Hypertension

Musleh Al Musalhi

Case
Mr. M is 45 years old. He is attending for a job check-up. Mr. M first clinic blood pressure measurement was 158/94 mmHg. What further history you need?

History
history should extract the following information: Risk factors for hypertension Extent of target organ damage Assessment of patients cardiovascular risk status Exclusion of secondary causes of hypertension

Risk Factors
Non-modifiable Age Gender Family History Ethnicity Modifiable Alcohol Cigarette Smoking Diabetes Mellitus Elevated serum lipids Excess Na+ in diet Obesity Sedentary Lifestyle Socioeconomic Stress

Target Organ Damage

Heart Left ventricular hypertrophy Angina or prior myocardial infarction Prior coronary revascularization Heart failure

Brain Stroke or transient ischemic attack

Chronic kidney disease

Peripheral arterial disease Retinopathy

Identifiable Causes of Hypertension

Sleep apnea Drug-induced or related causes Chronic kidney disease Primary aldosteronism Renovascular disease Chronic steroid therapy and Cushings syndrome Pheochromocytoma Coarctation of the aorta Thyroid or parathyroid disease

Mr. M history
From his records you notice that Mr. M blood pressure has increased since her last check. He is not doing any regular exercise and doesnt taking care of his diet. He does not smoke and has no notable medical history. His father had HTN for more than 20 yrs.

What is next?

Physical Examination
Height: 178 cm Weight: 96 kg BMI: 30.3 BP: 148/90 Heart rate: 76 Chest: Clear Heart: Regular rhythm, no gallops or murmurs audible Abdomen: soft, no bruits or organomegaly Fundoscopy : Normal

So, What investigations must be done??

Laboratory Tests
Electrocardiogram Urinalysis Blood glucose, and hematocrit Serum potassium, creatinine, or the corresponding estimated GFR, and calcium Lipid profile Measurement of urinary albumin excretion or albumin/creatinine ratio

Blood Pressure Classification

BP Classification Normal Prehypertension Stage 1 Hypertension Stage 2 Hypertension SBP mmHg <120 120139 140159 >160 and or or or DBP mmHg <80 8089 9099 >100

The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) , 2003

Blood Pressure Classification

Stage 1 hypertension: Clinic blood pressure (BP) is 140/90 mmHg or higher and ABPM or HBPM average is 135/85 mmHg or higher. Stage 2 hypertension:

Clinic BP 160/100 mmHg is or higher and ABPM or HBPM daytime average is 150/95 mmHg or higher.
Severe hypertension: Clinic BP is 180 mmHg or higher or Clinic diastolic BP is 110 mmHg or higher.
NICE clinical guideline 127 -2011 Hypertension: clinical management of primary hypertension in adults

Diagnosis

If the clinic blood pressure is 140/90 mmHg or higher, offer ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis of hypertension.

NICE clinical guideline 127 -2011 Hypertension: clinical management of primary hypertension in adults

Diagnosis
When using the following to confirm diagnosis, ensure: ABPM: at least two measurements per hour during the persons usual waking hours, average of at least 14 measurements to confirm diagnosis HBPM: two consecutive seated measurements, at least 1 minute apart blood pressure is recorded twice a day for at least 4 days and preferably for a week measurements on the first day are discarded average value of all remaining is used.

NICE clinical guideline 127 August 2011

Hypertension: clinical management of primary hypertension in adults
http://pathways.nice.org.uk/pathways/hypertension/hypert ension-overview

Guideline summary

Lifestyle Modifications
Dietary modifications and exercise
Low calorie diets have modest effect on BP in overweight individuals (avg. 5-6 mm Hg). Aerobic exercise (brisk walking, jogging, or cycling) for 30-60 min., 3-5 times/week, had small effect on BP (2-3 mm Hg).

Relaxation therapies
These activities (stress management, meditation, cognitive therapy, muscle relaxation) reduce by average of 3-4 mm Hg.

Lifestyle Modifications
Limit alcohol consumption
Excessive alcohol consumption is associated with raised blood pressure, poorer CV and hepatic health. Reducing alcohol can lower BP 3-4 mm Hg.

Limiting excessive consumption of coffee/caffeine (small benefit). Limit dietary sodium intake
< 6 g/day, modest reduction of 2-3 mm Hg.

Encourage smoking cessation (reduce risk of CV/pulmonary disease).

Initiating Treatment
Offer antihypertensive drug treatment to people aged under 80 years with Stage 1 hypertension who have one or more of the following:
Target organ damage, established cardiovascular disease, renal disease, diabetes, and 10-year CV risk equivalent to 20% or greater.

Offer antihypertensive drug treatment to people of any age with stage 2 hypertension.

Initiating Treatment
For people aged under 40 years with stage 1 hypertension and no evidence of target organ damage, CV disease, renal disease or diabetes, consider specialist evaluation of secondary causes of hypertension and more detailed assessment of potential target organ damage.

Anti-hypertension drugs
Group Eg. Contraindications Adverse effects

ACE-I

Lisinopril Captopril
Losartan Valsartan

Pregnancy Renovascular disease

Pregnancy Renovascular disease

Dry cough Hypotension Renal impairment

Hypotension Renal impairment

ARB

Group

Eg.

Contraindications

Adverse effects

Diuretics

Loop diuretics (Not used for hypertension) Thiazide diuretics Hydrochlorothiazide Indapamide* Hyperglysemia Hypokalemia Gout Hypokalemia Rash Erectile impotense Renal impairment Inhibit excretion of lithium

PotassiumAmiloride sparing diuretics Triamiloride & spironolactone

Renal insufficiency

Group

Eg.

Contraindications

Adverse effects

B- blockers

Atenolol Labetolol Carvedilol

Asthma & COPD 2nd or 3rd degree heart block Acute or unstable heart failure In combination with CCB Eg. Contraindications Adverse effects Flushing Headache Peripheral oedema

Group

CCB

Dihydropyri Amlodipine Pregnancy & breast feeding dines Nifedipine Benzthiazep Dilitazem ines Phenyalkyla Verapamil mines Pregnancy & breast feeding 2nd or 3rd degree heart block Pregnancy & breast feeding 2nd or 3rd degree heart block In combination with B blockers

Hypotension

Drug combinations in hypertension with comorbidities

Compelling indication DM Chronic kidney disease Recurrent stroke Heart failure Post MI Stable angina Lactation Diuretics Diuretics BB BB BB Methyldopa or hydralazine Recommended drug Diuretics BB ACE-i ACE-i ACE-i ACE-i ACE-i CCB ARB ARB ARB CCB

Blood Pressure Goals

People aged < 80 years with treated hypertension: <140/90 (home: 135/85) People aged > 80 years with treated hypertension: <150/90 (home: 145/85) For people with white coat effectdifference of 20/10 mmHg between clinic and average daily readingconsider adjunct ambulatory or home BP measurement to monitor BP.

Comparing NICE with JNC7 (U.S.): Diagnosis

NICE
Hypertension signaled from clinic reading (>140/90 mm Hg). Officially diagnosed using Ambulatory Blood Pressure Monitoring (>135/85 mm Hg)

JNC 7 (U.S.)
Mainly based on office BP reading (>140/90) Ambulatory or Home Blood Pressure Monitoring mainly used for selfmonitoring.

Comparing NICE with JNC7: Initiation of Medication Therapy

NICE:
Stage 1 (>135/85mmHg Ambulatory or Home BP)
Offer antihypertensive to patients under 80 years if the patient has: Target organ damage, established cardiovascular disease, renal disease, diabetes, and 10-year CV risk equivalent to 20% or greater.

JNC7:
After attempt of lifestyle modifications to lower BP, if still not at goal:
Stage 1: diuretic or medication for compelling indication Stage 2: diuretic + additional medication considering compelling indication.

Stage 2 (150/95 mmHg ABPM).

Offer antihypertensive therapy to patients of any age with Stage 2 hypertension

Comparing NICE with JNC7 (U.S.): First Medication Therapy Used.

NICE:
< 55 years: ACE inhibitor or ARB > 55 years: Calcium Channel Blocker
If CCB not tolerated or contraindicated, use diuretic.

JNC 7:
Thiazide diuretic for most
Unless diuretic cannot be used or if compelling indication requires use of another class of antihypertensive.

Comparing NICE with JNC7: Additional medication treatment

NICE:
Step 2: ACEi/ARB + Calcium Channel Blocker Step 3: ACEi/ARB + Calcium Channel Blocker + diuretic Step 4: add spironolactone if K < 4.5 mmol/L or increase doses of diuretic if K > 4.5 mmol/L.
Also can add alpha blocker or beta blocker

JNC 7:
Stage 2 (>160/100 mmHg):
Thiazide diuretic + ACEi or ARB or CCB or BB.

National NCD screening program

Made for those above the age of 40. Screen for hypertension, diabetes, chronic kidney disease, hypercholestrolemia and obesity.

Assessment
Confirm whether or not blood pressure is elevated. Presence of target organ damage (e.g. LVH, hypertensive retinopathy, increased albumin:creatinine ratio). Evaluate the persons cardiovascular risk. Consider possibility of secondary causes for the hypertension.

CVD risk assessment

Allow clinicians to predict the likelihood of patients developing coronary or
cardiovascular disease using lifestyle and clinical markers. 1. Established cardiovascular disease or high cardiovascular disease risk states (e.g. diabetes or CKD).

2.

By calculation of their 10 year CVD risk estimate.

Four major areas:

Coronary heart disease.

Cerebrovascular disease.
Peripheral artery disease. Aortic atherosclerosis and thoracic or abdominal aortic

aneurysm.

Why this risk models assessment is important for patient with Hypertension?

Address a patient's overall profile of risk rather than

treat one risk factor in isolation.

An individual with a number of modest risk factors may be at greater risk of developing cardiovascular disease than an individual with one high risk factor.

How to assess?
Different assessment models. Identify risk factors. Estimate an individual's risk over the next ten years using:
A. B. C. D. E. Gender. Age. Diabetic status. Smoking status. Total serum cholesterol (TC), high density lipoprotein cholesterol (HDLC). Blood pressure.

F.

Charts, Graphs or Computer programmes. QRISK 2 & framingham.

Case: A 56 year old male, diagnosed with hypertension 7 years back on a combination drugs. He presents to emergency department with headache & shortness of breath of one hour duration. On examination: BP: 250/145 mmHg, fine crepitation detected bilaterally.

Q. diagnosis? Hypertensive emergency

Hypertensive emergencies & urgencies

Hypertensive emergencies: sudden increase in systolic & diastolic BP associated with acute target-organ damage that require immediate management in hospital sitting.
Accelerated hypertension: recent significant increase over baseline BP that is associated with target organ damage (except papilledema). Malignant hypertension: .. Papilledema must present.

Hypertensive urgencies: severe elevation in BP without acute target-organ dysfunction or damage.

Urgency BP Symptoms >220/120 Severe headache Or Asymptomatic

Emergency >220/140 Shortness of breath Chest pain Nocturia Dysarthria Weakness Altered consciousness
Encephalopathy Pulmonary edema Cerebrovascular accident Renal insufficiency Cardiac ischemia Baseline lab tests IV line Monitor BP

Examination

Clinical cardiovascular disease present but stable

Therapy

Observe 3-6 hours Lower BP with short acting oral agent: Captopril, Clonidine, Labetalol, Prazocin Adjust current therapy Arrange follow-up evaluation in <24 hours

Plan

Immediate admission to ICU