hypertension on standard treatment protocol of nepal
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Definition of Hypertension
Dorland’s Medical Dictionary “Persistently high arterial blood pressure”
Diastolic Hypertension Elevated diastolic blood pressure with a normal systolic
pressureEssential Hypertension
Elevated blood pressure “having no obvious external cause,” or “idiopathic”
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Classification
So an specific cut off point is difficult WHO (1972) –systolic above 160/diastolic (phase V) more than 95
Currently Optimal-<120mmHg and<80 mmHg
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Category Blood Pressure, mm Hg
Normal SBP 90-119 and DBP 60-79
Prehypertension SBP 120-139 or DBP 80-89
Stage 1 HTN SBP 140-159 or DBP 90-99
Stage 2 HTN SBP ≥160 or DBP ≥100
DBP = diastolic blood pressure; SBP = systolic blood pressure
Measurement of BP
Accuracy is essentialReliability is questionable as wide variability in
individual.Source of ERROR-
1. Observer error e.g. hearing acuity, interpretation of Karotkow sound
2 Instrumental error eg loose cuff,leaking valve etc
3 subject error eg position , external stimuli-fear ,anxiety, physical environment
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WHO recommendationMeasurement of BP in individual
Uniform policy in all clinics &institutions to use rt or left arm
Recording in sitting position than supineSystolic at which sound first heardDiastolic -sound muffled disappear Measured at least 3 times over a period of 3 minutes &
lowest reading is takenFor comparability data should be taken every where in
uniform way
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Measurement in community
Incidence has limitation due to individual variation, ambiguity of normal BP insidious nature of condition
Prevalence- Developed countries-25% in adult population Developing countries-10 to 20% in adult population High altitude & places belonging to primitive culture-very low
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Measurement in community(cont)
The prevalence of hypertension was 44.9 percent (47.75% in male and 42.73% in females).The higher proportion of hypertensive cases were in age > 65 years (55.49%) than in the age group < 65 years (36.32%). The prevalence of hypertension was seen positively associated withnon vegetarian eating habits, alcohol consumption, and > 25 Body max index. (Prevalence and Associated Risk Factors of Hypertension Among People Aged 50 years and more in Banepa Municipality, Nepal)
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MortalityIn western world: deaths due to coronary heart diseaseIn eastern parts of the world: stroke deaths more commonDecline in mortality in last 2 decadesFall is equal in both sexesFall attributed to, use of effective drugs, modern diagnosis &treatment
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Risk Factors in HTN
Modifiable risk factors
• Stress• Smoking and HTN• Alcohol and BP• Obesity • Diabeties Mellitus • Salt and HTN• Occupation • Personality • Coffee and tea
Non modifiable risk factors
• Family History• Ethnicity and Race• Age • Sex/ Gender
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Cardiovascular Risk Factors
HypertensionCigarette smokingObesity (BMI>30)InactivityDyslipidemiaDiabetes Mellitus
Age >55 for men >65 for women
Microalbuminuria Or GFR <60mL/min
FH of Premature CVD Men <55 Women <65
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Birth Weight
Birth weight is also associated with the development of hypertension in later life.
The lower the birth weight the higher the likelihood of developing hypertension and heart disease
Clearly in-utero factors affect health at a later stage.
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Blood pressure is a continuous variable which fluctuates widely during the day physical stress mental stress
The definition of hypertension has been arbitrarily set as:
That blood pressure above which the benefits of treatment outweigh the risks in terms of morbidity and mortality
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Hypertension
Hypertension is not a diseaseIt is an arbitrarily defined disorder to which
both environmental and genetic factors contribute
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Causes for Secondary Hypertension
Renal disease 20% of resistant hypertensive patients chronic pyelonephritis renal artery stenosis polycystic kidneys
Drug Induced NSAIDs Oral contraceptive Corticosteroids
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Drug Induced Causes of HTN
Illicit Drugs Cocaine, amphetamines
Oral ContraceptivesAdrenal Steroids
Prednisone
Licorice (in some chewing tobacco)Decongestants (sympathomimetics)Non-adherence, inadequate doses, inappropriate
combinationsNon steroidal Anti-inflammatory drugs
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Diagnostic features of the HTN
No symptoms in 90 of the cases even when BP is very high i.e. > 160/100 mm of Hg
Headaches , dizzinessBP > 140/90 mm of Hg measured in the different
time and situations
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Treatment and management
A/C STP drug T. Amlodipine 5mg OD if BP doesnot go in the 140/90 mm of Hg add Hydrochlorothiazide 25 mg OD in morning.
If not controlled add T. Atenolol 50mg OD(if there is no CI for Beta blocker)
Lifestyle modification and dietary modificationCessation of the smoking and alcohol intake Regular physical exerciseControl salt, fat, obesityFollow healthy life styleContinuation of the medication untill medical consultation
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Malignant Hypertension:
May complicate any type of HTN. Necrotizing arteriolitis. Intravascular thrombosis. Rapidly progressive end organ damage. Renal failure Hypertensive encephalopathy. Left ventricular failure.
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Consequences of Hypertension:
Blood Vessels Atherosclerosis and its complications aneurism,
Dissection, Rupture, necrosis. Arteriolosclerosis, Heart
Hypertensive cardiomyopathy, IHD, MI. Kidney
Benign/Malignant nephrosclerosis. Infarction Eyes:
Hypertensive retinopathy Brain:
Haemorrhage, infarction, splinter & Lacunar hemorrhages
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Left ventricular Hypertrophy:
Left Ventricular HypertrophyLeft Ventricular Hypertrophy
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Hypertensive Retinopathy: Grade I – Thickening of
arterioles. Grade II – Focal Arteriolar
spasms. Vein constriction. Grade III – Hemorrhages
(Flame shape), dot-blot and Cotton wool and hard waxy exudates.
Grade IV - Papilloedema
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TREATMENT MODALITY IN GENERAL
Principle:- “lower the pressure, the better”Goal:- to have maximally tolerated reduction in
blood pressure
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MILD HYPERTENSION
Monodrug therapyDrug of choice:
1. Thiazide diuretic
eg. Hydrochlorthiazide
2. β1 blocker
eg. Propanolol
If monotherapy doesn’t work other drug can be added eg.Thiazide+ β1blocker
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ABCD treatment in HTN
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A ACE inhibitor Enalapril / Captopril
B Beta blocker Atenolol / propanolol
C Calcium channel blocker Amlodipine/ Morphe depine
D Diuretics Fursemide
Special cases
1.PREGNANCYToxemia of pregnancyDrug of choice: β1blocker
vasodilator Ca++ channel blocker-Contraindicated drugs are Diuretics,Resperine,Na nitroprusside, Non selective β -blocker
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2.Heart DiseaseAll A,B,C and D are usefulβ 1 blocker are contraindicated in left ventricular
failure & bradycardia3.Diabetic ACE inhibitor (Captopril) low dose thiazide, beta 1 blocker and Ca channel
blocker for long term therapy contraindicated diuretics
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4. Hypertensive EmergencyLife threatening, DP > 130 mmHgSodium nitroprusside (vasodilator) Diazoxide (arterial dilator ) Labetolol ( non selective adrenergic blocker )5. Hypertensive urgencyNifedipine (Sub lingual)Clonidine (oral or IM every 1-2 hrs)Captopril ( oral)Hydralazine (IM or IV slowly)
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Lifestyle Modification: 1
Weight Reduction Maintain normal body weight
BMI: 18.5 – 24.9 BP reduction: 5-20 mmHg/10 kg loss
DASH Eating Plan Dietary Approaches to Stop Hypertension
Fruits, Vegetables, Low-fat dairy Reduce saturated and total fat 8-14 mmHg BP reduction
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Lifestyle Modification: 2
Dietary Sodium Reduction 2.4 grams Sodium or 6 grams Sodium Chloride 2-8 mmHg BP reduction
Physical Activity Regular aerobic physical activity
Brisk walking, treadmill, exercise bike, bicycling, swimming (30 min. a day, most days of the week)
4-9 mmHg BP reduction
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Lifestyle Modification: 3
Moderation of alcohol consumption No more than 2 drinks per day in most men No more than 1 drink per day in women and lighter weight
individuals One drink equals:
½ ounce liquor or 12 oz. Beer or 5 oz. Wine or 1 ½ oz. 80 proof whisky
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Patient History: I
Duration and prior RxPharmaceutical profileFamily historySymptoms of secondary causesTarget organ damagePresence of other risk factors
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Patient History: II
Concomitant DiseasesDietary HistorySexual FunctionFeatures of Sleep ApneaAbility to modify life-style
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Physical Examination: I
Accurate measure of BP, BMIFundoscopyCarotid and thyroid abnormalitiesHeart sounds, rhythm, sizeRales, rhonchi on lung exam
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