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MANAGEMENT OF HYPERTENSION

This article discusses the prevalence, risk factors, and effects of hypertension, as well as the importance of proper diagnosis and control. It also provides guidelines for blood pressure assessment and classification.

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MANAGEMENT OF HYPERTENSION

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  1. MANAGEMENT OFHYPERTENSION Dr. HUSSEIN SAAD (MRCP) Assistant Professor CONSULTANT FAMILY MEDICINE College of Medicine King saud university

  2. EPIDEMIOLOGY ■In developed and developing countries alike, Essential Hypertension affects 25-35% of the adult population. Up to 60-70% of those beyond the seventh decade of life. ■ Each increment of 20 mm Hg in systolic blood pressure or 10 mm Hg in diastolic blood pressure doubles the risk of cardiovascular disease events independent of other factors.

  3. Prevalence of Hypertension in Obese and non-Obese Saudis The study group: 14.805 males: 6225 females: 8580 The age: 14 – 70 years Non-obese prevalence: 4.8 % males 2.8 % females Obese prevalence: 8 % males 8 % females Mohsen A El-Hazmi, Saudi Medical Journal 2001; vol 22 (1): 44-48

  4. Hypertension among attendants of primary health care centers in Al-Qassim region Saudi Arabia. Khalid A,et al Saudi Med J 2001; Vol. 22 (11) 960-963 The study sample: 1114 The prevalence: 30 % Higher in: ● Age > 40 years ● Overweight and obese people ● illiteracy Awareness: 20 % 0f hypertensive women 25 % of hypertensive men

  5. EPIDEMIOLOGY In the Framingham Heart Study: ◊Those belowAge of 55 diastolic Bp is the strongest predictor of cardiovascular risk ◊Above 55 years, diastolic Bp was negatively related to the risk of coronary events, so the pulse pressure became superior predictor to the systolic Bp.

  6. Systolic Diastolic 95 90 85 80 75 70 65 175 165 155 145 135 125 115 105 4 3 2 1 Systolic pressure (mm Hg) Diastolic pressure (mm Hg) 30-34 40-44 80-84 50-54 60-64 75-79 70-74 30-34 40-44 50-54 60-64 70-74 75-79 80-84 35-39 45-49 55-59 35-39 45-49 55-59 65-69 65-69 Age (y) Age (y) What happens to blood pressure with aging? •Systolic pressure increases with age • Diastolic pressure increases with age but peaks between 55 and 60 years then starts to decrease. • Arterial stiffness: cause of elevated systolic and lower diastolic pressure with aging •Entirecohort study •Studycohortwithdeaths, myocardialinfarctions and congestive heartfailuresexcluded BP values over lifetime period in population studies Franklin SS, Fustin W 4th, Wong ND, et al. Circulation. 1997;96:308-315.

  7. Pulse Pressure and Total Mortality P<0.00001 event rate % < 25 50 60 > 65 30 40 pulse pressure (mm Hg) Mitchell, G.F. & Pfeffer, M.A., Curr Opin Cardiol 1999; 14: 361-9

  8. 3.0 2.5 SBP 170 mm Hg (p=0.8129) 2.0 CHD hazard ratio SBP 150 mm Hg (p=0.0228) 1.5 SBP 130 mm Hg (p=0.0559) 1.0 SBP 110 mm Hg (p=0.0294) 0,5 70 100 110 80 60 90 diastolic blood pressure (mm Hg) Pulse Pressure and Coronary Risk Franklin, S.S. et al., Circulation 1999; 100: 354-60

  9. Are we achieving adequate control Up to 65% of Americans with hypertension do not achieve adequate blood pressure control. The World Health Organization now projects that by 2030, ischemic heart disease and stroke will become the second and third leading causes of death worldwide.

  10. Trends in awareness, treatment, and control of high BP in adults ages 18 -74 National Health and Nutrition Examination Survey, Percent II (1976- 80) III (Phase 1 1988- 91) III (Phase 2 1991- 94) 1999- 00

  11. DIAGNOSIS Two or more elevated readings are obtained on at least two visits over a period of one to several weeks.

  12. Blood Pressure Assessment:Patient preparation and posture Standardized technique: Posture The patient should be calmly seated with his or her back well supported and arm supported at the level of the heart. His or her feet should touch the floor and legs should not be crossed.

  13. Definitions and classification of blood pressure 2007 guidelines for the management of arterial hypertension The task force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) Systolic Diastolic Optimal<120And<80 Normal 120–129And/or80–84 High normal 130–139 And/or 85–89 Grade 1 HTN 140–159And/or90–99 Grade 2 HTN 160–179And/or 100–109 Grade 3 HTN 180 And/or110 Dr. HUSSEIN SAAD

  14. Definitions and classification of blood pressure 2007 guidelines for the management of arterial hypertension The task force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) Isolated Systolic HTN ≥140 and <90 Systolic Diastolic Grade 1 isolated HTN 140–159And <90 Grade 2 isolated HTN 160–179And<90 Grade 3 isolated HTN 180 And <90 Dr. HUSSEIN SAAD

  15. If the clinic blood pressure is 140/90 mmHg or higher, offer ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis of hypertension. Diagnosis

  16. When using the following to confirm diagnosis, ensure: ABPM: at least two measurements per hour during the person’s usual waking hours, average of at least 14 measurements to confirm diagnosis HBPM: two consecutive seated measurements, at least 1 minute apart blood pressure is recorded twice a day for at least 4 days and preferably for a week measurements on the first day are discarded average value of all remaining is used. Diagnosis

  17. Home measurement of blood pressure Morning and Evening, for an initial 7-day period. Which patients? • For the diagnosis of hypertension • Suspected non adherence • White coat hypertension • Masked hypertension Average BP equal to or over 135/85 mmHg should be considered elevated

  18. Suggested use of ABPM in the Management of Hypertension Office BP > 140/90 mmHg in low risk patients (with no target-organ disease) Perform ABPM Mean awake BP Less than 135/85 mmHg Mean awake BP equals or over 135/85 mmHg Follow-up with periodic home-BP measurement Life style Modification Initiate antihypertensive therapy ABPM: Ambulatory Blood Pressure Monitoring BP: Blood Pressure Adapted from White W, NEJM 348:24, June 12, 2003

  19. ABPM

  20. ABPM has to be considered: • Suspected white coat hypertension • Suspected episodic hypertension • Hypertension resistant to increasing medication • Hypotensive symptoms while taking antihypertensive medications

  21. Blood Pressure Measurement • Patients should be seated with back supported and arm bared and supported. • Measurements should begin after at least 5 minutes of rest. • Appropriate size of Cuff. Why?

  22. Update in NICE 2011 Stage 1 hypertension: • Clinic blood pressure (BP) is 140/90 mmHg or higher and • ABPM or HBPM average is 135/85 mmHg or higher. Stage 2 hypertension: • Clinic BP 160/100 mmHg is or higher and • ABPM or HBPM daytime average is 150/95 mmHg or higher. Severe hypertension: • Clinic BP is 180 mmHg or higher or • Clinic diastolic BP is 110 mmHg or higher.

  23. White-Coat Hypertensionis it Innocent? • Raised clinic blood pressure in the presence of a normal daytime ambulatory blood pressure. • Results of Event-Based Studies have shown that the risk of cardiovascular disease is lower in patients with white-coat hypertension. • Check for any Metabolic risk factor, if present you have to start medication.

  24. BENEFITS OF LOWERING BLOOD PRESSURE • The Clinical Trials had shown: Reduction in • STROKE35 – 40 % • MI 20 – 25 % • HEART FAILURE > 50%

  25. Increase in wall to lumen ratio Decreased lumen Functional occlusion Rarefaction Microvascularremodellingleads to capillaryrarefaction Normotensive HYPERTENSIVE Endothelial dysfunction, Mechanical trauma, Release of growth factors, Proliferation of smooth muscle cells Levy BI. J Hypertens. 2006;24(suppl 5):6-9.

  26. Risk Factors • Smoking • Dyslipidaemia • Diabetes Mellitus • Obesity • Age older than 60 years • Sex (men or postmenopausal women) • F.H. of cardiovascular disease

  27. How to approach a patient with Hypertension ? • Medical History • Physical Examination • Routine Laboratory Tests • Optional Tests • Non-Pharmacological Treatment • Drug Treatment

  28. Patient Evaluation Evaluation of patients with documented HTN has three objectives: • Assess lifestyle and identify other CV risk factors or concomitant disorders that affects prognosis and guides treatment. • Reveal identifiable Causes of high BP. • Assess the presence or absence of Target Organ Damage and CVD.

  29. MEDICAL HISTORY • Patient History of Cardiovascular Disease • Current and Previous Medications • Smoking • Lifestyle Factors • Family History

  30. PHYSICAL EXAMINATION • Blood Pressure (Readings ?) • Height, Weight and Pulse • Exam. Of Neck, Heart, Lungs, Abdomen and Extremities • Funduscopic Examination (Arterial narrowing “copper wiring”, A-V nipping, Flame shaped haemorrhages, Soft exudates, Papilloedema)

  31. ROUTINE LAPORATORY TESTS • CBC • Urine Analysis and Microalbuminuria • Urea , Creatinine, Electrolytes, Uric Acid and Calcium • Fasting Plasma Glucose • Lipid Profile (T.ch, Trig, LDL and HDL) • ECG • Chest X-ray ??

  32. Who should be screened for causes of secondary hypertension?

  33. Target Organ Damage • Heart • Left ventricular hypertrophy • Angina or prior myocardial infarction • Heart failure • Brain • Stroke or transient ischemic attack • Chronic kidney disease • Peripheral arterial disease • Retinopathy

  34. High/Very high risk subjects ► BP 180 mmHg systolic and/or 110 mmHg diastolic ► Systolic BP > 160 mmHg with low diastolic BP (<70 mmHg) ► Diabetes mellitus ► Metabolic syndrome ►≥ 3 cardiovascular risk factors

  35. High/Very high risk subjects One or more of the following subclinical organ damages: ►ECG with LVH and strain ►Echo. of concentric LVH ►U/S evidence of carotid artery wall thickening or plaque ► Moderate increase in serum creatinine ►Reduced creatinine clearance ►Microalbuminuria or proteinuria ►Established cardiovascular or renal disease

  36. OPTIONAL TESTS • 24-hour Urinary Protein • Creatinine Clearance • Echocardiography • Ultrasonography • Thyroid Stimulating Hormone • 24-hour Urinary Vanyl Mandelic Acid • 24-hour Urinary Catechleamines • 24-hour Urinary Free Hydrocortisol

  37. What is the goal of management of hypertension? Treating (Non-Diabetic) SBP and DBP to targets that are < 140 / 90is associated with decrease in CVD Complications. Hansson et al, Principal results of the Hypertension Optimal treatment, HOT Study Group, Lancet 1998; 351: 1755 – 62.

  38. The Target for Blood pressure Control • < 140/90 mmHg for people with diabetes . • Limited data suggest possible worsening of both renal and CVD outcomes if systolic blood pressure is lowered to < 110 mmHg.

  39. GUIDELINES: JNC 7 & ESH/ESC 2007,BHS 2004, Canada 2010 &NICE 2011 • All support combination therapy +++ • Support initiation of therapy with drug combinations • Approve low-dose fixed combinations for initiation of therapy

  40. CLASSES OF ANTIHYPERTENSIVE DRUGS ■BETA BLOCKERS • Atenolol • Bisoprolol • Carvedilol ■ACE Inhibitors • Captopril • Lisinopril • Enalapril

  41. Angiotensin-receptor blocker ARB therapy may cut the risk of Alzheimer's disease (AD) by reducing amyloid deposition in the brain. 890 hypertensive patients with available brain autopsy data. The risk for AD was 24% lower in those prescribed ACE inhibitor. Ihab Hajjar, MD, and colleagues from University of Southern California Archives of Neurology, September 13, 2012

  42. CLASSES OF ANTIHYPERTENSIVE DRUGS Angiotensin II Receptor Blockers •Losartan • Candesartan • Valsartan • Irbesartan ■Calcium Channel Blockers ( Long Acting) • Nifedipine Retard • Amlodipine • Felodipine ■Diuretics ( Thiazides, Indapamide SR) ■Vasodilators

  43. NICE 2011 Aged over 55 years or black person of any age Aged under55 years C2 A Step 1 Key A – ACE inhibitor or low-cost angiotensin II receptor blocker (ARB)1 C – Calcium-channel blocker (CCB) D – Thiazide-like diuretic A + C2 Step 2 A + C + D Step 3 Resistant hypertension A + C + D + consider further diuretic3, 4 or alpha- or beta-blocker5 Consider seeking expert advice Step 4

  44. Updated Guideline issued by NICE 2011 In hypertensive patients aged 55 or older or black patients of any age: • The first choice for initial therapy should be either a calcium-channel blocker or a Thiazide-type diuretic. • If a third drug is needed an ACE inhibitor or ARB is a choice. NICE clinical guideline 34, Hypertension: management of hypertension in adults in primary care, 2011. www.nice.org.uk

  45. Updated Guideline issued by NICE 2011 In hypertensive patients younger than 55, the first choice for initial therapy should be: • An ACE inhibitor (or an ARB if an ACE inhibitor is not tolerated). • Adding an ACE inhibitor to a calcium-channel blocker or a diuretic (or vice versa are logical combinations). NICE clinical guideline 34, Hypertension: management of hypertension in adults in primary care, 2011. www.nice.org.uk

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