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B2B - Hypertension Dr Jen Leppard, MD, CCFP-EM March 28, 2014.

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Presentation on theme: "B2B - Hypertension Dr Jen Leppard, MD, CCFP-EM March 28, 2014."— Presentation transcript:

1 B2B - Hypertension Dr Jen Leppard, MD, CCFP-EM March 28, 2014

2 LMCC Objectives – HTN 1.Diagnose HTN and determine its severity 2.Investigate target organ damage and 2 o causes 3.List medical management 4.Recognition and management of HTN urgencies and emergencies

3 1a. Diagnosis 2014 Canadian Guidelines: o >160/>100 X 3 o OR o >140/>90 X 5 o can use office, ambulatory, or home BP cuffs to measure

4 BP: 140-179 / 90-109 ABPM (If available) ABPM (If available) Office BPM Office BPM Home BPM (If available) Home BPM (If available) Yes Hypertension Visit 2 Target Organ Damage or Diabetes or BP ≥ 180/110? Hypertension Visit 2 Target Organ Damage or Diabetes or BP ≥ 180/110? Hypertension Visit 1 BP Measurement, History and Physical examination Hypertension Visit 1 BP Measurement, History and Physical examination Hypertensive Urgency / Emergency Hypertensive Urgency / Emergency Diagnosis of HTN Diagnosis of HTN No Diagnostic algorithm for hypertension 2014

5 Criteria for Diagnosis of HTN and Criteria for F/U BP: 140-179 / 90-109 ABPM (If available) Diagnosis of HTN Awake BP >135 SBP or > 85 DBP or 24-hour > 130 SBP or > 80 DBP Awake BP >135 SBP or > 85 DBP or 24-hour > 130 SBP or > 80 DBP Awake BP <135/85 and 24-hour <130/80 Awake BP <135/85 and 24-hour <130/80 Continue to follow-up Office BP Diagnosis of HTN Hypertension visit 3 > 160 SBP or > 100 DBP > 140 SBP or > 90 DBP < 140 / 90 Diagnosis of HTN Continue to follow-up <160 / 100 Hypertension visit 4-5 ABPM or HBPM or Home BPM > 135/85 < 135/85 Diagnosis of HTN Continue to follow-up Patients with high normal blood pressure (office SBP 130-139 and/or DBP 85-89) should be followed annually. Repeat Home BPM If < 135/85 If < 135/85 or 2014

6 1b. Severity End organ damage o Acute vs Chronic Acute - discussed with hypertensive emergencies Chronic Target Organ Damage

7 2a. Investigations of Target Organ Damage MCQ 10: What test is not needed in ambulatory testing for HTN? A.Urine, urine albumin (DM) B.Lytes + creatinine C.Fasting glucose + cholesterol D.CBC + diff E.ECG

8 Routine Laboratory Tests Preliminary Investigations of patients with hypertension 1.Urinalysis 2.Blood chemistry (potassium, sodium and creatinine) 3.Fasting glucose and/or glycated hemoglobin (A1c) 4.Fasting total cholesterol and high density lipoprotein cholesterol (HDL), low density lipoprotein cholesterol (LDL), triglycerides 5.Standard 12-leads ECG Currently there is insufficient evidence to recommend routine testing of microalbuminuria in people with hypertension who do not have diabetes 2014

9 Types of HTN Secondary HTN 5-10% Identifiable Cause ABCDE Essential HTN Most common (90%) Cause unknown

10 2b. Secondary HTN A – Apnea, Aldosterone o Obstructive Sleep Apnea o Hyperaldosteronism B – Bruits, Bad kidneys o Renovascular disease (atherosclerosis, fibromuscular dysplasia) o Renal parenchymal disease C – Catecholamines, Coarct, Cushing’s o Pheochromocytoma o Coarctation of the Aorta o Cushing’s Disease D – Drugs, Diet E – Erythropoietin, Endocrine Disorders o Increased EPO from endogenous or exogenous sources o Hypo or Hyperthyroid, Hyperparathyroid,

11 CDMQ: What are the clinical clues and investigations for 2 o causes?

12 Secondary HTN Obstructive Sleep Apnea Body habitus Bed partner complaints Daytime somnolence Sleep study HyperaldosteronismMay look cushingoidLow K+, high Na+ 24 hour urinary aldosterone level

13 Secondary HTN Pheochromocy toma Headache, labile or paroxysmal HTN Palpitations, pallor, diaphoresis 24 hour urine metanephrines Aortic Coarctation Decreased BP in lower extremities Delayed femoral pulse ECHO CT Angio Cushing’s Disease CushingoidDexamethasone suppression test Stimulant Drugs Sympathomimetic toxidromeUrine tox ECG

14 Secondary HTN HypothyroidWeight gain, constipation, hair loss, fatigue Serum TSH HyperthyroidWeight loss, temperature intolerance, tachycardia, tremors Serum TSH HyperparathyroidSigns of hypercalcemiaSerum PTH Calcium DrugsNSAIDS, steroids, estrogens decongestants, EPO, MAOIs, SNRIs, SSRIs, stimulants, excessive EtOH, licorice root, immunosuppresants DietObesity High salt intake

15 Ambulatory Management Non-Pharmacologic Physical Exercise – 30-60min 4-7X/day Weight Reduction Alcohol Consumption - < 2 drinks/day DASH Diet – ( D ietary A pproach to S top H TN) Sodium Intake - < 2000mg Sodium/day (5g salt) Stress Management

16 Ambulatory Management Pharmacotherapy A ACEi (Ramipril) ARBs (Candsartan) A ACEi (Ramipril) ARBs (Candsartan) B Beta-Blockers (Metoprolol) B Beta-Blockers (Metoprolol) C CCB (Amlodipine) C CCB (Amlodipine) D Diuretic (HCTZ) D Diuretic (HCTZ)

17 Specific Pharmacotherapy CAD ACEI /ARB Angina/recent MI: Beta-blocker DM + Renal: ACEI/ARB CCB Thiazide

18 Specific Pharmacotherapy Asthma Avoid Beta-Blocker CKD (no DM) ACEI/ARB Thiazide

19 Improving Compliance Tailor pill-taking to fit patients’ daily habits Once Daily Dosing Combination pills Dosettes/Blister Packs

20 4. HTN Emergencies HTN Emergency = ACUTE Target Organ Damage

21 What are the target organs?

22 MCQ 9: Which is not an HTN emergency? A.35 M 220/140, dizzy, normal neuro exam B.50 M 200/120, chest pain, CXR wide mediastinum C.25 F 28 wks pregnant, 150/80, seizure D.80 F 220/120, left arm weakness E.45 F 200/120, crackles to apex, JVP 6cm

23 ACS Pulmonary edema Aortic Dissection HTN emergencies are…

24 Bleeds, seizures Encephalopathy (not just headache, dizzy) Acute Kidney Injury

25 Investigations for HTN emergency ACS Pulmonary edema Aortic Dissection Bleeds, seizure, encephalopathy AKI

26 Treat HTN emergency: General Management BP: Reduce MAP by 25% Iv medications: Labetolol Nitroprusside Hydralazine

27 CDMQ: 45 F 220/120, bilateral crackles, JVP 6cm, Sat 80%. List specific treatment (3)?

28 Specific Treatment: Pulmonary Edema BiPAP Nitro Drip IV Furosemide iv

29 Specific Treatment: ACS Nitro* (Beta Blocker) ASA Anti-platelet

30 Specific Treatment Aortic Dissection Type A – Ascending – Surgical Mgt Type B – Descending – Medical Nitroprusside + beta blocker (esmolol) OR Labetalol

31 Specific Treatment: Seizure+ preg (Eclampsia)

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