hypertension in a nutshell sohil rangwala mdcm, ccfp
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Hypertension in a nutshell
Sohil RangwalaMDCM, CCFP
Quick facts1 in 5 Canadians have hypertension
Over 40% of Canadians aged 55-65 have hypertension
All adults with borderline BP 130-139/80-89 should get annual screening
Prevalence of Hypertension in Canada
21.8%
Number of Canadian adults
18+ suffering from hypertension
Number of Canadian adults
18+ suffering from hypertension
*Interpret with caution; coefficient of variation between 16.6% and 33.3%.Data are from the Canadian Health Measures Survey, Cycle 2, Statistics Canada.
…have hypertension.
3.3%*
3.3%*
21.8%
21.8%
52.4%
52.4%
Questions to ask on history-Review of systems
headache
visual changes
chest pain, dyspnea, PND
leg swelling, exertional calf pain
neurological deficits, vertigo
Obstructive Sleep Apnea
palpitations, excessive sweating, weight changes
Questions to ask on HistoryPMHX
CAD
PAD
CKD
DM2
dyslipidemia
obesity
cognitive changes
Questions to ask on history-Medications
NSAID’s
COX-2 inhibitors
anabolic steroids
SSRI’s, SNRI’s
OCP’s
decongestants
Questions to ask on history-Social/habits- i.e risk factors
Age >55
Male
Family history
Smoker
Obseity
Poor diet, salt intake
Dyslglycemia
Stress
ETOH, drugs
Physical Exam- How to take a BP
Physical examNeuro:
check for abnormal cranial nerve exam ,papilledema, cotton wool spots, retinal hemorrhages
CVS: heart murmurs, renovascular bruits, carotid bruits,
decreased or absent peripheral pulses, extremity swelling
BP: 140-179 / 90-109BP: 140-179 / 90-109
ABPM (If available)
ABPM (If available)
Office BPM
Office BPM
Home BPM (If available)Home BPM (If available)
Yes
Hypertension Visit 2Target Organ Damage
or Diabetesor BP ≥ 180/110?
Hypertension Visit 2Target Organ Damage
or Diabetesor BP ≥ 180/110?
Hypertension Visit 1BP Measurement,
History and Physical examination
Hypertension Visit 1BP Measurement,
History and Physical examination
HypertensiveUrgency /
Emergency
HypertensiveUrgency /
Emergency
Diagnosisof HTN
Diagnosisof HTN
No
Diagnostic algorithm for hypertension
2014
Criteria for the diagnosis of hypertension and recommendations
for follow-up BP: 140-179 / 90-109BP: 140-179 / 90-109
ABPM (If available)ABPM (If available)
Diagnosisof HTN
Awake BP>135 SBP or>85 DBP or
24-hour>130 SBP or
>80 DBP
Awake BP>135 SBP or>85 DBP or
24-hour>130 SBP or
>80 DBP
Awake BP<135/85
and24-hour<130/80
Awake BP<135/85
and24-hour<130/80
Continue to follow-up
Office BPOffice BP
Diagnosisof HTN
Hypertension visit 3
>160 SBP or >100 DBP
>140 SBP or>90 DBP
< 140 / 90
Diagnosisof HTN
Continue to follow-up
<160 / 100
Hypertension visit 4-5
ABPM or HBPMor
Patients with high normal blood pressure (office SBP 130-139 and/or DBP 85-89) should be followed annually.
Repeat Home BPM
Repeat Home BPM
If<
135/85
If<
135/85
or
2014
Diagnostic tests after first visit
Urinalysis
Fasting blood sugar
Electrolytes and creatinine
Fasting lipid profile
ECG
ACR( only if DM)
End organ damage?Cerbrovascular disease (Stroke,TIA)
Vascular Dementia
Hypertensive retinopathy
LVH
CAD-MI, angina
CKD -Egfr less than 60 or albuminuria
PAD- intermittent claudication, ABI less than 0.9
Hypertensive urgency and emergency
Urgency:
Asymptomatic diastolic BP ≥ 130 mmHg
Emergency:
Hypertensive encephalopathy
Acute aortic dissection
Acute left ventricular failure
Acute myocardial ischemia
Secondary causes of Hypertension
Renal artery stenosis
Sleep apnea
Hypothyroidism, Hyperthyroidism
Coarctition of aorta
Hyperaldosteronism
Cushing’s disease
Hyperparatyhroidism
Drug side effects
Investigations for secondary HTN
TSH
Calcium, albumin, PTH
Renal doppler
Dexamethasone suppression test
Sleep study
Plasma aldosterone: plasma renin ratio
Urine for metanephrines
Echocardiogram
Population SBP DBP
Diabetes 130 80
High risk (TOD or CV risk factors) 140 90
Low risk (no TOD or CV risk factors)
160 100
Very elderly 160 NA
Usual blood pressure threshold values for initiation of
pharmacological treatment
TOD=target organ damage*This higher treatment target for the very elderly reflects current evidence andheightened concerns of precipitating adverse effects, particularly in frail patients. Decisions regarding initiating and intensifying pharmacotherapy in the very elderly should be based upon an individualized risk-benefit analysis.
2014
Population SBP DBP
Diabetes <130 <80
All others < 80 y.a. (including CKD)
<140 <90
Very elderly (≥ 80 years) <150* NA
Treatment consists of health behaviour ±pharmacological management
What are the Targets?
*This higher treatment target for the very elderly reflects current evidence andheightened concerns of precipitating adverse effects, particularly in frail patients. Decisions regarding initiating and intensifying pharmacotherapy in the very elderly should be based upon an individualized risk-benefit analysis.
2014
Impact of health behaviours on blood pressure
Intervention Systolic BP(mmHg)
Diastolic BP(mmHg)
Diet and weight control -6.0 -4.8
Reduced salt/sodium intake - 5.4 - 2.8
Reduced alcohol intake (heavy drinkers) -3.4 -3.4
DASH diet -11.4 -5.5
Physical activity -3.1 -1.8
Relaxation therapies -3.7 -3.5
Multiple interventions -5.5 -4.5
Clinical Guideline : Methods, evidence and recommendations National Institute for Health and Clinical Excellence (NICE) May 2011
2014
Health Behaviours in Adults with Hypertension:
SummaryIntervention TargetReduce foods with added sodium → 2000 mg /day
Weight loss BMI <25 kg/m2
Alcohol restriction < 2 drinks/day
Physical activity 30-60 minutes 4-7 days/week
Dietary patterns DASH diet
Smoking cessation Smoke free environment
Waist circumference
Men <102 cm Women <88 cm
2014
Treatment of Systolic-Diastolic Hypertension without Other Compelling Indications
CONSIDER
• Nonadherence• Secondary HTN• Interfering drugs
or lifestyle• White coat effect
Dual Combination
Triple or Quadruple Therapy
Lifestyle modification
Thiazidediuretic ACEI Long-acting
CCB
TARGET <140/90 mmHg
ARB
*Not indicated as first line therapy
over 60 y
Initial therapy
A combination of 2 first line drugs may be considered as initial
therapy if the blood pressure is >20 mmHg systolic or >10 mmHg
diastolic above target
Beta-blocker*
Treatment Thiazide Diuretic-
HCTZ- risk Hypokalemia
ACE- Ramipril- cough, monitor renal function, can cause
hyperkalemia
ARB- Telmesartan- , monitor renal function, can cause
hyperkalemia
CCB- Amlodipine- Leg swelling, constipation
B-Blocker metoprolol- fatigue, not generally for use over age 60
The treatment of hypertension is all about vascular protection
Male
55 y or older
Smoking
Type 2 Diabetes
Total-C/HDL-C ratio of 6 or higher
Premature Family History of CV disease
Previous Stroke or TIA
LVH
ECG abnormalities
Microalbuminuria or Proteinuria
Peripheral Vascular Disease
ASCOT-LLA Lancet 2003;361:1149-58
Statins are recommended in high risk hypertensive patients based on having established atherosclerotic disease or at least 3 of the following:
2014
Vascular Protection for Hypertensive Patients: ASA
Low dose ASA in patients >50 years
Caution should be exercised if BP is not controlled.
Hansson L, Zanchetti A, Carruthers SG, et al. Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomised trial. Lancet 1998; 351: 1755-1762.
2014
ConclusionHigh prevalence, with significant mortality and
morbidity
Routine screening and monitoring is important
Lifestyle and pharmacological therapies available!
Referenceswww. hypertension.ca- CHEP 2014 guidelines