Hypertension

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Hypertension

  1. 1. Introduction to Hypertension Management Rade N. Pejic, M.D. Instructor of Clinical Family and Community Medicine Tulane University Department of Family and Community Medicine
  2. 2. Objectives • Define Hypertension (HTN) • Learn how to measure blood pressure • Understand initial clinical evaluation • Identify causes of secondary HTN • Describe lifestyle modifications that lower blood pressure • Select appropriate anti-HTN medications • Provide appropriate follow-up care Tulane University Department of Family and Community Medicine
  3. 3. Case 1 • 55 y/o AAF seen your office for CPE • Medical history is unremarkable • BP = 158/92 • PE is unremarkable • What do you do? Tulane University Department of Family and Community Medicine
  4. 4. Case 2 • 72 y/o Caucasian female. No complaints. • ROS: arthritis • PM/S/OB-Gyn/F/S Hx all unremarkable • No Allergies • Takes IB daily for OA • Blood Pressure = 168/86. Similar on 2 prior visits. • 2/6 SM at LSB/Right 2 ICS • Rest of exam unremarkable x OA of hands/knees Tulane University Department of Family and Community Medicine
  5. 5. Case 3 • 26 y/o med student comes in for CPE • No complaints • Recent URI with nasal congestion • PM/S Hx negative • Social Hx: Binge drinker, occ tob, occ marijuana. Lives with roommate. • FHx: neg Tulane University Department of Family and Community Medicine
  6. 6. Case 3 • BP 160/100 • Pulse 108 • PE: Pupils 5mm, nares red with clear d/c, tachycardic, no murmur. Chest clear. Abd neg. Ext warm/moist. Tulane University Department of Family and Community Medicine
  7. 7. Case 4 • 42 y/o white male comes in for STD check up. • Pt nervous about recent sexual contact. • Medical history unremarkable • BP 152/94 • Exam unremarkable • STD labs draw/Pt counseled/Will return in one week for results of labs Tulane University Department of Family and Community Medicine
  8. 8. What is Hypertension? Tulane University Department of Family and Community Medicine
  9. 9. Hypertension • HTN = abnormal elevation of BP • BP limits are different in children and pregnancy. • BP goal is different if you have diabetes or chronic kidney disease. • JNC-7 Guidelines for adults. Tulane University Department of Family and Community Medicine
  10. 10. JNC-7 • Released May 2003 • Reclassified BP – Normal <120/80 – PreHTN 120-139/80-89 – Stage 1 140-159/90-99 – Stage 2 >160/100 Tulane University Department of Family and Community Medicine
  11. 11. JNC-7 • Systolic is MORE important than diastolic • Risk of CV disease doubles for every 20/10 increase above 115/75 • “PreHTN” emphasized • Thiazide diuretics • Goal BP <140/90 and <130/80 with DM/CKD • Start with 2 meds if BP >20/10 above goal Tulane University Department of Family and Community Medicine
  12. 12. Why do we care? • Relationship b/w BP and CVD is positive and continuous. • We want to prevent: Stroke, MI, HF, kidney damage, retinopathy, peripheral artery dz, other morbidity of atherosclerosis. Tulane University Department of Family and Community Medicine
  13. 13. Does treatment help? • YES • 35-40% decline in stroke • 25% decline in CAD/MI • >50% decline in HF Tulane University Department of Family and Community Medicine
  14. 14. Clinical Evaluation Tulane University Department of Family and Community Medicine
  15. 15. Accurate BP Measurement • How do you take a BP? Tulane University Department of Family and Community Medicine
  16. 16. Proper BP Measurement • MD should check • Lower edge of cuff • PT seated/quiet/calm 2.5cm above AC fossa • Arm resting at heart • Palp radial artery to level determine systolic • Proper cuff: should • Use Bell to ausc over cover 2/3 of arm and brachial artery bladder should circle • Inflate cuff to 20-30 80% of arm mmHg above est syst. Tulane University Department of Family and Community Medicine
  17. 17. BP Measurement • Deflate cuff at • Check both arms 2mmHg/seca • Listen for Korotkoff I and V. • Record at nearest 2mm Hg • Repeat in 30 sec Tulane University Department of Family and Community Medicine
  18. 18. Factors that INCREASE BP • Talking • Cold Temp • EtOH • Tob • Arm below heart • Small Cuff Tulane University Department of Family and Community Medicine
  19. 19. Factors the DECREASE BP • Cuff too large • Arm above heart • Diastolic lower when supine • MD Bias Tulane University Department of Family and Community Medicine
  20. 20. Diagnosis of HTN • Repeated abnormal elevation of BP using proper technique/cuff on 3 separate occasions over at least 6 weeks • A single blood pressure >200/120 • Keep in mind: – Risk factors – Evidence of end-organ disease Tulane University Department of Family and Community Medicine
  21. 21. White Coat HTN • May be as great as 20/10 above pt’s normal BP. • Consider home BP monitoring, ambulatory monitoring, RN visits • Always calibrate pt’s home BP machine with office manometer Tulane University Department of Family and Community Medicine
  22. 22. Hypertension • Primary (“essential”) 95% of cases • Secondary 5% of cases Tulane University Department of Family and Community Medicine
  23. 23. What is Secondary HTN? • HTN that has a demonstrable underlying cause. • Such as? Tulane University Department of Family and Community Medicine
  24. 24. Secondary HTN • ABCDE mnemonic Tulane University Department of Family and Community Medicine
  25. 25. “A” • Accuracy • Apnea (OSA) • Aldosteronism (hyperaldosteronism) Tulane University Department of Family and Community Medicine
  26. 26. “B” • Bruits (renal artery stenosis/FMD) • Bad Kidneys (intrinsic kidney dz) Tulane University Department of Family and Community Medicine
  27. 27. “C” • Catecholamines • Coarctation • Cushing’s Syndrome Tulane University Department of Family and Community Medicine
  28. 28. “D” • Drugs (stimulants, OCPs, NSAIDS) • Diet (high Na/low K, Mg, Ca) Tulane University Department of Family and Community Medicine
  29. 29. “E” • Erythropoietin: elevated EPO in COPD or renal failure or exogenous use for anemia • Endocrine: Thyroid/Parathyroid, pregnacy, pheochromocytoma, acromegaly Tulane University Department of Family and Community Medicine
  30. 30. Clinical Evaluation • History • Physical Exam • Laboratory Evaluation Tulane University Department of Family and Community Medicine
  31. 31. History • Risk Factors • Symptoms of end organ damage • Review PMHx/PSHx/POB-GynHx • Review Family and Social history • Review Meds Tulane University Department of Family and Community Medicine
  32. 32. Physical Exam • Vital Signs: Accurate BP, BMI • Retinopathy • Thyroid • Neck circumference >17 inches • C/V exam: LVH, valvular prob, pulses and bruits, leg edema • Cushinoid features? Tulane University Department of Family and Community Medicine
  33. 33. Laboratory Evaluation • CBC • Chem-7 (“renal lytes”) – Always calculate GFR. Use MDRD equation or similar equation. • U/A • Urine albumin:creatinine ratio • FLP • EKG Tulane University Department of Family and Community Medicine
  34. 34. What do labs mean? • CBC: Look for elevated Hb/HCT • Chem7: Look for low K, elevated Bun/Cr, elevated Ca. Calc GFR • U/A: Look for protein/blood • Alb:Cr ratio: Look for microscopic albumin • FLP: Look for abnormal lipids • EKG: Look for LVH, CAD, arrhythmia Tulane University Department of Family and Community Medicine
  35. 35. Treatment • Life style modifications for all pts – Decrease weight: lowers BP 5-20mmHg/10 Kg – DASH diet: 8-14 mmHg – Low Na diet: 2-8 mmHg – Aerobic exercise: 4-9 mmHg – Decrease EtOH: 2-4 mmHg Tulane University Department of Family and Community Medicine
  36. 36. Treatment • Empathize with patient to encourage trust, motivation, and adherence to therapy • Consider cultural beliefs and individual attitudes in formulating treatment plan • Involve the whole family. Tulane University Department of Family and Community Medicine
  37. 37. Medications • ACE-I • ARB • Alpha Blockers • Beta Blockers • Calcium Channel Blockers – Dihydropridines – Non-Dihydropridines Tulane University Department of Family and Community Medicine
  38. 38. Medications • Diuretics – CAI – Loop – Potassium Sparing/Aldosterone Blockers – Thiazide Tulane University Department of Family and Community Medicine
  39. 39. Medications • Nitrates • Misc: – Hydralazine – Midoxidil – Nitroprusside – Methyldopa – Clonidine Tulane University Department of Family and Community Medicine
  40. 40. Which one do you pick? • JNC-7 Recommendations – Stage 1 w/o compelling indications to choose something else, then use THIAZIDE – Stage 2 w/o compelling indications to choose something else, then use THIAZIDE plus ACE Tulane University Department of Family and Community Medicine
  41. 41. Cautions/Contraindications for Thiazide • Allergy to thiazide • Allergy to sulfa • Anuria/ESRD • Electrolyte problems/low K/low Na • Gout/Hyperuricemia • Severe liver disease • Pregnancy • Pancreatitis? Tulane University Department of Family and Community Medicine
  42. 42. “Compelling Indications” • Heart Failure • Post-MI • High Risk CAD • DM • CKD • Recurrent CVA prevention Tulane University Department of Family and Community Medicine
  43. 43. Heart Failure • ACE-I/ARB • BB • Loop Diuretic • Aldosterone Blocker Tulane University Department of Family and Community Medicine
  44. 44. Post-MI • BB • ACE-I • Aldosterone Blocker Tulane University Department of Family and Community Medicine
  45. 45. High Risk of CAD • BB • ACE-I • CCB • Thiazide Tulane University Department of Family and Community Medicine
  46. 46. Diabetes • ACE-I/ARB: Prevent nephropathy Tulane University Department of Family and Community Medicine
  47. 47. Chronic Kidney Disease • ACE-I • ARB • Non-Dihydropyridine CCB Tulane University Department of Family and Community Medicine
  48. 48. Recurrent Stroke Prevention • ACE-I Tulane University Department of Family and Community Medicine
  49. 49. Other Clinical Considerations • Young: Use ACE-I/ARB • Elderly: Use Thiazide or Dihydro-CCB • PVD: Treat like CAD but CCB may relieve leg claudication. • Migraine: BB or CCB • BPH: Alpha Blocker • African-Americans: Thiazides Tulane University Department of Family and Community Medicine
  50. 50. Clinical Follow-Up • Initially, see pt as much as needed to stabilize BP • Then, every 4-6 months for 1st year. • Or, more often if pt needs motivation • Monitor BP, Weight, RL, U/A, Lipids, EKG • Encourage diet/exercise Tulane University Department of Family and Community Medicine
  51. 51. Side Notes • Remember CI to Thiazides • Thiazides may inhibit bone loss. • ACE-I: Can cause cough, angioedema, increase Cr (ok if <30% baseline). • BB: Reactive airway dz, depression, AVB • CCB: AVB, avoid short acting CCB • ACE-I plus ARB? Tulane University Department of Family and Community Medicine
  52. 52. Case 1 • 55 y/o AAF seen your office for CPE • Medical history is unremarkable • BP = 158/92 • PE is unremarkable • What do you do? Tulane University Department of Family and Community Medicine
  53. 53. Case 1 Con’t • You have her return in 2 weeks for a RN visit to check her BP. • BP at that visit 162/88 Tulane University Department of Family and Community Medicine
  54. 54. Case 1 Con’t What do you do now? 1. Have her check BP at home/pharmacy 2. Come back to see you with results in 1 month. Tulane University Department of Family and Community Medicine
  55. 55. Case 1 Con’t 1 month later her BP in your office is 160/86 and her home BP measurements are: 150/80 162/84 158/88 160/82 156/86 Tulane University Department of Family and Community Medicine
  56. 56. Case 1 Con’t How should you proceed? 1. Labs 2. EKG 3. Lifestyle modifications 4. Continue home BP measurement 5. Have patient return in 4-6 months Tulane University Department of Family and Community Medicine
  57. 57. Case 1 Con’t Your patient returns 1 year later. Since her last visit her weight has increased by 2 lbs and her BP today is 166/90. Labs and EKG done at the last visit were normal. What is her BP goal? Tulane University Department of Family and Community Medicine
  58. 58. Case 1 Con’t • Her BP goal is < 140/90 • How should you proceed? Tulane University Department of Family and Community Medicine
  59. 59. Case 1 Con’t • Reinforce need to make lifestyle modifications. • Consider referral to dietician. • Start thiazide diuretic (HCTZ 12.5 QD) • Have patient schedule more frequent appointments to stabilize BP and motivate her. Tulane University Department of Family and Community Medicine
  60. 60. Case 2 • 72 y/o Caucasian female. No complaints. • ROS: arthritis • PM/S/OB-Gyn/F/S Hx all unremarkable • No Allergies • Takes IB daily for OA • Blood Pressure = 168/86. Similar on 2 prior visits. • 2/6 SM at LSB/Right 2 ICS • Rest of exam unremarkable x OA of hands/knees Tulane University Department of Family and Community Medicine
  61. 61. What is your assessment? Tulane University Department of Family and Community Medicine
  62. 62. Case 2 Con’t • Assessment: 72 y/o female with – Stage 2 HTN – OA hands/knees Tulane University Department of Family and Community Medicine
  63. 63. What labs/studies do you want? Tulane University Department of Family and Community Medicine
  64. 64. Case 2 Con’t • CBC • Chem 7 • U/A • MicroAlb? • FLP • EKG Tulane University Department of Family and Community Medicine
  65. 65. Case 2 Con’t • All labs reported as normal • EKG: NSR 80 • Creatinine = 1.2 • What is her GFR? Tulane University Department of Family and Community Medicine
  66. 66. Case 2 Con’t • GFR = 47.5 • Is this normal? Tulane University Department of Family and Community Medicine
  67. 67. NO • Normal GFR 90-140 • 60-89 mild ckd • 30-59 mod ckd • 15-29 severe ckd • <15 is ESRD “failure” Tulane University Department of Family and Community Medicine
  68. 68. Case 2 Con’t • What is her BP goal? • <130/80 Tulane University Department of Family and Community Medicine
  69. 69. Case 2 Con’t • How would you treat her? Tulane University Department of Family and Community Medicine
  70. 70. Case 2: Treatment • Life style modifications – Weight Reduction – DASH Diet – Low Na Diet – Exercise – Decrease EtOH Tulane University Department of Family and Community Medicine
  71. 71. Case 2: Treatment • Avoid NSAID’s • Use Acetaminophen for OA Tulane University Department of Family and Community Medicine
  72. 72. Case 2: Treatment • Because she’s >20 mmHg above her goal BP and she had moderate kidney disease you should consider meds. – Thiazide: Good for elderly – ACE-I: Protect kidney Tulane University Department of Family and Community Medicine
  73. 73. Case 3 • 26 y/o med student comes in for CPE • No complaints • Recent URI with nasal congestion • PM/S Hx negative • Social Hx: Binge drinker, occ tob, occ marijuana. Lives with roommate. • FHx: neg Tulane University Department of Family and Community Medicine
  74. 74. Case 3 • BP 160/100 • Pulse 108 • PE: Pupils 5mm, nares red with clear d/c, tachycardic, no murmur. Chest clear. Abd neg. Ext warm/moist. Tulane University Department of Family and Community Medicine
  75. 75. Case 3 • What is your Assessment? Tulane University Department of Family and Community Medicine
  76. 76. Assessment • HTN • Tachycardia • Mydriasis • Rhinorrhea • Poly-substance use/?abuse Tulane University Department of Family and Community Medicine
  77. 77. What do you do now? Tulane University Department of Family and Community Medicine
  78. 78. Case 3: Work-Up • Ask patient about medications/drugs/other secondary causes of HTN…pheo? • Get EKG Tulane University Department of Family and Community Medicine
  79. 79. Case 3: work up • Pt states that he is on Advil cold and sinus for recent URI. • He admits to nasal inhalation of roommates Ritalin over the last several days while studying • EKG: Sinus Tach 108. No ST changes. Tulane University Department of Family and Community Medicine
  80. 80. Case 3: Diagnosis/Treatment • Likely stimulant induced hypertension • D/C Advil cold and sinus • D/C Ritalin • RTC in 1 week to recheck BP. Tulane University Department of Family and Community Medicine
  81. 81. Case 3 Con’t • One week later the BP is still elevated. • What other concerns do you have? Tulane University Department of Family and Community Medicine
  82. 82. Case 3 Con’t • You need to r/o other causes of secondary hypertension. – Pheochomocytoma – HyperThyroidism – Persistent drug abuse…cocaine? – HyperAldosteronism – Steroids – Renal artery disease Tulane University Department of Family and Community Medicine
  83. 83. Case 4 • 42 y/o white male comes in for STD check up. • Pt nervous about recent sexual contact. • Medical history unremarkable • BP 152/94 • Exam unremarkable • STD labs draw/Pt counseled/Will return in one week for results of labs Tulane University Department of Family and Community Medicine
  84. 84. Case 4 Con’t • One week later: • STD labs negative • Pt’s BP 148/98 • You ask patient to return for f/u BP in 1 month. Tulane University Department of Family and Community Medicine
  85. 85. Case 4 Con’t • One month later: • BP 156/94 • Exam negative • EKG: NSR 72 • What do you do next? Tulane University Department of Family and Community Medicine
  86. 86. Case 4 Con’t • You need to r/o “white coat” HTN. • You have patient check BP at local pharmacy and bring list in for you in 1 month. Tulane University Department of Family and Community Medicine
  87. 87. Case 4 Con’t • One month later: • Pt brings in list of BP taken at Ralph’s Pharmacy. • BP: 130/82, 133/80, 138,84, 128/78 • Dx: White Coat HTN but also “pre-HTN” • Rec: Life style modifications. Recheck 1 yr Tulane University Department of Family and Community Medicine
  88. 88. Summary • Follow JNC 7 Guidelines • Make sure you have accurate BP • Encourage lifestyle changes • Remember secondary causes of HTN • Start thiazide unless compelling indication • Encourage/Motivate patients. Be respectful and culturally sensitive. Involve the whole family. Tulane University Department of Family and Community Medicine

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