1. Hypertension Family Medicine Specialist CME October 15-17, 2012 Pakse

2. Objectives Review diagnosis and best treatments for hypertension Explore opportunities to screen for hypertension Review strategies for successful community treatment of hypertension

3. Case number 1 A 65 year old woman who lives in Sekong comes to the provincial hospital because of pneumonia. She has no medical problems but she is obese and her diet is high in salt. You treat her pneumonia but notice that her blood pressure is 150/100.

4. Discussion questions Does she have a diagnosis of hypertension? What will you counsel her? When will you see her again?

5. Diagnosis of Hypertension Visit 1: any patient with hypertensive crisis Visit 2: BP> 180/110 ; or BP>140/90 with target organ damage, DM, or chronic kidney disease Visit 3: BP>160/100 Visit 4: BP>140/90

6. Target organ damage Cerebrovascular disease (stroke, TIA) Cardiac disease (myocardial infarction, heart failure) Chronic renal disease Peripheral artery disease

7. Lifestyle counseling Lifestyle goalEstimated BP reduction Increase physical activity-4.9/-3.7 mmHg Loose weight-7.2/-5.9 mmHg (per 4.5 kg) Decrease alcohol use-3.9/-2.4 mmHg Decrease salt in diet-5.1/-2.7 mmHg Decrease stress-6.1/-4.3 mmHg Stop smoking

8. Follow up If BP high in visit 1, follow-up within 1 month. If on lifestyle treatment alone, follow-up every 3-6 months, or every 1-2 months if very BP high. If starting antihypertensives follow-up every 1- 2 months to adjust medications until target BP reached on two visits. When target BP reached, follow-up every 3- 6months.

9. Case number 2 The woman from Sekong comes back to your clinic for follow up of her pneumonia. The pneumonia is improved but her blood pressure today is 180/110. You examine her and find no evidence of end organ damage.

10. Discussion questions Does she have a diagnosis of hypertension? Will you treat her with medication? What is the target blood pressure? What medications will you use first?

11. Target Blood Pressure <140/90 mmHg Patients with diabetes <130/80 mmHg

12. When to start treatment DBP > 100 mmHg or SBP > 160 mmHg in patients without macrovascular target organ damage or other cardiovascular risk factors. DBP > 90 mmHg or SBP> 140 mmHg with macrovascular target organ damage or other cardiovascular risk factors. Be careful with elderly frail patients…

13. First line drug therapy Thiazide or thiazide-like diuretic Calcium channel blocker (long acting) ACE-I (angiotensin converting enzyme inhibitor) ARB (angiotensin receptor blocker) Beta blocker (less than age 60)

14. Case number 3 A 50 year old man from Salavan has been treated for one month with an ACE-I. His blood pressure is still high. He is trying to use lifestyle modification.

15. Discussion questions What will you do now? What drug combinations are best?

16. Second line drug therapy Multiple drugs are often needed to control BP especially in patients with DM Low dose of several drugs better than high dose of 1or 2 drugs Beta Blockers, ACE and ARB are not additive Best to combine them with a diuretic or calcium channel blocker Do not combine ACE-I and ARB

17. Hypertension medications for patients with other diseases

18. Case number 4 A 48 year old obese male with Type 2 DM presents with hypertension.

19. Discussion questions What are the best hypertension medications to use in this patient? What if he has recently suffered from angina or a myocardial infarction? What if he is suffering from congestive heart failure?

20. With diabetes First: ACE-I or ARB Second: add CCB Avoid diuretics With recent MI or angina First: ACE-I or ARB; beta blockers Second: add CCB With heart failure First: ACE-I or ARB; beta blockers; aldosterone antagonists Second: add CCB

21. Case number 5 A 54 year old woman with chronic kidney disease develops proteinuria and hypertension.

22. Discussion questions What antihypertensive medication would you use first line, and second line for this patient?

23. Non-diabetic chronic kidney disease with proteinuria First line: ACE-I or ARB Second: any combinations of other drugs Watch potassium levels…

24. As a family medicine specialist in Lao PDR What are opportunities for screening patients for HTN? How can a community health center and a district hospital collaborate to improve HTN management? How can such collaboration be achieved?

25. With your patients… How can you promote lifestyle change? How can you teach and help them understand the risks of poor BP control? How can you encourage follow-up?