1. EMERGENCY MEETING FOR PHILHEALTH REQUIREMENTS CLINICAL PRACTICE GUIDELINES ON HYPERTENSION CLINICAL PATHWAYS ON HYPERTENSION MAKATI MEDICAL CENTER DEPARTMENT OF MEDICINE SECTION OF CARDIOLOGY

2. DIAGNOSIS OF HYPERTENSION Patients with a blood pressure of 140/90 mm Hg or higher, recorded on at least 2 separate occasions at rest.

3. BP MEASUREMENTS: Steps in taking blood pressure: Snug application of compression cuff Palpation of radial artery as compression cuff is inflated Palpation of radial artery as cuff is deflated as 2 – 3 mm Hg per heartbeat Careful placement of stethoscope bell Inflation of compression cuff above systolic pressure Deflation of the cuff at a rate of 2 – 3 mm Hg per heartbeat to determine systolic and diastolic blood pressure.

4. BP MEASUREMENTS: Must Remember: Position of the patient. –The patient may be sitting or lying. When the patient is recumbent, the cuff is essentially at cardiac level. If the patient is sitting, the arm and forearm should be supported on a tabletop at heart level. If the patient can rest for a while before the blood pressure is taken, it would seem preferable to use the lying position. The difference in the reading obtained in both positions ordinarily should not be significant. At times the pressure may be much lower when the patient is standing and whenever this condition is suspected, readings should be taken in the lying, sitting and standing positions

5. DIAGNOSTIC EVALUATION FAMILY AND CLINICAL HISTORY 1.Duration and previous level of high BP 2.Indications of secondary hypertension 3.Risk Factors 4.Symptoms of Organ Damage 5.Previous antihypertensive therapy (efficacy, adverse events) 6.Personal, Family, Environmental Factors PHYSICAL EXAMINATIONS 1.Signs suggesting secondary hypertension 2.Signs of organ damage 3.Evidence of visceral obesity

6. CLASSIFICATION OF HYPERTENSION Adapted from JNC VII Guidelines for Hypertension BLOOD PRESSURE (BP) STAGE SYSTOLIC BP (mm Hg)DIASTOLIC BP (mm Hg) NORMAL < 120< 80 PREHYPERTENSION 120 – 13980 -89 STAGE 1 HYPERTENSION 140 – 15990 – 99 STAGE 2 HYPERTENSION > 160> 100

7. LAB INVESTIGATIONS (FOR NEW PATIENTS OR PATIENTS LOST TO FOLLOW UP) ROUTINE TESTS Fasting Plasma Glucose Serum total cholesterol, LDL cholesterol, HDL cholesterol, Triglycerides Serum Potassium, Uric Acid, Creatinine Estimated creatinine clearance (cockgraft-Fault formula) or glomerular filtration rate (MDRD) Formula Complete Blood Count Urinalysis (Complemented by microalbuminuria; dipstick test and microscopic examination) Electrocardiogram Chest X-Ray Adapted from the Compendium of Abridged ESC Guidelines 2008.

8. LAB INVESTIGATIONS (FOR NEW PATIENTS OR PATIENTS LOST TO FOLLOW UP) RECOMMENDED TESTS Echocardiogram Carotid Ultrasound Quantitative proteinuria (if dipstick test is positive) Ankle Brachial Index (ABI) Fundoscopy Glucose Tolerance Test (If fasting plasma glucose > 5.6 mmol/L ) (100 mg/dL) Home and 24 hour ambulatory BP monitoring Pulse wave velocity measurement (where available) **if clinically indicated

9. LAB INVESTIGATIONS (FOR NEW PATIENTS OR PATIENTS LOST TO FOLLOW UP) EXTENDED EVALUATION Further search for cerebral, cardiac, renal and vascular damage Mandatory in complicated hypertension Search for secondary hypertension when suggested by history, physical examination or routine tests; measurement of renin, aldosterone, corticosteroids, catecholamines in plasma and/or urine; arteriographies; renal and adrenal ultrasound, computer assisted tomography; magnetic resonance imaging

10. CRITERIA FOR HOSPITAL ADMISSION 1.Patients with hypertensive emergencies/ urgency should be admitted to the hospital 2. Symptomatic Stage 2 Hypertension (associated with severe headache, shortness of breath, epistaxis or severe anxiety) HYPERTENSIVE EMERGENCY Severe elevations in blood pressure (BP) that are complicated by evidence of progressive target organ dysfunction, and will require immediate BP reduction HYPERTENSIVE URGENCY Severe elevations of BP but without evidence of progressive target organ dysfunction and would be better defined as severe elevations in BP without acute, progressive target organ damage

11. Clinical Characteristics of the Hypertensive Emergency BLOOD PRESSURE Usually > 220/140 mm Hg FUNDOSCOPIC FINDINGS Hemorrhages, exudates, papilledema NEUROLOGIC STATUS Headache, Confusion, Somnolence, Stupor, Visual loss, Seizures, Foacl neurologic deficits, coma CARDIAC FINDINGS Prominent apical pulsation, cardiac enlargement, congestive heart failure RENAL SYMPTOMS Azotemia, Proteinuria, Oliguria$ GI SYMPTOMS Nausea, Vomiting

12. TREATMENT: For Stage I Hypertension THIAZIDE DIURETICS (for most) May consider ACE-I, ARB, BB, CCB Are the drugs of choice (if without compelling indications) A SECOND DRUG: POTASSIUM SPARING DIURETICS ALDOSTERONE RECEPTOR BLOCKERS BETA BLOCKERS ACE INHIBITORS ANGIOTENSIN II ANTAGONIST CALCIUM CHANNEL BLOCKERS ALPHA I BLOCKERS CENTRAL ALPHA II AGONISTS DIRECT VASODILATORS ADDITIONAL COMBINATION DRUG: ACE I + CCB Either as a separate prescription or in fixed dose combinations with thiazide diuretics may be used when the BP remains uncontrolled or when BP is > 20 mm Hg above systolic goal or 10 mm Hg above diastolic goal.

13. TREATMENT: For Hypertension with Compelling Indications DRUGCOMPELLING INDICATIONS DIURETICS Heart failure, High coronary disease risk, diabetes, recurrent stroke prevention BETA BLOCKERS Post Myocardial Infarction, Heart Failure, High Coronary Disease Risk, Diabetes ACE INHIBITORS Heart Failure, High coronary disease risk, diabetes, Recurrent stroke prevention, Chronic kidney disease, post MI ANGIOTENSIN RECEPTOR BLOCKER HCeart Failure, diabetes, chronic kidney disease CALCIUM CHANNEL BLOCKER High coronary disease risk, Diabetes ALDOSTERONE ANTAGONIST Heart Failure, Post MI

14. For Stage 2 Hypertension (JNC VII) – SBP > 160 mm Hg/ DBP > 100 mm Hg we may use initially the following medications: CLONIDINE or CAPTOPRIL CLONIDINE 75 mcg tablet sublingual every 15 mintues for a maximum of 3 doses Is a centrally acting alpha-adrenergic agonist with onset of action 30 to 60 minutes after oral administration, and maximal effects are usually seen within 2 to 4 hours. The most common adverse effect in the acute setting is drowsiness affecting up to 45% of patients. Clonidine may be a poor choice monitoring of mental status is important. Dry mouth is a common complaint, and lightheadedness is occasionally observed. CAPTOPRIL 25 mg tabletSublingual every 15 minutes for a maxiumum of 3 doses An angiotensin-converting enzyme inhibitor, is well tolerated and can effectively reduce BP in a hypertensive urgency. Given by mouth, captopril is usually effective within 15 to 30 minutes and may be repeated in 1 to 2 hours, depending on the response. The drug has been administered sublingually. In which case the onset of action is within 10 to 20 minutes with a maximal effect reached within 1 hour. Administration may lead to acute renal failure in patients with high grade bilateral renal artery stenosis, and some reflex tachycardia may be observed.

15. If unresponsive to sublingual medications then the following formulary parenteral drugs may be used for hypertensive emergencies, vasodilators (Sodium nitroprusside, nicardipine HCl, Nitroglycerine, Hydralazine Hcl and adrenergic inhibitor – Esmolol Hcl) and titrate accordingly AGENTDOSEONSET/ DURATION OF ACTION (AFTER DISCONTINUATION) PRECAUTIONS NITROGLYCERINE 5 – 100 ug as IV infusion 2 – 5 minutes/ 5 – 10 minutes Headache, tachycardia, vomiting, flushing, methemoglobinemia NICARDIPINE 5 – 15 mg/ hr IV infusion 1 – 5 minutes/ 15 – 30 minutes, but may exceed 12 hours after prolonged infucion Tachycardias, nausea, vomiting, headache, increased intracranial pressure; hypotension protracted after prolonged infusions

16. If unresponsive to sublingual medications then the following formulary parenteral drugs may be used for hypertensive emergencies, vasodilators (Sodium nitroprusside, nicardipine HCl, Nitroglycerine, Hydralazine Hcl and adrenergic inhibitor – Esmolol Hcl) and titrate accordingly AGENTDOSEONSET/ DURATION OF ACTION (AFTER DISCONTINUATION) PRECAUTIONS HYDRALAZINE 5 – 20 mg as IV bolus or 10 to 40 mg IM; repeat every 4 – 6 hours 10 minutes IV > 1 hour 20 - 30 minutes IM/ 4 – 6 hours Tachycardia, headache, vomiting, aggravation of angina pectoris, sodium and water retention and increased intracranial pressure ESMOLOL 500 ug/ kg bolus injection IV or 50 to 100 ug/kg/minute by infusion. May repeat bolus after 5 minutes or increase infusion rate to 300 ug/ kg/ min 1 – 5 minutes/ 15 – 30 minutes First degree heart block, congestive heart failure, asthma

17. For HYPERTENSIVE EMERGENCIES – The 1 st drug to be given ASAP to lower Blood Pressure to 2/3 of Systolic Blood Pressure For HYPERTENSIVE PATIENTS with suspected NEUROLOGIC COMPONENT – Keep Blood pressure at least 140 – 160 mm Hg until patient stabilizes OVERLAP Shift if FIRST DRUG of choice is not effective and patient is not responding.

18. Clinical Pathways for Hypertension Stage 2 – SBP > 160 mm Hg/ DBP > 100 mm Hg 1 st 15 minutes2 nd 15 minutes3 rd 15 minutes ASSESSMENT Initial evaluation Include Neurologic Evaluation Assessed Severity Hypertensive Urgency Hypertensive Emergency Stage 2 Hypertension Risk Factors Assessed Response to treatment assessed DIAGNOSTICS Baseline Laboratory tests Stat 5 (Na, K, FBS, Hb, Hct) 12 Lead ECG Additional hypertensive work-up upon consultants discretion: TREATMENTS/ MEDICATIONS Clonidine 75 mcg tablet sublingual or Captopril 25 mg tablet sublingual Insert IV access Clonidine 75 mcg tablet sublingual or Captopril 25 mg tablet sublingual Start parenteral anti- hypertensive TEACHING Patients are oriented briefed on the signs and symptoms of hypertension

19. For Hypertensive urgency, control BP to at least 2/3 of SBP within 24 hours For Symptomatic Stage 2 Hypertension, control symptoms and discharge with maintenance medications Upon discharge: 1.Patient education – lifestyle management 2.Home medications (anti-hypertensive medications) 3.Schedule for follow-up

20. Is the patient pregnant or up to 2 weeks postpartum? Toxidrome present? Flushing, increased BP/HR? Diagnosis: Consider Eclampsia vs preeclampsia Emergent labor & delivery Emergent OB consult Chest pain or SOB present? Diagnosis: Cathecholamine excess? Possibilities: -Pheochromocytoma -Cocaine / sypmathomimetics -Antihypertensive withdrawal Mental status changes with a focal neurological deficit? Diagnosis: -Acute myocardial infarction -Aortic dissection -Acute left ventricular failure Diagnosis: Hypertensive encephalopathy Diagnosis: Stroke YES NO Clinical Pathway: Hypertensive Emergencies and Urgencies

21. 1. Repeat BP elevated 2. Active, ongoing end-organ damage ruled out 3. History of HTN-related end-organ damage Treatment options for patients on HTN meds: 1. Restart if non-compliant 2. Increase dose 3. Add another antihypertensive (Indeterminate) Treatment options for patients not on HTN meds: 1. Give oral meds 2. Not starting any meds (Indeterminate) 1. Observe for several hrs 2. Repeat BP 3. Follow-up in 24-72 hrs Hypertensive Urgency

22. Lifestyle Modification Not At Goal Blood Pressure (< 140/90 mmHg) (< 130/80 mmHg for those with Diabetes or Chronic Kidney Disease) Initial Drug Choices Without Compelling Indications With Compelling Indications Stage 1 Hypertension (SBP 140-159 or DBP 90-99 mmHg) Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination Stage 2 Hypertension (SBP ≥ 160 or DBP ≥ 100-99 mmHg) Two-drug combination for most. (usually thiazide-type diuretic and ACEI, or ARB, BB, or CCB) Drugs for the compelling indications Other antihypertensive drugs (diuretics, ACE, ARB, BB, CCB) as needed Not at Goal Blood Pressure Optimize dosages or add additional drugs until goal blood pressure is achieved. Consider consultation with hypertension specialist Algorithm for Treatment of Hypertension