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  • In the top 10 DX in FM offices
  • Hypertension

    1. 1. Hypertension Catherine Florio Pipas, MD Community & Family Medicine 2007
    2. 2. <ul><li>Accurate diagnosis </li></ul><ul><li>Classification </li></ul><ul><li>Evaluation ( Initial and follow up) </li></ul><ul><ul><li>Risk factors and target organ disease </li></ul></ul><ul><ul><li>Treatment </li></ul></ul><ul><ul><li>Lifestyle Modification </li></ul></ul><ul><ul><li>Drug treatments </li></ul></ul><ul><ul><li>Co-Morbid conditions </li></ul></ul>An Approach to Hypertension ( JNC 7 Report JAMA 2003;289:2560-2572)
    3. 3. Hypertension - Facts <ul><li>50 million adult Americans have hypertension (60%>60), (80% >80) , (90%> 90) </li></ul><ul><ul><li>95% is primary (idiopathic) </li></ul></ul><ul><ul><li>5% of adult HTN is secondary </li></ul></ul><ul><ul><ul><li>Renal (parenchymal/vascular) </li></ul></ul></ul><ul><ul><ul><li>Endocrine (adrenal/parathyroid) </li></ul></ul></ul><ul><ul><ul><li>Pregnancy related </li></ul></ul></ul><ul><ul><ul><li>Result of drug therapy </li></ul></ul></ul><ul><ul><ul><li>Coarctation of aorta </li></ul></ul></ul><ul><ul><ul><li>Sleep apnea </li></ul></ul></ul>
    4. 4. Hypertension - Trends <ul><ul><ul><li>National Health and Nutrition Examination Survey Trials (NHANES) demonstrate that since 1976-1994: </li></ul></ul></ul><ul><ul><ul><ul><li>-More patients are aware they have HTN </li></ul></ul></ul></ul><ul><ul><ul><ul><li>-More patients are under therapy for HTN </li></ul></ul></ul></ul><ul><ul><ul><ul><li>-More patients under therapy are in control </li></ul></ul></ul></ul><ul><ul><ul><ul><li>-However since 1991 these increases have leveled off </li></ul></ul></ul></ul><ul><ul><ul><li>Age-adjusted mortality rates for strokes and CHD have decreased since 1976 but since 1991 the rates are leveling off </li></ul></ul></ul><ul><ul><ul><li>The frequency of end-stage renal disease and heart failure is increasing </li></ul></ul></ul>
    5. 5. <ul><li>CC: Mr Charlie Bont is a 44- year old, black male who presents for a comprehensive health assessment required by his new employer. </li></ul><ul><li>SH: Mr Bont, an electrician, offered a substantial increase in salary, benefits, and supervisory responsibility . </li></ul><ul><li>ROS: No current complaints </li></ul>Hypertension Case 1 of 15
    6. 6. Hypertension Case - Cont. <ul><li>PMH: Last visit to a physician was a pre-employment evaluation prior to his previous job 11 years ago. Reported as normal. </li></ul><ul><li>PE: Vital signs - BP 156/98 right arm sitting; respirations 14/min; pulse 68 and regular; temp 98.6; weight 223 lbs; </li></ul><ul><li>height 5 feet 7 inches . BMI 34.6 </li></ul>2 of 15
    7. 7. Hypertension Case - Cont. <ul><li>1. Considering only this preliminary data, List three “ medical concerns ” that warrant further evaluation. </li></ul>3 of 15
    8. 8. Hypertension Case - Cont. <ul><li>2. Give four conditions required of the patient, the measurement and/or the instrument needed to accurately confirm the “ diagnosis of hypertension ” </li></ul><ul><li>versus </li></ul><ul><li> “ elevated BP” </li></ul>4 of 15
    9. 9. Hypertension - Diagnosis <ul><li>Measurement in the office </li></ul><ul><ul><li>BP evaluated on two separate visits </li></ul></ul><ul><ul><li>Bare arm in seated position </li></ul></ul><ul><ul><li>No smoking or caffeine for at least thirty minutes prior </li></ul></ul><ul><ul><li>Cuff bladder should nearly encircle the arm (at least 80%) </li></ul></ul><ul><ul><li>BP measured after at least 5 minutes of rest </li></ul></ul><ul><ul><li>Two or more readings should be repeated (at least 2 minutes apart) </li></ul></ul>
    10. 10. JNC-7* Adult BP Classification * Joint National Commision on Prevention, Detection, Evaluation and Treatment of High Blood Pressure * For adults ≥18 years old * If SBP and DBP in different classes, choose the highest class
    11. 11. JNC-6 Classification Hypertension - Age < 18 years * Lifestyle modifications recommended ** Pharmacologic therapy recommended
    12. 12. <ul><li>You have established the presence of “ stage 1 hypertension ” in Mr Bont. What history that would be important in defining other cardiovascular risk factors or the presence of target organ disease . Include the specifics, if necessary to define increased risk. Ex. Hypercholesterolemia (chol >200) </li></ul><ul><li>Component of History: </li></ul><ul><li>Past medical history ROS </li></ul><ul><li>Social habits Nutritional history </li></ul><ul><li>Psychosocial/environmental history Family history </li></ul>Hypertension Case - Cont. 7 of 15
    13. 13. Hypertension Evaluation <ul><li>Additional Major CV Risk Factors </li></ul><ul><li>Smoking </li></ul><ul><li>Dyslipidemia </li></ul><ul><li>Diabetes </li></ul><ul><li>Obesity (BMI>30) </li></ul><ul><li>Physical inactivity </li></ul><ul><li>Microalbuminuria or GFR < 60ml/min </li></ul><ul><li>Age >55 men, >65women </li></ul><ul><li>FH of premature CVD </li></ul><ul><ul><li>Men <55 yo </li></ul></ul><ul><ul><li>Women <65 yo </li></ul></ul><ul><li>Target-organ damage </li></ul><ul><li>Heart disease </li></ul><ul><ul><li>- LVH </li></ul></ul><ul><ul><li>- Angina or prior MI </li></ul></ul><ul><ul><li>- Prior CABG </li></ul></ul><ul><ul><li>- Heart failure </li></ul></ul><ul><li>Stroke or TIA </li></ul><ul><li>Nephropathy </li></ul><ul><li>Peripheral arterial disease </li></ul><ul><li>Retinopathy </li></ul>
    14. 14. Hypertension Case- PE <ul><li>Describe components of the PHYSICAL EXAM that alert you to the presence of target organ disease, other CV risk factors or secondary hypertension . </li></ul><ul><li>Component of physical exam: </li></ul><ul><li>VS- Wght, BP, </li></ul><ul><li>Eyes Neck </li></ul><ul><li>Heart Lungs </li></ul><ul><li>Abdomen Extremities </li></ul><ul><li>Neurologic </li></ul>8 of 15
    15. 15. PE COMPONENTS <ul><li>History/Physical Exam: </li></ul><ul><li>BP both arms, BMI </li></ul><ul><li>Fundoscopic exam </li></ul><ul><li>Thyroid Exam </li></ul><ul><li>Carotid , femoral & abdominal bruits </li></ul><ul><li>Pulmonary and Cardiac exam </li></ul><ul><ul><li>LV apex - (S3 &S4 gallop) </li></ul></ul><ul><li>Abdominal Exam (kidneys, masses, AAA) </li></ul><ul><li>Peripheral vascular pulses and edema </li></ul><ul><li>Neurologic exam </li></ul>
    16. 16. Hypertension Case - Cont. <ul><li>What initial lab tests or studies would you perform on Mr Bont. </li></ul><ul><li>Give rationale for choosing the test and the findings that might alert you. </li></ul>9 of 15
    17. 17. Hypertension – Initial Lab and Test Evaluation* <ul><li>Labs: </li></ul><ul><li>Electrolytes </li></ul><ul><ul><li>K+/ Na+ </li></ul></ul><ul><ul><li>BUN/Creatinine </li></ul></ul><ul><ul><li>Fasting blood glucose </li></ul></ul><ul><li>Fasting Lipid panel </li></ul><ul><li>Urinalysis (GFR) </li></ul><ul><li>EKG </li></ul><ul><li>NEW JNC 7- Hct and Ca </li></ul>
    18. 18. Hypertension - Additional Testing <ul><li>Consider further evaluation if any of the following are present: </li></ul><ul><li>Abdominal trauma </li></ul><ul><li>Sudden onset of severe HTN </li></ul><ul><li>History of abnormal urinalysis </li></ul><ul><li>Elevated creatinine </li></ul><ul><li>Hypokalemia </li></ul><ul><li>Hypercalcemia </li></ul><ul><li>Consider secondary causes of hypertension: </li></ul><ul><li>Resistant HTN </li></ul><ul><li>Paroxysmal HTN </li></ul><ul><li>Abdominal mass or bruit </li></ul><ul><li>Cushing Syndrome </li></ul>
    19. 19. Hypertension Case - Cont. <ul><li>Mr Bont has </li></ul><ul><li>STAGE 1 HTN </li></ul><ul><li>Negative History and PE </li></ul><ul><li>Normal Labs and EKG </li></ul><ul><li>Describe your initial approach to his treatment. </li></ul>10 of 15
    20. 20. JNC-7* Adult BP Classification and Treatment Recommendations * Joint National Commision on Prevention, Detection, Evaluation and Treatment of High Blood Pressure * For adults ≥18 years old * If SBP and DBP in different classes, choose the highest class
    21. 21. Lifestyle Modifications PREVENTION for all !!!!!!!!!!! <ul><li>Weight loss (10lb wght loss reduces SBP 5-20mm Hg ) </li></ul><ul><ul><li>BMI 18.5-24.9 </li></ul></ul><ul><li>Limit ETOH (reduces SBP 2-4 mm HG) </li></ul><ul><ul><li>- Men 1-2/daily(1 oz ethanol, 24 oz beer, 10 oz wine or 3.0 oz whiskey) </li></ul></ul><ul><ul><li>- Women 1 daily(0.5 oz ethanol) </li></ul></ul><ul><li>Increase aerobic physical activity (reduces SBP 4-9mm HG) </li></ul><ul><ul><li>30-45 minutes most days of week </li></ul></ul><ul><li>Reduce sodium intake (reduces SBP 2-8mm HG) </li></ul><ul><ul><li>2.4 g sodium or 6 g salt (1 teaspoon table salt)) </li></ul></ul><ul><li>Stop smoking </li></ul><ul><li>Improve diet (reduces SBP 8-14 mm HG) </li></ul><ul><ul><li>Decrease intake of saturated fat and cholesterol </li></ul></ul><ul><ul><li>Increase fruits, vegetables and lowfat dairy </li></ul></ul>
    22. 22. Hypertension Case - Cont. <ul><li>BP 156/98 </li></ul><ul><li>You have decided to initiate drug treatment for Mr. Bont, what drug did you initiate and why? </li></ul>11 of 15
    23. 23. Hypertension - Drug Therapy <ul><li>JNC-7 recommends drug therapy be pushed to achieve goal BP of < 140/90 or <130/80 if DM or Nephropathy </li></ul><ul><li>Thiazides are best choice for most with Stage 1 </li></ul><ul><li>Use long-acting formulations that provide total 24-hour coverage with QD dosing when possible </li></ul><ul><li>Pts with BP >160/100 likely need two medications (thiazide plus another) </li></ul><ul><li>Patients with Co-Morbidities should have appropriate medications used </li></ul>
    24. 24. Hypertension Case - Cont. <ul><li>Briefly state the class and describe the mechanism of action for each of the following drugs: </li></ul><ul><li>PRIMARY SECONDARY </li></ul><ul><li>Hydrochlorothiazide </li></ul><ul><li>Propanolol </li></ul><ul><li>Benazepril Hydralazine </li></ul><ul><li>Diltiazem Clonidine </li></ul><ul><li>Losartan Doxazosin </li></ul>12 of 15
    25. 25. <ul><li>Individualize the pharmacologic treatment that you might initiate for hypertensive patients with CO-MORBIDITIES: </li></ul><ul><li>82-year old man with congestive heart failure </li></ul><ul><li>61-year old man post myocardial infarction </li></ul><ul><li>3. 40 year old with multiple CV risk factors </li></ul><ul><li>4. 42-year old man with Type II diabetes </li></ul><ul><li>5. 62-year old woman with chronic renal disease </li></ul><ul><li>6. 79 -yr old with Recurrent Stroke </li></ul>Hypertension Case - Cont. 13 of 15
    26. 26. <ul><li>Mr Bont returns after being on an antihypertensive agent for six weeks. His blood pressure is now 154/98. </li></ul><ul><li>List possible reasons for his lack of response to pharmacologic therapy . </li></ul>Hypertension Case - Cont. 14 of 15
    27. 27. REFRACTORY HTN <ul><li>40% Non compliance </li></ul><ul><li>40% Sub Optimal Therapy </li></ul><ul><li>10% Exogenous causes </li></ul><ul><li>10% Secondary HTN </li></ul>
    28. 28. <ul><li>What potential strategies would increase adherence and improve responsiveness to treatment ? </li></ul>Hypertension Case - Cont. 15 of 15
    29. 29. JNC 7 REPORTS :“Motivation improves when patients have positive experiences with and trust in their clinicians. Empathy builds trust and is a potent motivator” <ul><li>Patients previous knowledge and experiences </li></ul><ul><li>Patients cultural beliefs, concerns and fears </li></ul><ul><li>Verbal and written confirmation of goals </li></ul><ul><li>Ambulatory monitoring </li></ul><ul><li>Identify barriers </li></ul>
    30. 30. Summary:Approach to HTN <ul><li>Accurate Diagnosis </li></ul><ul><li>Staging </li></ul><ul><ul><li>Classification via JNC 7 2003 </li></ul></ul><ul><ul><ul><li>Remember PREHYPERTENSIVES (120-139 or 80-89) </li></ul></ul></ul><ul><ul><li>Assess H, PE, Labs and CV Risk factors </li></ul></ul><ul><li>Treatment </li></ul><ul><ul><li>Life Style Modifications/ Prevention for all </li></ul></ul><ul><ul><li>Thiazide Diuretics as first line </li></ul></ul><ul><ul><li>Consider Co-Morbid conditions </li></ul></ul><ul><li>Consider your causes if refractory( </li></ul>