1. INCIDENTAL HYPERTENSION: How to manage
Dr. Saulat Siddique,
Professor of Cardiology,
Shaikh Zayed Hospital, Lahore.
FAMILYCON 2013,
4-5-6 January, 2013, Lahore.

2. Q. No.1 Regarding Blood Pressure measurement;
SBP is when the first Korotkoff sound is heard
DBP is when the sounds become muffled (Korotkoff phase IV)
BP reading should be rounded to the nearest 5 or zero e.g. 130/85mmHg
BP reading should be written as 132/86mmHg i.e. recorded to the nearest even number

3. BLOOD PRESSURE MEASUREMENT
Record the result for systolic and diastolic pressures to the nearest 2mmHg. For the systolic reading, record the level at which the first (at least two consecutive) sound is heard.
For the diastolic reading, use phase V Korotkoff (disappearance of sound). Only use phase IV Korotkoff (muffilng of sound) if sound continues towards zero.
PHL/PCS Hypertension Guidelines, 2009

4. Started on anti-hypertensive medication Advised life style measures
Q. No. 2. A 43 year old previously healthy male visits his family practitioner for symptoms of flu. His BP is found to be 146/96. He should be;
Started on anti-hypertensive medication
Advised life style measures
Given a sedative
Asked to come back for follow-up visit

5. Q. No. 3 Regarding the BP cuff;
Cuff size is same as bladder size
Length should cover the full arm circumference
Width should be half the arm circumference
Inappropriately small cuff will give a falsely low reading

6. BLOOD PRESSURE MEASUREMENT
The bladder length should be at least 80% and the width at least 40% of the circumference of the mid-upper arm. Use of a ‘standard size’ cuff in people with large arm can result in artificially high blood pressure reading. If an oversized cuff cannot be satisfactorily fitted on a large arm then the utilization of an appropriately sized cuff on the forearm with radial artery auscultation should be considered.
PHL/PCS Hypertension Guidelines, 2009

7. BLOOD PRESSURE MEASUREMENT
Patients should sit for several minutes in a quiet and comfortable place
Use appropriate cuff size for age and weight
Have cuff at heart level
Deflate the
Take minimum 2 measurements at least 1-2minutes apart.
Ask the patients to return for 1-2 more visits, if BP is elevated on first visit (to confirm the diagnosis of hypertension), before starting treatment
PHL/PCS Hypertension Guidelines, 2009

8. BLOOD PRESSURE MEASUREMENT
NICE guidelines (2011) state that there should be complete skin contact of the stethoscope with no clothing in between
The Pakistani guidelines state that, “In Pakistani setting, BP is quite often measured with shirt sleeve on rather than bare arm, especially in ladies. A recent Canadian Study indicates that there is no difference in BP reading if average thickness of sleeves is 4.3 mm or less.”

9. Q. No. 4. Life style measures include;
Low sodium diet
Exercise like weight lifting and push-ups
Diet rich in potassium
Aerobic exercise

10. LIFESTYLE MODIFICATIONS TO REDUCE BLOOD PRESSURE
Ask patients about their diet and exercise patterns, and offer guidance and written or audiovisual information
Regular aerobic physical activity is recommended for all persons, but those with advanced or unstable CVD may require a medical evaluation before initiation of exercise or a medically supervised exercise program. Isometric exercise such as heavy weight lifting can have a pressor effect and should be avoided.
Ask about alcohol consumption and encourage patients to cut down if they drink excessively
Discourage excessive consumption of coffee and other caffeine-rich products
Encourage patients to reduce their salt intake or use a substitute
Offer smokers advice and help to stop smoking
DO NOT OFFER
Calcium, magnesium or potassium supplements to reduce blood pressure
Relaxation therapies can reduce blood pressure and patients may wish to try them. However, primary care teams are not recommended to provide them routinely
PHL/PCS, Hypertension Guidelines 2009

11. IMPACT OF LIFE-STYLE CHANGES ON REDUCTION OF SBP
Intervention
Reduction in SBP (mmHg)
Increased Magnesium (Mg)
0 – 1
Increased Calcium (Ca) 2
Increased Potassium (K) 4
Fish Oil 6
Reduced Sodium (Na)
Reduced Weight 8
Exercise 10
Dash Diet 12
PHL/PCS, Hypertension Guidelines 2009

12. Q. No Follow-up visit after 2 weeks reveals sitting BP of 138/90 in the right arm and 148/92 in the left arm. He should be;
Investigated for stenosis in the right subclavian/axillary artery.
Sent for fundoscopy
Checked for waist circumference
Checked for postural hypotension

13. BLOOD PRESSURE MEASUREMENT
Measure Blood Pressure in both arms. Take the higher value as baseline
Difference of 5/10 mm can be considered as normal
Waist circumference is an essential part of the physical examination as is fundoscopy
Measure BP in standing position in elderly, diabetes and in case of hypotension inducing drugs
PHL/PCS, Hypertension Guidelines 2009

14. Q. No. 6. The following are essential in his work-up;
Serum sodium and potassium
Urine for VMA
Echocardiography
Complete Lipid Profile

15. INVESTIGATIONS (Minimal)
Urine analysis for proteins (can be done with a dipstick as a starter)
Serum creatinine levels
Serum potassium and sodium levels
Random blood sugar
ECG for evidence of established coronary artery disease (CAD) or LVH
Chest X Ray (PA view)
PHL/PCS, Hypertension Guidelines 2009

16. LIPID PROFILE Part of special investigations in Pakistani guidelines
ESC guidelines recommend complete Lipid Profile as an essential test
NICE guidelines recommend that only total cholesterol and HDL should be done

17. SPECIAL INVESTIGATIONS (On case to case basis)
Echocardiogram
Lipid Profile
Carotid (and femoral) ultrasound
C-reactive protein
Microalbuminuria (essential test in diabetics)
Quantitative proteinuria (if dipstick test positive)
Search for secondary hypertension: measurement of renin, aldosterone, corticosteroids, catecholamines, arteriography, renal & adrenal ultrasound, computer assisted tomography (CAT), magnetic resonance imaging
PHL/PCS, Hypertension Guidelines 2009

18. Q. No. 7. He should be started on;
ACEI
ARB
CCB
Diuretic
Combination Tablet

19. Antihypertensive Drug Treatment: NICE 2011
A = ACEi or ARB
C = CCB
D = Thiazide-like diuretic such as chlorthalidone (12.5 mg–25 mg once daily) or indapamide rather than thiazide diuretic such as bendroflumethiazide or hydrochlorothiazide.
C* = CCB preferred but consider thiazide-like diuretics in people with oedema or a high risk of heart failure
Further diuretic** = low-dose spironolactone or higher doses of a thiazide-like diuretic

20. Q. No. 8. He should also be prescribed;
Aspirin mg OD
Atorvastatin 10mg OD
Bromazepam 3mg OD

21. Aspirin is only recommended in those with IHD, CKD and in high cardiovascular risk subjects in the ESC guidelines
Statins are recommended in IHD, DM and in high cardiovascular risk subjects in the ESC guidelines or if cholesterol levels are high.

22. HISTORY Detailed history is essential
Prior history of high BP, kidney disorders, stroke, heart disease, diabetes, dyslipidemia.
Complications of pregnancy
Drug history
NSAIDs
Oral Contraceptives
Previous antihypertensives
Family history of hypertension, heart disease, diabetes
Smoking and dietary habits
PHL/PCS, Hypertension Guidelines 2009

23. SIGNS OF ORGAN DAMAGE
Brain: murmurs over neck arteries, motor or sensory defects
Retina: fundoscopic abnormalities
Heart: location and characterstics of apical impulse, abnormal cardiac rhythms, ventricular gallop, pulmonary rales, dependent edema
Peripheral arteries: absence, reduction, or asymmetry
PHL/PCS, Hypertension Guidelines 2009

24. The importance of 24-hour blood pressure control in hypertension management
ESC/ESH Guidelines1
NICE Guidelines 20112
“If the clinic BP ≥140/90 mm Hg offer 24-hour ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis of hypertension (NEW 2011)
“when possible recommend treatment with drug taken once a day”
“Drugs which exert their antihypertensive effect over 24 hours with a once-a-day administration should be preferred” 24
1. Mancia G, et all. J Hypertens. 2007;25: NICE Guidelines 2011.

25. NICE Chart of AB/CD with de-emphasis on beta-blockers
< 55 years
> 55 years or Asian / Chinese
STEP 1 A
C or D
STEP 2
A+C or A+D
STEP 3
A+C+D
STEP 4
Add: Further D/C therapy
Alpha Blockers
Beta Blockers etc
A: ACEI/ARB C: CCB,
D: Diuretic 

26. Thanks