EMERGENCY MEETINGFOR PHILHEALTH REQUIREMENTS

CLINICAL PRACTICE GUIDELINES ON HYPERTENSION

CLINICAL PATHWAYS ON

HYPERTENSION

MAKATI MEDICAL CENTER

DEPARTMENT OF MEDICINE

SECTION OF CARDIOLOGY

DIAGNOSIS OF HYPERTENSION

• Patients with a blood pressure of 140/90 mm Hg or higher, recorded on at least 2 separate occasions at rest.

BP MEASUREMENTS:

Steps in taking blood pressure:• Snug application of compression cuff• Palpation of radial artery as compression cuff is inflated• Palpation of radial artery as cuff is deflated as 2 – 3 mm Hg

per heartbeat• Careful placement of stethoscope bell• Inflation of compression cuff above systolic pressure• Deflation of the cuff at a rate of 2 – 3 mm Hg per heartbeat

to determine systolic and diastolic blood pressure.

BP MEASUREMENTS:Must Remember:• Position of the patient.

– The patient may be sitting or lying. When the patient is recumbent, the cuff is essentially at cardiac level. If the patient is sitting, the arm and forearm should be supported on a tabletop at heart level.

• If the patient can rest for a while before the blood pressure is taken, it would seem preferable to use the lying position.

• The difference in the reading obtained in both positions ordinarily should not be significant. At times the pressure may be much lower when the patient is standing and whenever this condition is suspected, readings should be taken in the lying, sitting and standing positions

DIAGNOSTIC EVALUATION

FAMILY AND CLINICAL HISTORY1. Duration and previous level of high BP2. Indications of secondary hypertension3. Risk Factors4. Symptoms of Organ Damage5. Previous antihypertensive therapy (efficacy, adverse events)6. Personal, Family, Environmental Factors

PHYSICAL EXAMINATIONS 1. Signs suggesting secondary hypertension2. Signs of organ damage3. Evidence of visceral obesity

CLASSIFICATION OF HYPERTENSIONAdapted from JNC VII Guidelines for Hypertension

BLOOD PRESSURE (BP) STAGE

SYSTOLIC BP (mm Hg) DIASTOLIC BP (mm Hg)

NORMAL < 120 < 80

PREHYPERTENSION 120 – 139 80 -89

STAGE 1 HYPERTENSION

140 – 159 90 – 99

STAGE 2 HYPERTENSION

> 160 > 100

LAB INVESTIGATIONS (FOR NEW PATIENTS OR PATIENTS LOST TO FOLLOW UP)

ROUTINE TESTS Fasting Plasma GlucoseSerum total cholesterol, LDL cholesterol, HDL cholesterol, TriglyceridesSerum Potassium, Uric Acid, CreatinineEstimated creatinine clearance (cockgraft-Fault formula) or glomerular filtration rate (MDRD) FormulaComplete Blood CountUrinalysis (Complemented by microalbuminuria; dipstick test and microscopic examination)ElectrocardiogramChest X-Ray

Adapted from the Compendium of Abridged ESC Guidelines 2008.

LAB INVESTIGATIONS (FOR NEW PATIENTS OR PATIENTS LOST TO FOLLOW UP)

RECOMMENDED TESTSEchocardiogramCarotid UltrasoundQuantitative proteinuria (if dipstick test is positive)Ankle Brachial Index (ABI)FundoscopyGlucose Tolerance Test (If fasting plasma glucose > 5.6 mmol/L ) (100 mg/dL)Home and 24 hour ambulatory BP monitoringPulse wave velocity measurement (where available)

**if clinically indicated

LAB INVESTIGATIONS (FOR NEW PATIENTS OR PATIENTS LOST TO FOLLOW UP)

EXTENDED EVALUATIONFurther search for cerebral, cardiac, renal and vascular damageMandatory in complicated hypertension Search for secondary hypertension when suggested by history, physical examination or routine tests; measurement of renin, aldosterone, corticosteroids, catecholamines in plasma and/or urine; arteriographies; renal and adrenal ultrasound, computer assisted tomography; magnetic resonance imaging

CRITERIA FOR HOSPITAL ADMISSION

1. Patients with hypertensive emergencies/ urgency should be admitted to the hospital

2. Symptomatic Stage 2 Hypertension(associated with severe headache, shortness of breath, epistaxis or severe anxiety)

HYPERTENSIVE

EMERGENCY

Severe elevations in blood pressure (BP) that are complicated by evidence of progressive target organ

dysfunction, and will require immediate BP reduction

HYPERTENSIVE

URGENCY

Severe elevations of BP but without evidence of progressive target organ dysfunction and would be better defined as severe elevations in BP without acute, progressive target organ damage

Clinical Characteristics of the Hypertensive Emergency

BLOOD PRESSURE Usually > 220/140 mm Hg

FUNDOSCOPIC FINDINGS Hemorrhages, exudates, papilledema

NEUROLOGIC STATUS Headache, Confusion, Somnolence, Stupor, Visual loss, Seizures, Foacl neurologic deficits, coma

CARDIAC FINDINGS Prominent apical pulsation, cardiac enlargement, congestive heart failure

RENAL SYMPTOMS Azotemia, Proteinuria, Oliguria$

GI SYMPTOMS Nausea, Vomiting

TREATMENT: For Stage I Hypertension

THIAZIDE DIURETICS (for most)

May consider ACE-I, ARB, BB, CCB

Are the drugs of choice (if without compelling indications)

A SECOND DRUG:

POTASSIUM SPARING DIURETICS

ALDOSTERONE RECEPTOR BLOCKERS

BETA BLOCKERS

ACE INHIBITORS

ANGIOTENSIN II ANTAGONIST

CALCIUM CHANNEL BLOCKERS

ALPHA I BLOCKERS

CENTRAL ALPHA II AGONISTS

DIRECT VASODILATORS

ADDITIONAL COMBINATION DRUG:

ACE I + CCB

Either as a separate prescription or in fixed dose combinations with thiazide diuretics may be used when the BP remains uncontrolled or when BP is > 20 mm Hg above systolic goal or 10 mm Hg above diastolic goal.

TREATMENT: For Hypertension with Compelling Indications

DRUG COMPELLING INDICATIONS

DIURETICS Heart failure, High coronary disease risk, diabetes, recurrent stroke prevention

BETA BLOCKERS Post Myocardial Infarction, Heart Failure, High Coronary Disease Risk, Diabetes

ACE INHIBITORS Heart Failure, High coronary disease risk, diabetes, Recurrent stroke prevention, Chronic kidney disease, post MI

ANGIOTENSIN RECEPTOR BLOCKER HCeart Failure, diabetes, chronic kidney disease

CALCIUM CHANNEL BLOCKER High coronary disease risk, Diabetes

ALDOSTERONE ANTAGONIST Heart Failure, Post MI

For Stage 2 Hypertension (JNC VII) – SBP > 160 mm Hg/ DBP > 100 mm Hg we may use initially the following medications:

CLONIDINE or CAPTOPRIL

CLONIDINE

75 mcg tablet sublingual every 15

mintues for a maximum of 3 doses

Is a centrally acting alpha-adrenergic agonist with onset of action 30 to 60 minutes after oral administration, and maximal effects are usually seen within 2 to 4 hours. The most common adverse effect in the acute setting is drowsiness affecting up to 45% of patients. Clonidine may be a poor choice monitoring of mental status is important. Dry mouth is a common complaint, and lightheadedness is occasionally observed.

CAPTOPRIL

25 mg tabletSublingual

every 15 minutes for a maxiumum of 3 doses

An angiotensin-converting enzyme inhibitor, is well tolerated and can effectively reduce BP in a hypertensive urgency. Given by mouth, captopril is usually effective within 15 to 30 minutes and may be repeated in 1 to 2 hours, depending on the response. The drug has been administered sublingually. In which case the onset of action is within 10 to 20 minutes with a maximal effect reached within 1 hour. Administration may lead to acute renal failure in patients with high grade bilateral renal artery stenosis, and some reflex tachycardia may be observed.

If unresponsive to sublingual medications then the following formulary parenteral drugs may be used for hypertensive emergencies, vasodilators

(Sodium nitroprusside, nicardipine HCl, Nitroglycerine, Hydralazine Hcl and adrenergic inhibitor – Esmolol Hcl) and titrate accordingly

AGENT DOSE ONSET/ DURATION OF ACTION (AFTER

DISCONTINUATION)

PRECAUTIONS

NITROGLYCERINE 5 – 100 ug as IV infusion

2 – 5 minutes/ 5 – 10 minutes

Headache, tachycardia, vomiting, flushing, methemoglobinemia

NICARDIPINE 5 – 15 mg/ hr IV infusion

1 – 5 minutes/ 15 – 30 minutes, but may exceed 12 hours after prolonged infucion

Tachycardias, nausea, vomiting, headache, increased intracranial pressure; hypotension protracted after prolonged infusions

If unresponsive to sublingual medications then the following formulary parenteral drugs may be used for hypertensive emergencies, vasodilators (Sodium

nitroprusside, nicardipine HCl, Nitroglycerine, Hydralazine Hcl and adrenergic inhibitor – Esmolol Hcl) and titrate accordingly

AGENT DOSE ONSET/ DURATION OF ACTION (AFTER

DISCONTINUATION)

PRECAUTIONS

HYDRALAZINE 5 – 20 mg as IV bolus or 10 to 40 mg IM; repeat every4 – 6 hours

10 minutes IV > 1 hour20 - 30 minutes IM/ 4 – 6 hours

Tachycardia, headache, vomiting, aggravation of angina pectoris, sodium and water retention and increased intracranial pressure

ESMOLOL 500 ug/ kg bolus injection IV or 50 to 100 ug/kg/minute by infusion. May repeat bolus after5 minutes or increase infusion rate to 300 ug/ kg/ min

1 – 5 minutes/ 15 – 30 minutes

First degree heart block, congestive heart failure, asthma

• For HYPERTENSIVE EMERGENCIES – The 1st drug to be given ASAP to lower Blood Pressure to 2/3 of Systolic Blood Pressure

• For HYPERTENSIVE PATIENTS with suspected NEUROLOGIC COMPONENT – Keep Blood pressure at least 140 – 160 mm Hg until patient stabilizes

• OVERLAP

• Shift if FIRST DRUG of choice is not effective and patient is not responding.

Clinical Pathways for Hypertension Stage 2 – SBP > 160 mm Hg/ DBP > 100 mm Hg

1st 15 minutes 2nd 15 minutes 3rd 15 minutes

ASSESSMENT Initial evaluation• Include Neurologic EvaluationAssessed Severity• Hypertensive Urgency• Hypertensive Emergency• Stage 2 Hypertension

Risk Factors Assessed

Response to treatment assessed

DIAGNOSTICS BaselineLaboratory testsStat 5 (Na, K, FBS,Hb, Hct)12 Lead ECG

Additional hypertensive work-up upon consultants discretion:

TREATMENTS/ MEDICATIONS

Clonidine 75 mcg tablet sublingual or Captopril 25 mg tablet sublingualInsert IV access

Clonidine 75 mcg tablet sublingual or Captopril 25 mg tablet sublingual

Start parenteral anti-hypertensive

TEACHING Patients are oriented briefed on the signs and symptoms of hypertension

• For Hypertensive urgency, control BP to at least 2/3 of SBP within 24 hours

• For Symptomatic Stage 2 Hypertension, control symptoms and discharge with maintenance medications

• Upon discharge:1. Patient education – lifestyle management2. Home medications (anti-hypertensive medications)3. Schedule for follow-up

Is the patient pregnant or up to 2 weeks postpartum?

Toxidrome present?Flushing, increased BP/HR?

Diagnosis: Consider Eclampsia vs preeclampsia

Emergent labor & deliveryEmergent OB consult

Chest pain or SOB present?

Diagnosis: Cathecholamine excess?Possibilities:-Pheochromocytoma-Cocaine / sypmathomimetics-Antihypertensive withdrawal

Mental status changes with a focal neurological deficit?

Diagnosis: -Acute myocardial infarction-Aortic dissection-Acute left ventricular failure

Diagnosis: Hypertensive encephalopathy

Diagnosis: Stroke

YES

YES

YES

YES

NO

NO

NO

NO

Clinical Pathway: Hypertensive Emergencies and Urgencies

1. Repeat BP elevated2. Active, ongoing end-organ damage ruled out3. History of HTN-related end-organ damage

Treatment options for patients on HTN meds:1. Restart if non-compliant2. Increase dose3. Add another antihypertensive(Indeterminate)

Treatment options for patients not on HTN meds:1. Give oral meds2. Not starting any meds(Indeterminate)

1. Observe for several hrs2. Repeat BP3. Follow-up in 24-72 hrs

Hypertensive Urgency

Lifestyle Modification

Not At Goal Blood Pressure (<140/90 mmHg)

(<130/80 mmHg for those with Diabetes or Chronic Kidney

Disease)

Initial Drug Choices

Without CompellingIndications

With CompellingIndications

Stage 1Hypertension(SBP 140-159 or

DBP 90-99 mmHg)Thiazide-type

diuretics for most. May consider ACEI, ARB, BB, CCB, or

combination

Stage 2Hypertension(SBP ≥ 160 orDBP ≥ 100-99

mmHg)Two-drug

combination for most. (usually thiazide-type

diuretic and ACEI, or ARB, BB, or CCB)

Drugs for the compelling indications

Other antihypertensive drugs (diuretics,

ACE, ARB, BB, CCB) as needed

Not at Goal Blood Pressure

Optimize dosages or add additional drugs until goal blood pressure is achieved. Consider consultation with hypertension specialist

Algorithm for Treatment ofHypertension