1. Hypertension in a nutshell
Sohil Rangwala
MDCM, CCFP

2. Quick facts 1 in 5 Canadians have hypertension
Over 40% of Canadians aged have hypertension
All adults with borderline BP /80-89 should get annual screening

3. 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:
Type: Measured data, weighted to represent the Canadian population
Excludes: Age <18; pregnant women
Ages:
Confidence intervals: Total Canadians 21.8% ( )
18 to % ( )
40 to % ( )
60 to % ( )
…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

4. 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

5. Questions to ask on History PMHX
CAD
PAD
CKD
DM2
dyslipidemia
obesity
cognitive changes

6. Questions to ask on history- Medications
NSAID’s
COX-2 inhibitors
anabolic steroids
SSRI’s, SNRI’s
OCP’s
decongestants

7. 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

8. Physical Exam- How to take a BP

9. 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

10. Diagnostic algorithm for hypertension
2014 10

11. Diagnostic tests after first visit
Urinalysis
Fasting blood sugar
Electrolytes and creatinine
Fasting lipid profile
ECG
ACR( only if DM)

12. 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

13. Hypertensive urgency and emergency
Asymptomatic diastolic BP ≥ 130 mmHg
Emergency:
Hypertensive encephalopathy
Acute aortic dissection
Acute left ventricular failure
Acute myocardial ischemia

14. Secondary causes of Hypertension
Renal artery stenosis
Sleep apnea
Hypothyroidism, Hyperthyroidism
Coarctition of aorta
Hyperaldosteronism
Cushing’s disease
Hyperparatyhroidism
Drug side effects

15. Investigations for secondary HTN
TSH
Calcium, albumin, PTH
Renal doppler
Dexamethasone suppression test
Sleep study
Plasma aldosterone: plasma renin ratio
Urine for metanephrines
Echocardiogram

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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:
2014 22

23. 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:
2014 23

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

25. References
www. hypertension.ca- CHEP 2016 guidelines