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APPROACH TO HYPERTENSION IN PRIMARY CARE

APPROACH TO HYPERTENSION IN PRIMARY CARE. Doç. Dr. Nurver Turfaner Department of Family Medicine. Benefits of Controlling Hypertension.

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APPROACH TO HYPERTENSION IN PRIMARY CARE

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  1. APPROACH TO HYPERTENSION IN PRIMARY CARE

  2. Doç. Dr. NurverTurfaner • Department of FamilyMedicine

  3. Benefits of ControllingHypertension • By controlling hypertension, the risk of myocardial infarction is reduced up to 25%, the risk of stroke can be reduced by up to 40% and the risk of congestive heart failure can be reduced to the half. The treatment of isolated systolic hypertension in the elderly reduces overall mortality by 13%.

  4. PathologicConsequences of Hypertension • Hypertension is an independent predisposing factor for heart failure, coronary artery disease, stroke, renal disease and peripheral arterial disease.

  5. HEART • Heart disease is the most common cause of death in hypertensive patients. Hypertensive heart disease is the result of structural and functional adaptations leading to left ventricular hypertrophy, (CHF), abnormalities of blood flow due to atherosclerotic coronary artery disease or microvascular disease, and cardiac arrhythmias..

  6. HEART • Individuals with left ventricular hypertrophy are at increased risk for CHD, stroke, CHF, and sudden death. Aggressive control of hypertension can regress or reverse left ventricular hypertrophy and reduce the risk of cardiovascular disease

  7. BRAIN • Stroke is themostfrequentcause of death in theworld; it accountsfor 5 milliondeathseachyear, with an additional 15 millionpersonshavingnon-fatalstrokes. Elevatedbloodpressure is thestrongest risk factorforstroke. Theincidence of strokerisesprogressivelywithincreasingbloodpressurelevels, particularlysystolicbloodpressure in individuals >65 years. Treatment of hypertensionconvincinglydecreasestheincidence of bothischemicandhemorrhagicstrokes.

  8. KIDNEY • Thekidney is both a targetand a cause of hypertension. Primaryrenaldisease is themostcommonetiology of secondaryhypertension. Renal risk appearsto be morecloselyrelatedtosystolicthentodiastolicbloodpressure. Proteinuria is a reliable marker of theseverity of chronicrenaldiseaseand is a predictor of itsprogression. Patientswithhighurine proteine excretion (> 3 gr/24 hours) have a morerapid rate of progression.

  9. KIDNEY • Clinically, macroalbuminuria (a random urine albumine/creatinine ratio>300 mg/g) or microalbuminuria (a random urine albumine/creatinine ratio 30-300mg/g) are early markers of renal injury. These are also risk factors for renal disease progression and cardiovascular disease.

  10. Peripheral Arteries • Inadditiontocontributingtothepathogenesis of hypertension, bloodvesselsmay be a target organ foratherosclereoticdiseasesecondarytolong- standingelevatedbloodpressure. Intermittantclaudication is theclassicsymptom of PAD (Peripheralarterialdisease). Theankle-brachialindex is defined as theratio of non-invasivelyassessedankletobrachial (arm) systolicbloodpressure. An ankle-brachialindex < 0.90 is considereddiagnostic of PAD and is associatedwith > 50% stenosis in at leastonemajorlowerlimbvessel.

  11. ClinicalDisorders of Hypertension • Depending on methods of patientascertainment 80-95% of hypertensivepatientsarediagnosed as havingessentialhypertension (alsoreferredto as primaryoridiopathichypertension). Intheremaining 5-20 % of hypertensivepatients, a specificunderlyingdisordercausingtheelevation of bloodpressure can be identified.

  12. ESSENTIAL HYPERTENSION • Essential hypertension tends to be familial and is likely to be the consequence of an interaction between environmental and genetic factors. The prevalance of essential hypertension increases with age.

  13. OBESITY AND METABOLIC SYNDROME • There is a well documented association between obesity (body mass index> 40 kg/m2) and hypertension. Centrally located body fat is a more important determinant of blood pressure evaluation than is peripheral body fat. It has been established that 60-70% of hypertension in adults may be directly attributable to adiposity.

  14. OBESITY AND METABOLIC SYNDROME • Hypertension and dyslipidemia frequently occur together and in association with resistance to insulin-stimulated glucose uptake. • The constellation of insuline resistance, abdominal obesity, hypertension, and dyslipidemia has been designated as the metabolic syndrome.

  15. RENAL PARENCHYMAL DISEASES • Nearlyalldisorders of thekidneymaycausehypertensionandrenaldisease is themostcommoncause of secondaryhypertension. • Hypertension is present in morethan 80% of patientswithchronicrenalfailure. Conversely, hypertensionmaycausenephrosclerosis,and in someinstances it may be difficulttodeterminewhetherhypertensionorrenaldisaeasewastheinitialdisorder. Proteinuria >1000mg/dayand an activeurinesedimentareindicative of primaryrenaldisease.

  16. RENOVASCULAR HYPERTENSION • Hypertension due to an occlusive lesion of a renal artery, renovascular hypertension, is a potentially curable form of hypertension. • It is mostly seen in older atherosclerotic patients who have a plaque obstructing the renal artery and patients with fibromuscular dysplasia.

  17. RENOVASCULAR HYPERTENSION • Although fibromuscular dysplasia may occur at any age, it has a strong predilection for young women. The prevalance in females is 8 fold than in males. • Contrast arteriography is the gold standard for evaluation and identification of renal artery lesions. • PTRA (Percutaneus Transluminal Renal Angioplasty) is the initial treatment. Surgical revascularization may be undertaken if PTRA is unsuccessful.

  18. PRIMARY ALDOSTERONISM • Primary aldosteronism should be considered in all patients with refractory hypertension. In a hypertensive patient with unprovoked hypokalemia (i.e, unrelated to diuretics,vomiting or diarrhea), the prevalance of primary hyperaldosteronism approaches 40-50%. • In patients on diuretics, serum potassium<3.1 meq/L also raises the possibility of primary hyperaldosteronism.

  19. BloodPressureClassification

  20. Measurement of Blood Pressure • Theprimary test usedtoscreenforhypertension is measurementwithmercuryor a calibratedaneroidorelectronicsphygmomanometerby a trainedtechnician • Thepatientshould be properlypositionedafter at least a 5-minute rest • Continuous 24- hourbloodpressuremonitoring has beenshownto be morepredictive of end-organ damagethanstandardofficemeasurement.

  21. Measurement of Blood Pressure • Office-basedmeasurementsaretypically done withsphygmomanometer. Theaccuracydepends on theexaminer, patientfactors, andtheinstrumentused. • Twomeasurements at seperatevisitsarenecessaryfordiagnosis. • Alternativestoofficemeasurements: • Homemonitors • Ambulatorymeasurement: Identifiespatientswith ‘WhitecoatHypertension’

  22. Proper training of observers, • Positioning of the patient • Selection of cuff-size are essential. • Recent regulations prevent the use of mercury potential toxicity!! • Office measurements are made with aneroid sphygmomanometers or with oscillometric devices. • Instruments should be calibrated periodically and their accuracy should be confirmed.

  23. Measurement of Blood Pressure • Thecenter of thecuffshould be at heartlevelandthewidth of thebladdercuffshouldequal at least 40% of thearmcircumference; thelength of thecuffbladdershould be enoughtoencircle at least 80% of thearmcircumference. • Systolicbloodpressure is thefirst of at leasttworegular ‘tapping’ Korotkoffsounds, anddiastolicbloodpressure is thepoint at whichthelastregularKorotkoffsound is heard.

  24. Patient’s Relevant History • Duration of hypertension • Previoustherapies: responsesandsideeffects • Familyhistory of hypertensionandcardiovasculardisease • Dietaryandpsychosocialhistory • Other risk factors: weightchange, dyslipidemia, smoking, diabetes,physicalinactivity

  25. Patient’s Relevant History • Evidence of secondaryhypertension: history of renaldisease; change in appearance; muscleweakness; spells of sweating, palpitations,tremor; erraticsleep, snoring, daytimesomnolence; symptoms of hypo-orhyperthyroidism; use of agentsthatmayincreasebloodpressure • Evidence of target organ: history of TIA, stroke, transientblindness; angina, myocardialinfarction, congestiveheartfailure; sexualfunction • Othercomorbidities

  26. BasicLaboratoryTestsforInitialEvaluation

  27. Lifestyle Modifications to Manage Hypertension

  28. Risk Factors For Hypertension • Hypertensionincreaseswithageand a normotensiveadult at age 55 has upto 90% lifetime risk of becominghypertensive. • Tobacco • Alcohol • Overweightandobesity • Sedentary life-style • Inadequatefruit, vegetable, K intake • Excesssodiumintake • allcontributetohypertension.

  29. TREATMENT • Inuncomplicatedhypertension: thespecificchoice of drug is lessimportantthantheattainment of goalbloodpressure. • Ifbloodpressure is morethan 20/10 mm Hgabovetargetlevel : twoantihypertensivemedications • Oneshouldusually be hydrochlorothiazide

  30. TREATMENT • JNC 7 encouragestheuse of specificantihypertensiveagentsforhypertension. • Life-stylemodification is an importantcomponent of hypertensionmanagement. • TreatmentwithACE inhibitorsandARB’s isassociatedwithdecreased risk of new-onsetdiabetesmellitusin patientswithhypertension.

  31. TREATMENT • Pre-hypertension: SBP: 120-139 mmHg • DBP: 80-89 mmHg • Stage 1 hypertension: SBP: 140-159 mmHg • DBP: 90-99 mmHg • Life-style and diet modification (only) • Stage 1 Hypertension+ Diabetes or cardiovascular disease: Pharmacotherapy+Diuretics • Aerobic Exercise: (45-60 min.), at least 3 days/per week, preferably daily

  32. Diet in Hypertension • Low salt, low-fat, high-fruit, high vegetable diet, limited alcohol consumption (fever than two drinks/day) • Modest weight loss (3% to 9% of total body weight) • Na restriction It is more effective in blacks In whites: SBP decreases by 4.2 mmHg DBP decreases by 2.0 mmHg In blacks: SBP decreases by 6.4 mmHg DBP decreases by 2.0 mmHg Limit of sodium intake daily: 2-4 g/day (stage 1 and prehypertension)

  33. DASH DIET: dietaryapproachto stop hypertension • Low in saturated fat • High in fruits and vegetables (8-10 servings • High in low fat dairy products Results in: ↓ SBP:>11 mmHg ↓DBP: >5 mmHg + Na restriction (<2g daily) ↑Fiber intake, ↑K intake

  34. PharmacologicTreatment of Hypertension Thiazide Diuretic Plus: • ACE inhibitor • Aldosterone antagonist • Angiotensin receptor blocker • Β-blocker • Calcium channel blocker

  35. PharmacologicTreatment of Hypertension Calcium Channel Blocker Plus: ACE inhibitor Angiotensin receptor blocker Β-blocker

  36. THANKS YOU FOR YOUR ATTENTION

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