Management of hypertension

1. Management of hypertension Dr. Sadananda

2. Grade 1 hypertension Grade 2 Grade 3 Isolated systolic hypertension Grade 1 Grade 2 140-159 / 90-99 160-179 / 100-109 >180 / >110 140-159 / <90 > 160 / <90 BHS Classification of blood pressure levels

3. Routine use of ambulatory BP monitoring is not recommended

4. Hypertension Management Issues Measurement Investigation Non-pharmacological treatment Thresholds for drug treatment Targets for drug treatment Drug choices Other treatments Follow up/ referral

5. Routine investigations • Urine strip test for protein and blood • Serum creatinine and electrolytes • Blood glucose - ideally fasted • Blood lipid profile (at least total and high density lipoprotein (HDL) cholesterol) – ideally fasted for consideration of triglycerides • Electrocardiogram

8. Lifestyle measures • Maintain normal weight for adults (body mass index 20-25 kg/m2) • Reduce salt intake to <100 mmol/day (<6g NaCl or <2.4 g Na+/day) • Limit alcohol consumption to 3 units/day for men and 2 units/day for women • Engage in regular aerobic physical exercise (brisk walking rather than weight lifting) for 30 minutes per day, ideally on most of days of the week but at least on three days of the week • Consume at least five portions/day of fresh fruit and vegetables • Reduce the intake of total and saturated fat

10. Suggested target blood pressures during antihypertensive treatment. Systolic and diastolic blood pressures should both be attained, e.g. <140/85 mmHg means less than 140 mmHg for systolic blood pressure and less than 85 mmHg for diastolic blood pressure Clinic BP (mmHg) No diabetesDiabetes Optimal treated BP pressure<140/85<130/80 Audit Standard<150/90 <140/80 Audit standard reflects the minimum recommended levels of blood pressure control. Despite best practice, the Audit Standard will not be achievable in all treated hypertensives. For ambulatory (mean daytime) or home blood pressure monitoring - reducing these targets by ~10/5 is recommended.

12. Beta Blockers • women of childbearing potential • patients with evidence of increased sympathetic drive • patients with intolerance of or contraindications to ACE inhibitors and angiotensin-II receptor antagonists • If a patient taking a beta-blocker needs a second drug, add a calcium-channel blocker rather than a thiazide-type diuretic, to reduce the patient’s risk of developing diabetes.

15. Other medications for hypertensive patients • Aspirin: use 75mg daily if patient is aged 50 years with blood pressure controlled to <150/90 mm Hg and either; target organ damage, diabetes mellitus, or 10 year risk of cardiovascular disease of 20% • (2) Statin: use sufficient doses to reach targets if patient is aged up to at least 80 years with a total cholesterol concentration 3.5 mmol/l • (3) Vitamins— no benefit shown, do not prescribe

16. Lipid targets Targets for lipid lowering Ideal - TC<4.0mmol/l or LDL <2.0mmol/l or 25%  in TC or 30%  in LDL-C whichever is the greater ‘Audit’ - TC <5.0mmol/l or LDL <3.0mmol/l or 25%  in TC or 30%  in LDL-C whichever is the greater

17. Referral Refer immediately if the patient has signs of: – accelerated (malignant) hypertension (blood pressure more than 180/110 mmHg with signs of papilloedema and/or retinal haemorrhage) – suspected phaeochromocytoma (possible signs include labile or postural hypotension, headache,palpitations, pallor and diaphoresis). Consider referral if: – the patient has unusual signs and symptoms – the patient has signs or symptoms suggesting a secondary cause – the patient has symptoms of postural hypotension, or a fall in systolic blood pressure when standing of 20 mmHg or more

18. Thank You