Hypertension in the District

Hospital
AP Dr. Khin Swe Ei
MBBS MMedSc(Anaes) Dip.STDs/AIDS
Coordinator FMDHP
4.5% of global disease burden. The prevalence of
hypertension in Malaysians aged 18 years and above was
32.7% and for aged 30 years and above was 43.5% in 2011.

Hypertension is defined as persistent elevation of systolic BP

of 140mmHg or greater and/or diastolic BP of 90 mmHg or
greater.
This definition is based on the average of two or more
properly measured, seated, BP readings on each of two or
more clinic visits.
When SBP and DBP fall into different categories, the higher
category should be selected to classify the individuals BP.
 Classification
Category SBP DBP Recommended
follow-up

Normal <120 <80 Recheck every two

years

Prehypertension 120-139 80-89 Recheck in one year Life style mod.DASH

Hypertension Stage 1 140-159 90-99 Confirm within two Life style mod.DASH
months

Hypertension Stage 2 =>160 -179 =>100-109 Evaluate within one Plus Drugs
month

Hypertension Stage 3 180 110 Evaluate immediately

or within one week
d/o clinical situation

Joint National Committee on Hypertension

 Why is it important
Hypertension is a silent disease; the majority of cases (61%) in the country
remain undiagnosed. Blood pressure should be measured at every chance
encounter.

Untreated or sub-optimally controlled hypertension leads to increased

cardiovascular, cerebrovascular and renal morbidity and mortality.

A systolic BP of 120 to 139 and/or diastolic BP of 80 to 89 mmHg is defined

as prehypertension and should be treated in certain high risk groups.

Therapeutic lifestyle changes should be recommended for all individuals

with hypertension and pre-hypertension.
 Why management at DH specifically mentioned in this
lectures title
Family Practice provides continuing and comprehensive health care for the
individual and the family. It is the result of the evolved and enhanced
expression of general medical practice and is uniquely defined within the
family context

Family medicine is the academic field that is engaged in the study of content
and process of care delivered by Family Practice physicians (Generalist
physicians).
It aims towards understanding and changing health problems that cannot be
successfully managed by dealing exclusively with the individual and his /her
illness, abstracted from the pattern of recurrent interpersonal situations that
shape and transform a human life.

SO where are the places of Family Practice????

Ransom DC,Vandervoort HE: The development of Family Medicine:Problematic trends.JAMA 225:1098-1102,1973
 The Fundamental Principles of Family Medicine
1.Access to Care : know the obstacles and limitations
2.Continuity of Care : of medical info, doctor patient relationship, continuity
of families
3.Comprehensive Care
4.Coordination of care
3+4= (Integrated Care): Integrated care is a concept bringing together inputs,
delivery, management and organization of services related to diagnosis,
treatment, care, rehabilitation and health promotion. Integration is a means
to improve services in relation to access, quality, user satisfaction and
efficiency.(WHO)
5. Contextual Care: the process by which family physician help patients to
define the meaning of the medical problems and illnesses in their lives. This
then allows the patient and physician to develop a collaborative plan that
factors patient and family values into a strategy for managing problems
involving each of these contexts.
 Clinical vignette
A 66 year old man presenting with a positive
history of Dm on follow up found to have an avg
BP of 135/85 mm Hg. BMI = 38. He had fatigue,
saw spots before his eyes,feeling of
heaviness,occasional nose bleeds and early
morning pulsatile occipital headaches.
Consumes six pack of beer at weekends.Has
smoked a pack of cigarette/day for 14 years.
Symptoms of hypertension
Tinnitus, lightheadedness, dizziness and/or vertigo - tinnitus is an undesirable noise/sound (such
as ringing, hissing, whistling, or roaring), heard through the ear or head. The most common cause
is damage to the nerve endings in the ear. Hypertension can increase pressure against the blood
vessel walls of the auditory apparatus, leads to tinnitus.
Recurrent distended headache or head heaviness - The science and physiology behind
headaches offer support to well-increased blood pressure causes auto-regulation in the blood
vessels of the tissue underneath the skull (where most headaches start). The auto-regulation
leads to constriction of those blood vessels causing a headache.
Chest oppression, and/or palpitations - most hypertensive undergo stress (or fear/fright)
situations that increase adrenalin levels within the body, which causes rapid heartbeat
(palpitation) or chest oppression to meet out this stressful situation. Nose bleeding - human nose
has numerous blood vessels, which are very delicate; even a slightest knock, bump or increased
blood pressure can cause it to bleed.
Shortness of breath - anxiety is characterizing by multiple and/or nonspecific worries that
interfere with the person's life in some ways. This anxiety stimulates the adrenal gland which in-
turn generates a need for extra oxygen to burn excess energy needs, this oxygen shortfall causes
shortness of breath.
Irritated and getting anger readily - stress, anxiety, or anger makes the adrenal gland to produce
an excess adrenaline hormone. Overtime, this high level of adrenaline secretion is being practice
in the body; this in-turn makes us getting anger or irritated easily. In addition, hypertension can
cause problems with your brain, characterized by memory loss, personality changes, trouble
concentration, irritability, and getting anger readily.
Face or eye turns red - people with hypertension are getting anger/anxious easily, this mood
swing in addition with elevated blood pressure causing blushing due to rush of blood to the head
(face).

Visual problem or variation - elevated blood pressure can cause swelling of the macula (the
central area in the retina) and optic nerves. This reduces the ability to see well or causes vision
variation with respect to the blood pressure fluctuations.

Weakness or fatigue - prolong hypertension consumes excess energy, as well as strain every
blood vessel and organs that it connects. Therefore, prolong high blood pressure leads to
weakness or fatigue. In addition, hypertension due to excess pressure increases the excretion of
vital minerals as urine makes you feel weak.

Disturbed sleep - it has well known a fact that sleeping allows the heart to slow down; however
rapid eye movement (REM) sleep is characterizing by increased heart rate, raised blood pressure,
and the body does not regulate its temperature. Most of the vivid dreams occur during this REM
sleep stage. For people already having high blood pressure may experience night sweat and
increased alertness, which affects the normal sleep cycle.

Sore back and/or knees due to elevated blood pressure, an excess amount of calcium has
removed in urine; shortage of calcium makes your back and/or knees painful
When investigating a patient with hypertension,
every effort has to be made:
1. to exclude secondary causes,
2. determine the risk factors and
3. assess the presence and extent of target
organ damage.
 Important things to ask in history
A. Vertigo, syncope, palpitations, unusual fatigue,headaches.(symptoms of hypertension/ of
secondary hypertension and hypertensive Cardiovascular disease)

B. Weakness in one or more of her extremities, weakness of her facial muscles, difficulty in
talking,in swallowing, transient blindness in one eye (major signs associated with CVA,TIA. Becos
Hypertension doubles the risk of a CVA. Obesity and Diabetes mellitus also. All three risk factors
are cumulative)
TIA importance: Increases the patients risk of having CVA within next three months by 10-15%.
Greatest risk within 48 hours.

C. Amaurosis fugax important cos needs immediate evaluation since caused by embolus to the
central retinal artery due to either carotid artery stenosis or local ophthalmic artery disease.

D. Tachy, bradycardia,palpitations,snoring or excessive sleepiness (5-20%) of all hypertensions

are secondary:
Fever, AI, atherosclerosis,AV shunt, hyperkinetic heart syndrome,coarctation,renovascular
disease,polycystic kidneys,hypohyperthyroidism,parathyroid disease,hypercalcemia,
acromegaly,primary aldosteronism,pheochrmo, cushings,OSA,Increased ICP,In female
Preeclampsia, excessive alcohol.

E. Taking any OTC drugs : contraceptives, nasal decongestants,Tricyclics, MOAIs

NSAIDs,caffiene,steroids,sympathomimetics,appetite suppressants,Erythropoietin
 PHYSICAL EXAM
BP and Pulse all four extremities and doppler if available. In lying, standing, sitting

More then 10mmmhg difference in arms --------Aortic dissection, compression or obstruction

>20 mm subclavian steal syndrome

Orthostatic hypotension---=> 20 mm drop in SBP or=> 10mm diastolic within 3 minutes of

going from sit to standing

ABI=ankle SBP/highest brachial BP. Normal >1. Below 0.9 = PAD. Below 0.3= severePAD severe
ischemia

Fundoscopy changes

Heart n lungs

Evaluation of all pulses

Renal bruit, Wide pulse pressure(AI, AV shunts, thyrotox,), absent or weak pulses
 Investigations
Goal is to determine secondary causes and target organ damage
Baseline data
FBS
Urinalysis
Lipid profile
ECG
Hematocrit
BUSE
creatinine
TSH maybe
Complete blood count :Rule out Polycythemia, general medical
screen
management
CLINICAL PRACTICE GUIDELINES MOH,Malaysia.

Sequel of Hypertension that you may see in the District Hospital are
TIA, Stroke, ESRD, Acute Coronary syndromes,
LV Failure, Congestive Heart Failure.
These will be managed as per internal medicine guidelines.
The patient must recognize that hypertension requires life long
surveillance and therapy, it can be treated through life style
modifications and the failure to obtain blood pressure control
may result in complications.

Once diagnosed the patient should be encouraged to follow life

style modifications for 3-6 months, later pharmacologic therapy
is added to life style modifications.

A metanalysis from 14 trials revealed:

-pharmacological therapy reduces the likelihood of stroke by
42% and CAD by14%,with a 5-6 mm Hg decrease in diastolic BP.
-Treatment of isolated systolic hypertension reduced the
incidence od stroke by 37% and Coronary heart disease events
by 27%
Patient Education plan
1. Weight Reduction Goal:<BMI 27.waist circumference less than 34 in. women and 39 in. inmen
Plan : diet, increase physical activity. for Asians, the normal range has been proposed to be 18.5 to
23.5 kg/m2. weight loss as little as 4.5kg or 5% of baseline weight can significantly reduces BP.

2. Moderation of alcohol intake.

Goal: 1oz(30 ml) of ethanol (720ml beer, 300ml wine,60 ml of whiskey)
Plan :restrict intake to no more than 21 units for men and 14 units for women per week (1 unit
equivalent to 1/2 a pint of beer or 100ml of wine or 20 ml of proof whisky).

3. Physical activity Goal is to achieve a moderate level of physical fitness

Plan: aerobic exercise x 15-45 min most days of the week Recommend brisk walking for 30 60
minutes x at least 5 times a week.
4. Moderation of dietary sodium Goal No more than 100 mmol/day (6 gm of NaCl)
Plan : revision of Diet
5. Maintain adequate intake of dietary potassium ( 90 mmol /day)
6. Maintain adequate intake of calcium and magnesium

7. Reduce intake of dietary saturated fat and cholesterol for cardiovascular health
8 Stop use of tobacco products will reduce the cardiovascular risks
*DASH = Dietary approaches to stop hypertension
Opportunistic Health Promotion and education for the patients family
 Physical Inactivity