Hypertension- management

HYPERTENSION

AND ITS MANAGEMENT

O HYPERTENSION IS A CHRONIC MEDICAL CONDITION IN WHICH THE BLOOD PRESSURE IN THE ARTERIES IS ELEVATED

STAGING OF HYPERTENSION

CATEGORY SYSTOLIC BP DIASTOLIC BP

NORMAL < 120 <80PREHYPERTENSION 120-139

OR80-90

STAGE 1 HYPERTENSION 140-159 OR

90-99

STAGE 2 HYPERTENSION >= 160 OR

>= 100

JNC 7 CLASSIFICATION

O ISOLATED SYSTOLIC HYPERTENSION- SYSTOLIC PRESSURE OF 140 mmHg OR MORE AND A DIATOLIC PRESSURE OF LESS THAN 90 mmHg.

O WHITE COAT HYPERTENSION-

PHENOMENON IN WHICH A PATIENT EXHIBIT A BLOOD PRESSURE LEVEL ABOVE THE NORMAL RANGE IN CLINICAL SETTINGS BUT NOT SO IN OTHER SETTINGS.

CLASSIFICATION OF HYPERTENSION

ESSENTIALHYPERTENSION(90%)

SECONDARY HYPERTENSION(10%)

CAUSES OF SECONDARY HYPERTENSION (10%)

O CHRONIC KIDNEY DISEASEO SLEEP APNEAO PHEOCHROMOCYTOMAO COARCTATION OF THE AORTAO PREGNANCYO ALCOHOL ADDICTIONO THYROID DYSFUNCTION

RISK FACTORS

NON-MODIFIABLE RISK FACTORS

• AGE• SEX• GENETIC FACTORS• ETHNICITY

MODIFIABLE RISK FACTORS

• OBESITY• SALT INTAKE• SATURATED FAT• DIETARY FIBRE• ALCOHOL• PHYSICAL ACTIVITY• ENVIRONMENTAL STRESS• SOCIO-ECONOMIC STATUS• HEART RATE

RULE OF HALVES

1. WHOLE COMMUNITY2. NORMOTENSIVE SUBJECTS3. HYPERTENSIVE SUBJECTS4. UNDIAGNOSED HYPERTENSION5. DIAGNOSED HYPERTENSION6. DIAGNOSED BUT UNTREATED7. DIAGNOSED AND TREATED8. INADEQUATELY TREATED9. ADEQUATELY TREATED

TRACKING OF BLOOD PRESSURE

HYPERTENSIVE URGENCY

O SEVERE HEADACHEO SHORTNESS OF BREATHO NOSEBLEEDSO SEVERE ANXIETY

HYPERTENSIVE EMERGENCYO STROKEO LOSS OF CONSCIOUSNESSO MEMORY LOSSO HEART ATTACKO LOSS OF KIDNEY FUNCTIONO DAMAGE TO EYES AND KIDNEYSO AORTIC DISSECTIONO PULMONARY EDEMA

PREVENTION OF HYPERTENSION

PRIMARY PREVENTION SECONDARY PREVENTION• POPULATION STRATEGY• HIGH-RISK STRATEGY

PRIMARY PREVENTIONO ALL MEASURES TO REDUCE THE

INCIDENCE OF DISEASE IN A POPULATION BY REDUCING THE RISK OF ONSET

POPULATION STRATEGYO NUTRITIONO WEIGHT REDUCTIONO EXERCISE PROMOTIONO BEHAVIOURAL CHANGESO HEALTH EDUCATIONO SELF-CARE

HIGH-RISK STRATEGYO AIM IS TO PREVENT THE ATTAINMENT

OF LEVELS OF BLOOD PRESSURE AT WHICH THE INSTITUTION OF TREATMENT WOULD BE CONSIDERED

SECONDARY PREVENTIONO EARLY CASE DETECTIONO TREATMENTO PATIENT COMPLIANCE

MANAGEMENT OF HYPERTENSION

LIFE-STYLE MODIFICATION

PHARMACOLOGICAL MANAGEMENT

LIFE-STYLE MODIFICATIONMODIFICATION APPRX SBP

REDUCTIONWEIGHT REDUCTION 5 - 20 mmHgADOPT DASH EATING PLAN 8 - 14 mmHgDIETARY SODIUM REDUCTION 2 - 8 mmHgPHYSICAL ACTIVITY 4 – 9 mmHgMODERATION OF ALCOHOL CONSUMPTION

2 - 4 mmHg

O WEIGHT REDUCTION – ACC. TO JNC 7, 5-20 POINTS REDUCTION IN BP PER 10 KG WEIGHT LOSS

O DIETARY APPROACHES TO STOP HYPERTENSION –

DIET RICH IN FRUITS, VEGETABLES AND LOW-FAT DAIRY PRODUCTS.HIGH PROTEIN AND FIBRE

O SALT REDUCTION-LESS THAN 2400 mg PER DAY

O PHYSICAL ACTIVITY-BRISK WALKING ATLEAST 30 MIN/MOST DAYS OF THE WEEK

O ALCHOL REDUCTION-NO MORE THAN 2 DRINKS/ DAY

GOAL BLOOD PRESSURE

O < 140/90 mmHg FOR PATIENTS WITH HYPERTENSION

O <130/80 mmHg FOR PATIENTS WITH DIABETES OR CHRONIC KIDNEY DISEASE

PATIENTS WITH HYPERTENSION ALREADY ON TREATMENT

IF SYSTOLIC BP < 140 mmHgAND DIASTOLIC BP <90mmHg

ADVISE TO CONTINUE SAME TREATMENT AND LSM COUNSELLING

IF SYSTOLIC BP >= 140 mmHgAND DIASTOLIC BP >=90mmHg

REGULAR FOLLOW-UP

FOLLOW THE SAME PROTOCOLOF NEWLY DETECTED HYPERTENSIVE PATIENTS TO ACHIEVE GOAL BLOOD PRESSURE

NEWLY DETECTED STAGE I HYPERTENSION

ASSESS RISK FACTORSIF YES IF NO

LSM AND T.AMLODIPINE2.5 mg Hg

RECHECK BP AFTER 2 WEEKS

IF BP >= 140/90 mm Hg,INCREASE DOSE OF AMLO TO MAX- 10 mg/ DAY

LSM ONLY

RECHECK BP AFTER 2 WEEKS

IF BP >= 140/90 mm Hg,LSM WITH AMLODIPINE 2.5 mg/ day

NEWLY DETECTED STAGE II HYPERTENSION

LSM AND T.AMLODIPINE 5 mg/day

RECHECK BP AFTER 2 WEEKS

IF BP >= 140/90 mmHg

INCREASE DOSE OF AMLODIPINE TO MAX- 10mg/ day

RECHECK BP AFTER 2 WEEKS

GOAL BP ACHIEVED GOAL BP NOT ACHIEVED

CONTINUE SAME ADD SECOND DRUG

SECOND DRUGISOLATED HYPERTENSION NOT CONTROLLED WITH T.AMLO 10 MG/DAYADD T.HYDROTHIAZIDE 25 MG OD ORT.ENALAPRIL 2.5-20 MG PER DAY ORT.ATENOLOL 25-100 MG PER DAY

HYPERTENSION WITH DIABETESADD T.ENALAPRIL 2.5-20 MG PER DAY(if sr. creatinine is <2mg)

SECOND DRUGHYPERTENSION WITH IHDADD T.ATENOLOL 25-100 MG PER DAYWITH T.ASPIRIN 75 MG OD ANDT.ISOSORBITRATE DINITRATE 5-10 MG TDS

HYPERTESION WITH CKDAVOID ENALAPRIL IF SR. CREATININE > 2 mgADD T.ATENOLOL 25-100 mg PER DAY(cautious use in PVD)

SECOND DRUG

HYPERTENSION WITH BRONCHIAL ASTHMA OR COPDAVOID ATENOLOLT.ENALAPRIL 2.5-20 mg PER DAY (OR)T.HYDROCHLOROTHIAZIDE 25 mg OD