INCIDENTAL HYPERTENSION: How to manage Dr. Saulat Siddique, Professor of Cardiology, Shaikh Zayed Hospital, Lahore. FAMILYCON 2013, 4-5-6 January, 2013, Lahore.

Q. No.1 Regarding Blood Pressure measurement; SBP is when the first Korotkoff sound is heard DBP is when the sounds become muffled (Korotkoff phase IV) BP reading should be rounded to the nearest 5 or zero e.g. 130/85mmHg BP reading should be written as 132/86mmHg i.e. recorded to the nearest even number

BLOOD PRESSURE MEASUREMENT Record the result for systolic and diastolic pressures to the nearest 2mmHg. For the systolic reading, record the level at which the first (at least two consecutive) sound is heard. For the diastolic reading, use phase V Korotkoff (disappearance of sound). Only use phase IV Korotkoff (muffilng of sound) if sound continues towards zero. PHL/PCS Hypertension Guidelines, 2009

Started on anti-hypertensive medication Advised life style measures Q. No. 2. A 43 year old previously healthy male visits his family practitioner for symptoms of flu. His BP is found to be 146/96. He should be; Started on anti-hypertensive medication Advised life style measures Given a sedative Asked to come back for follow-up visit

Q. No. 3 Regarding the BP cuff; Cuff size is same as bladder size Length should cover the full arm circumference Width should be half the arm circumference Inappropriately small cuff will give a falsely low reading

BLOOD PRESSURE MEASUREMENT The bladder length should be at least 80% and the width at least 40% of the circumference of the mid-upper arm. Use of a ‘standard size’ cuff in people with large arm can result in artificially high blood pressure reading. If an oversized cuff cannot be satisfactorily fitted on a large arm then the utilization of an appropriately sized cuff on the forearm with radial artery auscultation should be considered. PHL/PCS Hypertension Guidelines, 2009

BLOOD PRESSURE MEASUREMENT Patients should sit for several minutes in a quiet and comfortable place Use appropriate cuff size for age and weight Have cuff at heart level Deflate the cuff @2-3mmHg/beat Take minimum 2 measurements at least 1-2minutes apart. Ask the patients to return for 1-2 more visits, if BP is elevated on first visit (to confirm the diagnosis of hypertension), before starting treatment PHL/PCS Hypertension Guidelines, 2009

BLOOD PRESSURE MEASUREMENT NICE guidelines (2011) state that there should be complete skin contact of the stethoscope with no clothing in between The Pakistani guidelines state that, “In Pakistani setting, BP is quite often measured with shirt sleeve on rather than bare arm, especially in ladies. A recent Canadian Study indicates that there is no difference in BP reading if average thickness of sleeves is 4.3 mm or less.”

Q. No. 4. Life style measures include; Low sodium diet Exercise like weight lifting and push-ups Diet rich in potassium Aerobic exercise

LIFESTYLE MODIFICATIONS TO REDUCE BLOOD PRESSURE Ask patients about their diet and exercise patterns, and offer guidance and written or audiovisual information Regular aerobic physical activity is recommended for all persons, but those with advanced or unstable CVD may require a medical evaluation before initiation of exercise or a medically supervised exercise program. Isometric exercise such as heavy weight lifting can have a pressor effect and should be avoided. Ask about alcohol consumption and encourage patients to cut down if they drink excessively Discourage excessive consumption of coffee and other caffeine-rich products Encourage patients to reduce their salt intake or use a substitute Offer smokers advice and help to stop smoking DO NOT OFFER Calcium, magnesium or potassium supplements to reduce blood pressure Relaxation therapies can reduce blood pressure and patients may wish to try them. However, primary care teams are not recommended to provide them routinely PHL/PCS, Hypertension Guidelines 2009

IMPACT OF LIFE-STYLE CHANGES ON REDUCTION OF SBP Intervention Reduction in SBP (mmHg) Increased Magnesium (Mg) 0 – 1 Increased Calcium (Ca) 2 Increased Potassium (K) 4 Fish Oil 6 Reduced Sodium (Na) Reduced Weight 8 Exercise 10 Dash Diet 12 PHL/PCS, Hypertension Guidelines 2009

Q. No. 5. Follow-up visit after 2 weeks reveals sitting BP of 138/90 in the right arm and 148/92 in the left arm. He should be; Investigated for stenosis in the right subclavian/axillary artery. Sent for fundoscopy Checked for waist circumference Checked for postural hypotension

BLOOD PRESSURE MEASUREMENT Measure Blood Pressure in both arms. Take the higher value as baseline Difference of 5/10 mm can be considered as normal Waist circumference is an essential part of the physical examination as is fundoscopy Measure BP in standing position in elderly, diabetes and in case of hypotension inducing drugs PHL/PCS, Hypertension Guidelines 2009

Q. No. 6. The following are essential in his work-up; Serum sodium and potassium Urine for VMA Echocardiography Complete Lipid Profile

INVESTIGATIONS (Minimal) Urine analysis for proteins (can be done with a dipstick as a starter) Serum creatinine levels Serum potassium and sodium levels Random blood sugar ECG for evidence of established coronary artery disease (CAD) or LVH Chest X Ray (PA view) PHL/PCS, Hypertension Guidelines 2009

LIPID PROFILE Part of special investigations in Pakistani guidelines ESC guidelines recommend complete Lipid Profile as an essential test NICE guidelines recommend that only total cholesterol and HDL should be done

SPECIAL INVESTIGATIONS (On case to case basis) Echocardiogram Lipid Profile Carotid (and femoral) ultrasound C-reactive protein Microalbuminuria (essential test in diabetics) Quantitative proteinuria (if dipstick test positive) Search for secondary hypertension: measurement of renin, aldosterone, corticosteroids, catecholamines, arteriography, renal & adrenal ultrasound, computer assisted tomography (CAT), magnetic resonance imaging PHL/PCS, Hypertension Guidelines 2009

Q. No. 7. He should be started on; ACEI ARB CCB Diuretic Combination Tablet

Antihypertensive Drug Treatment: NICE 2011 A = ACEi or ARB C = CCB D = Thiazide-like diuretic such as chlorthalidone (12.5 mg–25 mg once daily) or indapamide rather than thiazide diuretic such as bendroflumethiazide or hydrochlorothiazide. C* = CCB preferred but consider thiazide-like diuretics in people with oedema or a high risk of heart failure Further diuretic** = low-dose spironolactone or higher doses of a thiazide-like diuretic

Q. No. 8. He should also be prescribed; Aspirin 75mg OD Atorvastatin 10mg OD Bromazepam 3mg OD

Aspirin is only recommended in those with IHD, CKD and in high cardiovascular risk subjects in the ESC guidelines Statins are recommended in IHD, DM and in high cardiovascular risk subjects in the ESC guidelines or if cholesterol levels are high.

HISTORY Detailed history is essential Prior history of high BP, kidney disorders, stroke, heart disease, diabetes, dyslipidemia. Complications of pregnancy Drug history NSAIDs Oral Contraceptives Previous antihypertensives Family history of hypertension, heart disease, diabetes Smoking and dietary habits PHL/PCS, Hypertension Guidelines 2009

SIGNS OF ORGAN DAMAGE Brain: murmurs over neck arteries, motor or sensory defects Retina: fundoscopic abnormalities Heart: location and characterstics of apical impulse, abnormal cardiac rhythms, ventricular gallop, pulmonary rales, dependent edema Peripheral arteries: absence, reduction, or asymmetry PHL/PCS, Hypertension Guidelines 2009

The importance of 24-hour blood pressure control in hypertension management ESC/ESH Guidelines1 NICE Guidelines 20112 “If the clinic BP ≥140/90 mm Hg offer 24-hour ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis of hypertension (NEW 2011) “when possible recommend treatment with drug taken once a day” “Drugs which exert their antihypertensive effect over 24 hours with a once-a-day administration should be preferred” 24 1. Mancia G, et all. J Hypertens. 2007;25:1105-1187. 2. NICE Guidelines 2011.

NICE Chart of AB/CD with de-emphasis on beta-blockers < 55 years > 55 years or Asian / Chinese STEP 1 A C or D STEP 2 A+C or A+D STEP 3 A+C+D STEP 4 Add: Further D/C therapy   Alpha Blockers Beta Blockers etc A: ACEI/ARB C: CCB, D: Diuretic 

Thanks