Hypertension

Blood Pressure Classification

SBP mmHg Normal Prehypertension Stage 1 Hypertension Stage 2 Hypertension <120 120139 140159 >160 and or or or DBP mmHg <80 8089 9099 >100

National Joint Committee 7

In adults, classification of
hypertension is based on an

average of two or more blood

pressure readings obtained more

than 1 minute apart at two or more

visits.

A daytime awake average blood pressure measurement of 130 to 135/85 mm Hg is considered the threshold for ambulatory blood pressure monitoring and corresponds to an office reading of approximately 140/90 mm Hg.

Clinic measures (office measures) Ambulatory blood pressure measures :

2mesurements /hr (daytime mean)

Home blood pressure measures:

at least 4 days, discard 1st day , take the average of all the rest measures

2 measures ( 1 min apart) , twice a day , for

Office BP Measurement
Use auscultatory method with a properly calibrated and validated instrument. Patient should be seated quietly for 5 minutes in a chair (rather than on an exam table), feet on the floor, and arm supported at heart level. Measurement of BP in the standing position is indicated periodically, especially in those at risk for postural hypotension Appropriate-sized cuff should be used to ensure accuracy. Clinicians should provide to patients, verbally and in writing, their specific BP numbers and BP goals.

Fallacies of Office BP Measurement

Too loose cuff unsupported arm/back Too fast/slow deflation Too low elbow Paretic arm Cuff over clothes Talking , cold , alcohol ingestion
Tight clothes
Resting for too long Too rapid deflation(SBP only)

false high BP.

False low BP

Ambulatory blood pressure monitoring

provides information about BP during daily activities and sleep. It is warranted for evaluation of white-coat hypertension in the absence of target organ injury. It is also helpful to assess patients with apparent drug resistance, hypotensive symptoms with antihypertensive medications, episodic hypertension, and autonomic dysfunction.

Patient evaluation:
(1)

(2) (3)

to assess lifestyle and identify other cardiovascular risk factors or concomitant disorders that may affect prognosis and guide treatment to reveal identifiable causes of high BP to assess the presence or absence of target organ damage and CVD.

CVD Risk
Each increment of 20/10 mmHg >115/75 mmHg doubles the risk of CVD

Hypertension

CVD

The relationship between blood pressure and cardiovascular morbidity and mortality is linear, and the risk for ischemic heart disease and stroke progressively increases in patients with a blood pressure higher than 115/75 mm Hg.

CVD Risk Factors

Hypertension* Cigarette smoking Obesity* (BMI >30 kg/m2) Physical inactivity

Dyslipidemia*
Diabetes mellitus* Microalbuminuria or estimated GFR <60 ml/min

Age (older than 55 for men, 65 for women)

Family history of premature CVD (men metabolic syndrome. *Components of the under age 55 or women under age 65)

Patient evaluation:
(1)

(2) (3)

to assess lifestyle and identify other cardiovascular risk factors or concomitant disorders that may affect prognosis and guide treatment to reveal identifiable causes of high BP to assess the presence or absence of target organ damage and CVD.

Identifiable causes of hypertension

Sleep apnea Drug-induced or related causes Chronic kidney disease Primary aldosteronism Renovascular disease Chronic steroid therapy and Cushings syndrome Pheochromocytoma Coarctation of the aorta Thyroid or parathyroid disease

Patient evaluation:
(1)

(2) (3)

to assess lifestyle and identify other cardiovascular risk factors or concomitant disorders that may affect prognosis and guide treatment to reveal identifiable causes of high BP to assess the presence or absence of target organ damage and CVD.

Target Organ Damage

Heart Left ventricular hypertrophy Angina or prior myocardial infarction Prior coronary revascularization Heart failure Brain Stroke or transient ischemic attack Chronic kidney disease Peripheral arterial disease Retinopathy

Investigations:

Serum BUN, creatinine, and BL sugar, electrolytes collection of urine for urinalysis (haematuria), albumin: creatinine ratio and estimated glomerular filtration rate (e GFR). CBC, lipid profile. ECG, Echocardiography---- LVH. Renal ultrasonography. Fundus examination.

More extensive testing for identifiable causes is not indicated generally unless BP control is not achieved.

Fundus Examination

Benefits of Lowering BP
Average Percent Reduction Stroke incidence Myocardial infarction 3540% 2025%

Heart failure

50%

Goals of Therapy
Reduce CVD and renal morbidity and mortality.

BP <140/90 mmHg
BP <130/80 mmHg in patients with diabetes or chronic kidney disease. In the very elderly ( >80 years old) initiate treatment at stage 2 HTN , treatment target of 150/90)

Classification:
Stage 1 : (Bl pr 140-159/90-99)
if target organ organ damage or CVS risk----------offer ttt Life style modification/education/annul review of care once the bl pr is stable If younger than 40 years old ----------consider 2ry causes Stage 2 : (bl pr >160/100)-- offer ttt + life style mod/ education/ annual review

If Bl pr 180/ 110 Severe HTN---- Offer ttt (dont wait for ABPM confirmation if target organ damage or CVD risk) Accelerated HTN ----refer immediately to specialist if associated with retinal hge papilloedema.

Non pharmacological treatment

Modification recommendation Approximate systolic BP reduction, range 5-20 mmHg per 10-kg weight loss 8 to 14 mmHg Weight reduction Adopt DASH eating plan Dietary sodium reduction Physical activity Maintain normal body weight (BMI, 18.5 to 24.9 kg/m2) Consume a diet rich in fruits, vegetables, and low-fat dairy products with a reduced content of saturated and total fat Reduce dietary sodium intake to no more than 100 meq/day (2.4 g sodium or 6 g sodium chloride) Engage in regular aerobic physical activity such as brisk walking (at least 30 minutes per day, most days of the week)

2 to 8 mmHg

4 to 9 mmHg

Moderation of alcohol consumption

2 to 4 mmHg Limit consumption to no more than 2 drinks per day in most men and no more than 1 drink per day in women and lighter-weight persons

Adapted from The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, JAMA 2003; 289:2560.

Weight reduction

Maintain normal body weight (BMI, 18.5 to 24.9 kg/m2) 5-20 mmHg decrease per 10-kg weight loss

Dietary Approaches to Stop Hypertension (DASH)

8 to 14 mmHg

Its an eating plan that follows heart healthy guidelines to limit saturated fat and cholesterol. It focuses on increasing intake of foods rich in nutrients that are expected to lower blood pressure, mainly minerals (like potassium, calcium, and magnesium), protein, and fiber.

Physical activity

Engage in regular aerobic physical activity such as brisk walking (at least 30 minutes per day, most days of the week)

4 to 9 mmHg

Age <55

Aged >55 or black pt

Step 1:

CCB (?diuretic) Step 2: ACE I or ARB + CCB Step 3: ACE I or ARB + CCB + diuretic (thiazidelike diuertic) Step 4 (resistant HTN): ACE I or ARB + CCB + further diuretic ( 25 mg spironolactone or higher dose thiazide) (consider referral to specialist)

ACE I or ARB

If single-agent antihypertensive therapy is ineffective after 1 to 3 months of treatment, switching to or adding a drug with a complementary mechanism of action is indicated. Initial treatment with two antihypertensive agents may particularly be warranted for patients whose blood pressure is more than 20 mm Hg above the blood pressure goal, and those with stage 2 or higher hypertension often require treatment with more than one agent.

Hypertension with compelling indication

Systolic heart failure

ACE inhibitor or ARB, beta blocker, diuretic, aldosterone antagonist* Diuretic, perhaps ACE inhibitor

High coronary disease risk

Post-myocardial infarction Angina pectoris Atrial fibrillation , Atrial flutter

ACE inhibitor, beta blocker, aldosterone antagonist Beta blocker, calcium channel blocker rate control Beta blocker, nondihydropyridine calcium channel blocker ACE inhibitor and/or ARB Diuretic, perhaps ACE inhibitor

Proteinuric chronic renal failure Diabetes mellitus (no proteinuria)

Benign prostatic hypertrophy Essential tremor Hyperthyroidism

Alpha blocker Beta blocker (noncardioselective) Beta blocker

Osteoporosis

Thiazide diuretic

Perioperative hypertension Migraine

Beta blocker

Beta blocker, calcium channel blocker

Raynaud's syndrome

Dihydropyridine calcium channel blocker

Contraindications

Angioedema ----ACE inhibitor Bronchospastic disease ----- --- Beta blocker Liver disease ----------Methyldopa Pregnancy --------ACE inhibitor, ARB (includes women likely to become pregnant) Second or third degree heart block ---------Beta blocker, nondihydropyridine calcium channel blocker Gout --------------Diuretic Depression ---------Beta blocker, central alpha agonist Hyperkalemia-------Aldosterone antagonist, ACE inhibitor, ARB Hyponatremia ---------Thiazide diuretic Renovascular disease------- ----ACE inhibitor or ARB

Thiazides (low ceiling diuretics)

Indapamide hemihydrate

Diuretic combinations:

Moduretic
Aldactazide Lasilactone

(amiloride+hydrochlorothiazide)

(spironolactone+hydrochlorothiazide)

(spironolactone+furosemide)

Beta blockers

Alpha and Beta blockers

carvedilol

Beta blockers + Diuretic combinations

Bisoprolol + hydrochlorothiazide

Atenolol + chlorthalidone (Blokium Diu)

ACEIs

ACE +diuretic combinations

Capoten+ hydrochlorothiazide

ACE +diuretic combinations

prendopril + Indapamide

ARB

ARBs + Diuretic combnations

Losartan + hydrochlorothiazide

ALPHA BLOCKER

Prazosin

Doxazosin

Non dihydropyridine Ca channel blocker

Dihydropyridine Ca channel blocker

Verapamil

Centrally acting drugs

Methyl dopa (aldomet)

Clonidine ( catapress)

Case

A 50-year-old woman is evaluated during a routine office visit. She is asymptomatic and takes no medications. Her father and sister have essential hypertension. On physical examination, vital signs are normal except for a blood pressure of 136/86 mm Hg. BMI is 24. The remainder of the physical examination, including cardiopulmonary and funduscopic examinations, is normal. Laboratory studies, including levels of plasma fasting glucose, blood urea nitrogen, and serum creatinine levels and a urinalysis, are normal. Radiograph of the chest and an electrocardiogram are normal.

Which of the following is the most appropriate next step in this patients management? A) Ambulatory blood pressure monitoring B) Follow-up in 1 month C) Hydrochlorothiazide D) Lifestyle modification

Case 2

30y old male, accidently he develop severe dizziness , headache, came to ER, when his BP was 180/110, no family history of HTN, pt experienced buffiness in his face , mild LL edema What is your DD? What is investigation suitable for this pt? What is suitable antihypertensive medication?

Case 3

Diabetic pt 54 years old, DM scince 15 years. He is not tightly controled. He has peripheral neuropathy, she start to complain of mild LL oedema, headache, also he experienced chest pain in his last few months. His PB is 135/90. his doctor advise him to do full investigation.

Which investigation is needed? What is appropriate ttt for his BP?

Case 4

A 54 y old man with diabetes has elevated blood pressure averaging 150/90, he has complication of peripheral neuropathy , urinalysis is +ve for proteinuria. What is the target Bp control? What is the suitable anti-hypertension?

Case 5

70 y old women with no medical history has an elevated BP 165/80 on routine check up, repeated measures over the next month confirm the elevated BP. Physical exam, CBC, biochemistry are all normal. Select the most appropriate medication?

Hypertensive Emergencies
Stroke Encephalopathy

Aortic Dissection

Decompensated Heart Failure

Acute Coronary Syndrome Acute Renal Failure

From D Sicca, MD

Severe Hypertension

BP > 180/110 mm Hg
Progressive Target Organ Damage?
Yes HTN Emergency
Parenteral Rx Admit to ICU No 1st Episode HTN Urgency Oral Rx in ED Clinic appt: 24h Frequent Episodes Uncontrolled HTN Refill Rx Clinic in 72h

TRATMENT OF HTN EMERGENCY

Take home messages

In persons older than 50 years, systolic blood pressure greater than 140 mmHg is a much more important (CVD) risk factor than diastolic blood pressure. The risk of CVD beginning at 115/75 mmHg doubles with each increment of 20/10 mmHg; individuals who are normotensive at age 55 have a 90 percent lifetime risk for developing hypertension.

Take home messages

Thiazide-type diuretics should be used in drug treatment for most patients with uncomplicated hypertension, either alone or combined with drugs from other classes. Certain high-risk conditions are compelling indications for the initial use of other antihypertensive drug classes (ACE inhibitors, angiotensin receptor blockers, beta-blockers, calcium channel blockers).

Take home messages

Most patients with hypertension will require two or more antihypertensive medications to achieve goal blood pressure (<140/90 mmHg, or <130/80 mmHg for patients with diabetes or chronic kidney disease).

Take home messages

The most effective therapy prescribed by the most careful clinician will control hypertension only if patients are motivated. Motivation improves when patients have positive experiences with, and trust in, the clinician. Empathy builds trust and is a potent motivator.

The responsible physicians judgment remains paramount.

Thank you