HYPERTENSION introduction, recommendations for accurate measurements of BP, evaluation of patient with hypertension, management of patient with hypertension, resistant hypertension, hypertensive crisis, hypertensive emergencies

1. HYPERTENSION
INSP DR MAHADEV DEUJA
THURSDAY, MARCH 8, 2018

2. Introduction BP Measurements Etiology Evaluation Management
Objectives
 Introduction
 Accurate method of measurement of BP
 Etiology of hypertension
 Evaluation of patient with hypertension
 Management of patient with hypertension
Introduction BP Measurements Etiology Evaluation Management

3. Introduction BP Measurements Etiology Evaluation Management
Hypertension
 Leading cause of death and DALY world wide
 Responsible for 1 out of 8 deaths
 ≈5 y loss of life
 2nd only to cigarette smoking as a preventable cause of death
 Risk factor for CAD, HF, CKD, CVA, PAD and retinopathy
 Reducing BP reduces the incidence
 HF 50%; CVA 40%; MI 25%
 single most effective intervention for slowing the rate of progression of hypertension-
related kidney disease.
 33% adult (US)
Introduction

4. Introduction BP Measurements Etiology Evaluation Management
What Is HTN?
 Chronically elevated BP above normal
 Clinically , level of blood pressure at which the institution of
therapy reduces BP - related morbidity and mortality.
Introduction

5. Introduction BP Measurements Etiology Evaluation Management
Criteria for defining HTN
JNC7 JNC8 Panel Member
Report
SBP, mmHg
General population ≥140 ≥140
≥ 60 yrs of age
without diabetes or
CKD
* ≥150
DBP, mmHg
General population ≥90 ≥90
Introduction

6. Introduction BP Measurements Etiology Evaluation Management
Categories Of BP In Adults
2017 ACC/AHA
BP Category SBP DBP
NORMAL <120 AND < 80
EVEVATED 120-129 AND < 80
HYPERTENSION
STAGE 1 130-139 OR 80-89
STAGE 2 ≥140 OR ≥ 90
Introduction

7. Introduction BP Measurements Etiology Evaluation Management
Correct Measurement Of BP
 Diagnosis and management of HTN primarily depends on BP readings.
 Recommendation for accurate measurement of BP in the office
 Step 1: Properly prepare the patient
 Step 2: Use proper technique for BP measurements
 Step 3: Take the proper measurements needed for diagnosis and treatment of
elevated BP/hypertension
 Step 4: Properly document accurate BP readings
 Step 5: Average the readings
 Step 6: Provide BP readings to patient
BP Measurements

8. Introduction BP Measurements Etiology Evaluation Management
Step 1- Patient Preparation
 Have the patient relax, sitting in a chair (feet on floor,
back supported) for >5 min.
 No caffeine, exercise, and smoking for ≥ 30 min before
measurement.
 Ensure patient has emptied his/her bladder.
 No talk during the period of rest or measurement.
 Remove all clothing covering the location of cuff
placement.
BP Measurements

9. Introduction BP Measurements Etiology Evaluation Management
Step 2: Proper Technique
 Use validated and periodically calibrated
sphygmomanometer.
 Patient’s arm should be supported
 Place middle of the cuff on the patient’s upper arm at
the level of the right atrium .
 Use correct cuff size
 bladder encircles 80% of the arm .
BP Measurements

10. Introduction BP Measurements Etiology Evaluation Management
Step 3: Proper Measurements
 Record BP in both arms at 1st visit. Use the arm with higher
reading for subsequent measurements.
 Separate repeated measurements by 1–2 min.
 For auscultatory determinations
 use palpatory method to estimate SBP. Inflate the cuff 20–30 mm
Hg above this level
 Deflate the cuff pressure 2 mm Hg/sec, and listen for
Korotkoff sounds.
BP Measurements

11. Introduction BP Measurements Etiology Evaluation Management
Step 4: Document
 SBP- onset of the 1st Korotkoff sound and DBP as
disappearance of all Korotkoff sounds,
Note the time of most recent BP medication taken
before measurements.
BP Measurements

12. Introduction BP Measurements Etiology Evaluation Management
Step 5: Use an average of ≥2 readings obtained on ≥2
occasions to estimate the individual’s level of BP.
Step 6: Provide BP readings to patient
 both verbally and in writing.
BP Measurements

13. Introduction BP Measurements Etiology Evaluation Management
Other Noninvasive Methods:-
 ABPM (Ambulatory BP monitoring)
 – Record at regular intervals (eg, 20-30 min) over 24-48h
 HBPM (Home BP measurement)
 – Record BP by automated oscillometric devices
http://www.uspreventiveservicestaskforce.org/Page/Document/evidencesummary19/
hypertension-in-adults-screening-and-home-monitoring#citation2. Dec 2014
BP Measurements

14. Introduction BP Measurements Etiology Evaluation ManagementBP Measurements

15. Introduction BP Measurements Etiology Evaluation Management
Causes Of Hypertension
 80-95% - primary or "essential, " hypertension.
 tends to be familial and is likely to be the consequence of an interaction
between environmental and genetic factors.
 5-20% - secondary hypertension
 Common causes
 Renal parenchymal - 1-2%
 Reno vascular disease - 5-34%
 Pulmonary aldesteronism - 8-20%
 Obstructive sleep apnea - 25-50%
 Drug or alcohol induced - 2-4%
Etiology

16. Introduction BP Measurements Etiology Evaluation Management
 Uncommon causes
 Pheochromocytoma /paraganglioma
 Cushing’s syndrome
 Hypothyroidism
 Coarctation of aorta
 Primary hyperparathyroidism
 CAH
 Minralocorticoid excess syndrome- rare
 Acromegaly - rare
Etiology

17. Introduction BP Measurements Etiology Evaluation Management
Patient Evaluation
 Designed to
Identify target organ damage
+
Identify possible secondary causes of hypertension
+
Assist in planning an effective treatment regimen
Evaluation

18. Introduction BP Measurements Etiology Evaluation Management
Historical Features Favoring HTN Cause
 Primary hypertension
• Slow and gradual rise in BP
• Weight gain, high-sodium diet, decreased physical
activity, heavy alcohol
• Family history of HTN
Evaluation

19. Introduction BP Measurements Etiology Evaluation Management
cont…
Secondary hypertension
 BP liability, episodic pallor and dizziness
(Pheochromocytoma)
 Snoring, hyper somnolence (obstructive sleep apnea)
 Prostatism (CKD due to post-renal urinary tract
obstruction)
 Muscle cramps, weakness (hypokalemia - primary or
secondary aldosteronism)
 Weight loss, palpitations, heat intolerance
(hyperthyroidism)
Evaluation

20. Introduction BP Measurements Etiology Evaluation Management
Cont…
 Edema, fatigue, frequent urination (kidney disease or failure)
 H/o coarctation repair (residual hypertension)
 Central obesity, facial rounding, easy bruisability (Cushing's
synd )
 Medication or substance use (e.g., alcohol, NSAIDS, cocaine,
amphetamines)
 Absence of family history
Evaluation

21. Introduction BP Measurements Etiology Evaluation Management
Physical Examination
Accurate measurement of BP
+
Assessment of hypertension-related TOD .
+
Attention should be paid to physical features that
suggest secondary hypertension
Evaluation

22. Introduction BP Measurements Etiology Evaluation Management
Physical features suggesting
secondary causes
 Abdominal mass, skin pallor-(Renal parenchymal )
 Bruits over abdominal, carotid or femoral artery–
(Renovascular )
 Arrhythmias ;especially Af –( primary aldesteronism)
 Obesity, Mallampati class III–IV, loss of normal nocturnal
BP fall – (obstructive sleep apnea)
 Fine tremor, tachycardia, sweating, abdominal pain –
(Drug- cocaine, ephedrine, MAO inhibitors or alcohol)
Evaluation

23. Introduction BP Measurements Etiology Evaluation Management
Laboratory Tests
Basic
+
Optional
+
Additional
Evaluation

24.  Basic
 All newly diagnosed
hypertensive
 to facilitate CVD risk factor
profiling
 to establish a baseline for
medication use
 For screening secondary
causes
Basic Test Include
 FBS
 CBC
 Lipid profile
 Serum creatinine with eGFR
 Serum Na+, K+, Ca++
 TSH
 Urinalysis
 ECG
Evaluation

25.  Optional
 May provide information
regarding TOD
Optional testing
 ECHO
 Uric acid
 Urinary albumin to
creatinine ratio
Evaluation

26.  Additional
 Increased hypertension
severity
 Poor response to standard
treatment approaches
 Disproportionate severity of
TOD for the level of BP
 Historical or clinical clues that
support a secondary cause.
 Additional test include
 Renal USG
 Renal Duplex Doppler USG;
MRA; abdominal CT
 Plasma aldosterone/ renin
ratio
 24-h urinary fractionated
metanephrines
 Overnight dexamethasone
suppression test
Evaluation

27. Introduction BP Measurements Etiology Evaluation Management
Management of HTN
Treatment strategies
+
Non pharmacological treatment
+
Pharmacological treatment
+
Special considerations
Management

28. Introduction BP Measurements Etiology Evaluation Management
Treatment Strategies
Normal BP
(BP <120/80
mm Hg)
Promote optimal
lifestyle habits
Reassess in
1 yr
Elevated BP
(BP 120–129/<80
mm Hg)
Non
pharmacologic
therapy
Reassess in
3–6 mo
Management

29. Stage 1
Hypertens
ion
(BP 130–
139/80-89
mm Hg)
Clinical
ASCVD
or
estimated
10-y CVD
risk
≥10%*
Non
pharmacol
ogic
therapy
Non
pharmacol
ogic
+
Pharmaco
logic
therapy
Reassess
in1 mo
BP
goal
met
Reassess in
3–6 m
Assess and
optimize
adherence
to therapy
Consider
intensificatio
n of therapy
yes
no
yes
no
•patients with DM or CKD are automatically placed in the high-risk category.
•BP goal <130/80 mmHg
Management

30. Stage 2
Hypertension
(BP ≥140/90
mm Hg)
Non
pharmacologic
+
Pharmacologic
therapy
Reassess
in 1 month
BP
goal
met?
Reassess in 3–6
month
Assess and
optimize
adherence to
therapy
Consider
intensification of
therapy
yes
no
•Consider initiation with 2 antihypertensive agents of different classes.
•BP ≥160/100 mm Hg should be promptly treated, carefully monitored, and subject to
upward medication dose adjustment as necessary to control BP
Management

31. Introduction BP Measurements Etiology Evaluation Management
Non Pharmacologic Interventions
 Weight loss
 Ideal body weight is best goal.
 Expect about 1 mm Hg / kg reduction in body weight.
 Healthy diet
 DASH dietary pattern
 Fruits, vegetables, whole grains, and low-fat dairy products with reduced
content of saturated and trans l fat
 Reduced intake of dietary sodium
 <1,500 mg/d is optimal goal
Management

32. Introduction BP Measurements Etiology Evaluation Management
Cont…
 Enhanced intake of dietary potassium
3,500–5,000 mg/d, preferably by consumption of a
diet rich in potassium
 Regular aerobic, dynamic resistance or isometric
resistance exercises (at least 3/week)
 Reduce alcohol to
• ≤ 2 drinks daily- Men • ≤ 1 drink daily - Women
Management

33. Introduction BP Measurements Etiology Evaluation Management
General Principles Of Drug Therapy
 Primary agents -thiazide diuretics, ACEI, ARBs, and CCBs
 Beta blockers - not recommended as 1st -line agents unless
the patient has IHD or HF
 Started on a single agent, but can consider 2 drugs of
different classes for those with stage 2 HTN
 Patient-specific factors- age, concurrent medications, drug
adherence, drug interactions, the overall treatment regimen,
costs, and co morbidities, should be considered.
Management

34. Introduction BP Measurements Etiology Evaluation Management
Choice Of Antihypertensive
Primary prevention of CV complication
 Lowering BP more important than the choice of drug
Secondary CV protection with underlying co morbid
illnesses (compelling indications)
 Not all antihypertensives provide the same benefit.
Management

35. Introduction BP Measurements Etiology Evaluation Management
Primary Antihypertensive Drugs
Thiazide or thiazide-type diuretics
 Chlorthalidone Hydrochlorothiazide Indapamide
 Chlorthalidone preferred -prolonged half-life and
proven trial reduction of CVD
 Monitor for ↓Na+ and ↓K+, uric acid and Ca++ levels.
 Use with caution in patients with history of acute gout
Management

36. Introduction BP Measurements Etiology Evaluation Management
ACE Inhibitors/ ARB’s
ACE Injhibitors - Captopril , Enalapril , Losartan
ARB’s- Telmisartan , Candesartan
 Do not use ACE inhibitors and ARBs or direct renin inhibitor
 ↑ed risk of hyperkalemia, especially in patients with CKD or in
those on K+ supplements or K+-sparing drugs
 May cause ARF in patients with severe b/l RAS
 Do not use if h/o angioedema
 Avoid in pregnancy
Management

37. Introduction BP Measurements Etiology Evaluation Management
CCB’s
CCB— dihydropyridines
 Amlodipine Nifedipine
 Avoid use in patients with HFrEF; amlodipine may be used if required
 Associated with dose-related pedal edema, women > men
CCB— nondihydropyridines
 Diltiazem Verapamil
 Avoid routine use with beta blockers due to increased risk of bradycardia
and heart block
 Do not use in patients with HFrEF
Management

38. Introduction BP Measurements Etiology Evaluation Management
Patients With Co Morbidities
 CAD/Post MI: BB, ACEI/ARB
 Systolic HF: ACEI or ARB, BB, aldosterone blocker, thiazide
 Diastolic HF: ACEI or ARB, BB, thiazide
 DM: ACEI or ARB, thiazide, BB, CCB
 Kidney disease: ACEI or ARB
 Stroke or TIA: Thiazide, ACEI
An effective approach to high blood pressure control: science advisory from
AHA/ACC/CDC. Hypertension 2014;63:878-85
Management

39. Introduction BP Measurements Etiology Evaluation Management
Resistant Hypertension
Confirm
Treatment
Resistance
• BP ≥130/80 mm Hg and Patient on ≥3 antihypertensive at
optimal doses, including a diuretic, if possible
• OR
• BP <130/80 mm Hg but patient requires ≥4
antihypertensive
Exclude
Pseudo-
Resistance
• Ensure accurate BP measurements
• Assess for non adherence with prescribed regimen
• Exclude white coat effect
Management

40. Introduction BP Measurements Etiology Evaluation ManagementManagement
Identify and
Reverse
Contributing
Factors
• Obesity
• Physical Inactivity
• Excessive alcohol
• High salt, low-fiber diet
Discontinue
or Minimize
Interfering
Substances
• NSAIDs
• Sympathomimetic (e.g., amphetamines, decongestants)
• Stimulants
• Oral contraceptives, Licorice
• Ephedra

41. Introduction BP Measurements Etiology Evaluation Management
Screen for
Secondary
Causes
• Primary aldosteronism
• CKD
• RAS
• Pheochromocytoma
• Obstructive sleep apnea
Pharmacolo
gic
Treatment
• Maximize diuretic therapy
• Add a Aldesterone antagonist
• Add other agents with different mechanisms of actions
• Use loop diuretics in patients with CKD and/or patients
receiving potent vasodilators (e.g., minoxidil)
Management

42. Introduction BP Measurements Etiology Evaluation Management
Hypertensive Crisis
SBP >180 mm Hg and/or DBP >120
mm Hg
Target
organ
damage
Hypertensive
Emergency
Markedly elevated BP
Reinstitute/intensify oral
antihypertensive and arrange f/u.
NoYES
Management

43. Hypertensive
Emergency
Admit to ICU
Conditions
• Aortic dissection
• Severe pre-eclampsia or eclampsia
• Pheochromocytoma crisis
↓ SBP to <140 mm Hg during 1st
hr and to <120 mmHg in aortic
disection
↓ BP by max 25% over 1st hr
160/100-110 mm Hg over next 2-6 hr
Normal over next 24-48 hr
NoYes
Management

44. Introduction BP Measurements Etiology Evaluation Management
Common IV Anti Hypertensive
Labetalol
 Initial dose - 0.3–1.0-mg/kg (max- 20 mg) slow IV X 10 min OR
 0.4–1.0-mg/kg/h IV infusion up to 3 mg/kg/h.
 Adjust rate up to total cumulative dose of 300 mg.
 Can be repeated every 4–6 h.
 C/I in RAD or COPD.
 Especially useful in hyperadrenergic syndromes.
 May worsen HF and should not be given in patients with 2nd & 3rd deg
heart block or bradycardia.
Management

45. Introduction BP Measurements Etiology Evaluation Management
Enalapril
 Initial dose-1.25 mg over 5-min
 Doses can be increased up to 5 mg every 6 h .
 C/I in pregnancy and should not be used in acute MI or b/l
RAS.
 Mainly useful in high plasma renin activity.
 Onset of action is slow (15 min) and BP response is
unpredictable
Management

46. Introduction BP Measurements Etiology Evaluation Management
Sodium Nitropruside
 Initial 0.3–0.5 mcg/kg/min;
 increase by 0.5 mcg/kg/min to achieve BP target
 maximum dose 10 mcg/kg/min
 Shorten the duration of treatment as possible.
 Infusion rates ≥4–10 mcg/kg/min or duration >30 min,
coadminister thiosulfate to prevent cyanide toxicity.
 Intra-arterial BP monitoring is recommended .
 Lower dose is required for elderly.
 Tachyphylaxis common.
Management

47. Introduction BP Measurements Etiology Evaluation Management
Take Home Message
 HTN is the common cause of morbidity and disability
worldwide.
 Reducing chronically increased BP using medications clearly
reduces the incidence of CAD, stroke, congestive heart
failure, and CKD.
 Latest guidelines have reduced the cut off point for diagnosis
and treatment of HTN.
 For primary prevention of CV complication lowering BP more
important than the choice of drug.

48. Introduction BP Measurements Etiology Evaluation Management
Mcq’s
 According to ACC/AHA 2017 guideline, HTN IS?
1. SBP ≥ 130 or DBP ≥ 80
2. SBP ≥ 140 or DBP ≥ 90
3. SBP ≥ 130 or DBP ≥ 90
4. SBP ≥ 130 and DBP ≥ 80

49. Introduction BP Measurements Etiology Evaluation Management
Mcq’s
 According to ACC/AHA 2017 guideline, antihypertensive drug
is started in a patient with ?
1. BP ≥ 140/90 mmHg
2. CKD and DM with BP ≥ 130/80 mmHg
3. Age ≥ 65 with BP ≥ 130/80 mmHg
4. Preexisting atherosclerotic CVD with BP ≥ 130/80
5. All of the above

50. Introduction BP Measurements Etiology Evaluation Management
Mcq’s
 According to ACC/AHA 2017 guideline, therapeutic
goal of a patient on antihypertensive drugs is ?
1. BP ≤130/80
2. BP ≤ 130/90
3. BP ≤ 140/80
4. BP ≤ 140/90

51. Introduction BP Measurements Etiology Evaluation Management
Mcq’s
 Hypertension can be seen in all of the following
except
1. Pheochromocytoma
2. Hyperthyroidism
3. Adissons disease
4. Cushings syndrome

52. Introduction BP Measurements Etiology Evaluation Management
Mcq’s
 Antihypertensive C/I in pregnancy is?
1. Beta blocker
2. ACEI
3. Diuretics
4. Calcium channel blocker

53. Introduction BP Measurements Etiology Evaluation Management
References
 Brook RD, Rajagopalan S. 2017
ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA
Guideline for the Prevention, Detection, Evaluation, and
Management of High Blood Pressure in Adults. A report of the
American College of Cardiology/American Heart Association Task
Force on Clinical Practice Guidelines. J Am Soc Hypertens. 2018;
 Kasper D, Fauci A, Hauser S et al. Harrison's Principles of
Internal Medicine 19/E (Vol.1 & Vol.2). McGraw Hill Professional;
2015.
 Muntner P, Carey RM, Gidding S, et al. Potential U.S. Population
Impact of the 2017 American College of Cardiology/American
Heart Association High Blood Pressure Guideline. Circulation.
2017;