Hypertension - Deciphered

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  • NOTES FOR PRESENTERS:
    Recommendation 1.2.3 [new 2011] in full: shown on the slide.
    Related new recommendations
    When considering a diagnosis of hypertension, measure blood pressure in both arms. If the difference in readings between arms is more than 20 mmHg, repeat the measurements. If the difference in readings between arms remains more than 20 mmHg on the second measurement, measure subsequent blood pressures in the arm with the higher reading. [new 2011] [1.2.1]
    If blood pressure measured in the clinic is 140/90 mmHg or higher take a second measurement during the consultation. If the second measurement is substantially different from the first, take a third measurement. Record the lower of the last two measurements as the clinic blood pressure. [new 2011] [1.2.2]
    If a person is unable to tolerate ABPM, home blood pressure monitoring (HBPM) is a suitable alternative to confirm the diagnosis of hypertension. [new 2011] [1.2.4]
    If the person has severe hypertension, consider starting antihypertensive drug treatment immediately, without waiting for the results of ABPM or HBPM. [new 2011] [1.2.5]
    While waiting for confirmation of a diagnosis of hypertension, carry out investigations for target organ damage (such as left ventricular hypertrophy, chronic kidney disease and hypertensive retinopathy) (see recommendation 1.3.3, slide 19) and a formal assessment of cardiovascular risk using a cardiovascular risk assessment tool (see recommendation 1.3.2, slide 19). [new 2011] [1.2.6]
    Additional information
    See slide 18 for recommendations about measuring blood pressure.
  • NOTES FOR PRESENTERS:
    Recommendations in full:
    When using ABPM to confirm a diagnosis of hypertension, ensure that at least two measurements per hour are taken during the person’s usual waking hours (for example, between 08:00 and 22:00). Use the average value of at least 14 measurements taken during the person’s usual waking hours to confirm a diagnosis of hypertension. [new 2011] [1.2.9]
    When using HBPM to confirm a diagnosis of hypertension, ensure that:
    for each blood pressure recording, two consecutive measurements are taken, at least 1 minute apart and with the person seated and
    blood pressure is recorded twice daily, ideally in the morning and evening and
    blood pressure recording continues for at least 4 days, ideally for 7 days.
    Discard the measurements taken on the first day and use the average value of all the remaining measurements to confirm a diagnosis of hypertension. [new 2011] [1.2.10]
    Related new recommendations
    If hypertension is not diagnosed but there is evidence of target organ damage such as left ventricular hypertrophy, albuminuria or proteinuria, consider carrying out investigations for alternative causes of the target organ damage. [new 2011] [1.2.7]
    If hypertension is not diagnosed, measure the person’s clinic blood pressure at least every 5 years subsequently, and consider measuring it more frequently if the person’s clinic blood pressure is close to 140/90 mmHg. [new 2011] [1.2.8]
    Additional information:
    An extensive review of the evidence by the guideline development group has identified that ABPM multiple blood pressure measurements away from the clinic setting are the best predictor of blood pressure-related clinical outcomes. They concluded that ABPM appeared to provide the best method of confirming a diagnosis of hypertension. They stated that ABPM would not only be a more effective means of diagnosis but also, a more cost-effective means of establishing the diagnosis of hypertension.
    Recommendations 1.2.11 and 1.2.12 covering specialist assessment and investigation have been amended since the previous guideline in 2004. It is possible that this amendment may reflect a change in practice.
    The BHS have developed a section of their website (http://www.bhsoc.org//index.php?cID=161) to assist in the setting up and management of an Ambulatory Blood Pressure Monitoring clinic
  • m
  • Hypertension - Deciphered

    1. 1. HYPERTENSION- DECIPHERED DR SYED RAZA MD,MRCP(UK),FRCP (Edin),CCT, FACC
    2. 2. Facts and Figures • 30 per cent of women and men have high blood pressure • 30 per cent of people with high blood pressure DO NOT KNOW that they have it. • Three times more likely to develop heart disease and stroke Twice as likely to die from these as people with a normal blood pressure • Only about 10% individuals reach target goals
    3. 3. Which one is normal blood pressure ? • • • • • A) 148/88 mmHg in 68 years old B) 136/86 mmHg in a diabetic C) 138/ 90 in 40 years old D) 138/88 mmHg in Renal failure E) 130/80 mmHg in a diabetic
    4. 4. ANSWER • ALL ARE NORMAL BLOOD PRESSURE READINGS
    5. 5. Guidelines for management of Hypertension
    6. 6. Diagnosis (1) If the clinic blood pressure is 140/90 mmHg or higher, offer ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis of hypertension.
    7. 7. Diagnosis (2) When using the following to confirm diagnosis, ensure: ABPM: –at least two measurements per hour during the person’s usual waking hours, average of at least 14 measurements to confirm diagnosis HBPM: –two consecutive seated measurements, at least 1 minute apart –blood pressure is recorded twice a day for at least 4 days and preferably for a week –measurements on the first day are discarded – average value of all remaining is used.
    8. 8. Value of accurate measurement of BP • Underestimating /Untreated 5 mm Hg of excessive systolic blood pressure would be a 25% increase over current levels of fatal strokes and fatal myocardial infarctions . • Overestimating true blood pressure by 5 mm Hg would lead to inappropriate treatment with antihypertension medications adverse drug effects, psychological effects of misdiagnosis, and unnecessary cost.
    9. 9. Assessment of Hypertension • 1. Assess for risk factors and co-morbidities. • 2. Look for Target organ damage • 3. Look for secondary cause for hypertension.
    10. 10. ASSESMENT OF CV RISK AND TOD – Blood Glucose and Cholesterol – test urine for presence of protein – take blood to measure creatinine, estimated GFR electrolytes. – examine fundi for hypertensive retinopathy – arrange a 12-lead ECG.
    11. 11. Window to Vascular Health
    12. 12. Secondary Causes
    13. 13. Stages of Hypertension • Stage 1 hypertension: • Clinic blood pressure (BP) is 140/90 mmHg or higher and • ABPM or HBPM average is 135/85 mmHg or higher. • Stage 2 hypertension: • Clinic BP 160/100 mmHg is or higher and • ABPM or HBPM daytime average is 150/95 mmHg or higher. • Severe hypertension: • Clinic BP is 180 mmHg or higher or • Clinic diastolic BP is 110 mmHg or higher.
    14. 14. Hypertensive Crisis 58/m presents to ER with chest pain and SOB. Clinically in acute pulmonary edema ECG – ischemic BP : 240/120 mmHg What is the diagnosis ? A.Hypertensive Urgency. B.Hypertensive Emergency.
    15. 15. How will you Manage such a Patient ? • Hypertensive Emergency • Reduction of Blood Pressure with in an hour • Hypertensive Urgency • Reduction of Blood Pressure in 48 - 72 hours
    16. 16. Hypertensive CRISIS Hypertensive Emergency • BP > 220/120 • Target organ damage • BP to be normalized within one hour • Intravenous therapy • Treated as In patient Hypertensive Urgency • BP > 220/120 • No target organ damage • BP to be normalized 4872hours • Oral Therapy. • Treated as Out Patient
    17. 17. HYPERTENSION MYTHS • Blood pressure causes Headache • ‘’I have no symptoms, why should I take medication? • ‘’How soon can I stop medication once blood pressure is controlled ?’’ • ‘’My blood pressure is all due to stress’ ’ • ‘’I do not want to take tablets as they have side effects.’’
    18. 18. HYPERTENSION MYTHS: contd ‘’ My blood pressure is high because I had a very salty meal last night.’’ ‘’ I have been advised to take blood pressure pill at night’’ ‘My blood pressure is higher in the left arm as I am left handed’ ‘My blood pressure is always normal with my own BP machine at home’
    19. 19. Hypertension in the Young • • • • Look for a secondary cause Either on no treatment or multiple drugs Diastolic BP control is more important Choice of drugs ?
    20. 20. Which Drug to Choose ? • • • • • • MI : Beta- Blocker Acute Pulmonary Edema : NTG Aortic Dissection : Labetalol Intracranial Hemorrhage : Nicardipine Acute Kidney Injury : Fenoldopam Pre-Eclampsia : Labetalol
    21. 21. Drug to Choose for Stable Patients • LVH - ACE inhibitor, calcium antagonist, ARB • Asymptomatic atherosclerosis - Calcium antagonist, ACE inhibitor • Micro-albuminuria - ACE inhibitor, ARB • Renal dysfunction - ACE inhibitor, ARB • Previous stroke - ACEI (Perindopril + Indapamide) • Previous myocardial infarction - BB, ACE inhibitor, ARB • Angina pectoris -BB, calcium antagonist • Heart failure - Diuretic, BB, ACE inhibitor, ARB, Aldactone • Aortic aneurysm & Atrial fibrillation : BB
    22. 22. Drug to Choose for Stable Patients - contd • ESRD/proteinuria - ACE inhibitor, ARB • Peripheral artery disease - ACE inhibitor, calcium antagonist • ISH (elderly) - Diuretic, calcium antagonist • Diabetes mellitus -- ACE inhibitor, ARB • Pregnancy - Methyldopa, calcium antagonist • Blacks - Calcium antagonist + Hydralazine
    23. 23. Which Diuretic ? Thiazide type diuretic (Indapamide and Chlorthalidone) first line agent – recommend by American guidelines. British /NICE guidelines : Second line – in combination. Thiazide diuretic HCT – metabolic derangement Loop diuretic : Furosemide – third line.
    24. 24. FIXED DOSE COMBINATION • A+C • A+D • B+D x • Recommendation for Stage 2 Hypertension.
    25. 25. Life Style Modification
    26. 26. How Low is ‘Low Salt’?
    27. 27. Recommendation for Salt Intake 2.3 gm per day 1.5 gm per day if a. Hypertension b.Diabetes c. > 51 d.Black e.Renal Disease
    28. 28. Take Home Message • 1. Hypertension is common • 2. Is a silent killer • 3. Associated with high Cardiovascular morbidity • 4. Correct measurement of blood pressure • 5. Choose the right medication / right dosage • 6. Educate your patients
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