1. Group work 5 Hypertension case discussions

2. Objectives At the end of this session, the trainees should: Be able to explain steps of correct BP measurement. Be able to describe the long-term treatment plans. Be aware to include patients and families in the development of treatment plans. Be able to discuss white coat hypertension. Consider the role of other disciplines, e.g., pharmacy, nursing, social work, and allied health, in the treatment of hypertension.

3. Accurate BP Measurement Persons should be seated quietly for 5 minutes with feet on the floor and the arm supported at heart level”Persons should be seated quietly for 5 minutes with feet on the floor and the arm supported at heart level” Cuff must be appropriately sized (cuff bladder must encircle 80% of the arm)Cuff must be appropriately sized (cuff bladder must encircle 80% of the arm) Lower edge of cuff 2.5cm above AC fossa Palp radial artery to determine systolic. Use Bell to ausc over brachial artery. sInflate cuff to 20-30 mmHg above est systs

4. Accurate BP Measurement Caffeine and Tobacco can transiently raise BP substantially (30 min apart)Caffeine and Tobacco can transiently raise BP substantially (30 min apart) no talking at time of measurement no talking at time of measurement Empty bladderEmpty bladder 2 hours post exercise2 hours post exercise JNC VII

5. HYPERTENSION CASE

6. A 60 yr old male diagnosed as hypertension presents together with his son with 4 week history of swollen, painful knee. He is a widow living alone. No history of injury. Has orthopnea for the last four weeks. He is using thiazide diuretics since 3 months. Blood pressure: 160/100 mmHg. His investigations show uric acid 10.5 mg/dl and postprandial blood glucose 250 mg/dl. Other findings unremarkable.

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

8. ANSWER Good rapport. History taking. Medical examination. Initial investigations Identify secondary causes of htn. Identify contributory and CVD risk factors. Determine the presence of TOD. Contraindications to specific drugs

9. Investigations –Urine analysis – Hemoglobin level – Fasting plasma glucose level – Serum creatinine and electrolytes(k + ) – Lipid profile fasting T Cholesterol,HDL, LDL and triglycerides. – Electrocardiogram

11. ANSWER Stage of hypertension: Hypertension: Grade 2 Cardiovascular risk factors: Hypertension, DM Risk stratification:

12. Target organ damage: Associated clinical condition

14. ANSWER Management: Non-pharmacological DASH diet Weight reduction Excersice

19. Indication for aspirin Primary prevention(75-100 mg) - Age  50 y - Satisfactory control of their BP. - High or Very high absolute CV risk -  serum creatinine >107 mmol/L(1.3 mg /dl) Secondary prevention - Patients with status post MI -Status post-ischemic stroke. -Status post angioplasty, post coronary artery bypass graft.

20. Indicatins for statins Reduce LDL-C to < 3.3mmol/L(130mg/dl ) if one of the following is present Men >45y Women >55y Positive family history of premature CV D Smoking HDL-C <1mmol/l (<40mg) Reduce LDL-C to < 2.2 mmol/L (100mg/dl ) Evidence of CHD or DM

21. PATIENTS ARE DIFFERENT… THEIR TREATMENT NEED TO BE.