HYPERTENSION- DECIPHERED

DR SYED RAZAMD,MRCP(UK),FRCP (Edin),CCT, FACC

Facts and Figures

• 30 per cent of women and men have high blood pressure

• 30 per cent of people with high blood pressure DO NOT KNOW that they have it.

• Three times more likely to develop heart disease and stroke Twice as likely to die from these as people with a normal blood pressure

• Only about 10% individuals reach target goals

Which one is normal blood pressure ?

• A) 148/88 mmHg in 68 years old • B) 136/86 mmHg in a diabetic• C) 138/ 90 in 40 years old• D) 138/88 mmHg in Renal failure• E) 130/80 mmHg in a diabetic

ANSWER

• ALL ARE NORMAL BLOOD PRESSURE READINGS

Guidelines for management of Hypertension

If the clinic blood pressure is 140/90 mmHg or higher, offer ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis of hypertension.

Diagnosis (1)

When using the following to confirm diagnosis, ensure: ABPM:–at least two measurements per hour during the person’s usual waking hours, average of at least 14 measurements to confirm diagnosisHBPM:–two consecutive seated measurements, at least 1 minute apart–blood pressure is recorded twice a day for at least 4 days and preferably for a week–measurements on the first day are discarded – average value of all remaining is used.

Diagnosis (2)

Value of accurate measurement of BP

• Underestimating /Untreated 5 mm Hg of excessive systolic blood pressure would be a 25% increase over current levels of fatal strokes and fatal myocardial infarctions .

• Overestimating true blood pressure by 5 mm Hg would lead to inappropriate treatment with anti-hypertension medications

adverse drug effects, psychological effects of misdiagnosis, and unnecessary cost.

Assessment of Hypertension

• 1. Assess for risk factors and co-morbidities.

• 2. Look for Target organ damage

• 3. Look for secondary cause for hypertension.

ASSESMENT OF CV RISK AND TOD

– Blood Glucose and Cholesterol– test urine for presence of protein– take blood to measure creatinine, estimated GFR

electrolytes.– examine fundi for hypertensive retinopathy– arrange a 12-lead ECG.

Window to Vascular Health

Secondary Causes

Stages of Hypertension

• Stage 1 hypertension:• Clinic blood pressure (BP) is 140/90 mmHg or

higher and• ABPM or HBPM average is 135/85 mmHg or higher.

• Stage 2 hypertension: • Clinic BP 160/100 mmHg is or higher and• ABPM or HBPM daytime average is 150/95 mmHg

or higher.

• Severe hypertension: • Clinic BP is 180 mmHg or higher or• Clinic diastolic BP is 110 mmHg or higher.

Hypertensive Crisis

58/m presents to ER with chest pain and SOB. Clinically in acute pulmonary edemaECG – ischemicBP : 240/120 mmHg

What is the diagnosis ?A.Hypertensive Urgency.B.Hypertensive Emergency.

How will you Manage such a Patient ?

• Hypertensive Emergency• Reduction of Blood Pressure with in an hour

• Hypertensive Urgency• Reduction of Blood Pressure in 48 - 72 hours

Hypertensive CRISIS

Hypertensive Emergency• BP > 220/120• Target organ damage• BP to be normalized within

one hour• Intravenous therapy • Treated as In patient

Hypertensive Urgency• BP > 220/120• No target organ damage• BP to be normalized 48-

72hours• Oral Therapy.• Treated as Out Patient

HYPERTENSION MYTHS

• Blood pressure causes Headache• ‘’I have no symptoms, why should I take

medication?• ‘’How soon can I stop medication once blood

pressure is controlled ?’’• ‘’My blood pressure is all due to stress’ ’• ‘’I do not want to take tablets as they have

side effects.’’

HYPERTENSION MYTHS: contd

‘’ My blood pressure is high because I had a very salty meal last night.’’

‘’ I have been advised to take blood pressure pill at night’’

‘My blood pressure is higher in the left arm as I am left handed’

‘My blood pressure is always normal with my own BP machine at home’

Hypertension in the Young

• Look for a secondary cause• Either on no treatment or multiple drugs • Diastolic BP control is more important• Choice of drugs ?

Which Drug to Choose ?

• MI : Beta- Blocker• Acute Pulmonary Edema : NTG• Aortic Dissection : Labetalol• Intracranial Hemorrhage : Nicardipine• Acute Kidney Injury : Fenoldopam• Pre-Eclampsia : Labetalol

Drug to Choose for Stable Patients• LVH - ACE inhibitor, calcium antagonist, ARB• Asymptomatic atherosclerosis - Calcium antagonist,

ACE inhibitor• Micro-albuminuria - ACE inhibitor, ARB• Renal dysfunction - ACE inhibitor, ARB• Previous stroke - ACEI (Perindopril + Indapamide)• Previous myocardial infarction - BB, ACE inhibitor, ARB• Angina pectoris -BB, calcium antagonist• Heart failure - Diuretic, BB, ACE inhibitor, ARB,

Aldactone• Aortic aneurysm & Atrial fibrillation : BB

Drug to Choose for Stable Patients - contd

• ESRD/proteinuria - ACE inhibitor, ARB• Peripheral artery disease - ACE inhibitor,

calcium antagonist• ISH (elderly) - Diuretic, calcium antagonist• Diabetes mellitus -- ACE inhibitor, ARB• Pregnancy - Methyldopa, calcium antagonist• Blacks - Calcium antagonist + Hydralazine

Which Diuretic ?

Thiazide type diuretic (Indapamide and Chlorthalidone) first line agent – recommend by American guidelines. British /NICE guidelines : Second line – in

combination. Thiazide diuretic HCT – metabolic derangement Loop diuretic : Furosemide – third line.

FIXED DOSE COMBINATION

• A + C• A+D• B+D x

• Recommendation for Stage 2 Hypertension.

Life Style Modification

How Low is ‘Low Salt’?

Recommendation for Salt Intake

2.3 gm per day 1.5 gm per day ifa. Hypertensionb.Diabetesc. > 51d.Blacke.Renal Disease

Take Home Message

• 1. Hypertension is common• 2. Is a silent killer• 3. Associated with high Cardiovascular

morbidity• 4. Correct measurement of blood pressure• 5. Choose the right medication / right dosage• 6. Educate your patients