Case

HYPERTENSION

Source: NCHS and NHLBI. Hypertension is defined as SBP 140 mm Hg or DBP 90 mmHg, taking antihypertensive medication, or being told twice by a physician or other professional that one has hypertension.

BP Control Rates Trends in awareness, treatment, and control of high blood pressure in adults ages 18–74 National Health and Nutrition Examination Survey, Percent II 1976–80 II (Phase 1) 1988–91 II (Phase 2) 1991– – Awareness % Treatment % Control % Sources: Unpublished data for 1999–2000 computed by M. Wolz, National Heart, Lung, and Blood Institute; JNC 6. and American Heart Association: Statistical Fact Sheet 2013 Update

Hypertension

Essential HTN Risk factors Obesity---metabolic syndrome Excessive salt intake---low potassium intake Excessive alcohol intake Polycythemia Lack of exercise Non-steroid anti-inflammatory drugs Family history of essential HTN Caffeine and smoking increase the BP acutely but are not risk factors for the development of chronic essential HTN

Secondary Hypertension

National Heart, Lung, and Blood Institute National High Blood Pressure Education Program The Seventh Report of the Joint National Committee Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) U.S. Department of Health and Human Services National Institutes of Health National Heart, Lung, and Blood Institute

Blood Pressure Classification BP ClassificationSBP mmHgDBP mmHg Normal120and<80 Pre-hypertension or80-89 Stage 1 HTN or90-99 Stage 2 HTN>160 or>100

CategorySystolic blood pressure (mmHg) Diastolic blood pressure (mmHg) Optimal blood pressure <120<80 Normal blood pressure<130<85 High-normal blood pressure Grade 1 hypertension (mild) Grade 2 hypertension (moderate) Grade 3 hypertension (severe) >/= 180>/= 110 Isolated systolic hypertension >140<90

National Institute for Health and Clinic Excellence Hypertension Guidelines 2011 (UK)

Sphygmomanometer

Type of Instrument of Blood Pressure Measurement Home Blood Pressure Monitoring

Type of Instrument of Blood Pressure Measurement Ambulatory Pressure Monitoring

Blood Pressure

Measurement

White Coat Hypertension

Hypertension CAD, ECG, Arrthymia, Sudden Death Stroke, Ischemia, Hemorrhage, Alzheimer’s Disease, Cognitive Renal Disease Peripheral Vascular Disease Hypertensive Emergency And Increase Emergency Morbidity CHF LVH Aortic Dissection

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Increase risk of cardiovascular mortality by 7% Risk of stroke by 10%

This left ventricle is very thickened (slightly over 2 cm in thickness), but the rest of the heart is not greatly enlarged. This is typical for hypertensive heart disease. The hypertension creates a greater pressure load on the heart to induce the hypertrophy.

The left ventricle is markedly thickened in this patient with severe hypertension that was untreated for many years. The myocardial fibers have undergone hypertrophy.

Hypertensive Urgency Severe hypertension (diastolic blood pressure above 120 mmHg) in asymptomatic patients There is no proven benefit from rapid reduction in BP in asymptomatic patients who have no evidence of acute end-organ and are little short-term risk Severe hypertension (diastolic blood pressure above 120 mmHg) in end organ damage (MI,STROKE,AKI,CHF)

Malignant Hypertension

GradeDescriptionAlternative Description A:V Ratio IMinimal narrowing of retinal arteries 50% IINarrowing of retinal arteries in conjunction with regions of focal narrowing and arterio-venous nipping 33% IIIAbnormalities seen in Grade 1 and II, as well as retinal hemorrhages, hard exudation and cotton wool spots. 25% IVAbnormalities encountered in Grades I through III, as well as swelling of the optic nerve head and macular star <20% HYPERTENSIVE RETINOPATHY

Generalized arteriolar constriction- seen as `silver wiring` and Vascular tortuosities Hypertensive Retinopathy Grade 1

Arteriovenous nicking in association with hypertension Grade 2 (yellow arrow)

Flame-shaped hemorrhage in association with severe hypertension Grade 3 (yellow arrow)

Papilledema from malignant hypertension. There is blurring of the borders of the optic disk with hemorrhages (yellow arrows) and exudates (white arrow)

Diagnosis Hypertension

History

Physical Examination

Laboratory Tests Routine Tests Electrocardiogram Urinalysis Serum sodium, serum potassium, creatinine, or the corresponding estimated GFR, and calcium Blood glucose, and hematocrit Lipid profile, after 9- to 12-hour fast, that includes high density and low-density lipoprotein cholesterol, and triglycerides Optional tests Measurement of urinary albumin excretion or albumin/creatinine ratio More extensive testing for identifiable causes is not generally indicated unless BP control is not achieved

Lifestyle modifications High normal SBP >130 – 139 mmHg DBP 85 – 89 mmHg in high risk patients Drug therapy If BP is 140/90 mmHg

Benefits of Lowering BP Average Percent Reduction Stroke incidence35–40% Myocardial infarction 20–25% Heart failure50% Renal Failure35-50%

Lifestyle Modification Modification Approximate SBP reduction (range) Weight reduction 5–20 mmHg/10 kg weight loss Adopt DASH eating8–14 mmHg Dietary sodium2–8 mmHg Physical activity4–9 mmHg Moderation of alcohol consumption 2–4 mmHg

Dietary Approaches To Stop Hypertension (DASH)

Follow-up And Monitoring Patients should return for follow-up after 4 weeks and adjustment of medications until the BP goal is reached More frequent visits for stage 2 HTN or with complicating co-morbid conditions. Serum potassium and creatinine monitored 1–2 times per year.

Drug Therapy

Diuretics → Hypokalemia β-Adrenergic Blocking Agents → Bradycardia + Angiotensin-Converting Enzyme Inhibitors → Hyperkalemia + cough Angiotensin II Receptor Blockers → Hyperkalemia Calcium Channel Blocking Agents → Edema + Tachycardia + Bradycardia α-Adrenoceptor Antagonists → 1 st dose hypotension Drugs with Central Sympatholytic Action → Drowsiness Arteriolar Dilators → Tachycardia + Edema

Start in pre-hypertension (130 – 139)/(85 – 89) mmHg Lifestyle change CHF – Thiazide, ACE-1, Aldosterone, BB Post Myocardial Infarction – BB, ACEi Diabetes Mellitus – ACEi, ARB, Thiazide, CCB CKD – ACEi, ABB, Thiazide Stroke – SSB +ACEi

Key A – ACE inhibitor or angiotensin II receptor blocker (ARB) 12 C – Calcium- channel blocker (CCB) 13 D – Thiazide-like diuretic Resistant hypertension A + C + D + consider further diuretic 14, 15 or alpha- or beta-blocker 16 Consider seeking expert advice Aged over 55 years or black person of African Step 4 Step 3 Step 2 Step 1 A + C + D A Aged under 55 years C A + C 12 Choose a low-cost ARB. 13 A CCB is preferred but consider a thiazide-like diuretic if a CCB is not tolerated or the person has edema, evidence of heart failure or a high risk of heart failure. 14 Consider a low dose of spironolactone 15 or higher doses of a thiazide-like diuretic. 15 At the time of publication (August 2011), spironolactone did not have a UK marketing authorization for this indication. Informed consent should be obtained and documented. 16 Consider an alpha- or beta- blocker if further diuretic therapy is not tolerated, or is contraindicated or ineffective.

Combination Therapies