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
Hypertension - Deciphered
DR SYED RAZA
MD,MRCP(UK),FRCP (Edin),CCT, FACC
Facts and Figures
• 30 per cent of women and men have high blood
• 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
Which one is normal blood
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
• ALL ARE NORMAL BLOOD PRESSURE
If the clinic blood pressure is 140/90 mmHg or
higher, offer ambulatory blood pressure
monitoring (ABPM) to confirm the diagnosis of
When using the following to confirm diagnosis, ensure:
–at least two measurements per hour during the
person’s usual waking hours, average of at least 14
measurements to confirm diagnosis
–two consecutive seated measurements, at least 1
–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.
Value of accurate measurement of
• 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.
Assessment of Hypertension
• 1. Assess for risk factors and co-morbidities.
• 2. Look for Target organ damage
• 3. Look for secondary cause for hypertension.
ASSESMENT OF CV RISK AND TOD
– Blood Glucose and Cholesterol
– test urine for presence of protein
– take blood to measure creatinine, estimated GFR
– examine fundi for hypertensive retinopathy
– arrange a 12-lead ECG.
Stages of Hypertension
• Stage 1 hypertension:
• Clinic blood pressure (BP) is 140/90 mmHg or
• 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
• Severe hypertension:
• Clinic BP is 180 mmHg or higher or
• Clinic diastolic BP is 110 mmHg or higher.
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 ?
How will you Manage such a
• Hypertensive Emergency
• Reduction of Blood Pressure with in an hour
• Hypertensive Urgency
• Reduction of Blood Pressure in 48 - 72 hours
• BP > 220/120
• Target organ damage
• BP to be normalized within
• Intravenous therapy
• Treated as In patient
• BP > 220/120
• No target organ damage
• BP to be normalized 4872hours
• Oral Therapy.
• Treated as Out Patient
• Blood pressure causes Headache
• ‘’I have no symptoms, why should I take
• ‘’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
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’
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 ?
Which Drug to Choose ?
MI : Beta- Blocker
Acute Pulmonary Edema : NTG
Aortic Dissection : Labetalol
Intracranial Hemorrhage : Nicardipine
Acute Kidney Injury : Fenoldopam
Pre-Eclampsia : Labetalol
Which Diuretic ?
Thiazide type diuretic
(Indapamide and Chlorthalidone)
first line agent – recommend by American guidelines.
British /NICE guidelines : Second line – in
Thiazide diuretic HCT – metabolic derangement
Loop diuretic : Furosemide – third line.
FIXED DOSE COMBINATION
• B+D x
• Recommendation for Stage 2 Hypertension.
Recommendation for Salt Intake
2.3 gm per day
1.5 gm per day if
c. > 51
Take Home Message
• 1. Hypertension is common
• 2. Is a silent killer
• 3. Associated with high Cardiovascular
• 4. Correct measurement of blood pressure
• 5. Choose the right medication / right dosage
• 6. Educate your patients