Management of Hypertension

1. Management of Hypertension Introduction to Primary Care: a course of the Center of Post Graduate Studies in FM PO Box 27121 – Riyadh 11417 Tel: 4912326 – Fax: 4970847 1

2. Objectives to discuss the importance of hypertension in FP to describe the recommendations for screening of hypertension. to describe current guideline recommendations on the diagnosis of hypertension to describe the complications of hypertension

3. content • Epidemiology • Definition of hypertension • Types of hypertension • Evaluation of hypertensive patient History &physical examination Laboratory tests • Accurate BP Measurement • White Coat Hypertension

4. Epidemiology About 1/3 of middle aged patients have hypertension About ½ of elderly patients have hypertension. Responsible for 12% of deaths worldwide. 5-6% reduction in diastolic blood pressure over 5 years reduces risk of CVA by 35-40% and IHD by 20-25%

5. Proportion of deaths attributable to leading risk factors worldwide (2000) High blood pressure Tobacco High cholesterol Underweight Unsafe sex High BMI Physical inactivity High mortality, developing region Lower mortality, developing region Developed region Alcohol Indoor smoke from solid fuels Iron deficiency 0 1 2 3 4 5 6 7 8 Attributable Mortality (In millions; total 55,861,000)

6. World Health Report 2003 Of the 10 leading global disease burden risk factors • Highblood pressure • High cholesterol • Obesity • Physical inactivity • Insufficient consumption of fruits and vegetables • Smoking

7. Important Points: Hypertension is the most common treatable risk factor for cardiovascular disease in patients over 50 years. Only 70% are aware they have HTN Of those aware of their HTN, only 50% are being treated. Only 25% of all hypertensive patients have their BP under control. HTN is a risk factor for coronary artery disease (CAD), congestive heart failure (CHF), stroke, and renal failure. JNC VII

8. Definition • Persistent elevation • SBP ≥140 mmHg • And OR • DBP ≥90 mmHg\ • Several occassions • Three readings proper technique/cuff on 3 separate occasions over at least 4-6 weeks • Days-weeks (level-complication-end organ damage) • Not on anti hypertensive medications.

9. Recommendation for follow up

10. Types of hypertension • Primary (“essential”) 95% of cases • Secondary 5% of cases

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

12. Blood Pressure Classification *Treatment determined by highest BP category; **Consider treatment for compelling indications regardless of BP JNC 7 Express. JAMA. 2003 Sep 10; 290(10):1314

13. Cardiovascular Risk Factors • Hypertension (levels of SBP&DBP) • Smoking • Obesity (body mass index≥30kg/m2 ) • Physical inactivity • Dyslipidema (total cholesterol >250mg/dl i.e >6.5mmol/l,LDL-C155mg/dl i.e4.0mmol/l,HDL-C <40mg/dl i.e<1.0mmol/l) • DM* *Considered as coronary heart disease equivalent

14. Cardiovascular Risk Factors-contd • Microalbuminuria or estimated GFR<60ml/min • Age (older than 55for men,65 for women) • Family history of premature cardiovascular disease (men under age 55,women under age 65) • C-reactive protein ≥1mg/dl

15. Secondary Causes: ABCDE mnemonic • Apnea (OSA) • Aldosteronism (hyperaldosteronism) • Bruits (renal artery stenosis) • Bad Kidneys (intrinsic kidney disease) • Catecholamines • Coarctation • Cushing’s Syndrome

16. ABCDE mnemonic • Drugs (stimulants, OCPs, NSAIDS) • Diet (high Na/low K, Mg, Ca) • Erythropoietin: elevated EPO in COPD or • renal failure or exogenous use for anemia • Endocrine: Thyroid/Parathyroid, pregnacy,pheochromocytoma, acromegaly

18. Associated clinical condition ACCs • Cerebrovascular disease : ischemic stroke, cerebral hemorrhage, or TIA. • Heart disease : MI, angina, coronary revascularization, or CHF. • Renal disease : diabetic nephropathy or renal failure  creatinine ,men > 1.6 mg/dl (133umol/l) women > 1.45 mg/dl (124 umol/l ) • Vascular disease: (dissecting aneurysm or symptomatic arterial disease. • Advanced hypertensive retinopathy

19. White Coat Hypertension 20-30% of Apparently Resistant Hypertension May be due to “White-Coat Hypertension” Patients with WCH have an increased risk of CV events and often have some degree of end organ damage Use home or ambulatory monitoring to sort out

20. Home and Ambulatory BP Monitoring (ABPM) Often lower than office readings Useful to “calibrate” home monitors Nocturnal Dip (10-20% fall during the night) is physiologically important (Dippers vs. Non-Dippers) Can identify “windows of poor control” or windows of low BP and correlate with perceived symptoms

21. Checking blood pressure at home Some monitors are inaccurate and are not calibrated. Wrist monitors are not usually accurate. Can givemultiple recordings and help in the management of white coat hypertension. Involves patient in the management. Results should be factored up by 10/5.

22. Routine Laboratory Tests Investigation of all patients with hypertension 1. Urinalysis 2. Complete blood count 3. Blood chemistry (potassium, sodium and creatinine) 4. Fasting glucose 5. Fasting total cholesterol and high density lipoprotein cholesterol (HDL), low density lipoprotein cholesterol (LDL), triglycerides 6. Standard 12-leads ECG

23. Optional Laboratory Tests Investigation for specific patient subgroups • For those with diabetes or renal disease:assess urinary protein excretion, since lower blood pressure targets are appropriate if proteinuria is present. • Other secondary forms of hypertension require specific testing.

24. What do labs mean? • CBC: Look for elevated Hb/HCT • Chem7: Look for low K, elevated Bun/Cr, • elevated Ca. Calc GFR • U/A: Look for protein/blood • Alb:Cr ratio: Look for microscopic albumin • FLP: Look for abnormal lipids • EKG: Look for LVH, CAD, arrhythmia

25. Lifestyle Recommendations for Prevention of Hypertension for NON-Hypertensive Individuals. Healthy diet:High in fresh fruits, vegetables and low fat diary products, low in saturated fat and salt. Restriction of salt intake to less than 100 mmol/day in individuals considered salt-sensitive Maintenance of ideal body weight (BMI 18.5-24.9 kg/m2)

26. Lifestyle Recommendations for Prevention of Hypertension for NON-Hypertensive Individuals. • 4. Waist Circumference< 102 cm for men< 88 cm for women • 5. Regular physical activity: accumulation of 30-60 minutes of moderate intensity dynamic exercise 3-5/week at least 4/week • Smoke free environment • Abstinence from alcohol

27. True or False • For persons over age 50, DBP is more important than SBP as CVD risk factor.

28. False • For persons over age 50, SBP is a more important than DBP as CVD risk factor.

29. True or False • Those people whose BP is classified as prehypertensive should be initially treated with lifestyle modification from the time they are identified.

30. True • Those people whose BP is classified as prehypertensive should be initially treated with lifestyle modification from the time they are identified.

31. Normal blood pressure is defined in JNC 7 as: • <120/<70 • <120/<80 • 120-139/80-89 • 140-159/90-99 • ≥160/ ≥100

32. Which of the following is incorrect for the proper measurement of BP in the office setting? • Persons should be seated for at least 5 minutes resting before taking the BP • BP should be taken with the patient sitting on exam table with the arm relaxed in their lap • At least 2 measurements should be made • SBP is the point at which the first of two or more sounds is heard • DBP is the point before the disappearance of sound (phase 5)

33. THANKS