SYSTEMIC HYPERTENSION RATIONAL MANAGEMENT IN

GENERAL PRACTICE
Dr Anidu Pathirana
MBBS(Col.) MD(Col.) MRCP(UK)

SOME DIFFICULTIES GPS HAVE WITH HYPERTENSION MANAGEMENT

When to inform a patient as hypertensive When to refer to a Specialist

How to control high BP to the target

How to convince & persuade a patient to take medication (often several) lifelong, for an asymptomatic condition and where drugs may have significant side effects.

TAKE HOME MESSAGES

Measure

BP accurately and record Take adequate time to diagnose hypertension Decide BP target, try to hit it, tell target to patient Use low cost, tolerated drugs in effective combination Address CV risk reduction, decide on LDL, HbA1c targets and try to hit Convince the patient for follow up

SYSTEMIC HYPERTENSION DEFINITION

pressure elevation Systolic above 139 mmHg and/or Diastolic above 89 mmHg on repeated measurements in adults >18y

Blood

NORMAL DISTRIBUTION OF DIASTOLIC BP WITHIN A

POPULATION

20
% of screened population

15

10

50

60

70

80

90

100

110 120

130

Diastolic BP, mmHg

HYPERTENSION:
A PRACTICAL DEFINITION

That level of blood pressure at which investigation and treatment do less harm than good

HYPERTENSION IS COMMON
Prevalence

25% adult populations

Normotensive

at 55 year has a 90% lifetime risk of developing hypertension

HYPERTENSION IS SERIOUS
Global mortality 2000 Health risk factors

HYPERTENSION IS SERIOUS
Untreated

hypertension reduces life expectancy by 5 years

Hypertension

is responsible for - 25% of all premature deaths - 25% of all CAD deaths - 50% of all stroke deaths - 50% of all Congestive Heart Failure - Commonest cause of CKD overall

TARGET ORGAN DAMAGE

Angina, Heart Attack Heart failure Memory Loss or Stroke

Kidney damage Impaired vision or Blindness Decreased sexual ability

TREATMENT IS EFFECTIVE

HYPERTENSION IS TREATABLE
Antihypertensive

drug therapy (almost)

always
Lifestyle

changes Assist in hypertension control and reduce number of drugs

SBP REDUCTIONS AS LITTLE 2 MMHG REDUCES CV RISK BY 10%

2 mm Hg decrease in mean SBP

7% reduction in risk of ischemic heart disease mortality 10% reduction in risk of stroke mortality

140/90 mmHg

GOAL IS TO HIT THE TARGET

High

risk (CVD,CKD,DM) Others

>80y

< 130 and 80 mmHg < 140 and 90 mmHg

< 150 and 90 mmHg

should know their starting BP &

Patients

Goal BP

Hypertension

is mostly asymptomatic for opportunistic screening

Need

CASE HISTORY
A 38y old man BP 154/96 mmHg

WHAT TO DO Diagnostic pathway Treatment pathway

IMPORTANT QUESTIONS

When should I tell him as having Hypertension? Can I manage him or should I refer him to a Specialist? When should I start him on drugs? What are the best drugs? When should I see him next?

ACCURATE BLOOD PRESSURE MEASUREMENT

Equipment

should be regularly inspected and validated. should be trained and regularly

Operator

retrained.
Patient

must be properly prepared

TECHNIQUES OF BP MEASUREMENT
Clinic

measurements or nurse) BP measurement

(doctor

Home

(patient)

24h

ambulatory BP measurement (automatically)

TYPES OF B P MONITORS
Mercury

sphygmomanometers

Android

( Mercury-free)

Automated

upper arm devices

What size cuff? Size does matter

Using too small a cuff/bladder can overestimate the blood pressure
Bladder should encircle arm by 80-100%

Too tight clothing

If the sleeves are too tight or bulky they act as a tourniquet giving inaccurate readings

MYTH: The position of the arm is immaterial During BP measurement?

FACT: The arm should be well supported at HEART level (both sitting & standing) An unsupported arm is performing isometric exercise thus raising BP

MYTH: Mercury sphygmomanometer should be positioned level with the patients heart?

It should be level with eye

At what rate should the cuff be deflated on a Mercury sphygmomanometer?

FACT: 2mm/Hg per second

FACT:
BP should be recorded to
the nearest 2mm/Hg on mercury sphygmomanometer

RULES FOR MEASUREMENT

Seated for 5 min in a quite place No exercise, smoking, caffeine within 30 min. Measure in both arms on first visit. If difference >20 mmHg repeat measurements in both arms. If remains so measure subsequent BP in arm with higher reading. If BP >140/90: Take a second reading during same consultation. At least 1-2 min. apart. If it differs > 20 take a third measurement. Record lower of the last two measurement as the clinic BP

Care Pathway

Person having BP measured

Diagnosis and assessment of hypertension

Hypertension NOT diagnosed

Hypertension diagnosed

Review at least 1- 2 yearly

Management of hypertension

FOLLOW-UP BASED ON INITIAL BP

MEASUREMENTS FOR ADULTS

Initial B P value

Follow-up recommendation

Normal <130/85
Pre hypertension or high normal 130-139/85-89 140-159/90-99

Re check in2 years

Re check in 1 years Confirm within 2 months

160-179/100-109
>180/110

Confirm within 1 month

Evaluate & treat immediately or within 1 week

Visit 1
Elevated Out of the Clinic BP measurement Elevated Random Clinic BP Measurement

Hypertension Visit 1 BP Measurement, History and Physical examination

Hypertensive Urgency / Emergency

Diagnostic tests ordering at visit 1 or 2

Diagnosis of HTN

Urgent referral for urgent treatment

Impending

complications (e.g. TIA, LVF, angina)

Particularly severe hypertension (>220/120mmHg) Accelerated hypertension (severe hypertension and grade III-IV retinopathy)

Hypertension risk factors

Weight Family history Salt, Alcohol, Stress, Sleep

Concurrent conditions
Asthma Gout Pregnancy

Clues to 2o HT
Symptoms Drugs:OCP,NSAIDS Signs

HISTORY & EXAMINATION

Other CV risk factors

Lipids Smoking Diabetes Exercise

Target organ damage

Heart: angina,MI,HF Brain: TIA Eyes Kidneys

INVESTIGATIONS
Urinalysisprotein,blood,microalbuminuria

ECG
FBS Fasting

lipids Serum creatinine & e-GFR Serum electrolyte Hb%, PCV TSH, Ionized calcium Serum uric acid

ASYMPTOMATIC TARGET ORGAN DAMAGE

ECG

& Echo evidence of LVH CKD with eGFR <60 ml/min/1.76 m2 BSA Microalbuminuria- 30 mg/ g creatinine or 30-300 mg/24h Pulse pressure >60 mmHg in elderly Increased pulse wave velocity carotidfemoral Carotid IMT or plaque Ankle brachial index < 0.9

BP 140/90 mmHg + TOD,DM,CKD

or

Visit 2
Yes

Diagnosis of HTN

BP 180/110?
No

DIAGNOSTIC ALGORITHM CONT.

BP: 140-179 / 90-109

Clinic BP
Hypertension visit 3
160 SBP or 100 DBP < 160 / 100
Diagnosis of HTN
ABPM or HBPM

ABPM (If available)

HBPM

or

Awake BP < 135/85 and 24-hour < 130/80

Hypertension visit 4-5

140 SBP or 90 DBP
Diagnosis of HTN

Awake BP 135 SBP or 85 DBP Or 24-hour 130 SBP or 80 DBP

< 135/85

135 SBP or DBP 85

or

Continue to follow-up

Diagnosis of HTN

Continue to follow-up

Diagnosis of HTN

< 140 / 90

Continue to follow-up

DEFINITION BY OFFICE & OUT-OF-OFFICE B P

LEVELS

HOME/SELF BP MONITORING
Advise

patients on accurate, independently validated, well maintained monitors Advise use of appropriate cuff size Suggested measurement routine for patients
Two consecutive measurements 1 min apart, seated Measure BP for 7 days prior to appointment Record BP twice a day. Morning and evening Discard first 24 hours of readings Take an average of at least 12 of these readings

24 hour BP monitoring (ABPM)

Indications for ABPM

Possible white coat hypertension Informing equivocal decisions Determining efficacy of drug treatment over 24 hours Evaluation of symptomatic hypotension Unusual BP variability Evaluation of drug resistant hypertension

THE CONCEPT OF MASKED / WHITE COAT HYPERTENSION

Home or daytime ABPM SBP mmHg
140

Masked HTN

True hypertensive

135
True Normotensive White Coat HTN

135

140

Clinic SBP mmHg

From Pickering, Hypertension 1992

CLASSIFICATION OF CLINIC B P LEVELS

Category Stage 1 Stage 2 Stage 3 Isolated systolic hypertension Systolic 140-159 160-179 >180 >139 and/or and/or and/or and Diastolic 90-99 100-109 110 <90

WAYS TO LOWER PRESSURE

Get regular Physical activity Reduce weight Eat a healthy diet

Stop smoking
Eat less Sodium YoU can control your blood pressure Take youR medications Avoid Excess alcohol

LIFE STYLE MEASURES TO ALL

Physically Active
Get 30 to 60 minutes of exercise per day If you are overweight, losing 10 lbs (5 Kg) will reduce high blood pressure

Eat Healthy

Eat a healthy diet: fresh fruits & vegetables, low-fat dairy, whole grains, low-fat meat, fish, poultry

Smoke-Free

Stop smoking forever

LIFE STYLE MEASURES TO ALL

Less Salt Less Stress Less Alcohol
Hidden Salt Processed and restaurant foods contain high amounts of salt

Reduce stress You can control your blood pressure: Limit alcohol to less than 2 drinks a day for men and approximately 1 drink a day for women

Medications

If you are on medications: take them as directed by your doctor

INDICATIONS FOR DRUG THERAPY

Grade 2 & 3 High risk Grade 1 with TOD,DM,CKD or high CV risk Arguments for drug treatment for all Grade 1 -No need to wait till become high risk. That high risk may not be reversible then. -Safe drugs are now available at low cost Elderly patients drug therapy > 160 mmHg target 150 mmHg

RISK FACTORS
Male sex Age >55 y in male, >65 y in female Smoking Dyslipidemia ( total >190 mg/dl, LDL >115, HDL <40 in male & <46 in female, TG >150) FBS 102-125 mg/dl or abnormal IGT BMI > 30, Abdominal obesity > 90 cm in male & > 80 cm in female Family history of premature CV disease <55 y in male, <65 y in female

INITIATION OF LIFE STYLE CHANGES & DRUGS

DRUG THERAPY
Effective:

Proven in trials Minimal side effects

Tolerance:

Cost:

Low Four main classes: ACEI/ARA, BB, CCB, Diuretics

TAILORED THERAPY
Compelling

indications contra indications

Compelling

MOST PATIENTS NEED COMBINATION OF

DRUGS TO ACHIEVE TARGET
On

average each medication will reduce blood pressure 10/5 (Rule of 10/5) Stage1: start ONE drug Stage2: start COMBINATION of two Even in stage 1 hypertension two classes of drugs needed to BP goals

DRUG COMBINATIONS

GENERAL PRINCIPLE DRUG THERAPY

Low

dose and titrate up Long acting drugs 24h efficacy with once a day dosing at least 50% drug effect remaining at the end of 24h Each medication may require 2-3 dose adjustments Recommended interval between adjustments (new or dose increase) is 2 weeks Usually one adjustment per visit

STEP-UP

Stepwise Ladder Approach

Aged under 55 years Aged over 55 years

C2

Step 1 Step 2 Step 3 Step 4

A + C2

Key A ACEI or low-cost ARB C Calcium-channel blocker (CCB) D Thiazide-like diuretic

A+C+D

Resistant hypertension A + C + D + consider further diuretic3, 4 or alpha- or beta-blocker5 Consider seeking expert advice

Indications for Specialist referral

Possible underlying cause

Any clue in history or examination of a secondary cause, eg. low potassium, proteinuria, hematuria
Raised serum creatinine Sudden onset or worsening of hypertension Resistant to multi-drug regimen (> 3 drugs) Young age (<40 years)

Indications for Specialist referral

Therapeutic problems Multiple drug intolerance Multiple drug contraindications Persistent non-compliance Special situations Unusual blood pressure variability

Possible white coat hypertension

Hypertension in pregnancy

GLOBAL RISK REDUCTION

ADD-ON TREATMENT
Aspirin

75 mg/d if high renal and CV risk,TOD,DM with BP controlled <150/90

Statin:

Without previous CVD moderately high CV risk to target LDL 115 mg/dl Overt CHD target LDL 70 mg/dl

FOLLOW UP
Once

a month initially.More often if high risk

If

BP at goal and stable review at 3-6 m

Serum

creatinine & electrolyte in 6-12 m

Consider

reducing doses and number of agents after one year at or below goal BP

TAKE HOME MESSAGES

Measure

BP accurately and record Take adequate time to diagnose hypertension Decide BP target, try to hit it, tell target to patient Use low cost, tolerated drugs in a effective combination Address CV risk reduction, decide on LDL, HbA1c targets and try to hit Convince the patient for follow up

Compelling and possible indications, contraindications, and cautions for the major classes of antihypertensive drugs
Class of drug Beta-blockers Compelling indications MI, Angina Possible indications Heart failure Caution Heart failure, PVD, Diabetes (except with CHD) Combination with betablockade Compelling contraindications Asthma/COPD, Heart block

CCBs (dihydropyridine) CCBs (rate limiting)

Elderly, ISH Angina

Angina Elderly

Heart block Heart failure Gout

Thiazide/thiazide- Elderly like diuretics ISH Heart failure 2 o stroke prevention

BP NOT CONTROLLED
Improper BP measurement (large cuff) Poor compliance Volume overload- Inadequate diuretic, Excessive salt intake, progressive renal failure Failure to modify lifestyle- Weight gain, Stressful life, Excessive alcohol Drugs- NSAIDs, OCP, herbal medicine Obstructive sleep apnoea Unsuspected secondary cause

INFORMATION TO A NEWLY
DIAGNOSED PATIENT
You

are at significant risk of heart attack, stroke and kidney damage. risk can be significantly reduced by reducing your BP to target level

This

Your

target blood pressure is 140/90 (or less)

INFORMATION TO A NEWLY DIAGNOSED

PATIENT
Most

people need 2 or more drugs to control their blood pressure and need to stay on them for life Most medications take several weeks to show their full effect so be patient You need to visit every two weeks to adjust drug doses

INFORMATION TO A NEWLY DIAGNOSED PATIENT

Medications

only work if you take them!

Stopping

a treatment when blood pressure returns to normal can cause your blood pressure to rise again to dangerous levels

INFORMATION TO A NEWLY DIAGNOSED

PATIENT
Because

the medications have controlled the blood pressure does not mean that the blood pressure has been completely cured Your treatment is life long Life style changes, healthy diet, physical activity and reduce mental stress are helpful

CBPM 140/90 mmHg & ABPM/HBPM 135/85 mmHg Stage 1 hypertension

CBPM 160/100 mmHg & ABPM/HBPM 150/95 mmHg

Stage 2 hypertension

CARE PATHWAY
If TOD, established CVD,CKD,DM or 10-year CV risk > 20% Offer antihypertensive drug treatment

If younger than 40 years

Consider specialist referral

Offer lifestyle interventions

Offer patient education to support adherence to treatment Offer review of care to monitor blood pressure, provide support and discuss lifestyle, symptoms and medication

HEALTHY DIET
A

high sodium diet can increase blood pressure

Choose more often Fresh fruits and vegetables Low-fat milk products Whole grains Low-fat meat, fish, chicken and turkey Use herbs and spices to replace salt Foods with 5% or less of the daily value of sodium

Choose less often Fast food, restaurant and packaged foods Foods with more than the 15% daily value of sodium Ketchup, mustard, soy sauce, gravy Pickled foods, olives, salsa, chips Cured/smoked meat or fish

HOW TO READ FOOD LABELS

Check the serving size

Aim for less than 5% Sodium