Primary Hypertension

Shiva Seyrafian- 94/2/31

Accurate Measure of Blood PressureAssess blood pressure at all appropriate

visits

• When should blood pressure be measured?(Health care professionals should know the blood

pressure of all of their patients and clients)

(Blood pressure of all adults should be measured whenever it is appropriate using standardized techniques)

1. To screen for hypertension

2. To assess cardiovascular risk

3. To monitor antihypertensive treatment

A joint AHA/ACC/CDC algorithm-November 2013

BP: Recommended goal of 139/89 mm Hg or less

• Stage 1 hypertension (systolic BP 140-159 mm Hg or diastolic BP 90-99 mm Hg).

• Stage 2 hypertension (systolic BP ≥160 mm Hg or diastolic BP ≥100 mm Hg).

• Severe hypertension Clinic systolic blood pressure is 180 mmHg or higher or clinic diastolic blood pressure is 110 mmHg or higher.

http://emedicine.medscape.com/article/241381-treatment

Definitions

Management of hypertension

• The 2014 guidelines of the Eighth Joint National Committee (JNC 8) recommended three important changes to the 2003 guidelines:

• Setting more conservative blood-pressure goals for adults 60 years of age or older (150/90),

• And for patients with diabetes or chronic kidney disease (140/90).

New management of hypertension

• In the general population ages 60 and older, pharmacologic treatment at a systolic blood pressure (SBP) of 150 mmHg or higher or a diastolic blood pressure (DBP) of 90 mmHg or higher.

• Should be treated to a goal SBP lower than 150 mmHg and a goal DBP lower than 90 mmHg.

• Younger than age 60, initiate pharmacologic treatment at a DBP of 90 mmHg or higher or an SBP of 140 mmHg or higher and treat to goals below these respective thresholds.

• 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults: Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8),

Risk Factors for Developing Hypertension

• Poor dietary habits• High sodium intake• Sedentary lifestyle, physical inactivity• High alcohol consumption• Dyslipidemia,• Dysglycemia (e.g. Impaired fasting glucose,

diabetes) • Abdominal obesity

2014 Canadian Hypertension Education Program Recommendations

Assessment of the Overall Cardiovascular Risk

• Search for exogenous potentially modifiable factors that can induce/aggravate hypertension

-Prescription Drugs:• NSAIDs, including coxibs• Corticosteroids and anabolic steroids• Oral contraceptive and sex hormones• Vasoconstricting/sympathomimetic decongestants• Calcineurin inhibitors (cyclosporin, tacrolimus)• Erythropoietin and analogues• Antidepressants: Monoamine oxidase inhibitors (MAOIs), SNRIs, SSRIs• Midodrine

-Other:• Licorice root• Stimulants including cocaine• Salt• Excessive alcohol use

2013, the European Society of Hypertension

• With diabetes diastolic BP should be below 85 mm Hg.

• Salt intake should be limited to 5 to 6 g per day• Body-mass index (BMI) < 25 kg/m2 and waist

circumferences <102 cm in men and < 88 cm in women.

• Ambulatory BP monitoring (ABPM) should be incorporated into the assessment of risk

http://emedicine.medscape.com/article/241381-treatment

Epidemiology

• More than 20% of people in Isfahan have hypertension.(year: 1386-1388)

• Women more than men have hypertension.• In the USA prevalence is 29.1%,(2011-2012)

and similar between sexes. (NCHS Data Brief ■ No. 133 ■ October 2013)

SCORE 10-Year Fatal Cardiovascular Risk

Find the cell nearest to the person’s risk factors values :

AgeSex

Smoking StatusSystolic Blood Pressure

Total-Chol. / HDL-C. Ratio

SCORE Canada : Systematic

Cerebrovascular and cOronary

Risk Evaluation  

2014 Canadian HypertEvaluation in Canadaension Education Program Recommendations

Indications for ABPM  

In addition to patients with suspected white coat hypertension, ambulatory monitoring should be considered in the following circumstances:

• Suspected episodic hypertension (eg, pheochromocytoma)

• Hypertension resistant to increasing medication• Hypotensive symptoms while taking antihypertensive

medications• Autonomic dysfunction

White coat hypertension

• In patients diagnosed as being hypertensive on a first visit to a new physician, there is a mean 15 and 7 mmhg fall in the systolic and diastolic BP, respectively, by the third visit with some patients not reaching a stable value until the sixth visit .

• The prevalence of white coat hypertension ranges from 10 to more than 20 percent, and appears to be higher in children and the elderly

White coat hypertension

• White coat hypertension can also be seen in patients with apparently resistant hypertension

• The likelihood of normal ambulatory pressures is low (less than 5 percent) in patients with office diastolic pressures ≥105 mmHg but such patients may still have a white coat effect underestimates the efficacy of therapy

Definitions based upon ambulatory and home readings

 The diagnosis of hypertension using ambulatory blood pressure monitoring :

• A 24-hour average above 135/85 mmHg• Daytime (awake) average above 140/90 mmHg• Nighttime (asleep) average above 125/75 mmHg

Home Measurement of Blood Pressure

Home BP measurement should be encouraged to increase patient involvement in care

• Which patients?– Uncomplicated hypertension– Suspected non adherence– Office-induced blood pressure elevation (white coat

effect)– Masked hypertension

Average BP > 135/85 mm Hg should be considered elevated

2014 Canadian Hypertension Education Program Recommendations

Not all Patients are Suited to Home Measurement

• Undue anxiety in response to high blood pressure readings

• Physical or mental disability prevents accurate technique or recording

• Irregular pulse or arrhythmias prevent accurate readings• Lack of interest

Most patients can be trained to measure blood pressurePeriodic reassessment of technique and retraining is desirable

Recommended Electronic Blood Pressure Monitors for Home Blood Pressure Measurement

Home Measurement: Doing it Right

EQUIPMENT• Validated device• www.hypertension.ca • www.heartandstroke.ca/bp• Size is appropriate • Ensure the device is accurate in

the patient at purchase and annually

2014 Canadian Hypertension Education Program Recommendations

Recommended Models

• A&D® or LifeSource® Models: UA651, UA651BLE, UA705, UA767, UA767Fam, 767PAC, 767Plus, 787EJ, 787AC, 787W, 631, 853, 854, 855,  UA 1020CN (UA 1030CN)

• Atico International and Le Groupe Jean Coutu Models: KD-556, KD-5031, KD-5963, A58H0401

• Beurer North America LP Models: Beurer BM35, Beurer BM44, Beurer BM60, Beurer BM47, Beurer BM58

• HoMedics® Models:BPA-040-0CA (BP-A04-00CA)BPA-060-0CA (BP-A06-00CA)BPA-110-2CA (BP-A11-02CA)

• iHealth  Models: Blood Pressure DOCK-BP 3, iHealth BP5 

Recommended Models• Microlife® or BIOS® Models (also sold as 'private label

brands'): BP 3BTO-A, BP 3AC1-1, BP 3AC1-1 PC, BP 3AC1-2, BP 3AG1, BP 3BTO-1, BP 3BTO-A (2), BP 3BTO-AP, RM 100, BP A100 Plus, BP A 100, BP 3AL1 – 3E,  BP 3MX1-1, BP3MX1-3, 3AN1-3X, 3MS1-4K

• Omron® Models: HEM-705CPCAN, HEM-741CAN, HEM-711DLXCAN, HEM-773ACCAN, HEM-775CAN, HEM-790ITCAN, BP742CAN, BP760CAN, BP762CAN, BP785CAN, BP710CANN, BP742CANN, BP765CAN, BP761CAN, BP786CAN

• Physio Logic Model: HL868BA, 106-910, 106-915• Thermor: BIOS Diagnostics BD201, BIOS

Diagnostics BD215, BD209 (BD204), A6PC• Tremblay Harrison Inc Models : ABP-C1, ABP-C2 and

ABP-C3

Home Measurement of BP: Patient Education

DO

• Read and carefully follow the instructions provided with the device

• Relax in a comfortable chair with back support for 5 minutes

• Sit quietly without talking or distractions (e.g. TV)

DON’T•Measure if stressed, cold, in pain or if your bowel or bladder are uncomfortable •Measure within 1 hour of heavy physical activity•Measure within 30 minutes of smoking or drinking coffee

2014 Canadian Hypertension Education Program Recommendations

Laboratory testing in primary hypertension

 The only tests that should be routinely performed include:

• Hematocrit, urinalysis, routine blood chemistries (glucose, creatinine, electrolytes), and estimated glomerular filtration rate (eGFR)

• Lipid profile (total and HDL-cholesterol, triglycerides)

• Electrocardiogram

2014 Canadian Hypertension Education Program Recommendations

Additional tests in primary hypertension

May be needed:• Microalbuminuria is increasingly recognized to be an

independent risk factor for cardiovascular disease.

• Echocardiography is indicated to detect possible

1. end-organ damage in a patient with borderline blood pressure values, thereby identifying some patients who would not be treated based upon clinical criteria alone.

(Assessment of left ventricular dysfunction and the presence of left ventricular hypertrophy)

2014 Canadian Hypertension Education Program Recommendations

Cardiovascular risks of hypertension

• Hypertension accounts for an estimated 54 percent of all strokes and 47 percent of all ischemic heart disease events globally.

• Hypertension: the most important risk factor for premature cardiovascular disease,

• More common than cigarette smoking, dyslipidemia, and diabetes.

Components of cardiovascular risk factors in patients with hypertension

Major risk factors Target organ damageHypertension Heart disease

Cigarette smoking Left ventricular hypertrophyObesity (BMI ≥30 kg/m2) Angina or prior myocardial

infarctionPhysical inactivity Prior coronary revascularizationDyslipidemia Heart failureDiabetes mellitus Stroke or transient ischemic

attackMicroalbuminuria or estimated GFR <60 mL/min

Chronic kidney disease

Age >55 years for men, >65 years in women Peripheral arterial disease

Family history of premature coronary disease

Retinopathy

Men - <55 years Women - <65 years

The JNC 7 report. JAMA 2003; 289:2560.

Routine Laboratory Tests

Follow-up investigations of patients with hypertension

Diabetes develops in 1-3%/year of those with drug treated hypertension.

Assess for diabetes more frequently in:

1. treated with a diuretic or beta blocker,

2. obese,

3. sedentary,

4. with higher fasting glucose and

5. unhealthy eating patterns.• For those with diabetes or chronic kidney disease: assess

urinary albumin excretion, since therapeutic recommendations differ if proteinuria is present.

2014 Canadian Hypertension Education Program Recommendations

Who should be treated?

• In the absence of end-organ damage, a patient should not be labeled as having hypertension unless: the blood pressure is persistently elevated after three to six visits over a several month period.

• All patients should undergo appropriate nonpharmacologic (lifestyle) modification before medications.

Who should be treated?...

• Medication: persistently ≥140 mmHg and/or the diastolic pressure is persistently ≥90 mmHg.

• Starting with two drugs should be considered in patients with a baseline blood pressure above160/100 mmHg.

• The benefits of antihypertensive therapy are less clear or controversial in :

1. mild hypertension (blood pressure less than 150/90 mmHg) and no preexisting cardiovascular disease, and

2. elderly patients who are frail.

BEDTIME VERSUS MORNING

DOSING 

• The average nocturnal blood pressure is approximately 15 percent lower than daytime values.

• Failure of the blood pressure to fall by at least 10 percent during sleep is called "nondipping," and is a stronger predictor of adverse cardiovascular outcomes than daytime blood pressure.

• Taking at least one medication (non-diuretic) at bedtime significantly reduced all-cause mortality.

• Similar observations in hypertensive patients with CKD.

©2013 UpToDate ® Overview of hypertension in adults

Initiation of combination therapy

• Supine and standing pressures prior to the initiation of combination therapy in patients at increased risk for orthostatic (postural) hypotension, such as elderly patients and those with diabetes.

• Orthostatic hypotension: within two to five minutes of quiet standing, one or more of the following is present:

• At least a 20 mmHg fall in systolic pressure• At least a 10 mmHg fall in diastolic pressure• Symptoms of cerebral hypoperfusion, such as

dizziness

©2013 UpToDate ® Overview of hypertension in adults

New management of hypertension

• Referral: Goal BP cannot be reached using the above strategy or, To manage complicated patients.

• It's certainly not uncommon for elderly patients to become dizzy on standing because of the antihypertensive medication or medications they take. Such patients, are at an increased risk for falls and their sequelae.

2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults: Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8).

Perioperative management of hypertension

• Of 76 patients who died of a cardiovascular cause within 30 days of elective surgery, a preoperative history of hypertension was four times more likely than among 76 matched controls.

BLOOD PRESSURE RESPONSE DURING ANESTHESIA 

• Induction of anesthesia: systolic blood pressure can increase by 90 mmHg and heart rate by 40 beats per minute.

•  period of anesthesia: The mean arterial pressure tends to fall, intraoperative hypotension.

•  Immediate postoperative: Blood pressure and heart rate slowly increase. 

Perioperative management of hypertension

PERIOPERATIVE RISKS ASSOCIATED WITH HYPERTENSION

• Diastolic dysfunction from left ventricular hypertrophy, systolic dysfunction leading to congestive heart failure, renal impairment, and cerebrovascular and coronary occlusive disease.

Six independent predictors of major cardiac complications

High-risk type of surgery (examples include vascular surgery and any open intraperitoneal or intrathoracic procedures)

History of ischemic heart disease (history of MI or a positive exercise test, current complaint of chest pain considered to be secondary to myocardial ischemia, use of nitrate therapy, or ECG with pathological Q waves; do not count prior coronary revascularization procedure unless one of the other criteria for ischemic heart disease is present)

History of HF

History of cerebrovascular disease

Diabetes mellitus requiring treatment with insulin

Preoperative serum creatinine >2.0 mg/dL (177 µmol/L)

Safety of antihypertensive drugs preoperatively

• Abruptly discontinuing some medications (eg, beta blockers, clonidine ) may be associated with significant rebound hypertension.

• Most antihypertensive agents can be continued until the time of surgery, taken with small sips of water on the morning of surgery. 

• ACEI,ARB: withhold them on the morning of surgery in patients who are taking them for congestive heart failure in whom the baseline blood pressure is low, OR in renal failure patients to avoid significant hypotension during the induction of anesthesia.

Safety of antihypertensive drugs preoperatively…

• Calcium channel blockers :  increased incidence of postoperative bleeding, probably due to inhibition of platelet aggregation,

• Withdrawal syndromes: clonidine, methyldopa, guanfacine and the beta blockers are associated with acute withdrawal syndromes that can lead to adverse perioperative events. These drugs should not be abruptly stopped perioperatively.

Safety of antihypertensive drugs preoperatively…

• Centrally acting sympatholytic drugs: Rebound hypertension usually occurs after abrupt cessation of fairly large oral doses (eg, greater than 0.8 mg/day), but has also been noted with transdermal clonidine.

• Beta blockers:  reduce intraoperative myocardial ischemia, recommended that patients with one or more risk factor for CHD be given beta blockers perioperatively.

POSTOPERATIVE HYPERTENSION

Hypertension usually begins within 30 minutes of the completion of surgery and lasts approximately two hours.

• History of hypertension preoperatively• Pain• Excitement on emergence from anesthesia• Hypercarbia • Type of surgery

Indications for therapy

• A marked rise in blood pressure following surgery should be treated immediately.

• Remedial causes: pain, agitation, hypercarbia, hypoxia, hypervolemia, and bladder distention 

• Chronic antihypertensive therapy should resume with their usual medications.

• Therapy should be considered for patients with a sustained systolic blood pressure above 180 mmHg or diastolic blood pressure greater than 110 mmHg, once remedial causes have been excluded or treated.

Postoperative hypertension

Choice of drugs

• Patients taking diuretics may be given parenteralfurosemide or bumetanide .

• Patients taking beta blockers may be given parenteral propranolol , labetalol , or esmolol .

• Patients taking an ACE inhibitor may be given parenteral enalaprilat .

• Patients taking centrally acting agents can be given a clonidine patch.

• Patients taking calcium channel blockers can be given intravenous nicardipine .

Uptodate® Oct 2013Postoperative hypertension

SUMMARY 1 

• The ideal circumstance is to normalize blood pressure (eg, to less than 140/90 mmHg) for several months prior to elective surgery.

• It is not necessary to postpone elective procedures in patients with a blood pressure below 170/110 mmHg.

• Elective surgery should be postponed in patients with blood pressures above 170/110 mmHg.

• Such patients who require urgent surgery should be treated with a parenteral drug acutely.Perioperative management of hypertension

SUMMARY  2

• Patients who are taking chronic antihypertensive medications should continue taking their medication until the time of surgery.

• The drug can be administered with a sip of water on the morning of surgery and resumed postoperatively as needed.

• Alternative parenteral agents can be prescribed for patients who are unable to resume oral medications.

Perioperative management of hypertension

SUMMARY  3

• In particular, beta blockers and centrally acting agents such as clonidine should  not

 be stopped acutely.

If necessary, • Intravenous propranolol or labetalol can be

administered to patients taking beta blockers • Or transdermal clonidine can be administered

to patients taking clonidine.

Perioperative management of hypertension

SUMMARY  4

• Remedial causes of postoperative hypertension such as pain, agitation, hypercarbia, hypoxia, hypervolemia, and bladder distention should be excluded or treated.

• Once this has been done, therapy should be considered for patients with a persistent systolic blood pressure above 180 mmHg or a diastolic blood pressure above 110 mmHg.

Perioperative management of hypertension

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