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7/31/2019 Approach to Hypertension at Primary Care Level
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APPROACH TO
HYPERTENSION
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KEY FEATURE
PROBLEM (CASE 1)
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Mr. Wong, a 56-year-old gentleman,
sees you today because of URTI.You decide to check his BP and thereading is repeatedly 152/94 and
152/90 while seated. He had beenmonitoring his BP at homeoccasionally and the measurements
for the past 1 year ranged betweenSBP 140-160, DBP 90-100.
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Mr. Wong, a 56-year-old gentleman,
sees you today because of URTI.You decide to check his BP and thereading is repeatedly 152/94 and
152/90 while seated. He had beenmonitoring his BP at homeoccasionally and the measurements
for the past 1 year ranged betweenSBP 140-160, DBP 90-100.
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Hypertension is defined aspersistentelevation of
systolic BP 140mmHgand/or
distolic BP 90mmHg
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There is a positive relationshipbetween raised BP and the risk ofdeveloping cardiovascular,
cerebrovascular and renal disease
The aim of identifying & treating high
BP is to reduce these risks
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Classification of BP for adult aged 18 orolder (JNC 7th report, 2003)
Category Systolic Distolic Prevalence in Malaysia(1996)
Normal/optimal
< 120 and 140 and
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Classification of BP for adult aged 18 orolder (JNC 7th report, 2003)
Category Systolic Distolic Prevalence in Malaysia(1996)
Normal/optimal
< 120 and 140 and
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Metabolic syndrome:Componentsof metabolicsyndrome
Waistcircum-
ferance (cm)
BP(mmHg)
FBS(mmol/L)
TG(mmol/L)
HDL(mmol/L)
NCEP ATP III
2004
3 out of 5criteria
> 90 (M)
> 80 (F)
130/85 5.6 1.7 < 1.0 (M)
< 1.3 (F)
IDF 2005
Waistcriterion +2 out of 4other criteria
> 90 (M)> 80 (F)
130/85 5.6 1.7 < 1.0 (M)< 1.3 (F)
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Mr. Wong, a 56-year-old gentleman,
sees you today because of URTI.You decide to check his BP and thereading is repeatedly 152/94 and
152/90 while seated. He had beenmonitoring his BP at homeoccasionally and the measurements
for the past 1 year ranged betweenSBP 140-160, DBP 90-100.
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Question 1:
In the history taking,
what are the other aspectsthat you should elicit?
List up to 6 aspects
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Smoking status
Past medical history (esp diabetes andhyperlipidaemia)
Family history of hypertension or premature
death) Evidence of target organ damage
Symptoms of target organ damage (angina,
intermittent claudication etc)
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Diet history (salt and alcohol intake)
Drug history Level of physical activity
Symptoms suggestive of secondaryhypertension (intermittent headache,sweating etc)
Psychosocial factors that could influencethe course and outcome of the care of
this patient (e.g. family situation, workenvironment and educationalbackground)
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smoking status
Past medical history (esp diabetes andhyperlipidaemia)
Family history of hypertension or premature
death) Evidence of target organ damage (hx of CVA,
MI, LVH, renal disease etc)
Symptoms of target organ damage (angina,intermittent claudication etc)
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Risk factors for CVD:
Modifiable risk factors Un-modifiable risk factors
Hypertension Diabetes mellitis
Dyslipidaemia Cigarette smoking Microalbuminuria Estimated GFR 55 yr for men,> 65 yr for women)
Family history ofpremature CVD(male 1 relative
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Smoking status
Past medical history (esp diabetes andhyperlipidaemia)
Family history of hypertension or premature
death) Evidence of target organ damage
Symptoms of target organ damage (angina,
intermittent claudication etc)
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Possible Target Organ damageinclude:
Organsystem
Manifestations
Cardiac LVH, CAD, heart failure
CNS TIA, CVA/strokePeripheralvasculature
Absence of one or more majorpulses in extremities with or withoutintermittent claudication
Renal GFR
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Diet history (salt and alcohol intake)
Drug history Level of physical activity
Symptoms suggestive of secondaryhypertension (intermittent headache,sweating, palpitation, tremor etc)
Psychosocial factors that could influencethe course and outcome of the care of
this patient (e.g. family situation, workenvironment and educationalbackground)
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Secondary causes ofhypertension: Drug induced or drug related
(OCP, steroids, NSAIDs, COX 2 inhibitor,amphetamine, illicit drugs etc)
Primary hyperaldosteronism
Pheochromocytoma Cushing syndrome
Chronic kidney disease
Renovascular disease Thyroid or parathyroid disease
Coactation of aorta
Sleep apnea
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Secondary causes ofhypertension
Suggestive symptoms orsigns
Suggestedinvestigations
Phaeochromocytoma Paroxysmal headache,sweating, palpitatin,normotension between theseepisodes
24 hour urinarycatecholamine, CTor MRI of abdomen
Hyperaldosteronism Hypokalaemia (not essential) or
suggestive symptoms (muscleweakness, hypotonia, muscletetany, cramps, cardiacarrythmias)
Refer
endocrinologist
Renal disease Nocturia, dark urine, sallowcomplexion
RFT, GFR, albumincreatinine ratio,renal ultrasound,renal arteryimaging
Sleep apnoea Somnolence, snoring Sleep study
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Diet history (salt and alcohol intake)
Drug history Level of physical activity
Symptoms suggestive of secondaryhypertension (intermittent headache,sweating etc)
Psychosocial factors that could influencethe course and outcome of the care of
this patient (e.g. family situation, workenvironment and educationalbackground)
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Question 2:
List up to 3 tests/
investigations that youwould perform in this case.
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The aim of investigations
are:To determine the presence ofother cardiovascular risk factors
To determine the presence of andassess the extend of target organ
damage
To exclude secondary causes ofhypertension
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Baseline investigations should includ
Fasting lipid profile
Fasting blood glucose
Renal function tests (Sr. electrolyte,
urea, creatinine, uric acid)
UFEME and urine microalbumin
ECG
Other depending on the findings e.g. 24hour urinary catecholamine, echo etc
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C-Reactive Protein (CRP)
It is an acute phase protein associated withinflammation
The standard assays (used to monitorinflammatory states) can only detect CRPlevel >0.8mg/L but the levels of CRP used toassess atherosclerotic risk (hsCRP) aremuch lower
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C-Reactive Protein (CRP)
Although not yet a therapeutic target, hsCRPhave been shown to predict the long-termrisk of MI, ischaemic stroke, PVD
In the primary prevention setting, AHA andCDC only recommend screening patients atmoderate risk (10 yr risk 5-20%), i.e.screening for hsCRP level is not
recommended for patients at low (10-yr risk 20%) because it is unlikely tomeaningfully alter management decision
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C-Reactive Protein (CRP)
AHA and CDC do not recommend CRPscreening in patients with established CVD
Other inflammatory markers are VCAM-1,lipoprotein-associated phospholipase 2
hsCRP level (mg/L) Risk of cardiovascular disease< 1 Low
1-3 Intermediate
>3 High
> 10 To repeat as it is suggestive of acute inflammation
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Question 3:
What lifestyle changes would you
recommend to Mr. Wong?List up to 2 recommendations.
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Reduce salt intake (< 6g/day equivalent to
1 teaspoon of salt)
Reduce alcohol intake
(< 21 units for men and
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disease blocker
Uncomplicatedhypertensionwith no co-
morbidconditions
+ -Unless (1) women ofchild beaing age; (2)patients withevidence of incresed
sympathetic drive
++ ++ + -
Elderly with noco-morbidconditions
+++ + + + +++ +/-
Diabetes(withoutnephropathy)
+ +/- +++ ++ + +/-
Diabetes (withnephropathy)
++ +/- +++ +++ ++(only
nonhydropyridineCCB)
+/-
Coronary heartdisease
+ +++ +++ + ++ +
Heart failure +++ +++(metoprolol,
bisoprolol, carvedilol)
+++ +++ +(current evidence
available foramlodipine andfelodipine only)
+
Concomitant Diuretics blocker ACEIs ARBs CCBs Peripheral
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disease blocker
Non-diabeticrenovasculardisease
++ + +++ ++ +(only
nonhydropyridineCCB)
+
Renal arterystenosis
+ + ++(contraindicated in
bilateral arterystenosis)
++(contraindicated in
bilateral renal arterystenosis)
+ +
Peripheralvasculardisease
+ +/- + + + +
Dyslipidaemia +/- +/- + + + +
Gout +/- + + + + +
Asthma + - + + + -
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At diagnosis:
Patient education What is hypertension
What is the purpose of treating
hypertension Self BP monitoring
Advice on lifestyle changes e.g. smoking
cessation, exercise, salt and alcohol intakeetc
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Subsequent review:
Measure BP and other relevantparameter (e.g. glucose level inpatients with concurrent diabetes,
weight in overweight patients etc) tosee if target has been reached
Adverse effects of medications
Development of complications
C di i T BP
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Concurrent conditions Target BP
Adult > 65 yr (with no diabetes,chronic kidney disease orproteinuria 0.25g/day)
< 140/90
Adult < 65 yr < 130/85
Adults any age with diabetes < 130/85
Adults any age with renalinsufficiency
< 130/85
Adults any age with proteinuria
0.25-1.0g/day
< 130/85
Adults any age with proteinuria> 1g/day (in people with and
without diabetes)
< 125/75
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Adverse effects Thiazidediuretics
-blocker ACEIs CCBs ARBs
Constipation - - - + -
Cough angio-oedema
- - + - Rarereport
Dyspnoea - + - - -
Gout + - - - -
Headache - - - + -Hyperglycaemia + - - - -
Hyperkalaemia - - + - +
Hypokalaemia + - - - -
Impotence + + - - -
Lethargy - + - - -
Oedema - - - + -
Posturalhypotension
+ - - - -
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Effective combination therapy:Effective combination Comments
ACEIs + diuretics Appropriate for concurrent heart failure,diabetes and secondary stroke prevention
ARBs + diuretics Appropriate for concurrent heart failure,diabetes and secondary stroke prevention
-blocker + diuretics Cost-effective, evidence of mortality &cardiovascular benefit esp in elderly.However, may increase risk of new onsetdiabetes & increase glucose level indiabetics
-blocker + CCBs(dihydropyridine)
Appropriate for concurrent CAD
ACEIs/ ARBs + CCBs Appropriate for concurrent diabetesand/or dyslipidaemia
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Consider the following if target BP is
not reached on 3 drugs (includingdiuretics)
BP measurement artefact e.g.
inadequate cuff size Non-compliance
Secondary hypertension
White coat hypertension Volume overload in patients with
chronic kidney disease
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KEY FEATUREPROBLEM (CASE 2)
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Martha is a 58 yr old lady with 5 yr history
of hypertension. You have tried manyantihypertensive medications and have
little success in achieving target BP.
Today, she mentions that she is finding itvery difficult to stay awake during the day
even though she goes to bed exhausted
at 9pm each night. Her husband hadbeen sleeping in the spare bedroom dueto her snoring.
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Martha is 152cm tall, weights 90 kg,has a BMI of 39 and has a sedentary
life. She is a non drinker. She takesnaproxen everyday for an
osteoarthritic knee.
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Question 1:
Lists 3 factors from the
history that could becontributing to Marthas
resistant hypertension
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Obesity
Medication, NSAIDs in this case
Sleep apnoea
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KEY FEATUREPROBLEM (CASE 3)
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En. Jamal, aged 61 yrs gentleman, had seenyour colleague for the past 2 years for labile
BP. He is an anxious person who gets verynervous about his visits to the doctor. He hasnot received any medication to date for the
control of his BP by your colleague.3 months ago he purchased a home BPmonitor and on this device, he obtainedreadings of up to 255/105mmHg during periodof stress.
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On examining En. Jamal, you note a BP of140/90mmHg (pulse rate 72/min) whichincreases to 170/100mmHg (pulse rate 90/min)as the examination proceeds. After leaving himto rest for 10 minutes, his BP decreases to135/90mmHg when measured by your nurse
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Question 1:
List 2 differential diagnoses
for this scenario.
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White coat hypertension
Phaechromocytoma
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Question 2
Lists 2 tests/investigations
that you would performto confirm your diagnosis
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24 hour ambulatory BPmonitoring (ABPM)
24 hour urinary catecholamine
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24 hour ambulatory BP
monitoring Cardiovascular outcome are best related toBP recordings outside the clinic setting
Acceptable limits are:
< 135/85mmHg during the day
< 120/75mmHg during the night
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Monitor BP at clinic regularly
self monitoring at home
+ repeat ABPM at 1-2 yearly interval ifpatients has no:
other comorbidities such as diabetes or
renal disease
Low 10 year risk of developing CVD
Evidence of target organ damage
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KEY FEATUREPROBLEM(HYPERTENSION CASE 4)
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Gary, aged 66 yrs, had well controlled
hypertension since his mid 40s. Over the yrs,he has been treated with enalapril 10mg od,and his usual BP on this regimen had beenabout 130-140/ 80-90. Approximately 6months ago, he presented for his repeatprescription and his BP was 156/96. Onreview 2 months later, it was 162/98 and after
a further 2 months, it was 168/100. At thisstage, a diuretics was added, but a monthlater there had been little change in his BP
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Garys past history include an uncomplicatedMI at the age of 60 yrs, smoking relatedCOPD, and T2DM controlled on glipizide. He
also has stable intermittent claudication forseveral years and is able to walk about 150mon the flat. He has no angina since his MI and
generally feels fairly well
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Question 1Lists 3 likely reasons for the
loss of control of Garys BPover the past 6 months?
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Artherosclerotic renal artery stenosis,given the evidence of arterial diseases invarious locations (MI and PVD) and risk
factors: T2DM, smoking, age, gender
Change in compliance e.g. due todepression
Hyperaldosteronism
PhaeochromocytomaCushing syndrome
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QuestionIf you are suspecting renal
artery stenosis, lists 2 tests/investigations that you will
perform
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UFEME
RFT
Renal duplex ultrasound
Renal isotope scanning before and aftercaptopril challenge
Angiography angioplasty stenting
CE-CTA (contrast enhanced CTangiography)
CE-MRA (contrast enhanced MRangiography)
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