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
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
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
The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) , 2003
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.
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.
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
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
Renal insufficiency
Group
Eg.
Contraindications
Adverse effects
B- blockers
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
JNC 7 (U.S.)
Mainly based on office BP reading (>140/90) Ambulatory or Home Blood Pressure Monitoring mainly used for selfmonitoring.
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.
JNC 7:
Thiazide diuretic for most
Unless diuretic cannot be used or if compelling indication requires use of another class of antihypertensive.
JNC 7:
Stage 2 (>160/100 mmHg):
Thiazide diuretic + ACEi or ARB or CCB or BB.
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.
2.
Cerebrovascular disease.
Peripheral artery disease. Aortic atherosclerosis and thoracic or abdominal aortic
aneurysm.
Why this risk models assessment is important for patient with Hypertension?
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.
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.
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
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