Hypertension S. Danish Hasan MD March 2 nd 2013. Objectives Basic Concepts Definitions Screening and...

HypertensioHypertensionn

S. Danish Hasan MDMarch 2nd 2013

ObjectivesObjectivesBasic ConceptsDefinitionsScreening and DiagnosisGuidelines Risk FactorsComplicationsTreatment and Adverse Effects

Basic ConceptsBasic ConceptsBlood Pressure

◦Amount of pressure on the arterial walls as the blood is pumped through them by the heart and circulated through the body

Systolic Blood Pressure◦Pressure on the walls when the heart

contractsDiastolic Blood Pressure

◦Pressure on the walls when the heart is relaxed (in between heart beats)

Basic ConceptsBasic Concepts

SystolicDiastolic

12080

Example

=

Systolic goes on top and Diastolic on the Botton

DefinitionsDefinitionsNormal Blood PressurePre HypertensionStage 1 HypertensionStage 2 HypertensionIsolated Systolic

HypertensionIsolated Diastolic

HypertensionMalignant

HypertensionHypertensive Urgency

<120/<80120-139/80-89140-159/90-99>159/99>139/<90

<140/>89

End organ damage>179/>119

DefinitionsDefinitionsPrimary/Essential Hypertension

Secondary/Identifiable Hypertension

Hypertension without a known or identifiable cause

Hypertension with a known or identifiable cause. Some causes include:1. Primary Renal Disease – AKD/CKD with glomerular or vascular disorders2. OCPs3. Drug induced – Chronic NSAID/Alcohol use/abuse, Antidepressants.4. Pheochromocytoma (adrenal tumor) - paroxysmal hypertension5. Primary hyperaldosteronism – htn(specially resistant), unexplained hypoK6. Renovascular dz – pt. with atherosclerosis ex. Renal artery stenosis7. Other Endocrine issues – hypo/hyperthyroidism, hyperparathyroid8. Cushing’s Syndrome9. OSA10. Coarctation of aorta

Screening and DiagnosisScreening and DiagnosisScreening

◦ Every 2 years for those in normal category◦ Every year for pre-hypertensive category

Who is diagnosed with HTN?◦ Initial screen +◦ 2 or more visits with documented high blood

pressure◦ Over a period of weeks to months◦ Should be measured in both arms

(>15mmHg difference = Subclavian stenosis/PAD)

◦ Postural BPs in >65, diabetics, dizziness weakness upon standing. Difference >20mmHg from supine to standing(Orthostatic Hypotension)

Guidelines for proper blood Guidelines for proper blood pressure measurementpressure measurementPatient Conditions

◦Posture◦Circumstances

Equipment◦Cuff◦Manometer

Technique◦Number of Readings◦Performance

Recordings

Guidelines – PostureGuidelines – PostureSitting pressures are recommended

for routine follow-up; the patient should sit quietly with the back supported for five minutes and the arm supported at the level of the heart

Check for postural changes by taking readings after five minutes supine, then immediately and two minutes after standing; this is particularly important in patients over age 65 years, diabetics, or those taking antihypertensive drugs

Guidelines - Guidelines - CircumstancesCircumstancesNo caffeine during the hour

preceding the readingno smoking during the preceding 30

minutesNo exogenous adrenergic

stimulants, such as phenylephrine in decongestants or eye drops for pupillary dilatation

A quiet, warm settingHome readings should be taken

upon varying circumstances (patient might be asked to keep a home log)

Guidelines - EquipmentGuidelines - EquipmentCuff size

◦length of the bladder should be 80 percent

◦width of the bladder should be at least 40 percent of the circumference of the upper arm

Manometer◦Aneroid gauges should be calibrated

every six months against a mercury manometer

Guidelines – Number of Guidelines – Number of ReadingsReadingsTake at least two readings on each visitseparated by as much time as possibleif readings vary by more than 5 mmHg,

take additional reading until two consecutive readings are close

For the diagnosis of hypertensiontake three readings at least one week

apartInitially, take blood pressure in both

arms; if pressures differ, use the higher arm

If the arm pressure is elevated, take the pressure in one leg, particularly in patients under age 30 years

Korotkoff Sounds–Reviewing Korotkoff Sounds–Reviewing BP 101BP 1015 PhasesPhase 1 – Clear Tapping Sound (SBP)Phase II – Swishing sound/soft

murmur onsetPhase III – Loup slapping/instense

soundPhase IV – Sudden Muffling SoundPhase V – Silence

Phase/Disappearance of Sound“Tap – Murmur – Slap – Muffle –

Silence”

Guidelines - PerformanceGuidelines - PerformanceInflate the bladder quickly to 20 mmHg

above the systolic pressure as estimated from loss of radial pulse

Deflate the bladder 3 mmHg per second

Record the Korotkoff phase V (disappearance) as the diastolic pressure except in children in whom use of phase IV (muffling) may be preferable

If the Korotkoff sounds are weak, have the patient raise the arm, open and close the hand five to ten times, and then inflate the bladder quickly

Guidelines - RecordingGuidelines - RecordingRecordingsNote the pressure, patient

position, arm, and cuff size: eg, 140/90, seated, right arm, large adult cuff

Risk Factors – Non Risk Factors – Non ModifiableModifiableEthnicity - Asian, Inuit, First

Nations/Aboriginal, African Americans◦Tends to be most common and most

severe in BlacksFamily History – mother, father or

both parentsAge >65Certain personality traits, such as

hostile attitudes and time urgency/impatience, as well as among those with depression

Risk Factors - ModifiableRisk Factors - ModifiableSmokingExcessive alcohol use (>14 drinks for

M and >9 drinks for F per week)Diet high in fat and salt (AHA <1500

mg)Weight / obesityDyslipidemia regardless of

obesity/weightLack of exerciseVitamin D DeficiencyOther medication

Prime suspects are canned soups and lunch meat

ComplciationsComplciations

ComplicationsComplications CVD - Hypertension is quantitatively the major risk factor for

premature CVD, being more common than cigarette smoking, dyslipidemia, or diabetes, the other major risk factors. In older patients, systolic pressure and pulse pressure are more powerful determinants of risk than diastolic pressure .

CHF - The risk of heart failure increases with the degree of blood pressure elevation.

Dysrythmias, MI, Sudden Cardiac Death – LVH is a common finding in patients with hypertension, and is associated with an enhanced incidence of heart failure, ventricular arrhythmias, death following myocardial infarction, and sudden cardiac death.

Ischemic Stroke - Hypertension is the most common and most important risk factor for ischemic stroke, the incidence of which can be markedly reduced by effective antihypertensive therapy.

Intracerebral hemorrhage - Hypertension is the most important risk factor for the development of intracerebral hemorrhage.

CKD/ESRD - Hypertension is a risk factor for chronic kidney disease and end-stage renal disease. It can both directly cause kidney disease, called hypertensive nephrosclerosis, and accelerate the progression of a variety of underlying renal diseases.

TreatmentsTreatmentsDietExerciseDieureticsBeta BlockersACE-InhibitorsARBsCalcium Channel BlockersOther MedicationsComplementary Therapies

Treatment – Lifestyle, Diet Treatment – Lifestyle, Diet and Exerciseand ExerciseDASH Diet – Dietary Approaches to Stop

Hypertension◦ eating more fruits, vegetables, whole-grain

foods, low-fat dairy, fish, poultry, and nuts. You should eat less red meat, saturated fats, and sweets. Reducing sodium in your diet can also have a significant effect.

Exercise◦ 50 minutes of moderate exercise per week -

gardening, walking briskly, bicycling, or other aerobic exercise. Muscle-strengthening activities are recommended at least two days a week and should work all major muscle groups.

Lifestyle◦ Quit smoking and alcohol

Treatment - DiureticsTreatment - DiureticsOften the first choice if diet and exercise

changes aren't enoughAlso called "water pills”Help the body shed excess sodium and water Side Effects:

◦ urinate more often◦ some may deplete potassium, causing muscle

weakness, leg cramps, and fatigue◦ Some can increase blood sugar levels in diabetics◦ Erectile dysfunction is a less common side effect

hydrochlorothiazide (HydroDiuril), furosemide (Lasix), spironolactone (Aldactone)

Treatment – beta-BlockersTreatment – beta-BlockersSlows the heart rateUsed to treat other heart conditionsMay be prescribed along with other

medicationsSide effects: insomnia, dizziness,

fatigue, cold hands and feet, and erectile dysfunction.

atenolol (Tenormin), metoprolol (Betaloc/Lopressor), bisoprolol

Treatment – ACE InhibitorsTreatment – ACE InhibitorsACE inhibitors reduce your body's supply

of angiotensin II -- a substance that makes blood vessels contract and narrow.

The result is more relaxed, open (dilated) arteries,

Side effects: dry cough, skin rash, or dizziness, and high levels of potassium. Women should not become pregnant while taking an ACE inhibitor(teratogenic).

lisinopril (Zestril), perindopril, enalapril, ramipril (Altace)

Treatment - ARBsTreatment - ARBsBlock receptors for angiotensin -- as

if placing a shield over a lockPrevents artery-tightening effects,

and lowers your blood pressure.ARBs can take several weeks to

become fully effective. Side effects: dizziness, muscle

cramps, insomnia, and high levels of potassium Teratogenic as well.

candesartan (Atacand), losartan (Cozaar), valsartan (Diovan)

Treatment – Calcium Treatment – Calcium Channel BlockersChannel BlockersSlow the movement of calcium into the

cells of the heart and blood vessels. Since calcium causes stronger heart contractions, these medications ease the heart's contraction and relax the blood vessels.

Side Effects: dizziness, heart palpitations, swelling of the ankles, and constipation.

Take with food or milk and avoid grapefruit juice and alcohol because of possible interactions.

amlodipine (Norvasc), diltiazem (Cardizem), felodipine (Renedil)

Other MedicationsOther MedicationsOther medications that relax the

blood vessels include vasodilators, alpha blockers, and central agonists.

Side effects: dizziness, a fast heart beat or heart palpitations, headaches, or diarrhea.

Usually if HTN is not controlled or if another comorbitity

Complimentary TherapiesComplimentary TherapiesAlong with lifestyle, diet and

exercise these help for HTNYogatai chideep breathing exercisesOther relaxation techniquesHerbal Remedies? Unproven

benefits and some actually increase blood pressure.

Questions?Questions?