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2000 Canadian Recommendations for the Management of Hypertension
2000 Canadian Recommendations
for the Management of Hypertension
Jan 18, 2001
2000 Canadian Recommendations for the Management of Hypertension
IntroductionHypertension as a Risk Factor
• Hypertension is a significant risk factor for:
– cerebrovascular disease– coronary artery disease– congestive heart failure– renal failure– peripheral vascular disease
2000 Canadian Recommendations for the Management of Hypertension
Introduction IIBenefits of Treating Hypertension
Younger than 60– reduces the risk of stroke by 42%– reduces the risk of coronary event by 14%
Older than 60– reduces overall mortality by 20% – reduces cardiovascular mortality by 33%– reduces incidence of stroke by 40%– reduces coronary artery disease by 15%
Introduction IIIBenefits of Treating to Target
• Older than 60 with isolated systolic hypertension (SBP 160 mm Hg and DBP < 90 mm Hg)
– 36% reduction in the risk of stroke– 25% reduction in the risk of coronary events
2000 Canadian Recommendations for the Management of Hypertension
23%16%
42%19%
Hypertensive patients who are treated but uncontrolled
Hypertensive patientswho are treated and controlled
Hypertensive patients who are unaware
Patients who are awarebut remain untreated
and uncontrolled
22% of Canadian adults 18 to 70 years of age have hypertension
Introduction IV The Challenge
Source : Joffres et al. (1997) Am. J. Hypertension 10: 1097-1102
2000 Canadian Recommendations for the Management of Hypertension
JNC VI Classification of Blood Pressure for Adults
Optimal <120 and <80
Normal <130 and <85
High–Normal 130–139 or 85–89
Hypertension
Stage 1 140–159 or 90–99
Stage 2 160–179 or 100–109
Stage 3 180 or 110
JNC 6 - Arch Int Med / Jan 1998
Category SBP DBP
Hypertension
1. Primary - 90% of all cases
- cause unknown
- “essential” or “idiopathic”
Benign gradual onset with prolonged course
Malignant abrupt with short course
can be fatal
severely damages
Hypertension
2. Secondary cause identifiable
- C.V., renal, pregnancy,
drugs, corticosteroids
- retain Na & H2O
Hypertension
Isolated hypertension:
If the patient has increased systolic BP with normal diastolic BP
Complications
• Heart - CAD - atherosclerotic changes
Angina, M.I., ( C.A. blood flow)
CHF - afterload, O2 need
Arrhythmias
• Brain - stroke microaneurysms
hemorrhage
Complications
• Kidneys renal failure
• Eyes visual disturbances
blindness
• Peripheral Vessels intermittent claudication
dissecting aortic aneurysm
Mechanisms of 1° Hypertension
1. Overactive SNS stimulation
- excite with nonepinephrine
- contractions
- vasoconstriction with workload &
B/P
Mechanisms of 1° Hypertension
2. Na & H2O retention by kidneys
- excessive secretion of renin
- H2O & Na retained
- volume & perfusion = B/P
- Most likely cause
Hypertension• Causes are however numerous &
interrelated
- environment
- psychological
- physiologic
Hypertension
• No obvious changes at first
• Changes widespread with time
• Large vessels sclerosed (narrowed)
• Small vessel damage
Vasoconstriction heart contractions (afterload) to maintain C.O.
chronic overwork
L.V. hypertrophy
coronary insufficiency M.I.
Con’t
LVF eventually
renal perfusion
Na & H2O retention
blood flow to kidneys, heart, eyes, brain
Progressive Impairment
Secondary Hypertension
Causes are numerous
• diabetes
• glomerulonephritis
• corticosteroid Rx
• Drugs - BCP - Amphetamines
- Estrogens - Thyroid hormones
Secondary Hypertension
Causes are numerous
• ICP
• anemia
• aortic regurgitation
Secondary Hypertension
Mechanisms1. secretion catecholamines
2. release renin
3. Na & blood volume
Dx: B/P high over several readings
averages >140
> 90
Assessment
1. Extent of organ involvement
2. Presence of C.V. risk factors
3. ID type
2000 Canadian Recommendations for the Management of Hypertension
Risk Assessment
Risk strata (typical 10 year risk of stroke or myocardial infarction): Low risk = less than 15%; medium risk = about 15-20% risk; high risk = about 20-30%; very high risk = 30% or more
1. TOD – Target Organ Damage2. ACC – Associated Clinical Conditions, including clinical cardiovascular disease or renal disease
Stratification of Risk to Quantify Prognosis
Reference: Chalmers J et al. WHO-ISH Hypertension Guidelines Committee. 1999 World Health Organization - International Society of Hypertension Guidelines for the Management of Hypertension. J Hypertens, 1999, 17:151-185.
Other Risk Factors & Disease History
Grade 1 Grade 2 Grade 3
BLOOD PRESSURE (mm Hg)
(mild hypertension)SBP 140-159 or
DBP 90-99
(moderate hypertension)SBP 160-179 or
DBP 100-109
(severe hypertension)SBP ? 180 or
DBP ? 110
MED RISKLOW RISK HIGH RISK
V HIGH RISK
V HIGH RISK
V HIGH RISKMED RISK MED RISK
HIGH RISKHIGH RISK
V HIGH RISKV HIGH RISK
I. no other risk factorsII. 1-2 risk factorsIII. 3 or more risk factors or TODor diabetes
IV. ACC
History
• Family Hx
• Diabetes
• Previous B/P
• results of hypertensives
• angina, dyspnea hx
• use of BCP, alcohol, steroids, diet pills
History con’t
• Weight gain
• Na intake
• stress, cultural food practices
• Risk factors chol.
Obesity
history of exercise
Physical Exam
• Retina edema, hemorrhage
• Neck distended veins, bruit
• Heart HR, murmurs
• Extremities p.p., edema
2000 Canadian Recommendations for the Management of Hypertension
Risk Stratification and Treatment
Lifestylemodifications(up to 12 months)
Lifestylemodifications(up to 6 mos)
Adapted from JNC VI; TOD = Target organ damage CCD = Clinical cardiovascular disease
Blood PressureStages (mm Hg) No Risk Factors
No TOD/CCD
One Risk Factorother than DMNo TOD/CCD
TOD/CCDand/or DM
High-Normal(130-139/ 85-89)
Lifestylemodifications
Lifestylemodifications
Drug therapy
Drug therapy
Drug therapyDrug therapyDrug therapyStages 2 and 3(160/ 100)
Stage 1(140-159/ 90-99)
Risk Group A Risk Group B Risk Group C
Interventions
• Nonpharmacological - weight reduction
- exercise
- Na
- relaxation
- monthly BP checks
- Ethol, coffee
- smoking cessation
Hypertensivepatient
Dietary Potassium
Dietary Sodium
Non Pharmacologic Recommendations for HypertensionLifestyle: Dietary
Magnesium supplementation
Calcium supplementation
For age over 44,
Restricted to a target range of 90-130 mmol/day. (Limitation of salt additives and foods with excessive added salt)
Daily dietary intake ≥ 60 mmol
Fresh fruits,
Vegetables,
Low fat dairy products,
Low fat diet,
in accordance with
Canada's Guide
to Healthy Eating
No conclusive studies for hypertension
No conclusive studies for hypertension
Jan 18, 2001
Pharmacological Diastolic > 95
1. Diuretics
a) thiazides - promote excretion Na & H2O
- Diuril, hydrodiuril
- hypokalemia possible
b) loop diuretics - loop of Henle
- minimize H2O & Na reabsorption
- Lasix
Pharmacological Diastolic > 95
1. Diuretics
c) Potassium sparing - promote H2O & Na excretion
- hyperkalemia
- aldactone
2. Sympatholytic Agents
- interrupt activity SNS with renin activity
- catapres & aldomet
Pharmacological Diastolic >95
3. Vasodilators
- dilate peripheral blood vessels
- Apresoline, minipres
4. Angiotension converting enzyme inhibitor
- inhibit Angio 1 to Angio 2
- afterload i.e. captopril
Pharmacological Diastolic >95
5. Ca channel blockers
- C.O. & rate
- nipedine
Hypertensive CrisisReduction in BP needed stat
• Malignant hypertension
• hypertensive encephalopathy - LOC
• heart failure
• toxemia
• dissecting aneurysm
• intracranial hemorrhage
Interventions for Crisis
ICU
IV Drugs
Monitoring
Continuous EKG
Management Long-term• Assess Knowledge - disease process
- consequences- administration drugs- diet- exercise- home monitoring
• Compliance
• Ineffective coping
Drugs• Never dose
• Never miss dose
• Take on time
• Side effects
• Never discontinue
Hypotensive Alert• Lie down with legs elevated
• No hot baths
• No excessive alcohol
Reasons for Noncompliance
• Asymptomatic
• Difficult lifestyle changes
• Annoying side effects
• Costs