HTN management in clinic and evaluation of secondary causes Tania Velazco PGY 2 May 2015

Objetives Introduction Risk factors Screening Diagnosis Classification Office evaluation Secondary causes of HTN Treatment

Introduction Most common reason for office visit About 30% of adults in the US have HTN Only 50% of patient had her HTN in good control Is one of the most important preventable contributor to disease and death It is directly responsible for ½ of all death due to coronary heart disease (MI) and 2/3 of CVA (strokes) Complications of hypertension include retinopathy, cerebrovascular disease, ischemic heart disease, LVH, Afib, HF, CKD, and PVD

Risk factors Age Obesity Family history Race, > AA Reduced nephron number /mass High-sodium diet Excessive alcohol consumption Physical inactivity Diabetes and dyslipidemia Personality traits with hostile behavior and depression Vit D deficiency

Screening The JNC 7 recommends screening every 2 years if blood pressure is less than 120/80 mm Hg and annually if greater The U.S. Preventive Services Task Force does not recommend a specific screening interval because of lack of evidence to support one

Diagnosis of HTN Clinic Dx: If the average of at least 2 readings obtained at 3 visits 2 to 4 weeks apart is at least 140 mm Hg (systolic) or at least 90 mm Hg (diastolic). Ambulatory blood pressure monitoring (ABPM)24-48h: BP every 15 to 20 mt during the daytime and every 30 to 60 mt during sleep. An Average >= 130/80. Six to eight hours of ABPM may be adequate if full 24-48 hour not possible. the Centers for Medicare & Medicaid Services pays for only 1 indication: diagnosing white coat hypertension Home blood pressure monitoring: 12 to 14 reading. Twice a day for 1 week. BP >= 135/85

Classification Stages of HTN by the JNC 7 guidelines: Normal: ≤120/80 mm Hg Prehypertensive: 120/80 to 139/89 mm Hg HTN stage 1: 140/90 to 159/99 mm Hg HTN stage 2: ≥160/100 mm Hg The 2014 guidelines avoid classification definitions and focus on evidence-based blood pressure goals

White coat HTN: Only elevated BP in clinic. 10 to 20 % White coat HTN: Only elevated BP in clinic. 10 to 20 %. No treatment needed just lifestyle modifications and regular follow-up. Masked HTN: Elevated BP at home but not in the office; as many as 10% to 40% clinic visits. In this population home readings and ambulatory blood pressure monitoring are useful Isolated systolic HTN: SBP > 140 but DBP is < 90. Elderly Isolated diastolic HTN: SBP < 140 but DBP > 90

Clinic evaluation: History taking CV risk factors or concomitant medical conditions Past treatment, doses and its effects Dietary habits and salt intake. Alcohol use Family history of HTN, renal disease, cardiovascular problems, stroke, and DM Increased stress

History taking: Symptoms of target organ damage: - Headache - transient weakness or blindness - Gradual Visual loss - Chest pain - Dyspnea - Claudication Symptoms of secondary causes: Palpitations, tachycardia, paroxysmal HA, and sweating suggest pheochromocytoma. Muscle weakness and polyuria suggest hypokalemia from excess aldosterone. Snoring and daytime sleepiness can indicate sleep apnea Heat intolerance and weight loss suggest hyperthyroidism.

History taking Prescriptions or OTC drugs Oral contraceptives Corticosteroids Licorice Sympathomimetics Antimigraine drugs Decongestants, such us pseudoephedrine Antidepressants, SSRI and tricyclics Weight loss medications Erythropoietin Cyclosporine Stimulants, as methylphenidate, amphetamines NSAIDs other than aspirin can decrease the efficacy of antihypertensive drugs. Cocaine, methamphetamines

Physical exam

Routine laboratory tests hemoglobin or hematocrit CMP: e-, Cr. Glucose fasting lipid levels urinalysis with microscopic examination Microalbuminuria may help to guide selection of therapy in patients with diabetes and indicates greater risk for CVD In gout, check uric acid levels before diuretics are prescribed 12-lead electrocardiography. Additional testing done if we are suspicion for secondary causes

Who to check for secondary causes: Sudden onset of severe HTN with previously normal blood pressure New-onset HTN at age <25 or >55 years Drug-resistant HTN (Patients on 3 or more drugs at maximal doses) Spontaneous hypokalemia Palpitations, headaches, and sweating Severe vascular disease, including CAD, carotid disease, and PVD Epigastric bruit Radial-femoral pulse delay, especially with an interscapular murmur.

Treatment goals JNC 8 recommends Kidney Disease Improving Global Outcomes (KDIGO) recommends a BP of 130/80 mm Hg for patients with CKD and below 130/80 mm Hg for patients excreting >30 mg urine albumin/d

Treatment algorisms

Non Pharmacologic Tx

Meds

FOLLOW UP Every 2 months for blood pressure of 140/90 to 159/99 mm Hg and within 1 month for higher blood pressure. If well-controlled hypertension q 6- to 12-month

Resources: ACP.org JNC 8 Up to date Clinical practice guidelines for the management of HTN in the community, a statement for the America society of HTN and the international society of HTN. Michael A. Weber, MD; Ernesto L. Schiffrin, MD; William B. White, MD. Official journal of the American society of hypertension, Inc, Journal of clinical hypertension