DR said : Concentrate on hypertension defeniti on and causes,ACS risk factors,how to diagnose and lines of mangement

Hypertension

The most common risk factor for:

CAD CHF Stroke

Major problem is public awareness ;

1/3 of pts aware of having high BP 1/3 hypertensive pts are on medication 1/3 of pts on medication have good BP control

Other problems;
Difficult to achieve good control of BP especially in the older pts with comorbid disease. Requirement of multiple medications .

Increment of 20mmHg in SBP & 10 mmHg in DBP double the risk of both IHD & stroke . The risk CAD starts from BP > 120/80

Incidence
50% for persons above 50yr 80% > 80 yr

JNC 7 classification
Normal: < 120 SBP & < 80 DBP Prehypertension : 120 - 139 / 80-89 Stage 1 : 140-159 / 90-99 Stage 2 : > 160 / 100

Definitions
Essentional ( primary, idiopathic) hypertension; 90% of all cases Clusters in families & represents a collection of genetically based disease.

Secondary HTN ;
High BP caused by a specific , potentially curable disorder.

Hypertensive urgency : DBP > 120 mmHg. Hypertensive emergency : DBP >120 mmHg plus acute or ongoing end organ damage.

Initial evaluation should include; 1) accurate measurement of BP 2) assessment of end organ damage. 3) screening for secondary causes.

BP measurement
Diagnosis of HTN should be made when at least 2 separate readings obtained at least 1-2 weeks apart average > 140/90.

Off tobacco & caffeine for > 30 min. before BP measurement. Suitable cuff that encircle 80% of the arm. large cuff ---- false low reading small cuff ---- false high reading

Target organ damage

Heart ; LVH, CHF, angina Brain ; stroke , TIA Kidney ; renal impairment , proteinurea Eyes ; retinopathy Peripheral artery disease

Secondary HTN
Considered when ; onset of HTN < 20 yr or > 60yr refractory HTN worsening of previously controlled HTN. azotemia induced or worsened by ACEI or ARBs. recurrent flash pulmonary edema with normal LV function.

Secondary HTN
Renal causes; 90% of all secondary HTN. Endocrine; Drugs ; steroids, alcohol, OCP, NSAID, nasal decongestants, cyclosporine, erythropoietin ,.. Sleep apnea Coarctataion of aorta.

Baseline lab tests

BUN , Cr, Na , k FBS Urine R&M , microalbuminurea EKG Lipids profile

Weight reduction ( for each 1 kg wt loss, SBP & DBP decreased by 1.6 mmHg /1.3 mmHg )

Physical activity ( engagement in regular aerobic exercise such as brisk walking at least 30 min / day, most days of the week can reduce SBP 4-9 mmHg )

Na restriction to 2.4g daily reduce SBP by 2-8 mmHg. Adopting diet rich in fruits & vegetables & low in saturated fats can reduce SBP by 814 mmHg.

Goal of treatment
for most pts , goal BP is < 140 / 90 . For pts with DM or CKD , goal BP is <130/80

 5 major classes have shown benefit outcome ; 1) thiazide- type diuretics 2) B-Blokers 3) Ca Channel Blokers 4) Angiotensin converting enzyme inhibitors (ACEI) 5) angiotesin receptor blokers (ARBs)

Comorbid conditions

Drug selection is dictated by the compelling indicaion .

Mono vs combined therapy

Single drug treatment is not usually adequate in most hypertensive pts particularly those with stage 2 HTN. In many studies , fewer than 30% of participants achieved goal BP <140/90 on mono therapy.

In many pts , 2nd , 3rd & even 4th line drugs are needed in order to attain goal BP.

Thank you