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Hypertension
ABC’s and D’sStephen Workman MD MSC
Division of GIM
Halifax NS Canada
Disclosures
No industry affiliations in the last ten years
No competing interests
Objectives
Present CV risk management as a good news story
Present several cases of a rare but treatable cause of HTN
UPDATE on HTN management and diagnosis in Canada 2018
(Hypertension 2020) Putting the Guidelines into Practice
Referral wish list
Show some favourite water features in Eastern Canada
A quiz!
Prevalence of HTN
15% 25% 40% (statscan)
Lifetime risk of hypertension for a normotensive Canadian aged 55-65
30% 60% 90% (statscan)
Treatment of SBP to < 150 has been shown to benefit patients older than
70 80 90 (HYVET NEJM)
Excellent control of BP, cholesterol NIDDM, obesity and smoking would reduce
CV death by 30% 50% 75%
CV death is a
GOOD NEWS STORY!!
CV morbidity and mortality: We are winning
Continued improvement yet
Cancer-- not decreasing
Population at risk for CHF as defined by BNP
BP and CHF
Why has CV death gone down so much?
Control of risk factors
BP control!! not if but when
Statins for everyone?
Smoking--way down
Exercise--not so much….
Diabetes. No.
Meander River Valley Near Windsor NS
Fun hypertension cases!
“It’s NEVER lupus.”
(House)
All the lupus patients are diagnosed BEFORE they become a diagnostic dilemma.
Quick--consult GIM stat!!
6_ year old woman Day 1 Post emergency colectomy.
HR 150. SBP 200. 98% on 3lpm. Clear CXR. CALL GIM!! It must be CHF!!
Two prior admissions for MI. N coronaries X2. On Statin ASA PLAVIX
Takotsubo CM on previous ECHO.
Colonoscopy with polypectomy. Post procedure bleed. Emergency colectomy.
Three year history of extreme and overwhelming fatigue.
DX?
Google says
Takotsubo is found in 3% of patients with PHEO
Many case reports and reviews
A pregnant young woman with IUGR
SBP 220
IUGR 30 at 38 Weeks
Three year history of rage attacks
(Very hard to accurately determine SBP due to extreme vasoconstriction)
24 hr Urinary catecholamines 10X ULN
Stat post op consult
72 year old man post prostate surgery
Labile BP and shocky at times
HGB 177 prior to surgery.
Yikes
Wow!
Pheochromocytoma
Rare but bad
Atypical symptoms the norm
24 hour urine for catecholamines can rule it out
Measured levels FAR higher than normal
Emmett and Meander River
Contrast previous cases with panic for Patient in ED
220/115.
58 yoa. Male. BMI 40. Long History of poorly controlled HTN. NIDDM. (BS 13)
Stopped meds/ran out two months ago. Visited Walk In clinic and sent in to the ED
No symptoms. Exam N. ECG possible LVH. Cr 122. U/A normal.
What Next?
Hypertensive Urgency does not exist
High BP (180 Systolic or 110 Diastolic) in a well patient.
No end organ damage.
Trip to ED increases admission and reduces BP control at six months and has no
effect on the already very low rates of MACE
1: Patel KK, Young L, Howell EH, Hu B, Rutecki G, Thomas G, Rothberg MB.
Characteristics and Outcomes of Patients Presenting With Hypertensive Urgency in
the Office Setting. JAMA Intern Med. 2016 Jul 1;176(7)
Assessment: High BP Yikes!
An emergency or not?
HTN >180/110 and NO target organ damage is an indication for immediate
treatment NOT an indication for ED trip/admission
Brain/eyes Heart Aorta Kidneys all can be damaged
Hypertension with evidence of injury:
CHF Angina Dissection ARF Papilledema Increase
ICP CVA(?)
All above require EMERGENT treatment
HTN Canada: What is new in 2020
1. Use chlorthalidone or indapamide NOT HCTZ
(Longer half life better control reduced death)
2. Use combination medications as initial treatment (27% improvement(1))
Either ACE / ARB AND Diuretic or
ACE / ARB AND CCB
3. Consider target SBP less than 120 based upon SPRINT evidence*
4. ABP or HBP no OABP
(1) Fixed dose combinations for HTN Lancet Sept 2018
#4 ABP!
OBP should NOT
Be used!
#3 Sprint and shared decisions
1: SPRINT Research Group,
Randomized Trial of Intensive versus Standard Blood-
Pressure Control. N Engl J Med. 2015
A is for Assessment and attitude
The disease is hypertension and the treatment is drugs
I don’t want to have a stroke or heart attack!
The disease is drugs and the treatment is hypertension
I don’t like to take pills you know!
Many people in the world do not have access to even the most basic medications
15% of people worldwide have HTN controlled
Lifestyle--I had no idea
Whelton PK, Carey RM, Aronow WS, et al 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. J Am Coll Cardiol
I will lose weight exercise AND eat less salt!!
GREAT--we can get you off the pills later
Meander River Falls
B--the basics
Diagnosis
BP true--q 4-5 min for five or six readings --runs the risk of missing masked
hypertension
ABP--The gold standard and always worthwhile when there is any doubt about the
diagnosis or patient acceptance
(GIM can arrange ABP’s)
Do a framingham risk score online FRS for all patients!
https://myhealth.alberta.ca/Alberta/Pages/Heart-Disease-Risk-Calculator.aspx
Derived from Pickering TG, et al. Hypertension 2002:40:795-6.
120
140
160
180
200
100
100 120 140 160 180 200
135
Manual Office BP mmHg
Am
bu
lato
ry B
P
mm
Hg
TRUEHYPERTENSION
NORMOTENSIONWHITE COAT HYPERTENSION
MASKED HYPERTENSION
White Coat and Masked Hypertension
Derived from Pickering TG, et al. Hypertension 2002:40:795-6.
0
5
10
15
20
25
30
35
Normal White coat Uncontrolled Masked
CV
eve
nts
pe
r 1
00
0
pat
ien
t-ye
arCV Events
Okhubo T, et al. J Am Coll Cardiol 2005;46;508-15
The Prognosis of White Coatand Masked Hypertension
Exogenous Causes!
● Nonsteroidal anti-inflammatory drugs (NSAIDs), including cyclo-oxygenase-2 inhibitors (coxibs)
● Corticosteroids and anabolic steroids
● Oral contraceptive and sex hormones
● Vasoconstricting/sympathomimetic decongestants
● Calcineurin inhibitors (cyclosporin, tacrolimus)
● Erythropoietin and analogues
● Antidepressants: Monoamine oxidase inhibitors (MAOIs), serotonin-norepinephrine reuptake
inhibitors (SNRIs), selective serotonin reuptake inhibitors (SSRIs)
Etcetera!
● Licorice root
● Stimulants including cocaine
● Salt
● Excessive alcohol intake
Pennant River Near Sambro NS
Odds and ends
Screen for sleep apnea with home sleep study via questionnaire or more
thoroughly with a home sleep study
Renal artery stenosis in older patients due to atherosclerosis is NOT an indication
for angioplasty
Specific considerations for medications
CHF/diastolic dysfunction/high LV filling pressures/peripheral edema/increased
BNP:
Chlorthalidone or indapamide reduce risk of overt CHF esp in elderly
Angina
Beta blocker or Diltiazem
Increased creatinine:
ACE or ARB increase dialysis free survival despite risk of decrease in GFR
Millrace, Kingston Ontario
I’m on three drugs ARB CCB DIURETIC what next?
Consider referral to Internal Medicine
Spironolactone in low dose
12.5mg increase to 25mg if needed
Follow lab, volume status
Advise stopping meds if nausea and vomiting and risk of acute kidney injury
Hyperaldosteronism (CMAJ June 5 2017)
Uncontrolled HTN (3 agents)
Low Potassium at diagnosis with with diuretics
Known Adrenal Mass and HTN
Associated with significantly worse CV endpoints
MACE 4-12X higher and death 2X age and BP matched controls
Work up with Renin Aldo Ratio (Aldo suppresses renin)
Test Renin Aldo Ratio with Potassium >4 and no Aldosterone blockade
Workup patients for whom adrenalectomy would be considered
Refer!
Referral wish list
ABP for diagnosis or to convince a patient of diagnosis
Resistant HTN--three drugs and not at target
Low Potassium either at presentation or with addition of Diuretic and patient would
consider adrenal surgery
Compliance poor or suspect (40% of patients non compliant at some point!)
High Framingham Risk score and resistant patient
Concern about secondary HTN
Summary
ABP or HBP
Treat risk not just BP FRS for patients
Hike
Dual agents as initial treatment and DO NOT use HCTZ as diuretic choice
Consider Adrenal surgery as option in select patients
I tell my patients that my goal is to reduce their CV risk as much as possible and
that 90% of CV risk can be avoided
The ‘Keyhole’ Fundy National Park
