Hypertension 2014

1. Hypertension 2014 Family Medicine Richard Birtwhistle MD

2. CFPC Objectives- Hypertension • 1 Screen for hypertension. • 2 Use correct technique and equipment to measure blood pressure. • 3 Make the diagnosis of hypertension only after multiple BP readings (i.e., at different times and during different visits). • 4 In patients with an established diagnosis of hypertension, assess and re-evaluate periodically the overall cardiovascular risk and end-organ complications: • a) Take an appropriate history. • b) Do the appropriate physical examination. • c) Arrange appropriate laboratory investigations. • 5 In appropriate patients with hypertension (e.g., young patients requiring multiple medications, patients with an abdominal bruit, patients with hypokalemia in the absence of diuretics): • a) Suspect secondary hypertension. • b) Investigate appropriately. • 6 Suggest individualized lifestyle modifications to patients with hypertension. (e.g., weight loss, exercise, limit alcohol consumption, dietary changes). • 7 In a patient diagnosed with hypertension, treat the hypertension with appropriate pharmacologic therapy (e.g., consider the patient’s age, concomitant disorders, other cardiovascular risk factors). • 8 Given a patient with the signs and symptoms of hypertensive urgency or crisis, make the diagnosis and treat promptly. • 9 In all patients diagnosed with hypertension, assess response to treatment, medication compliance, and side effects at follow-up visits.

3. CFPC Objectives Hypertension • Screen for hypertension 2012 Canadian Task Force on Preventive Health Care Recommendations • We recommend blood pressure measurement at all appropriate primary care visitsi,ii). (Strong recommendation; moderate quality evidence) • We recommend that blood pressure be measured according to the current techniques described in the Canadian Hypertension Education Program (CHEP) recommendations for office and out-of-office (ambulatory) blood pressure measurement). (Strong recommendation; moderate quality evidence) • For people who are found to have an elevated blood pressure during screening, the CHEP criteria for assessment and diagnosis of hypertension should be applied to determine whether the patient meets diagnostic criteria for hypertension. (Strong recommendation; moderate quality evidence) • Use correct technique and equipment to measure blood pressure

4. Blood Pressure Assessment:Patient preparation and posture Standardized Preparation: Patient 1. No acute anxiety, stress or pain. 2. No caffeine,smoking or nicotine in the preceding 30 minutes. 3. No use of substances containing adrenergic stimulants such as phenylephrine or pseudoephedrine (may be present in nasal decongestants or ophthalmic drops). 4. Bladder and bowel comfortable. 5. No tight clothing on arm or forearm. 6. Quiet room with comfortabletemperature 7. Rest for at least 5 minutes before measurement 8. Patient should stay silent prior and during the procedure.

5. 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.

6. Recommended Equipment for Measuring Blood Pressure • Automated oscillometric devices: • Use a validated automated device according to BHS, AAMI or IP clinical protocols. • For home blood pressure measurement devices, a logo on the packaging ensures that this type of device and model meets the international standards for accurate blood pressure measurement. AAMI=Association for the Advancement of Medical Instrumentation; BHS=British Hypertension Society; IP: International Protocol.

7. Use an appropriate size cuff For automated devices, follow the manufacturer’s directions. For manual readings using a stethoscope and sphygmomanometer, use the table as a guide.

8. CFPC Objectives Hypertension • Screen for hypertension • Use correct technique and equipment to measure blood pressure • Make the diagnosis of hypertension only after multiple BP readings (i.e., at different times and during different visits).

9. Criteria for the diagnosis of hypertension and recommendations for follow-up Elevated Out of the Office BP measurement Elevated Random Office BP Measurement 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)

10. Diagnostic algorithm for high Blood Pressure including Office, ABPM and Home Blood Pressure Measurement BP: 140-179 / 90-109 Clinic BP ABPM (If available) HBPM Hypertension visit 3 ≥ 160 SBP or ≥ 100 DBP Diagnosis of HTN ≥ 135 SBP or ≥ DBP 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 < 160 / 100 ABPM or HBPM 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 Continue to follow-up < 140 / 90

11. CFPC Objectives Hypertension • In patients with an established diagnosis of hypertension, assess and re-evaluate periodically the overall cardiovascular risk and end-organ complications: a) Take an appropriate history. b) Do the appropriate physical examination. c) Arrange appropriate laboratory investigations. • In appropriate patients with hypertension (e.g., young patients requiring multiple medications, patients with an abdominal bruit, patients with hypokalemia in the absence of diuretics): a) Suspect secondary hypertension. b) Investigate appropriately.

12. Diagnostic Work-Up • History and physical • Review for CV risk factors, evidence of TOD and HTN and monitor treatment • Routine laboratory tests (grade D) • Urinalysis • CBC, blood chemistry (potassium, sodium, creatinine), fasting glucose, fasting TC, HDL, LDL, triglycerides • Standard 12-lead ECG • Lab tests for specific subgroups • Diabetes & renal disease: protein excretion • Elevated creatinine, hx of renal disease or proteinuria - renal ultrasound

13. 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

14. Hypertension Male Increasing age Peripheral arterial disease Previous stroke or TIA Microalbuminuria or proteinuria Diabetes mellitus Smoking Source: 2011 CHEP Recommendations Family history of premature CVD Chronic kidney disease Abnormal lipid profile Sedentary lifestyle Left ventricular hypertrophy Search for Cardiovascular Risk Factors

15. 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 III. Assessment of the overall cardiovascular risk

16. CFPC Objectives Hypertension • Suggest individualized lifestyle modifications to patients with hypertension. (e.g., weight loss, exercise, limit alcohol consumption, dietary changes). • In a patient diagnosed with hypertension, treat the hypertension with appropriate pharmacologic therapy (e.g., consider the patient’s age, concomitant disorders, other cardiovascular risk factors).

17. Lifestyle Recommendations for Prevention and Treatment of Hypertension To reduce the possibility of becoming hypertensive, Reduce sodium intake to less than 1500 mg/day • Healthy diet: high in fresh fruits, vegetables, low fat dairy products, dietary and soluble fibre, whole grains and protein from plant sources, low in saturated fat, cholesterol and salt in accordance with Canada's Guide to Healthy Eating. • Regular physical activity: accumulation of 30-60 minutes of moderate intensity dynamic exercise 4-7 days per week in addition to daily activities; For non-hypertensive or stage 1 hypertensive individuals, the use of resistance or weight training exercise (such as free weight lifting, fixed-weight lifting, or handgrip exercise) does not adversely influence blood pressure. • Low risk alcohol consumption: (≤2 standard drinks/day and less than 14/week for men and less than 9/week for women) • Attaining and maintaining ideal body weight (BMI 18.5-24.9 kg/m2) • Waist Circumference: Men <102 cm Women <88 cm • Tobacco free environment

18. I. Indications for Pharmacotherapy Usual blood pressure threshold values for initiation of pharmacological treatment of hypertension

19. Indications for Pharmacotherapyafter diagnosis of hypertension (1) • Patients at low risk with stage 1 hypertension (140-159/90-99 mmHg) • lifestyle modification can be the sole therapy. • Patients with target organ damage(e.g. left ventricular hypertrophy) or chronic kidney disease (140-159/90-99 mmHg) • Treat with pharmacotherapy • Patients with diabetes should continue to be considered for pharmacotherapy if the blood pressure is equal or over 130/80 mmHg

20. ARB ACEI V. Treatment of Adults with Systolic/Diastolic Hypertension without Other Compelling Indications TARGET <140/90 mmHg INITIAL TREATMENT AND MONOTHERAPY Lifestyle modification therapy Thiazide Long acting CCB Beta-blocker* A combination of 2 first line drugs may be considered as initial therapy if the blood pressure is >20 mmHg systolic or >10 mmHg diastolic above target • BBs are not indicated as first line therapy for age 60 and above ACEI, ARB and direct renin inhibitors are contraindicated in pregnancy and caution is required in prescribing to women of child bearing potential

21. V.Considerations Regarding the Choice of First-Line Therapy • Use caution in initiating therapy with 2 drugs in whom adverse events are more likely (e.g. frail elderly, those with postural hypotension or who are dehydrated). • ACE inhibitors, renin inhibitors and ARBs are contraindicated in pregnancy and caution is required in prescribing to women of child bearing potential. • Beta adrenergic blockers are not recommended for patients age 60 and over without another compelling indication. • Diuretic-induced hypokalemia should be avoided through the use of potassium sparing agents if required. • The use of dual therapy with an ACE inhibitor and an ARB should only be considered in selected and closely monitored people with advanced heart failure or proteinuric nephropathy. • ACE-inhibitors are not recommended (as monotherapy)for black patients without another compelling indication.

22. 1. Add-on Therapy • IF BLOOD PRESSURE IS NOT CONTROLLED CONSIDER • Nonadherence • Secondary HTN • Interfering drugs or lifestyle • White coat effect 2. Triple or Quadruple Therapy V. Add-on Therapy for Systolic/Diastolic Hypertension without Other Compelling Indications If partial response to monotherapy If blood pressure is still not controlled, or there are adverse effects, other classes of antihypertensive drugs may be combined (such as alpha blockers or centrally acting agents).

23. Drug Combinations When combining drugs, use first-line therapies. Two drug combinations of beta blockers, ACE inhibitors and angiotensin receptor blockers have not been proven to have additive hypotensive effects. Therefore these potential two drug combinations should not be used unless there is a compelling (non blood pressure lowering) indication Combinations of an ACEI with an ARB do not reduce cardiovascular events more than the ACEI alone and have more adverse effects therefore are not generally recommended

24. Drug Combinations cont’d Caution should be exercised in combining a non dihydropyridine CCB (eg verapamil or diltiazem) and a beta blocker to reduce the risk of bradycardia or heart block. Monitor serum creatinine and potassium when combining K sparing diuretics, ACE inhibitors and/or angiotensin receptor blockers. If a diuretic is not used as first or second line therapy, triple dose therapy should include a diuretic, when not contraindicated.

25. III. Treatment Algorithm for Isolated Systolic Hypertension without Other Compelling Indications TARGET <140 mmHg (< 150 mmHg if age > 80 years) INITIAL TREATMENT AND MONOTHERAPY Lifestyle modification therapy Thiazide diuretic ARB Long-acting DHP CCB

26. VI. Treatment of Hypertension in Patients with Ischemic Heart Disease 1. Beta-blocker 2. Long-acting CCB Stable angina ACEI are recommended for most patients with established CAD* ARBs are not inferior to ACEI in IHD Short-acting nifedipine • • Caution should be exercised when combining a non DHP-CCB and a beta-blocker • • If abnormal systolic left ventricular function: avoid non DHP-CCB (Verapamil or Diltiazem) • Dual therapy with an ACEI and an ARB are not recommended in the absence of refractory heart failure • The combination of an ACEi and CCB is preferred *Those at low risk with well controlled risk factors may not benefit from ACEI therapy

27. VI. Treatment of Hypertension in Patients with Recent ST Segment Elevation-MI or non-ST Segment Elevation-MI Beta-blocker and ACEI or ARB Recent myocardial infarction If beta-blocker contraindicated or not effective Long-acting Dihydropyridine CCB* YES Heart Failure ? NO Long-acting CCB *Avoid non dihydropyridine CCBs (diltiazem, verapamil)

28. VII. Treatment of Hypertension with Left Ventricular Systolic Dysfunction Non dihydropyridine CCB • ACEI and Beta blocker • if ACEI intolerant: ARB Titrate doses of ACEI or ARB to those used in clinical trials Systolic cardiac dysfunction • If additional therapy is needed: • Diuretic (Thiazide for hypertension; Loop for volume control) • for CHF class III-IV or post MI: Aldosterone Antagonist If ACEI and ARB are contraindicated: Hydralazine and Isosorbide dinitrate in combination If additional antihypertensive therapy is needed: • ACEI / ARB Combination • Long-acting DHP-CCB (Amlodipine) Beta-blockers used in clinical trials were bisoprolol, carvedilol and metoprolol.

29. VIII. Treatment of Hypertensionfor Patients with Cerebrovascular Disease Strongly consider blood pressure reduction in all patients after the acute phase of stroke or TIA . An ACEI / diuretic combination is preferred Stroke TIA Combinations of an ACEI with an ARB are not recommended

30. IX. Treatment of Hypertension in Patients with Left Ventricular Hypertrophy Left ventricular hypertrophy Vasodilators: Hydralazine, Minoxidil can increase LVH Hypertensive patients with left ventricular hypertrophy should be treated with antihypertensive therapy to lower the rate of subsequent cardiovascular events. • ACEI • ARB, • CCB • Thiazide Diuretic • - BB (if age below 60)*

31. X. Treatment of Hypertension in Patients with Non Diabetic Chronic Kidney Disease Target BP: < 140/80 mmHg ACEI/ARB: Bilateral renal artery stenosis Chronic kidney disease and proteinuria * ACEI or ARB (if ACEI tolerated) Additive therapy: Thiazide diuretic. Alternate: If volume overload: loop diuretic Combination with other agents * albumin:creatinine ratio [ACR] > 30 mg/mmol or urinary protein > 500 mg/24hr Monitor serum potassium and creatinine carefully in patients with CKD prescribed an ACEI or ARB Combinations of a ACEI and a ARB are specifically not recommended in the absence of proteinuria

32. XI. Treatment of Hypertension in Patients with Renovascular Disease Does not imply specific treatment choice Renovascular disease Caution in the use of ACEI or ARB in bilateral renal artery stenosis or unilateral disease with solitary kidney Close follow-up and intervention (angioplasty and stenting or surgery) should be considered for patients with: uncontrolled hypertension despite therapy with three or more drugs, or deteriorating renal function, or bilateral atherosclerotic renal artery lesions (or tight atherosclerotic stenosis in a single kidney), or recurrent episodes of flash pulmonary edema

33. Treatment of Hypertension in association with Diabetes Mellitus with Nephropathy Diabetes Threshold equal or over 130/80 mmHg and TARGET below 130/80 mmHg A combination of 2 first line drugs may be considered as initial therapy if the blood pressure is >20 mmHg systolic or >10 mmHg diastolic above target. Combining an ACEi and a DHP-CCB is recommended. ACE Inhibitor or ARB 1. ACE Inhibitor or ARB or 2. DHP-CCB or Thiazide diuretic without Nephropathy > 2-drug combinations Monitor serum potassium and creatinine carefully in patients with CKD prescribed an ACEI or ARB Combinations of an ACEI with an ARB are specifically not recommended in the absence of proteinuria More than 3 drugs may be needed to reach target values for diabetic patients If Creatinine over 150 µmol/L or creatinine clearance below 30 ml/min ( 0.5 ml/sec), a loop diuretic should be substituted for a thiazide diuretic if control of volume is desired

34. CFPC Objectives Hypertension • Given a patient with the signs and symptoms of hypertensive urgency or crisis, make the diagnosis and treat promptly.

35. Management of a Hypertensive Emergency • Physical examination • Neurological examination • Cardiovascular exam • Fundoscopic exam • Investigations • Renal fn • ECG • Head CT/MRI if evidence of stroke sx

36. Management of a Hypertensive Emergency • Treatment • Rest in quiet room • IV nitroprusside, nicardipine, clevidipine or labetolol for those with acute neuro, renal or cardiac symptoms • Oral diuretic (lasix or hydrochlorothiazide) plus clonidine, CCB, ACE/ARB, B blocker for those who are asymptomatic and with normal renal function • * do not use sublingual nifedipine or captopril

37. CFPC Objectives Hypertension • In all patients diagnosed with hypertension, assess response to treatment, medication compliance, and side effects at follow-up visits.

38. Canadian Hypertension Education Program http://hypertension.ca/chep/