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2000 Canadian Recommendations for the Management of Hypertension

2000 Canadian Recommendations for the Management of Hypertension

Jan 18, 2001

Introduction Hypertension as a Risk Factor


Hypertension is a significant risk factor for: cerebrovascular disease coronary artery disease congestive heart failure renal failure peripheral vascular disease

2000 Canadian Recommendations for the Management of Hypertension

Introduction II Benefits of Treating Hypertension


Younger than 60 reduces the risk of stroke by 42% reduces the risk of coronary event by 14% Older than 60 reduces overall mortality by 20% reduces cardiovascular mortality by 33% reduces incidence of stroke by 40% reduces coronary artery disease by 15%

2000 Canadian Recommendations for the Management of Hypertension

Introduction III Benefits of Treating to Target


Older than 60 with isolated systolic hypertension (SBP 160 mm Hg and DBP < 90 mm Hg) 36% reduction in the risk of stroke 25% reduction in the risk of coronary events

Introduction IV The Challenge


22% of Canadian adults 18 to 70 years of age have hypertension
Hypertensive patients who are treated but uncontrolled Hypertensive patients who are treated and controlled

23% 19%

16%

42%

Patients who are aware but remain untreated and uncontrolled


Source : Joffres et al. (1997) Am. J. Hypertension 10: 1097-1102 2000 Canadian Recommendations for the Management of Hypertension

Hypertensive patients who are unaware

JNC VI Classification of Blood Pressure for Adults


Category Optimal Normal HighNormal Hypertension Stage 1 Stage 2 Stage 3
JNC 6 - Arch Int Med / Jan 1998

SBP <120 <130 130139 and and or

DBP <80 <85 8589

140159 160179 180

or or or

9099 100109 110

2000 Canadian Recommendations for the Management of Hypertension

Hypertension
1. Primary - 90% of all cases - cause unknown - essential or idiopathic Benign gradual onset with prolonged course Malignant abrupt with short course can be fatal severely damages

Hypertension
2. Secondary cause identifiable
- C.V., renal, pregnancy, drugs, corticosteroids

- retain Na & H2O

Hypertension
Isolated hypertension: If the patient has increased systolic BP with normal diastolic BP

Complications
Heart - CAD - atherosclerotic changes
Angina, M.I., ( C.A. blood flow) CHF - afterload, O2 need Arrhythmias Brain - stroke microaneurysms hemorrhage

Complications
Kidneys renal failure
Eyes visual disturbances

blindness
Peripheral Vessels intermittent claudication dissecting aortic aneurysm

Mechanisms of 1 Hypertension
1. Overactive SNS stimulation
- excite with nonepinephrine

- contractions
- vasoconstriction with workload & B/P

Mechanisms of 1 Hypertension
2. Na & H2O retention by kidneys
- excessive secretion of renin

- H2O & Na retained


- volume & perfusion = B/P - Most likely cause

Hypertension
Causes are however numerous &
interrelated

- environment
- psychological - physiologic

Hypertension
No obvious changes at first
Changes widespread with time Large vessels sclerosed (narrowed)

Small vessel damage

Vasoconstriction heart contractions (afterload) to maintain C.O. chronic overwork L.V. hypertrophy coronary insufficiency M.I.

Cont
LVF eventually renal perfusion Na & H2O retention blood flow to kidneys, heart, eyes, brain Progressive Impairment

Secondary Hypertension
Causes are numerous
diabetes glomerulonephritis corticosteroid Rx Drugs - BCP - Amphetamines

- Estrogens - Thyroid hormones

Secondary Hypertension
Causes are numerous
ICP

anemia
aortic regurgitation

Secondary Hypertension
Mechanisms
1. secretion catecholamines 2. release renin 3. Na & blood volume Dx: B/P high over several readings averages >140 > 90

Assessment
1. Extent of organ involvement
2. Presence of C.V. risk factors 3. ID type

History
Family Hx
Diabetes

Previous B/P
results of hypertensives angina, dyspnea hx use of BCP, alcohol, steroids, diet pills

History cont
Weight gain
Na intake

stress, cultural food practices


Risk factors chol. Obesity history of exercise

Physical Exam
Retina
Neck Heart

edema, hemorrhage
distended veins, bruit HR, murmurs

Extremities p.p., edema

Interventions
Nonpharmacological - weight reduction - exercise - Na - relaxation - monthly BP checks - Ethol, coffee - smoking cessation

Non Pharmacologic Recommendations for Hypertension Lifestyle: Dietary


Dietary Sodium

Hypertensive patient

For age over 44, Restricted to a target range of 90-130 mmol/day. (Limitation of salt additives and foods with excessive added salt)

Fresh fruits, Vegetables, Low fat dairy products, Low fat diet, in accordance with Canada's Guide to Healthy Eating

Dietary Potassium
Daily dietary intake 60 mmol

Calcium supplementation
No conclusive studies for hypertension

Magnesium supplementation
No conclusive studies for hypertension

Jan 18, 2001

Pharmacological Diastolic > 95


1. Diuretics a) thiazides - promote excretion Na & H2O - Diuril, hydrodiuril - hypokalemia possible b) loop diuretics - loop of Henle - minimize H2O & Na reabsorption - Lasix

Pharmacological Diastolic > 95


1. Diuretics c) Potassium sparing - promote H2O & Na excretion - hyperkalemia - aldactone 2. Sympatholytic Agents - interrupt activity SNS with renin activity - catapres & aldomet

Pharmacological Diastolic >95


3. Vasodilators
- dilate peripheral blood vessels - Apresoline, minipres 4. Angiotension converting enzyme inhibitor - inhibit Angio 1 to Angio 2 - afterload i.e. captopril

Pharmacological Diastolic >95


5. Ca channel blockers
- C.O. & rate - nipedine

Hypertensive Crisis
Reduction in BP needed stat
Malignant hypertension
hypertensive encephalopathy - LOC heart failure toxemia dissecting aneurysm intracranial hemorrhage

Interventions for Crisis


ICU
IV Drugs Monitoring

Continuous EKG

Management Long-term
Assess Knowledge - disease process - consequences - administration drugs - diet - exercise - home monitoring Compliance Ineffective coping

Drugs
Never dose
Never miss dose

Take on time
Side effects Never discontinue

Hypotensive Alert
Lie down with legs elevated
No hot baths No excessive alcohol

Reasons for Noncompliance


Asymptomatic
Difficult lifestyle changes Annoying side effects

Costs

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