Transcript Evaluation of hypertensive patient

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
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
Proportion of deaths attributable to
leading risk factors worldwide (2000)
High mortality, developing region
Lower mortality, developing region
Developed region
0
1
2
3
4
5
6
Attributable Mortality
(In millions; total 55,861,000)
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Epidemiology
 Hypertension is the most common
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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.
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%
Studies in KSA
author
ALNOZHA Mansour
M
study
Community-based study age
of( 30-70 years) of selected
households during period (
1995 - 2000 )
Wahid Saeed AA Prevalence of hypertension
and sociodemographic
characteristics of adult
hypertensives in (PHCCs) in
Riyadh city (March 1993 to
March 1994 ).
EL-HAZMI M. A. F.
(1) ; WARSY A. S.
(2) ; ALSWAILEM A. R. (3)
; ABDUL MOHSEN
AL-SWAILEM (3) ;
Prevalence of hypertension in
adult Saudi population
results
The prevalence of hypertension was 26.1%
in crude terms. Males (28.6%) ,females
(23.9% )(p<0.001). urban population
(27.9%), rural population
(22.4%) (p<0.001).
Saudi medical journal ISSN 03795284 2007, vol. 28, no1, pp. 77-84 [8
page(s) (article)] (41 ref.)
overall prevalence of hypertension of
15.4%.
PMID: 8953202 [PubMed - indexed for
MEDLINE
The highest prevalence was in the Eastern
province and the lowest in the Central and
South-Western provinces.
Saudi medical journal ISSN 037952841998, vol. 19, no2, pp. 117-122 (19
ref.)
Definition
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Persistent elevation
SBP ≥140 mmHg
And OR
DBP ≥90 mmHg\
Several occasions
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.
Screening
 Highly recommended for normal asymptomatic ,low risk,
individuals.
 Recommends screening for high blood pressure in adults
age 18 years and older. grade A recommendation.
service
18-39y
40-64y
Over 65y
Hypertension
screening
Blood pressure every 2 years if less
than 120/80;
every year if 120 to 139/80 to 89 mm
Hg
U.S. Preventive Services Task Force (USPSTF) www.ctfphc.org
Recommendation for follow up
Initial blood pressure ,mmHg
Systolic
Diastolic
Follow up recommendation
<130
<85
Recheck in 2 years
130-139
85-89
Recheck in 1 years
140-159
90-99
Confirm within 2 months
160-179
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
ESSENTIAL HYPERTENSION
 > 90% of all cases
 multifactorial
 interplay of genetics and environment
 genes - polygenic
 environment - obesity, salt, smoking
 environment - intrauterine growth
 MAJORITY OF CASES ASSOCIATED WITH
HIGH CIRCULATING RENIN
Stage of
hypertensio
n:
Cardiovascular
risk factors
Secondary causes
Target
organ
damage
Associated
clinical
condition
ACCs
EVALUATION OF HYPERTENSIVE
PATIENT
Blood Pressure Classification
BP
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
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,HDLC <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
Target Organ Damage
Cerebrovascular disease
- transient ischemic attacks
- ischemic or hemorrhagic stroke
Hypertensive retinopathy
Left ventricular dysfunction/LVH
Coronary artery disease
- myocardial infarction
- angina pectoris
- congestive heart failure
Chronic kidney disease
Peripheral artery disease
- intermittent claudication
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
BP Measurement Techniques
Method
Brief Description
In-office
Self-measurement
Ambulatory BP
monitoring
Two readings, 5 minutes apart. Sitting in chair, not
on exam table. Confirm elevated reading in
contralateral arm.
Provides information on response to therapy. May
help improve adherence to therapy and evaluate
“white-coat” HTN.
Indicated for evaluation of “white-coat” HTN. Can
be used to confirm self-measurement when
inconsistent with in-office measurement.
Reimbursable.
http://hin.nhlbi.nih.gov/nhbpep_slds/menu.htm; Accessed October 20, 2003; 8:15AM
White Coat Hypertension
 20-30% of Apparently Resistant
Hypertension May be due to “White-Coat
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
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 pre
hypertensive should be initially treated with
lifestyle modification from the time they are
identified.
True
• Those people whose BP is classified as pre
hypertensive 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