HYPERTENSION Workshop

1. HYPERTENSION Workshop September, 2007 Information was produced and/or compiled by the Alberta Provincial Stroke Strategy and written permission is required prior to reprinting any of the material located within this document. 09/07:09/08[R]

2. High Blood PressureGet the Low Down!

3. Average Canadian

4. Who Has Hypertension? • What is the chance he has hypertension? • What is the chance he will get hypertension if not already? • If he has hypertension, what is the chance he knows his BP is high? • If he has hypertension, what is the chance he is treated and controlled?

5. The Challenge In Canada • Hypertension is a problem which increases with age • Hypertension is often unidentified • if identified - is poorly treated. • Recent data is showing that identification and management of hypertension in Canada has improved over the past few years.

6. We Need to Make a Difference!

7. What can be the result of hypertension?Hypertension increases the risk of what health problems?

8. Hypertension is a Major Risk Factor • Untreated high blood pressure increases risk of: • Stroke (4 times > risk hemorrhagic stroke) • Coronary Artery Disease • Congestive heart failure • Chronic Kidney Disease • Peripheral vascular disease • Dementia • Atrial Fibrillation • Effective treatment has been shown to reduce the risk of recurrent stroke and to reduce cognitive decline in patients with dementia Source: 2007 CHEP Recommendations

9. Hypertension • Stroke mortality doubles for every 20 mmHg increase in SBP or 10 mmHg increase in DBP • Prospective Studies Collaboration. Age-specific relevance of usual blood pressure to vascular mortality: A meta-analysis of individual data for one million adults in 61 prospective studies. Lancet 2002;360:1903-13.

10. Benefits of Treating Hypertension • Younger than 60 • reduces the risk of stroke by 42% • reduces the risk of coronary event by 14% • Older than 60 • reduces overall mortality by 20% • reduces cardiovascular mortality by 33% • reduces incidence of stroke by 40% • reduces coronary artery disease by 15% Source: 2007 CHEP Recommendations

11. What Are the Benefits of Treating Hypertension? For a decrease of 10/5 mm Hg (one medication or a change in lifestyle): • Heart attack by 15% • Heart failure by 50% • Stroke by 38% • Death by 10% Source: 2007 CHEP Recommendations

12. Lets get the Low Down on Hypertension • What is blood pressure? • Causes of hypertension • How to measure blood pressure • Diagnosis of hypertension • Types of hypertension • Lifestyle and Pharmaceutical treatment • BP target values • Review highlights of 2007 CHEP recommendations

13. What Is Blood Pressure? • Blood pressure is the amount of force on the walls of the arteries as the blood circulates around the body.

14. What is Blood Pressure? Systolic Pressure in the blood vessels as the heart beats or contracts & fills them with blood (i.e. 130) Diastolic The pressure in the blood vessels as the heart relaxes in between beats. (i.e. 80)

15. What is Blood Pressure? • Blood pressure goes up and down naturally throughout the day, and from one day to another. • A healthy blood pressure reading is less than 130/80 mmHg on a regular basis. • A client has high blood pressure if average or usual: • readings are ≥ 140/90 • readings are ≥ 130/80 ( for those with diabetes or chronic kidney disease) • High blood pressure = hypertension

16. 5 Factors Controlling Blood Pressure • Cardiac output • Peripheral Vascular Resistance • Volume of circulating blood • Viscosity • Elasticity of vessel walls

17. Classification of Hypertension The category pertains to the highest risk blood pressure *ISH=International Society of Hypertension. Chalmers J et al. J Hypertens 1999;17:151-85. Source: 2007 CHEP Recommendations

18. Blood pressure target values for treatment of hypertension Source: 2007 CHEP Recommendations

19. What Causes HYPERTENSION ? • POOR LIFESTYLE!! - interaction between genetics and environment. • 1 in 20 people a diseasesuch as of the kidneys

20. Factors that affect Blood Pressure • Age • Sex • Race • Diurnal Rhythm • Genetics • Obesity • Exercise • Emotions • Stress • Diet • Alcohol

21. Symptoms of High Blood Pressure Called the “Silent Killer” Usually no symptoms until initial event (Stroke or cardiac event) If symptoms are present this may be due to secondary hypertension or complications of hypertension

22. BP Measurement Technique Demonstrate: What is good technique? What should have been done?

23. BP Measurement Technique: 1)Client should rest for 5 minutes in a quiet comfortable room prior to the measurement. Should be in a sitting position with back supported and legs not crossed. 2) Select the appropriate cuff size as follows:

24. BP Measurement Technique: 3) Bare arm in a supported position, with antecubital fossa @ heart level. 4) Find brachial pulse (inner part of the arm near the elbow) using index & middle fingers.

25. BP Measurement Technique: 5)Apply the appropriate size cuff to the arm by positioning the center of the inflatable bladder directly over the brachial artery & secure snugly. • Ensure the lower edge of the cuff is 2cm above the elbow crease. NOTE: The bladder inside the cuff should encircle: • 80% of the arm in adults • 100% of the arm in children < 13years.

26. BP Measurement Technique: 6) Locate the client’s radial pulse on the thumb side of the wrist.

27. BP Measurement Technique: 7) Place manometer so center of the mercury column, or aneroid dial, is easily visible - Ensure tubing is unobstructed. 8) Take the clients pulse & rapidly increase the cuff pressure. Note the reading when the radialpulse disappears while deflating the cuff by releasing the valve all the way

28. BP Measurement Technique: 8) Locate brachial artery & place stethoscope gently but firmly over the artery, just below the lower edge of the cuff. 9) The column of mercury must be @ zero before the procedure begins, or the needle on the aneroid devise must be opposite zero when the cuff is deflated.

29. BP Measurement Technique: 10) Inflate the cuff rapidly to a pressure 20-30 mmHg above the previously determined level (based on the disappearance of the radial pulse). 11) Let the cuff deflate by slowly releasing the valve and allowing the mercury or needle to drop @ a rate of 2-3mmHg per second or per pulse beat while listening for audible Korotkoff sounds.

30. BP Measurement Technique: • Systolic: The 1st appearance of a clear tapping sound on the manometer (phase 1 Korotkoff). Note the reading on the manometer. • Diastolic: The point @ which the sound disappears on the manometer (phase V Korotkoff). Note the reading on the manometer.

31. BP Measurement Technique: • Once BP completed, record the Systolic & Diastolic numbers immediately. • Explain target values for BP to the client & provide education regarding the clients BP value and/or lifestyle modifications that may be helpful. • Contact the physician as required to report elevated BP values.

32. Rest for 5 minutes prior to measurement Calm, comfortable environment No tight clothing on arm or forearm No crossing of legs No talking during measurement No smoking 15-30 minutes prior No caffeine 1 hour prior No strenuous exercise 1 hour prior Ensure bladder is empty Appropriate cuff size Tips to Ensure an Accurate BP Measurement:

33. What is your Blood Pressure Measurement?

34. Sources of Potential Errors in BP Measurement:

35. No waiting time prior to measurement Arm positioned inappropriately Presence of background noise or conversation Rounding figures up or down Inappropriate cuff size or position of cuff Inadequate deflation of the cuff (too quickly or slowly) Instrument not calibrated Sources of Potential Errors in BP Measurement:

36. Types of BP Monitors: 1) Mercury Manometer: Usually fixed to a wall mount, or a portable unit on wheels. 2) Electronic Device: A portable unit which is most often used for home BP monitoring.

37. Types of BP Monitors: 3) Aneroid Manometer: Can be fixed to a wall mount, a portable hand held unit, or a portable unit on wheels. • Not Recommended: • May go out of calibration • 40% used are out of calibration • Require regular assessment of calibration every 6 - 12 months • A systematic process should be in place to ensure accuracy

38. 2007 Canadian Hypertension Education Program Recommendations • Annual process to develop and update evidence-based recommendations for HTN management • Incorporated all trials and meta-analyses published in the past year felt to have relevance for individuals with hypertension • The 2007 unabridged and “bottom line” reports available at www.hypertension.ca • CHEP is jointly sponsored by the Canadian Hypertension Society, Blood Pressure Canada, the Public Health Agency of Canada, the Heart and Stroke Foundation of Canada, the College of Family Physicians of Canada, the Canadian Council of Cardiovascular Nurses, the Canadian Pharmacists Association

39. Treat Hypertension in the Context of Overall Cardiovascular Risk • Assess global cardiovascular risk • The management plan for patients with hypertension must be based on their global cardiovascular risk • Consider informing patients of their global risk to improve the effectiveness of risk modification • Shared decision-making may improve the effectiveness of preventive health interventions. Simply counting risk factors may be misleading Source: 2007 Canadian Hypertension Education Program Recommendations

40. Diagnosing Hypertension

41. Assess blood pressure at all appropriate visits Blood pressure of all adults should be measured, whenever appropriate, by trained healthcare professionals using standardized techniques. • To screen for hypertension • To assess cardiovascular risk • To monitor antihypertensive treatment Assess blood pressure annually in those with high normal blood pressure. Source: 2007 Canadian Hypertension Education Program Recommendations

42. 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 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 Source: 2007 CHEP Recommendations

43. Clinic BP 24-h ABPM (If available) Home BPM(If available) Hypertension visit 3 >160 SBP or >100 DBP Diagnosis of HTN >135/85 < 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 ABPM or S/H BPM if available <160 /100 or or Hypertension visit 4-5 >140 SBP or >90 DBP Diagnosis of HTN Continue to follow-up Diagnosis of HTN Continue to follow-up Diagnosis of HTN < 140 / 90 Continue to follow-up 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. Source: 2007 CHEP Recommendations

44. Case #1 • Mr. W. is a 58 year old Sr. Administrator for a Health Region in Alberta. Seen in clinic to follow-up on BP 164/92 taken at a pharmacy • BPs during this visit 156/90 & 160/92 • Interview and review of the medical chart reveals: • Height 6 ’1” and weight 215 lbs (BMI 28.4 kg/m2) • Review of systems normal • Social drinker (~4 glasses of wine/week) • Quit smoking 10 years ago • No routine physical activity • Family history of CVD (father died at age 50 from MI) • Married, four children Is he hypertensive?

45. Diagnostic Work-Up • Check BP at all appropriate visits • Use standardized measurement technique: • Have patient rest for 5 minutes • Use a validated & calibrated device • Cuff encircles 80% of upper arm • Measure both arms at initial visit • Thereafter take 2 measurements on the side where BP is higher

46. Diagnostic Work-Up, cont… • History and physical • Review for CV risk factors, evidence of Target Organ Damage and HTN, monitor treatment • Routine laboratory tests • Urinalysis • blood chemistry (potassium, sodium, creatinine), fasting glucose, fasting TC, HDL, LDL, triglycerides • Standard 12-lead ECG • Lab tests for specific subgroups • Diabetes & renal disease: urinary albumin excretion • increased creatinine, hx of renal disease or proteinuria - renal ultrasound

47. Hypertension Male Increasing age Peripheral arterial disease Previous stroke or TIA Microalbuminuria or proteinuria Diabetes mellitus Smoking Family history of premature CVD Chronic kidney disease Abnormal lipid profile Sedentary lifestyle Left ventricular hypertrophy Abdominal obesity Coronary Artery Disease Search for Cardiovascular Risk Factors Source: 2007 CHEP Recommendations

48. Search for Target Organ Damage Cerebrovascular TIA Ischemic or Hemorrhagic Stroke Hypertensive retinopathy Left ventricular dysfunction Coronary artery disease Angina or prior MI CHF Chronic kidney disease Peripheral arterial disease Source: 2007 CHEP Recommendations

49. Case #1 Visit 2

50. LDL=3.1 mmol/L TC = 4.85 mmol/L TG=2.2 mmol/L HDL =1.32 mmol/L Normal 12 lead ECG Weight 7.5 lbs since first visit No routine physical activity BP 158/100 mmHg No evidence of Target Organ Damage Normal urinalysis Serum potassium=4.5 mmol/L (3.5-5.0) Serum creatinine 97 mmol/L (50-120) Fasting glucose=5.1 mmol/L Case #1: Visit 2 • Is he hypertensive? • What are the treatment and management options?