hypertension famco
TRANSCRIPT
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Hypertension
Musleh Al Musalhi
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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?
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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
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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
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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
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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
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Mr. M history
From his records you notice that Mr. M bloodpressure 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?
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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
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So, What investigations must be
done??
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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 oralbumin/creatinine ratio
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Blood Pressure Classification
Normal 100
BP Classification SBP mmHg DBP mmHg
The Seventh Report of the Joint National
Committee on Prevention, Detection, Evaluation,
and Treatment of High Blood Pressure (JNC 7) ,
2003
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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 orhigher.
Severe hypertension:
Clinic BP is 180 mmHg or higher or
Clinic diastolic BP is 110 mmHg or higher.
NICE clinical guideline 127 -2011Hypertension: clinical management of primary hypertension in adults
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If the clinic blood pressure is 140/90 mmHg orhigher, offer ambulatory blood pressure monitoring
(ABPM) to confirm the diagnosis of hypertension.
Diagnosis
NICE clinical guideline 127 -2011
Hypertension: clinical management of primary hypertension in adults
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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 14measurements 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.
Diagnosis
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NICE clinical guideline 127
August 2011
Hypertension: clinical management
of primary hypertension in adultshttp://pathways.nice.org.uk/pathways/hypertension/hypert
ension-overview
http://pathways.nice.org.uk/pathways/hypertension/hypertension-overviewhttp://pathways.nice.org.uk/pathways/hypertension/hypertension-overviewhttp://pathways.nice.org.uk/pathways/hypertension/hypertension-overviewhttp://pathways.nice.org.uk/pathways/hypertension/hypertension-overviewhttp://pathways.nice.org.uk/pathways/hypertension/hypertension-overviewhttp://pathways.nice.org.uk/pathways/hypertension/hypertension-overview -
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Guideline summary
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Lifestyle Modifications
Dietary modifications and exercise
Low calorie diets have modest effect on BP inoverweight individuals (avg. 5-6 mm Hg).
Aerobic exercise (brisk walking, jogging, or cycling)for 30-60 min., 3-5 times/week, had small effecton BP (2-3 mm Hg).
Relaxation therapies
These activities (stress management, meditation,cognitive therapy, muscle relaxation) reduce byaverage of 3-4 mm Hg.
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Lifestyle Modifications
Limit alcohol consumption
Excessive alcohol consumption is associated withraised 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 ofCV/pulmonary disease).
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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.
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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 secondarycauses of hypertension and more detailed
assessment of potential target organ damage.
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Anti-hypertension drugsAdverse effectsContraindicationsEg.Group
Dry cough
HypotensionRenal impairment
Pregnancy
Renovasculardisease
Lisinopril
Captopril
ACE-I
Hypotension
Renal impairmentPregnancyRenovasculardisease
Losartan
Valsartan
ARB
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Adverse
effectsContraindicationsEg.Group
Loop diuretics(Not used for
hypertension)
Diuretics
Hypokalemia
RashErectile
impotense
Hyperglysemia
HypokalemiaGoutHydrochlorothiazide
Indapamide*
Thiazide
diuretics
Renal
impairmentInhibit
excretion of
lithium
Renal insufficiencyAmiloride
Triamiloride
Potassium-
sparing diuretics&
spironolactone
AdverseContraindicationsEgGroup
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Adverse
effectsContraindicationsEg.Group
Asthma & COPD
2nd or 3rd degree heart block
Acute or unstable heart failure
In combination with CCB
Atenolol
Labetolol
CarvedilolB- blockers
Adverse
effectsContraindicationsEg.Group
Flushing
Headache
Peripheral
oedema
Pregnancy & breast feedingAmlodipineNifedipineDihydropyridinesCCB
Pregnancy & breast feeding
2nd or 3rd degree heart block
DilitazemBenzthiazep
ines
HypotensionPregnancy & breast feeding
2nd or 3rd degree heart block
In combination with B
blockers
VerapamilPhenyalkylamines
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Drug combinations in hypertension with
comorbiditiesRecommended drugCompelling indication
CCBARBACE-iBBDiureticsDMARBACE-iChronic kidney disease
ACE-iDiureticsRecurrent strokeARBACE-iBBDiureticsHeart failure
ACE-iBBPost MICCBBBStable angina
Methyldopa or hydralazineLactation
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Blood Pressure Goals
People aged < 80 years with treatedhypertension: 80 years with treatedhypertension:
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Comparing NICE with JNC7 (U.S.):
Diagnosis NICE
Hypertension signaled
from clinic reading
(>140/90 mm Hg).
Officially diagnosedusing Ambulatory
Blood Pressure
Monitoring (>135/85
mm Hg)
JNC 7 (U.S.) Mainly based on office
BP reading (>140/90)
Ambulatory or Home
Blood PressureMonitoring mainly
used for self-
monitoring.
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Comparing NICE with JNC7: Initiation
of Medication Therapy NICE: Stage 1 (>135/85mmHg
Ambulatory or Home BP) Offer antihypertensive to
patients under 80 years ifthe patient has: Target
organ damage, establishedcardiovascular disease,renal disease, diabetes, and10-year CV risk equivalentto 20% or greater.
Stage 2 (150/95 mmHgABPM). Offer antihypertensive
therapy to patients of anyage with Stage 2hypertension
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 medicationconsidering compellingindication.
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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 ifcompelling indication
requires use of another
class of
antihypertensive.
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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 < 4.5mmol/L or increase dosesof 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 orARB or CCB or BB.
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National NCD screening program
Made for those above the age of 40.
Screen for hypertension, diabetes, chronic
kidney disease, hypercholestrolemia and
obesity.
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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.
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CVD risk assessmentAllow 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.
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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.
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How to assess?
Different assessment models. Identify risk factors.
Estimate an individual's risk over the next tenyears using:
A. Gender.B. Age.
C. Diabetic status.
D. Smoking status.
E. Total serum cholesterol (TC), high density lipoprotein cholesterol (HDL-C).
F. Blood pressure.
Charts, Graphs or Computer programmes.
QRISK 2 & framingham.
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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 hourduration.
On examination: BP: 250/145 mmHg, finecrepitation detected bilaterally.
Q. diagnosis?
Hypertensive emergency
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Hypertensive emergencies & urgenciesHypertensive emergencies: sudden increase in
systolic & diastolic BP associated with acutetarget-organ damage that require immediatemanagement in hospital sitting. Accelerated hypertension: recent significant increase over
baseline BP that is associated with target organ damage (exceptpapilledema).
Malignant hypertension: .. Papilledema must present.
Hypertensive urgencies: severe elevation in BPwithout acute target-organ dysfunction ordamage.
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EmergencyUrgency>220/140>220/120BP Shortness of breath
Chest pain
Nocturia Dysarthria
Weakness
Altered consciousness
Severe headache
Or
Asymptomatic
Symptoms
Encephalopathy
Pulmonary edema Cerebrovascular accident
Renal insufficiency
Cardiac ischemia
Clinical cardiovascular
disease present but stableExamination
Baseline lab tests
IV line
Monitor BPObserve 3-6 hours
Lower BP with short acting
oral agent:Captopril, Clonidine,
Labetalol, Prazocin
Adjust current therapy
Therapy
Immediate admission toArrange follow-up Plan