hypertension in a nutshell sohil rangwala mdcm, ccfp

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Hypertension in a nutshell Sohil Rangwala MDCM, CCFP

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Page 1: Hypertension in a nutshell Sohil Rangwala MDCM, CCFP

Hypertension in a nutshell

Sohil RangwalaMDCM, CCFP

Page 2: Hypertension in a nutshell Sohil Rangwala MDCM, 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

Page 3: Hypertension in a nutshell Sohil Rangwala MDCM, CCFP

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%

Page 4: Hypertension in a nutshell Sohil Rangwala MDCM, CCFP

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

Page 5: Hypertension in a nutshell Sohil Rangwala MDCM, CCFP

Questions to ask on HistoryPMHX

CAD

PAD

CKD

DM2

dyslipidemia

obesity

cognitive changes

Page 6: Hypertension in a nutshell Sohil Rangwala MDCM, CCFP

Questions to ask on history-Medications

NSAID’s

COX-2 inhibitors

anabolic steroids

SSRI’s, SNRI’s

OCP’s

decongestants

Page 7: Hypertension in a nutshell Sohil Rangwala MDCM, CCFP

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

Page 8: Hypertension in a nutshell Sohil Rangwala MDCM, CCFP

Physical Exam- How to take a BP

Page 9: Hypertension in a nutshell Sohil Rangwala MDCM, CCFP

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

Page 10: Hypertension in a nutshell Sohil Rangwala MDCM, CCFP

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

Page 11: Hypertension in a nutshell Sohil Rangwala MDCM, CCFP

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

Page 12: Hypertension in a nutshell Sohil Rangwala MDCM, CCFP

Diagnostic tests after first visit

Urinalysis

Fasting blood sugar

Electrolytes and creatinine

Fasting lipid profile

ECG

ACR( only if DM)

Page 13: Hypertension in a nutshell Sohil Rangwala MDCM, CCFP

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

Page 14: Hypertension in a nutshell Sohil Rangwala MDCM, CCFP

Hypertensive urgency and emergency

Urgency:

Asymptomatic diastolic BP ≥ 130 mmHg

Emergency:

Hypertensive encephalopathy

Acute aortic dissection

Acute left ventricular failure

Acute myocardial ischemia

Page 15: Hypertension in a nutshell Sohil Rangwala MDCM, CCFP

Secondary causes of Hypertension

Renal artery stenosis

Sleep apnea

Hypothyroidism, Hyperthyroidism

Coarctition of aorta

Hyperaldosteronism

Cushing’s disease

Hyperparatyhroidism

Drug side effects

Page 16: Hypertension in a nutshell Sohil Rangwala MDCM, CCFP

Investigations for secondary HTN

TSH

Calcium, albumin, PTH

Renal doppler

Dexamethasone suppression test

Sleep study

Plasma aldosterone: plasma renin ratio

Urine for metanephrines

Echocardiogram

Page 17: Hypertension in a nutshell Sohil Rangwala MDCM, CCFP

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

Page 18: Hypertension in a nutshell Sohil Rangwala MDCM, CCFP

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

Page 19: Hypertension in a nutshell Sohil Rangwala MDCM, CCFP

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

Page 20: Hypertension in a nutshell Sohil Rangwala MDCM, CCFP

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

Page 21: Hypertension in a nutshell Sohil Rangwala MDCM, CCFP

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*

Page 22: Hypertension in a nutshell Sohil Rangwala MDCM, CCFP

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

Page 23: Hypertension in a nutshell Sohil Rangwala MDCM, CCFP

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

Page 24: Hypertension in a nutshell Sohil Rangwala MDCM, CCFP

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

Page 25: Hypertension in a nutshell Sohil Rangwala MDCM, CCFP

ConclusionHigh prevalence, with significant mortality and

morbidity

Routine screening and monitoring is important

Lifestyle and pharmacological therapies available!

Page 26: Hypertension in a nutshell Sohil Rangwala MDCM, CCFP

Referenceswww. hypertension.ca- CHEP 2014 guidelines