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(HYPERTENSION)
(PRIMARY CARE UNIT)
Definition)
 (Hypertension)
 ≥ ( Systolic
Diastolic
 Isolated Systolic Hypertension)
 ≥
< 90
 Isolated Office Hypertension (White coat Hypertension)

≥
 <
 Masked Hypertension

<
 ≥
Diagnosis)







 - –
Systolic Diastolic
Optimal < 120 < 80
Normal 120 – 129 80 - 84
High Normal 130 – 135 85 – 89
Grade I (mild HT) 140 – 159 90 – 99
Grade II (Moderate HT) 160 – 179 100 – 109
Grade III (Severe HT) ≥ 180 ≥ 110 Target Organ
Damages ; TOD
Isolated Systolic ≥ 140 ≤ 90 Systolic BP
SBP DBP






 Polycystic Kidney Disease,
Neurofibromatosis



 NSAIDs)

 Beta Blocker
 Diuretics
 Alpha - Blocker
Secondary Hypertension



 Hypokalemia Aldosterone hormone)
 Abdominal bruit (Renovascular disease)

Pheochromocytoma ?)
Target Organ Damage ; TOD)
Target Organ Damage ; TOD)
- Facial Palsy)
-
-
- (Stroke)
- Dementia)
-
Exudate)
Hemorrhage)
Papilledema)
- Retinopathy)
-
-
Carotid Bruit)
-
Atherosclerosis)
Target Organ Damage ; TOD)
- PMI
- S4 Gallop (Diastolic dysfunction)
-
- S3 Gallop (Systolic Dysfunction) or
Crepitation at lung bases
-
Left Ventricular Hypertrophy)
-
(Heart Failure)
- -
Chronic Kidney Disease)
Complete Blood count
Urinalysis and Urinary microalbumin
Serum Creatinine
Fasting plasma glucose
Lipid profile (Triglycerides, Total Cholesterol, HDL, LDL)
Serum Electrolyte
Electrocardiogram
Risk Factor Value
Age Male > 55 yrs & Female > 65 yrs
Smoking Positive
Dyslipidemia Cholesterol > 190 mg/dl or
LDL – C > 115 mg/dl or
Triglyceride > 150 mg/dl or
HDL – C < 40 (M) & < 50 (F) mg/dl
Fasting plasma Glucose 100-125 mg/dl (IFG)
Abnormal glucose tolerance test
Abdominal Obesity
(Waist circumference
Male ≥ 90 & Female ≥ 80 cm
Family History of Premature CVD
Metabolic syndrome
 Criteria's from NCEP ATPIII for diagnosis metabolic syndrome
should at least 3 of 5
 Abdominal Waist
 Male ≥ cms or inches & Female ≥ cms or inches
 Triglyceride
 HDL – C mg/dl in Male or mg/dl in female
 Blood pressure mmHg or continue anti-hypertensive drugs
 Fasting Blood glucose
Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on
Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults
(Adult Treatment Panel III)
• Ischemic stroke, Cerebral Hemorrhage,
Transient ischemic attack
• Myocardial infarction, Angina, Coronary
revascularization, Heart failure
• Diabetic nephropathy, renal impairment (Cr > 1.5 in male, >
1.4 in female mg/dl), Proteinuria (> 300mg/24 hr)
• Hemorrhage or exudates, papilledema
Target Organ Damage)
 Electrocardiographic or Echocardiography : LVH
 Carotid Wall thickening (IMT > 0.9 mm) or plaque
 Carotid – Femoral pulse wave velocity > 12 m/s
 Ankle-brachial index < 0.9
 Slight increase in plasma creatinine (1.3-1.5 (M) or 1.2-1.4 (F)
mg/dl)
 Low estimated GFR (<60 ml/min/1.73m2) or creatinine clearance
< 60 ml/min
 Microalbuminuria 30-300 mg/24hrs
SBP
18.5 – 23 kgs/m2 5-20 mmHg / 10 kgs
DASH (Dietary
Approach to Stop
Hypertension diet)
8-14 mmHg
100 mmol/day 6
grams/day ( )
2-8 mmHg
30
4-9 mmHg
2 drinks/day
1 drink/day
2-4 mmHg
Age < 55 yrs Age  55 yrs
A C or DStep 1
A + C or A + DStep 2
Step 3
Step 4
Resistance
Add Alpha-block or Beta-block or
Spironolactone or Consult specialists
A + C + D
Thiazide diuretics
Beta - Blocker
Alpha - Blocker
ACEI
Calcium Antagonist
ARBs
(mmHg)
< 140 / 90
< 130 / 80
< 130 – 135 / 80 – 85
< 1 /
≥ 1 /
< 130 / 80
< 125 / 75
CVD < 130 / 80
 Angiotensin Converting Enzyme inhibitor (ACEIs)
 Cough (Consider Change to ARBs)
 Creatinine Rising (Male < 1.3 , Female < 1.2 mg/dl Should F/U q
6 mo)
 Calcium Channel Blockers
 Edema, Postural Hypotension
 Diuretic
 Electrolyte imbalance -> Thiazide (Hypokalemia -> Weakness)
 Beta Blocker
 Bradycardia (Keep HR > 50 – 60 /min
?
References
 Chobanian AV, Bakris GL, Black HR, et al. Seventh report of the Joint
National Committee on Prevention, Detection, Evaluation and
Treatment of High Blood Pressure. Hypertension 2003;42:1206-52.
 Management of Hypertension in adults in primary care. NICE Guideline
34. National Institute for Health and Clinical Excellence.
http://guidance.nice.org.uk/CG34 (Accessed 10 June 2013)
 Mancia G, De Backer G, Dominiczak A, et al. 2007 Guidelines for the
Management of Arterial Hypertension: The Task Force for the
Management of Arterial Hypertension of the European Society of
Hypertension (ESH) and of the European Society of Cardiology (ESC). J
Hypertens 2007;25:1105-87
Reference (Cont.)
 Third Report of the National Cholesterol Education
Program (NCEP) Expert Panel on Detection, Evaluation,
and Treatment of High Blood Cholesterol in Adults (Adult
Treatment Panel III). http://circ.ahajournals.org/content/
106/25/3143.long (Accessed 17 June 2013)
 Picture source :
http://elianealhadeff.blogspot.com/2007/12/argosy-
virtually-human-serious-games.html

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CPG_Hypertension for Primary Health care unit

  • 3.  (Hypertension)  ≥ ( Systolic Diastolic  Isolated Systolic Hypertension)  ≥ < 90
  • 4.  Isolated Office Hypertension (White coat Hypertension)  ≥  <  Masked Hypertension  <  ≥
  • 7. Systolic Diastolic Optimal < 120 < 80 Normal 120 – 129 80 - 84 High Normal 130 – 135 85 – 89 Grade I (mild HT) 140 – 159 90 – 99 Grade II (Moderate HT) 160 – 179 100 – 109 Grade III (Severe HT) ≥ 180 ≥ 110 Target Organ Damages ; TOD Isolated Systolic ≥ 140 ≤ 90 Systolic BP SBP DBP
  • 8.
  • 9.
  • 10.        Polycystic Kidney Disease, Neurofibromatosis
  • 11.     NSAIDs)   Beta Blocker  Diuretics  Alpha - Blocker
  • 12. Secondary Hypertension     Hypokalemia Aldosterone hormone)  Abdominal bruit (Renovascular disease)  Pheochromocytoma ?)
  • 14. Target Organ Damage ; TOD) - Facial Palsy) - - - (Stroke) - Dementia) - Exudate) Hemorrhage) Papilledema) - Retinopathy) - - Carotid Bruit) - Atherosclerosis)
  • 15. Target Organ Damage ; TOD) - PMI - S4 Gallop (Diastolic dysfunction) - - S3 Gallop (Systolic Dysfunction) or Crepitation at lung bases - Left Ventricular Hypertrophy) - (Heart Failure) - - Chronic Kidney Disease)
  • 16. Complete Blood count Urinalysis and Urinary microalbumin Serum Creatinine Fasting plasma glucose Lipid profile (Triglycerides, Total Cholesterol, HDL, LDL) Serum Electrolyte Electrocardiogram
  • 17.
  • 18.
  • 19. Risk Factor Value Age Male > 55 yrs & Female > 65 yrs Smoking Positive Dyslipidemia Cholesterol > 190 mg/dl or LDL – C > 115 mg/dl or Triglyceride > 150 mg/dl or HDL – C < 40 (M) & < 50 (F) mg/dl Fasting plasma Glucose 100-125 mg/dl (IFG) Abnormal glucose tolerance test Abdominal Obesity (Waist circumference Male ≥ 90 & Female ≥ 80 cm Family History of Premature CVD
  • 20. Metabolic syndrome  Criteria's from NCEP ATPIII for diagnosis metabolic syndrome should at least 3 of 5  Abdominal Waist  Male ≥ cms or inches & Female ≥ cms or inches  Triglyceride  HDL – C mg/dl in Male or mg/dl in female  Blood pressure mmHg or continue anti-hypertensive drugs  Fasting Blood glucose Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III)
  • 21. • Ischemic stroke, Cerebral Hemorrhage, Transient ischemic attack • Myocardial infarction, Angina, Coronary revascularization, Heart failure • Diabetic nephropathy, renal impairment (Cr > 1.5 in male, > 1.4 in female mg/dl), Proteinuria (> 300mg/24 hr) • Hemorrhage or exudates, papilledema
  • 22. Target Organ Damage)  Electrocardiographic or Echocardiography : LVH  Carotid Wall thickening (IMT > 0.9 mm) or plaque  Carotid – Femoral pulse wave velocity > 12 m/s  Ankle-brachial index < 0.9  Slight increase in plasma creatinine (1.3-1.5 (M) or 1.2-1.4 (F) mg/dl)  Low estimated GFR (<60 ml/min/1.73m2) or creatinine clearance < 60 ml/min  Microalbuminuria 30-300 mg/24hrs
  • 23.
  • 24.
  • 25. SBP 18.5 – 23 kgs/m2 5-20 mmHg / 10 kgs DASH (Dietary Approach to Stop Hypertension diet) 8-14 mmHg 100 mmol/day 6 grams/day ( ) 2-8 mmHg 30 4-9 mmHg 2 drinks/day 1 drink/day 2-4 mmHg
  • 26. Age < 55 yrs Age  55 yrs A C or DStep 1 A + C or A + DStep 2 Step 3 Step 4 Resistance Add Alpha-block or Beta-block or Spironolactone or Consult specialists A + C + D
  • 27. Thiazide diuretics Beta - Blocker Alpha - Blocker ACEI Calcium Antagonist ARBs
  • 28. (mmHg) < 140 / 90 < 130 / 80 < 130 – 135 / 80 – 85 < 1 / ≥ 1 / < 130 / 80 < 125 / 75 CVD < 130 / 80
  • 29.
  • 30.  Angiotensin Converting Enzyme inhibitor (ACEIs)  Cough (Consider Change to ARBs)  Creatinine Rising (Male < 1.3 , Female < 1.2 mg/dl Should F/U q 6 mo)  Calcium Channel Blockers  Edema, Postural Hypotension  Diuretic  Electrolyte imbalance -> Thiazide (Hypokalemia -> Weakness)  Beta Blocker  Bradycardia (Keep HR > 50 – 60 /min
  • 31. ?
  • 32.
  • 33. References  Chobanian AV, Bakris GL, Black HR, et al. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure. Hypertension 2003;42:1206-52.  Management of Hypertension in adults in primary care. NICE Guideline 34. National Institute for Health and Clinical Excellence. http://guidance.nice.org.uk/CG34 (Accessed 10 June 2013)  Mancia G, De Backer G, Dominiczak A, et al. 2007 Guidelines for the Management of Arterial Hypertension: The Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). J Hypertens 2007;25:1105-87
  • 34. Reference (Cont.)  Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). http://circ.ahajournals.org/content/ 106/25/3143.long (Accessed 17 June 2013)  Picture source : http://elianealhadeff.blogspot.com/2007/12/argosy- virtually-human-serious-games.html

Editor's Notes

  1. Sodium Restriction -&gt; เกลือ 1 ช้อนชา ซีอิ้ว น้ำปลา ซอสปรุงรส 1 ช้อนโต๊ะเบียร์ไม่เกิน 1 ขวดต่อสัปดาห์ ไวน์ไม่เกิน 1 แก้ว/วัน44 ml ของสุรา 40%355 ml ของเบียร์ 5%148 ml ของเหล้าองุ่น 12%