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Part 1: Recommendations for Hypertension Diagnosis Assessment and Follow up

Part 1: Recommendations for Hypertension Diagnosis Assessment and Follow up. 2011 C anadian H ypertension E ducation P rogram Recommendations. CHEP 2011 Recommendations. What’s new? Increased emphasis on the use of single pill combinations (and more guidance on which combinations to use).

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Part 1: Recommendations for Hypertension Diagnosis Assessment and Follow up

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  1. Part 1: Recommendations for Hypertension Diagnosis Assessment and Follow up 2011 Canadian Hypertension Education Program Recommendations

  2. CHEP 2011 Recommendations What’s new? • Increased emphasis on the use of single pill combinations (and more guidance on which combinations to use). • In stroke patients avoid excessive blood pressure reductions, except in the setting of the most severe elevations • The most important step in prescription of antihypertensive therapy is achieving patient “buy-in”: new tips for improving adherence

  3. For your patients – ask them to sign up at www.myBPsite.ca for free access to the latest information & resources on high blood pressure • For health care professionals – sign up at www.htnupdate.ca for automatic updates and on current hypertension educational resources

  4. 2011 Canadian Hypertension Education Program (CHEP) • A red flag has been posted where recommendations were updated for 2011. • Slide kits for medical education and health care professionals, patient and public information can be downloaded (English and French versions) at: www.hypertension.ca/tools

  5. Key CHEP Messages for the Management of Hypertension • Assess blood pressure at all appropriate visits. • Promote a healthy lifestyle to lower blood pressure and reduce the risk of cardiovascular disease at each visit with interventions to reduce high dietary sodium, for smoking cessation, to reduce abdominal obesity, to promote a healthy weight, to increase physical activity and to manage dyslipidemia and dysglycemia. • Treat blood pressure to less than 140/90 mmHg in most people and to less than 130/80 mmHg in people with diabetes or chronic kidney disease using a combination of drugs and lifestyle modifications. • Advocate for healthy public policies to prevent hypertension and advance the health of patients and populations. • Keep up to date with resources for the prevention and control of hypertension by registering at www.htnupdate.ca and downloading and ordering tools at www.hypertension.ca/tools.

  6. 2011 Canadian Hypertension Education Program (CHEP) Table of contents HYPERTENSION DIAGNOSIS, ASSESSMENT AND FOLLOW-UP • Accurate measurement of blood pressure • Criteria for the diagnosis of hypertension and follow-up • Assessment of overall cardiovascular risk in hypertensive patients • Routine and optional laboratory tests for the investigation of patients with hypertension • Assessment of renovascular hypertension • Endocrine hypertension • Home measurement of blood pressure • Ambulatory blood pressure measurement • Role of echocardiography

  7. Accurate Measure of Blood Pressure1) Assess blood pressure at all appropriate visits When should blood pressure be measured? • Health care professionals should know the blood pressure of all of their patients and clients. Blood pressure of all adults should be measured whenever it is appropriate using standardized techniques. • To screen for hypertension • To assess cardiovascular risk • To monitor antihypertensive treatment

  8. Prevalence of Hypertension in Canada Mean systolic and diastolic BP by sex and age group, household population aged 20-79 years, March 2007 to February 2009 Wilkins et al. Health Reports Feb 2010

  9. Prevalence of Hypertension in Canada Wilkins et al. Health Reports Feb 2010

  10. 14 16 18 20 14 16 18 20 0 4 6 8 10 12 0 4 6 8 10 12 2 2 Life time risk of Hypertension in Normotensive Women and Men aged 65 years Risk of Hypertension % Risk of Hypertension % 100 100 Women Men 80 80 60 60 40 40 20 20 0 0 Years to Follow-up Years to Follow-up JAMA 2002: Framingham data.

  11. Reversible risks for developing hypertension • Obesity • Poor dietary habits • High sodium intake • Sedentary lifestyle • High alcohol consumption

  12. Incidence of hypertension in those identified with high normal blood pressure • 772 subjects, mean age 48.5 • Not receiving treatment for Hypertension • Average of 3 blood pressures at baseline: • SBP 130-139 and DBP < 89 OR • SBP < 139 and DBP 85-89 • Primary endpoint – new onset Hypertension Julius S. NEJM 2006;354:1685-97

  13. New onset hypertension in people with high normal blood pressure Julius S. NEJM 2006;354:1685-97

  14. Development of hypertension in those with high normal blood pressure Framingham cohort Vasan. Lancet 2001

  15. High risk of developing hypertension in those with high normal blood pressure Annual follow-up of patients with high normal blood pressure is recommended.

  16. Accurate Measurement of Blood Pressure • Automated office blood pressure measurements can be used in the assessment of office blood pressure*. • When used under proper conditions, automated office SBP of 135 mmHg or higher or DBP values of 85 mmHg or higher should be considered analogous to mean awake ambulatory SBP of 135 mmHg or higher or DBP of 85 mmHg or higher*. *see notes

  17. Use of standardized measurement techniques is recommended when assessing blood pressure • When using automated office oscillometric devices such as the BpTRU, the patient should be seated in a quiet room alone. With the device set to take measures at 1 or 2 minute intervals, the first measurement is taken by a health professional to verify cuff position and validity of the measurement. The patient is left alone after the first measurement while the device automatically takes subsequent readings.

  18. Elevated Out of the Office BP measurement Elevated Random Office BP Measurement II. Criteria for the diagnosis of hypertension and recommendations for follow-up Hypertension Visit 1 BP Measurement, History and Physical examination Hypertensive Urgency / Emergency Hypertension Visit 2 Target Organ Damage or Diabetes or Chronic Kidney Disease or BP >180/110? Diagnosis of HTN Yes No BP: 140-179 / 90-109 Clinic BPM ABPM (If available) Home BPM (If available) 2011 Canadian Hypertension Education Program Recommendations

  19. Elevated Out of the Office BP measurement Elevated Random Office BP Measurement Hypertensive Urgency / Emergency BP >140/90 mmHg and Target organ damage or Diabetes or Chronic Kidney Disease or BP >180/110? Diagnosis of HTN Yes No BP: 140-179 / 90-109mmHg II. Criteria for the diagnosis of hypertension and recommendations for follow-up Hypertension Visit 1 BP Measurement, History and Physical examination Diagnostic tests ordering at visit 1 or 2 Hypertension Visit 2 within 1 month 2011 Canadian Hypertension Education Program Recommendations

  20. Clinic BP ABPM (If available) Home BPM Hypertension visit 3 >160 SBP or >100 DBP Diagnosis of HTN >135/85 Awake BP <135/85 and 24-hour <130/80 Awake BP >135 SBP or >85 DBP or 24-hour >130 SBP or >80 DBP < 135/85 or <160 / 100 ABPM or HBPM or Hypertension visit 4-5 >140 SBP or >90 DBP Diagnosis of HTN Continue to follow-up Diagnosis of HTN Diagnosis of HTN Continue to follow-up Continue to follow-up < 140 / 90 II. Criteria for the diagnosis of hypertension and recommendations for follow-up BP: 140-179 / 90-109 Patients with high normal blood pressure (clinic SBP 130-139 and/or DBP 85-89) should be followed annually.

  21. II. Criteria for the diagnosis of hypertension and recommendations for follow-up Diagnosis of hypertension Non Pharmacological treatment With or without Pharmacological treatment *Consider home blood pressure measurement in hypertension management, to assess for the presence of masked hypertension or white coat effect and to enhance adherence. Are BP readings below target during 2 consecutive visits? Yes No Follow-up at 3-6 month intervals * Symptoms, Severe hypertension, Intolerance to anti-hypertensive treatment or Target Organ Damage Yes No Visits every 1 to 2 months* More frequentvisits *

  22. 135 The concept of masked hypertension 140 True hypertensive Masked HTN Home or Daytime ABPM SBP mmHg 135 True Normotensive White Coat HTN 140 Office SBP mmHg Derived from Pickering et al. Hypertension 2002: 40: 795-796.

  23. The prognosis of masked hypertension Prevalence of masked hypertension is approximately 10% in the general population but is higher in patients with diabetes J Hypertension 2007;25:2193-98

  24. Cerebrovascular disease transient ischemic attacks ischemic or hemorrhagic stroke vascular dementia Hypertensive retinopathy Left ventricular dysfunction Left ventricular hypertrophy Coronary artery disease myocardial infarction angina pectoris congestive heart failure Chronic kidney disease hypertensive nephropathy (GFR < 60 ml/min/1.73 m2) albuminuria Peripheral artery disease intermittent claudication ankle brachial index < 0.9 III. Assessment of the overall cardiovascular riskSearch for target organ damage

  25. III. Assessment of the overall cardiovascular risk • Search for exogenous potentially modifiable factors that can induce/aggravate hypertension • Prescription Drugs: • NSAIDs, including coxibs • Corticosteroids and anabolic steroids • Oral contraceptive and sex hormones • Vasoconstricting/sympathomimetic decongestants • Calcineurin inhibitors (cyclosporin, tacrolimus) • Erythropoietin and analogues • Antidepressants: Monoamine oxidase inhibitors (MAOIs), SNRIs, SSRIs • Midodrine • Other: • Licorice root • Stimulants including cocaine • Salt • Excessive alcohol use

  26. III. Assessment of the overall cardiovascular risk • Over 90% of hypertensive Canadians have other cardiovascular risks • Assess and manage hypertensive patients for dyslipidemia, dysglycemia (e.g. impaired fasting glucose, diabetes) abdominal obesity, unhealthy eating and physical inactivity

  27. III. Assessment of the overall cardiovascular risk Treat Hypertension in the Context of Overall Cardiovascular Risk • Overall cardiovascular risk should be assessed. In hypertensive patients consider using calculations that include cerebrovascular events. • In the absence of Canadian data to determine the accuracy of risk calculations, avoid using absolute levels of risk to support treatment decisions at specific risk thresholds. • Discuss global risk using analogies that describe comparative risk such as “Cardiovascular Age”, “Vascular Age” or “Heart Age” to inform patients of their risk status and to improve the effectiveness of risk factor modification. Simply counting risk factors may underestimate risk

  28. III. Assessment of the overall cardiovascular risk Cardiovascular Risk Factors • Presence of Risk Factors • Increasing age • Male gender • Smoking • Family history of premature cardiovascular disease (age< 55 in men and < 65 in women) • Dyslipidemia • Sedentary lifestyle • Unhealthy eating • Abdominal obesity • Dysglycemia (diabetes, impaired glucose tolerance, impaired fasting glucose) • Presence of Target Organ Damage • Microalbuminuria or proteinuria • Left ventricular hypertrophy • Chronic kidney disease (glomerular filtration rate < 60 ml/min/1.73 m2) • Presence of atherosclerotic vascular disease • Previous stroke or TIA • Coronary Heart Disease • Peripheral arterial disease CV Risk Factors that may alter thresholds and targets in the treatment of HTN

  29. Methods of Risk Assessment • Clinical impression • Risk factor counting • Risk calculation or equation tools • Framingham hard coronary heart disease (CHD)http://hp2011.nhlbihin.net/atpiii/calculator.asp?usertype=prof • SCORE Canada – Systematic Cerebrovascular and Coronary Risk Evaluation www.scorecanada.ca • Cardiovascular Age™ www.myhealthcheckup.com • Others: see notes

  30. SCORE Canada : Systematic Cerebrovascular and cOronary Risk Evaluation   SCORE 10 year Fatal Cardiovascular Risk Evaluation in Canada Find the cell nearest to the person’s risk factors values : Age Sex Smoking Status Systolic Blood Pressure Total-Chol. / HDL-C. Ratio * Systematic Coronary Risk Evaluation

  31. Non smoker Smoker Systolic BP Total Cholesterol (mmol/L) SCORE Canada: Relative Risk Evaluationfor use in those less than 40 years old = n times risk at same age

  32. Factors to take into account using SCORE Canada to estimate risk of Fatal CVD • Person approaching next age category • Pre-clinical evidence of atherosclerosis (imaging test) • Strong family history of premature CVD: Multiply risk by 1.4 • Obesity ; BMI > 30 kg/m2, ; Waist circumference > 102 cm (men) and > 88 cm (woman) • Sedentary lifestyle • Diabetes: multiply risk by 2 for men and by 4 for women • Raised serum triglycerides level • Raised level of C-reactive prot., Fibrinogen, Homocysteine, Apolipoprotein B or Lp(a)

  33. IV. Routine Laboratory Tests Preliminary Investigations of patients with hypertension • Urinalysis • Blood chemistry (potassium, sodium and creatinine) • Fasting glucose • Fasting total cholesterol and high density lipoprotein cholesterol (HDL), low density lipoprotein cholesterol (LDL), triglycerides • Standard 12-leads ECG Currently there is insufficient evidence to recommend routine testing of microalbuminuria in people with hypertension who do not have diabetes

  34. IV. Routine Laboratory Tests Follow-up investigations of patients with hypertension • During the maintenance phase of hypertension management, tests (including electrolytes, creatinine, glucose, and fasting lipids) should be repeated with a frequency reflecting the clinical situation. • Diabetes develops in 1-3%/year of those with drug treated hypertension. The risk is higher in those treated with a diuretic or beta blocker, in the obese, sedentary, with higher fasting glucose and who have unhealthy eating patterns. Assess for diabetes more frequently in these patients.

  35. IV. Optional Laboratory Tests Investigation in specific patient subgroups • For those with diabetes or chronic kidney disease: assess urinary albumin excretion, since therapeutic recommendations differ if proteinuria is present. • For those suspected of having an endocrine cause for the high blood pressure, or renovascular hypertension, see following slides. • Other secondary forms of hypertension require specific testing.

  36. Abnormal Urinary Albumin levels

  37. V. Screening for Renovascular Hypertension Patients presenting with two or more of the following clinical clues listed below suggesting renovascular hypertension should be investigated. • Sudden onset or worsening of hypertension and > age 55 or < age 30 • The presence of an abdominal bruit • Hypertension resistant to 3 or more drugs • A rise in creatinine of 30% or more associated with use of an angiotensin converting enzyme inhibitor or angiotensin II receptor blocker • Other atherosclerotic vascular disease, particularly in patients who smoke or have dyslipidemia • Recurrent pulmonary edema associated with hypertensive surges

  38. V. Screening for Renovascular Hypertension The following tests are recommended, when available, to screen for renal vascular disease: • captopril-enhanced radioisotope renal scan* • doppler sonography • magnetic resonance angiography • CT-angiography (for those with normal renal function * captopril-enhanced radioisotope renal scan is not recommended for those with glomerular filtration rates <60 mL/min)

  39. VI. Screening for Hyperaldosteronism Should be considered for patients with the following characteristics: • Spontaneous hypokalemia (<3.5 mmol/L). • Profound diuretic-induced hypokalemia (<3.0 mmol/L). • Hypertension refractory to treatment with 3 or more drugs. • Incidental adrenal adenomas.

  40. VI. Screening for hyperaldosteronism Screening for hyperaldosteronism should include plasma aldosterone and renin activity (or renin concentration) • measured in morning samples. • taken from patients in a sitting position after resting at least 15 minutes. • Aldosterone antagonists, ARBs, beta-blockers and clonidine should be discontinued prior to testing. • A positive screening test should lead to referral or further testing.

  41. VI. Renin, Aldosterone and Ratio Conversion factors

  42. VI. Screening for Pheochromocytoma • Should be considered for patients with the following characteristics: • Paroxysmal and/or severe sustained hypertension refractory to usual antihypertensive therapy; • Hypertension and symptoms suggestive of catecholamine excess (two or more of headaches, palpitations, sweating, etc); • Hypertension triggered by beta-blockers, monoamine oxidase inhibitors, micturition, or changes in abdominal pressure; • Incidentally discovered adrenal mass; • Multiple endocrine neoplasia (MEN) 2A or 2B; von Recklinghausen’s neurofibromatosis, or von Hippel-Lindau disease. 

  43. VI. Screening for Pheochromocytoma • Screening for pheochromocytoma should include a 24 hour urine for metanephrines and creatinine. • Assessment of urinary VMA is inadequate. • A normal plasma metanephrine level can be used to exclude pheochromocytoma in low risk patients but the test is performed by few laboratories.

  44. VII. Home measurement of blood pressure Home BP measurement should be encouraged to increase patient involvement in care • Which patients? • Uncomplicated hypertension • Suspected non adherence • Office-induced blood pressure elevation (white coat effect) • Masked hypertension Average BP > 135/85 mm Hg should be considered elevated

  45. Potential advantages of home blood pressure measurement • More rapid confirmation of the diagnosis of hypertension • Improved ability to predict cardiovascular prognosis • Improved blood pressure control • Can be used to assess patients for white coat hypertension (WCH) and masked hypertension • Reduced medication use in some (WCH) • Improved adherence to drug therapy

  46. Not all patients are suited to home measurement • Undue anxiety in response to high blood pressure readings • Physical or mental disability prevents accurate technique or recording • Arm not suited to blood pressure cuff (e.g. conical shaped arm) • Irregular pulse or arrhythmias prevent accurate readings • Lack of interest Most patients can be trained to measure blood pressurePeriodic reassessment of technique and retraining is desirable

  47. VII. Suggested Protocol for Home Measurement of Blood Pressure for the diagnosis of hypertension • Home blood pressure values should be based on: • Duplicate measures, • Morning and evening, • For an initial 7-day period. • First day home BP values should not be considered. • The following six days blood pressure readings should be averaged • Average BP equal to or over 135/85 mmHg should be considered elevated (for those patients whose clinic BP target is less than 140/90 mmHg).

  48. Recommended electronic blood pressure monitors for home blood pressure measurement • Monitors that have been validated as accurate and available in Canada are listed at www.hypertension.ca in the ‘device endorsements’ section • The boxes containing the device are also be marked with

  49. VII. Home Measurement of BP: Patient Education • Assist patients select a model with the correct size of cuff • Measure and record the patients mid arm circumference so they can match it to cuff size. • Recommend devices listed at www.hypertension.ca or marked with this symbol • Ask patients to carefully follow the instructions with device and to record only those blood pressures where they have followed recommended procedure • Advise patients that average readings equal to or over 135/85 mmHg are high • In patients with diabetes or chronic kidney disease, lower therapeutic targets and diagnostic criteria are likely required

  50. Web based home monitoring • Website resources are available www.heartandstroke.ca/bp • Individualized automated counseling and tracking to assist patients home monitor and to enhance self management of lifestyle.

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