APPROACH TO HYPERTENSION IN PRIMARY CARE

Doç. Dr. Nurver Turfaner Department of Family Medicine

Benefits of Controlling Hypertension By controlling hypertension, the risk of myocardial infarction is reduced up to 25%, the risk of stroke can be reduced by up to 40% and the risk of congestive heart failure can be reduced to the half. The treatment of isolated systolic hypertension in the elderly reduces overall mortality by 13%.

Pathologic Consequences of Hypertension Hypertension is an independent predisposing factor for heart failure, coronary artery disease, stroke, renal disease and peripheral arterial disease.

HEART Heart disease is the most common cause of death in hypertensive patients. Hypertensive heart disease is the result of structural and functional adaptations leading to left ventricular hypertrophy, (CHF), abnormalities of blood flow due to atherosclerotic coronary artery disease or microvascular disease, and cardiac arrhythmias..

HEART Individuals with left ventricular hypertrophy are at increased risk for CHD, stroke, CHF, and sudden death. Aggressive control of hypertension can regress or reverse left ventricular hypertrophy and reduce the risk of cardiovascular disease

BRAIN Stroke is the most frequent cause of death in the world; it accounts for 5 million deaths each year, with an additional 15 million persons having non-fatal strokes. Elevated blood pressure is the strongest risk factor for stroke. The incidence of stroke rises progressively with increasing blood pressure levels, particularly systolic blood pressure in individuals >65 years. Treatment of hypertension convincingly decreases the incidence of both ischemic and hemorrhagic strokes.

KIDNEY The kidney is both a target and a cause of hypertension. Primary renal disease is the most common etiology of secondary hypertension. Renal risk appears to be more closely related to systolic then to diastolic blood pressure. Proteinuria is a reliable marker of the severity of chronic renal disease and is a predictor of its progression. Patients with high urine proteine excretion (> 3 gr/24 hours) have a more rapid rate of progression.

KIDNEY Clinically, macroalbuminuria (a random urine albumine/creatinine ratio>300 mg/g) or microalbuminuria (a random urine albumine/creatinine ratio mg/g) are early markers of renal injury. These are also risk factors for renal disease progression and cardiovascular disease.

Peripheral Arteries In addition to contributing to the pathogenesis of hypertension, blood vessels may be a target organ for atherosclereotic disease secondary to long- standing elevated blood pressure. Intermittant claudication is the classic symptom of PAD (Peripheral arterial disease). The ankle-brachial index is defined as the ratio of non-invasively assessed ankle to brachial (arm) systolic blood pressure. An ankle-brachial index 50% stenosis in at least one major lower limb vessel.

Clinical Disorders of Hypertension Depending on methods of patient ascertainment 80-95% of hypertensive patients are diagnosed as having essential hypertension (also referred to as primary or idiopathic hypertension). In the remaining 5-20 % of hypertensive patients, a specific underlying disorder causing the elevation of blood pressure can be identified.

ESSENTIAL HYPERTENSION Essential hypertension tends to be familial and is likely to be the consequence of an interaction between environmental and genetic factors. The prevalance of essential hypertension increases with age.

OBESITY AND METABOLIC SYNDROME There is a well documented association between obesity (body mass index > 40 kg/m 2 ) and hypertension. Centrally located body fat is a more important determinant of blood pressure evaluation than is peripheral body fat. It has been established that 60-70% of hypertension in adults may be directly attributable to adiposity.

OBESITY AND METABOLIC SYNDROME Hypertension and dyslipidemia frequently occur together and in association with resistance to insulin- stimulated glucose uptake. The constellation of insuline resistance, abdominal obesity, hypertension, and dyslipidemia has been designated as the metabolic syndrome.

RENAL PARENCHYMAL DISEASES Nearly all disorders of the kidney may cause hypertension and renal disease is the most common cause of secondary hypertension. Hypertension is present in more than 80% of patients with chronic renal failure. Conversely, hypertension may cause nephrosclerosis,and in some instances it may be difficult to determine whether hypertension or renal disaease was the initial disorder. Proteinuria >1000mg/day and an active urine sediment are indicative of primary renal disease.

RENOVASCULAR HYPERTENSION Hypertension due to an occlusive lesion of a renal artery, renovascular hypertension, is a potentially curable form of hypertension. It is mostly seen in older atherosclerotic patients who have a plaque obstructing the renal artery and patients with fibromuscular dysplasia.

RENOVASCULAR HYPERTENSION Although fibromuscular dysplasia may occur at any age, it has a strong predilection for young women. The prevalance in females is 8 fold than in males. Contrast arteriography is the gold standard for evaluation and identification of renal artery lesions. PTRA (Percutaneus Transluminal Renal Angioplasty) is the initial treatment. Surgical revascularization may be undertaken if PTRA is unsuccessful.

PRIMARY ALDOSTERONISM Primary aldosteronism should be considered in all patients with refractory hypertension. In a hypertensive patient with unprovoked hypokalemia (i.e, unrelated to di u retics,vomiting or diarrhea), the prevalance of primary hyperaldosteronism approaches 40-50%. In patients on diuretics, serum potassium <3.1 meq/L also raises the possibility of primary hyperaldosteronism.

Blood Pressure Classification

Systolic mmHg Diastolic mmHg Normal <120and <80 Pre- hypertension or Stage 1 hypertension or Stage 2 hypertension ≥160or≥100 Isolated systolic hypertension ≥140and <90

Measurement of Blood Pressure The primary test used to screen for hypertension is measurement with mercury or a calibrated aneroid or electronic sphygmomanometer by a trained technician The patient should be properly positioned after at least a 5-minute rest Continuous 24- hour blood pressure monitoring has been shown to be more predictive of end-organ damage than standard office measurement.

Measurement of Blood Pressure Office-based measurements are typically done with sphygmomanometer. The accuracy depends on the examiner, patient factors, and the instrument used. Two measurements at seperate visits are necessary for diagnosis. Alternatives to office measurements: Home monitors Ambulatory measurement: Identifies patients with ‘White coat Hypertension’

Proper training of observers, Positioning of the patient Selection of cuff-size are essential. Recent regulations prevent the use of mercury potential toxicity!! Office measurements are made with aneroid sphygmomanometers or with oscillometric devices. Instruments should be calibrated periodically and their accuracy should be confirmed.

Measurement of Blood Pressure The center of the cuff should be at heart level and the width of the bladder cuff should equal at least 40% of the arm circumference; the length of the cuff bladder should be enough to encircle at least 80% of the arm circumference. Systolic blood pressure is the first of at least two regular ‘tapping’ Korotkoff sounds, and diastolic blood pressure is the point at which the last regular Korotkoff sound is heard.

Patient’s Relevant History Duration of hypertension Previous therapies: responses and side effects Family history of hypertension and cardiovascular disease Dietary and psychosocial history Other risk factors: weight change, dyslipidemia, smoking, diabetes,physical inactivity

Patient’s Relevant History Evidence of secondary hypertension: history of renal disease; change in appearance; muscle weakness; spells of sweating, palpitations,tremor; erratic sleep, snoring, daytime somnolence; symptoms of hypo-or hyperthyroidism; use of agents that may increase blood pressure Evidence of target organ: history of TIA, stroke, transient blindness; angina, myocardial infarction, congestive heart failure; sexual function Other comorbidities

Basic Laboratory Tests for Initial Evaluation SystemTest RenalMicroscopic urinalysis, albumin excretion, serum BUN and/or creatinine EndocrineSerum sodium, potassium, calcium, TSH MetabolicFasting blood glucose, total cholesterol, HDL and LDL T. cholesterol, triglycerides Other Hematocrit, electrocardiogram

Lifestyle Modifications to Manage Hypertension Weight reductionAttain and maintain BMI<25 kg/m 2 Dietary salt reduction<6 g NaCl/d Adapt DASH-type dietary plan Diet rich in fruits, vegetables, and low-fat dairy products with reduced content of saturated and total fat Moderation of alcohol consumption For those who drink alcohol, consume ≤2 drinks/day in men and ≤1 drink/day in women Physical activityRegular aerobic activity, e.g., brisk walking for 30 min/d

Risk Factors For Hypertension Hypertension increases with age and a normotensive adult at age 55 has up to 90% lifetime risk of becoming hypertensive. Tobacco Alcohol Overweight and obesity Sedentary life-style Inadequate fruit, vegetable, K intake Excess sodium intake all contribute to hypertension.

TREATMENT In uncomplicated hypertension: the specific choice of drug is less important than the attainment of goal blood pressure. If blood pressure is more than 20/10 mm Hg above target level : two antihypertensive medications One should usually be hydrochlorothiazide

TREATMENT JNC 7 encourages the use of specific antihypertensive agents for hypertension. Life-style modification is an important component of hypertension management. Treatment with ACE inhibitors and ARB’s is associated with decreased risk of new-onset diabetes mellitus in patients with hypertension.

TREATMENT Pre-hypertension: SBP: mmHg DBP: mmHg Stage 1 hypertension: SBP: mmHg DBP: mmHg Life-style and diet modification (only) Stage 1 Hypertension+ Diabetes or cardiovascular disease: Pharmacotherapy+Di u retics Aerobic Exercise: (45-60 min.), at least 3 days/per week, preferably daily

Diet in Hypertension Low salt, low-fat, high-fruit, high vegetable diet, limited alcohol consumption (fever than two drinks/day) Modest weight loss (3% to 9% of total body weight) Na restriction It is more effective in blacks In whites: SBP decreases by 4.2 mmHg DBP decreases by 2.0 mmHg In blacks: SBP decreases by 6.4 mmHg DBP decreases by 2.0 mmHg Limit of sodium intake daily: 2-4 g/day (stage 1 and prehypertension)

DASH DIET: dietary approach to stop hypertension Low in saturated fat High in fruits and vegetables (8-10 servings High in low fat dairy products Results in: ↓ SBP:>11 mmHg ↓ DBP: >5 mmHg + Na restriction (<2g daily) ↑ Fiber intake, ↑ K intake

Pharmacologic Treatment of Hypertension Thiazide Diuretic Plus: ACE inhibitor Aldosterone antagonist Angiotensin receptor blocker Β-blocker Calcium channel blocker

Pharmacologic Treatment of Hypertension Calcium Channel Blocker Plus: ACE inhibitor Angiotensin receptor blocker Β-blocke r

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