence of end organ
damage.
Discussion questions
•
•
•
•
Does she have a diagnosis of hypertension?
Will you treat her with medication?
What is the target blood pressure?
What medications will you use first?
Target Blood Pressure
• <140/90 mmHg
• Patients with diabetes <130/80 mmHg
When to start treatment
• DBP > 100 mmHg or SBP > 160 mmHg in patients
without macrovascular target organ damage or
other cardiovascular risk factors.
• DBP > 90 mmHg or SBP> 140 mmHg with
macrovascular target organ damage or other
cardiovascular risk factors.
Be careful with elderly frail patients…
First line drug therapy
•
•
•
•
•
Thiazide or thiazide-like diuretic
Calcium channel blocker (long acting)
ACE-I (angiotensin converting enzyme inhibitor)
ARB (angiotensin receptor blocker)
Beta blocker (less than age 60)
Case number 3
• A 50 year old man from
Salavan has been
treated for one month
with an ACE-I. His blood
pressure is still high. He
is trying to use lifestyle
modification.
Discussion questions
• What will you do now?
• What drug combinations are best?
Second line drug therapy
• Multiple drugs are often needed to control BP
especially in patients with DM
• Low dose of several drugs better than high
dose of 1or 2 drugs
• Beta Blockers, ACE and ARB are not additive
• Best to combine them with a diuretic or
calcium channel blocker
• Do not combine ACE-I and ARB
Hypertension medications for
patients with other diseases
Case number 4
• A 48 year old obese
male with Type 2 DM
presents with
hypertension.
Discussion questions
• What are the best hypertension medications
to use in this patient?
• What if he has recently suffered from angina
or a myocardial infarction?
• What if he is suffering from congestive heart
failure?
With diabetes
• First: ACE-I or ARB
• Second: add CCB
• Avoid diuretics
With recent MI or angina
• First: ACE-I or ARB; beta blockers
• Second: add CCB
With heart failure
• First: ACE-I or ARB; beta blockers;
aldosterone antagonists
• Second: add CCB
Case number 5
• A 54 year old woman
with chronic kidney
disease develops
proteinuria and
hypertension.
Discussion questions
• What antihypertensive medication would you
use first line, and second line for this patient?
Non-diabetic chronic kidney disease
with proteinuria
• First line: ACE-I or ARB
• Second: any combinations of other drugs
Watch potassium levels…
As a family medicine specialist in
Lao PDR
• What are opportunities for
screening patients for HTN?
• How can a community
health center and a district
hospital collaborate to
improve HTN management?
• How can such collaboration
be achieved?
With your patients…
• How can you promote
lifestyle change?
• How can you teach and
help them understand
the risks of poor BP
control?
• How can you encourage
follow-up?