MAKATI MEDICAL CENTER DEPARTMENT OF MEDICINE SECTION OF CARDIOLOGY

1. EMERGENCY MEETINGFOR PHILHEALTH REQUIREMENTSCLINICAL PRACTICE GUIDELINES ON HYPERTENSIONCLINICAL 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

6. CLASSIFICATION OF HYPERTENSIONAdapted from JNC VII Guidelines for Hypertension

7. LAB INVESTIGATIONS (FOR NEW PATIENTS OR PATIENTS LOST TO FOLLOW UP) Adapted from the Compendium of Abridged ESC Guidelines 2008.

8. LAB INVESTIGATIONS (FOR NEW PATIENTS OR PATIENTS LOST TO FOLLOW UP) **if clinically indicated

9. LAB INVESTIGATIONS (FOR NEW PATIENTS OR PATIENTS LOST TO FOLLOW UP)

10. CRITERIA FOR HOSPITAL ADMISSION • 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)

11. Clinical Characteristics of the Hypertensive Emergency

12. TREATMENT:For Stage I Hypertension

13. TREATMENT:For Hypertension with Compelling Indications

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

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

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

17. For HYPERTENSIVE EMERGENCIES – The 1st 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

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: • Patient education – lifestyle management • Home medications (anti-hypertensive medications) • Schedule for follow-up

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