1 1 ManagementofHypertension Introduction to Primary Care: a course of the Center of Post Graduate Studies in FM PO Box – Riyadh Tel: – Fax:

Objectives to discuss the importance of hypertension in FP to discuss the importance of hypertension in FP to describe the recommendations for screening of hypertension. to describe the recommendations for screening of hypertension. to describe current guideline recommendations on the diagnosis of hypertension to describe current guideline recommendations on the diagnosis of hypertension to describe the complications of hypertension to describe the complications of hypertension

content Epidemiology Epidemiology Definition of hypertension Types of hypertension Evaluation of hypertensive patient History &physical examination Laboratory tests Accurate BP Measurement Accurate BP Measurement White Coat Hypertension White Coat Hypertension

Epidemiology About 1/3 of middle aged patients have hypertension About 1/3 of middle aged patients have hypertension About ½ of elderly patients have hypertension. About ½ of elderly patients have hypertension. Responsible for 12% of deaths worldwide. Responsible for 12% of deaths worldwide. 5-6% reduction in diastolic blood pressure over 5 years reduces risk of CVA by 35-40% and IHD by 20-25% 5-6% reduction in diastolic blood pressure over 5 years reduces risk of CVA by 35-40% and IHD by 20-25%

Proportion of deaths attributable to leading risk factors worldwide (2000) Attributable Mortality (In millions; total 55,861,000) High mortality, developing region Lower mortality, developing region Developed region High blood pressure Tobacco High cholesterol Unsafe sex High BMI Physical inactivity Alcohol Indoor smoke from solid fuels Iron deficiency Underweight

–High blood pressure –High cholesterol –Obesity –Physical inactivity –Insufficient consumption of fruits and vegetables –Smoking World Health Report 2003 Of the 10 leading global disease burden risk factors

Important Points: Hypertension is the most common treatable risk factor for cardiovascular disease in patients over 50 years. Hypertension is the most common treatable risk factor for cardiovascular disease in patients over 50 years. Only 70% are aware they have HTN Only 70% are aware they have HTN Of those aware of their HTN, only 50% are being treated. Of those aware of their HTN, only 50% are being treated. Only 25% of all hypertensive patients have their BP under control. Only 25% of all hypertensive patients have their BP under control. HTN is a risk factor for coronary artery disease (CAD), congestive heart failure (CHF), stroke, and renal failure. HTN is a risk factor for coronary artery disease (CAD), congestive heart failure (CHF), stroke, and renal failure. JNC VII

Definition Persistent elevation SBP ≥140 mmHg And OR DBP ≥90 mmHg\ Several occassions Three readings proper technique/cuff on 3 separate occasions over at least 4-6 weeks Days-weeks (level-complication-end organ damage) Not on anti hypertensive medications.

Recommendation for follow up Initial blood pressure,mmHg Follow up recommendationDiastolic Systolic Recheck in 2 years<85<130 Recheck in 1 years Confirm within 2 months Evaluate or refer to source of care within 1 month Evaluate or refer to source of care immediately within 1week depending on the clinical situation >=110>=180

Types of hypertension Primary (“essential”) 95% of cases Secondary 5% of cases

Stage of hypertensio n : Cardiovascular risk factors Target organ damage Associated clinical condition ACCs Secondary causes EVALUATION OF HYPERTENSIVE PATIENT

Blood Pressure Classification BP Classification SBP mmHg*DBP mmHg Lifestyle Modification Drug Therapy** Normal <120and <80 EncourageNo Prehypertension or YesNo Stage 1 Hypertension or Yes Single Agent Stage 2 Hypertension ≥ 160or ≥ 100 YesCombo JNC 7 Express. JAMA Sep 10; 290(10):1314 *Treatment determined by highest BP category; **Consider treatment for compelling indications regardless of BP

Cardiovascular Risk Factors Hypertension (levels of SBP&DBP) Smoking Obesity (body mass index≥30kg/m 2 ) Physical inactivity Dyslipidema (total cholesterol >250mg/dl i.e >6.5mmol/l,LDL-C155mg/dl i.e4.0mmol/l,HDL-C <40mg/dl i.e<1.0mmol/l) DM* *Considered as coronary heart disease equivalent

Cardiovascular Risk Factors-contd Microalbuminuria or estimated GFR<60ml/min Age (older than 55for men,65 for women) Family history of premature cardiovascular disease (men under age 55,women under age 65) C-reactive protein ≥1mg/dl

Diagnostic Workup of Hypertension Assess risk factors and comorbidities. Reveal identifiable causes of hypertension. Assess presence of target organ damage. Conduct history and physical examination. Obtain laboratory tests: urinalysis, blood glucose, hematocrit and lipid panel, serum potassium, creatinine, and calcium. Optional: urinary albumin/creatinine ratio. Obtain electrocardiogram.

Secondary Causes: ABCDE mnemonic Apnea (OSA) Aldosteronism (hyperaldosteronism) Bruits (renal artery stenosis) Bad Kidneys (intrinsic kidney disease) Catecholamines Coarctation Cushing’s Syndrome

ABCDE mnemonic Drugs (stimulants, OCPs, NSAIDS) Diet (high Na/low K, Mg, Ca) Erythropoietin: elevated EPO in COPD or renal failure or exogenous use for anemia Endocrine: Thyroid/Parathyroid, pregnacy, pheochromocytoma, acromegaly

Target Organ Damage Cerebrovascular disease - transient ischemic attacks - ischemic or hemorrhagic stroke Hypertensive retinopathy Left ventricular dysfunction/LVH Coronary artery disease - myocardial infarction - angina pectoris - congestive heart failure Chronic kidney disease Peripheral artery disease - intermittent claudication

Associated clinical condition ACCs Cerebrovascular disease : ischemic stroke, cerebral hemorrhage, or TIA. Heart disease : MI, angina, coronary revascularization, or CHF. Renal disease : diabetic nephropathy or renal failure  creatinine,men > 1.6 mg/dl (133umol/l) women > 1.45 mg/dl (124 umol/l ) Vascular disease: (dissecting aneurysm or symptomatic arterial disease. Advanced hypertensive retinopathy

White Coat Hypertension 20-30% of Apparently Resistant Hypertension May be due to “White- Coat Hypertension” 20-30% of Apparently Resistant Hypertension May be due to “White- Coat Hypertension” Patients with WCH have an increased risk of CV events and often have some degree of end organ damage Patients with WCH have an increased risk of CV events and often have some degree of end organ damage Use home or ambulatory monitoring to sort out Use home or ambulatory monitoring to sort out

Home and Ambulatory BP Monitoring (ABPM) Often lower than office readings Often lower than office readings Useful to “calibrate” home monitors Useful to “calibrate” home monitors Nocturnal Dip (10-20% fall during the night) is physiologically important (Dippers vs. Non-Dippers) Nocturnal Dip (10-20% fall during the night) is physiologically important (Dippers vs. Non-Dippers) Can identify “windows of poor control” or windows of low BP and correlate with perceived symptoms Can identify “windows of poor control” or windows of low BP and correlate with perceived symptoms

Checking blood pressure at home Some monitors are inaccurate and are not calibrated. Some monitors are inaccurate and are not calibrated. Wrist monitors are not usually accurate. Wrist monitors are not usually accurate. Can give multiple recordings and help in the management of white coat hypertension. Can give multiple recordings and help in the management of white coat hypertension. Involves patient in the management. Involves patient in the management. Results should be factored up by 10/5. Results should be factored up by 10/5.

Routine Laboratory Tests 1. Urinalysis 2. Complete blood count 3. Blood chemistry (potassium, sodium and creatinine) 4. Fasting glucose 5. Fasting total cholesterol and high density lipoprotein cholesterol (HDL), low density lipoprotein cholesterol (LDL), triglycerides 6. Standard 12-leads ECG Investigation of all patients with hypertension

Optional Laboratory Tests Investigation for specific patient subgroups For those with diabetes or renal disease: assess urinary protein excretion, since lower blood pressure targets are appropriate if proteinuria is present. Other secondary forms of hypertension require specific testing.

What do labs mean? CBC: Look for elevated Hb/HCT Chem7: Look for low K, elevated Bun/Cr, elevated Ca. Calc GFR U/A: Look for protein/blood Alb:Cr ratio: Look for microscopic albumin FLP: Look for abnormal lipids EKG: Look for LVH, CAD, arrhythmia

1.Healthy diet: High in fresh fruits, vegetables and low fat diary products, low in saturated fat and salt. 2.Restriction of salt intake to less than 100 mmol/day in individuals considered salt- sensitive 3.Maintenance of ideal body weight (BMI kg/m 2 ) Lifestyle Recommendations for Prevention of Hypertension for NON-Hypertensive Individuals.

4. Waist Circumference < 102 cm for men < 88 cm for women 5. Regular physical activity: accumulation of minutes of moderate intensity dynamic exercise 3-5/week at least 4/week 6.Smoke free environment 7.Abstinence from alcohol Lifestyle Recommendations for Prevention of Hypertension for NON-Hypertensive Individuals.

For persons over age 50, DBP is more important than SBP as CVD risk factor. True or False

For persons over age 50, SBP is a more important than DBP as CVD risk factor. False

Those people whose BP is classified as prehypertensive should be initially treated with lifestyle modification from the time they are identified. True or False

Those people whose BP is classified as prehypertensive should be initially treated with lifestyle modification from the time they are identified. True

Normal blood pressure is defined in JNC 7 as: 1. <120/<70 2. <120/< / / ≥160/ ≥100

Which of the following is incorrect for the proper measurement of BP in the office setting? 1. Persons should be seated for at least 5 minutes resting before taking the BP 2. BP should be taken with the patient sitting on exam table with the arm relaxed in their lap 3. At least 2 measurements should be made 4. SBP is the point at which the first of two or more sounds is heard 5. DBP is the point before the disappearance of sound (phase 5)

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