Hypertension in a nutshell Sohil Rangwala MDCM, CCFP

Quick facts 1 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 3.3%* of those age 18 to 39 of those age 40 to 59 of those age 60 to 70 21.8% Number of Canadian adults 18+ suffering from hypertension 21.8% 52.4% NOTES: Defined as self-reported high blood pressure, on medications for high blood pressure, or has measured high blood pressure. Data: Canadian Health Measures Survey (CHMS) Cycle 2 (Statistics Canada) Years: 2009-2011 Type: Measured data, weighted to represent the Canadian population Excludes: Age <18; pregnant women Ages: 18-79 Confidence intervals: Total Canadians 21.8% (19.0-24.7) 18 to 39 3.3% (1.5-5.2) 40 to 59 21.8% (16.2-27.3) 60 to 79 52.4% (47.8-57.0) …have 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. 3

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 History PMHX 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 Obesity Poor diet, salt intake Diabetes/ Prediabetes Stress ETOH, drugs

Physical Exam- How to take a BP

Physical exam Neuro: CVS: 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

Diagnostic algorithm for hypertension 2014 10

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 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

Usual blood pressure threshold values for initiation of pharmacological treatment 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 NA TOD=target organ damage *This higher treatment target for the very elderly reflects current evidence and heightened 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 16

What are the Targets? Population SBP DBP Diabetes <130 <80 Treatment consists of health behaviour ±pharmacological management Population SBP DBP Diabetes <130 <80 All others < 80 y.a. (including CKD) <140 <90 Very elderly (≥ 80 years) <150* NA *This higher treatment target for the very elderly reflects current evidence and heightened 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 17

Impact of health behaviours on blood pressure Intervention Systolic BP (mmHg) Diastolic BP Diet and weight control -6.0 -4.8 Reduced salt/sodium intake - 5.4 - 2.8 Reduced alcohol intake (heavy drinkers) -3.4 DASH diet -11.4 -5.5 Physical activity -3.1 -1.8 Relaxation therapies -3.7 -3.5 Multiple interventions -4.5 Clinical Guideline : Methods, evidence and recommendations National Institute for Health and Clinical Excellence (NICE) May 2011 2014 18

Health Behaviours in Adults with Hypertension: Summary Intervention Target Reduce 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 Note: the extent of blood pressure change from each intervention should not be compared because the participants, the type and duration of intervention, and the basic design of the trials differed substantially. 2014 19

Treatment of Systolic-Diastolic Hypertension without Other Compelling Indications TARGET <140/90 mmHg Lifestyle modification 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 Initial therapy Thiazide diuretic ACEI ARB Long-acting CCB Beta- blocker* CONSIDER Nonadherence Secondary HTN Interfering drugs or lifestyle White coat effect Dual Combination *Not indicated as first line therapy over 60 y Triple or Quadruple Therapy 20

Treatment Thiazide Diuretic- ACE- ARB- CCB- B-Blocker 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 Statins are recommended in high risk hypertensive patients based on having established atherosclerotic disease or at least 3 of the following: 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 2014 22

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 23

Conclusion High prevalence, with significant mortality and morbidity Routine screening and monitoring is important Lifestyle and pharmacological therapies available!

References www. hypertension.ca- CHEP 2016 guidelines