Suitable for junior doctors and General Physicians.
Text of Hypertension - Deciphered
1.HYPERTENSION- DECIPHERED DR SYED RAZA MD,MRCP(UK),FRCP (Edin),CCT, FACC
2. 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 3. 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 4. ANSWER ALL ARE NORMAL BLOOD PRESSURE READINGS 5. Guidelines for management of Hypertension 6. Diagnosis (1)If the clinic blood pressure is 140/90 mmHg or higher, offer ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis of hypertension. 7. Diagnosis (2) When using the following to confirm diagnosis, ensure: ABPM: at least two measurements per hour during the persons usual waking hours, average of at least 14 measurements to confirm diagnosis HBPM: 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. 8. 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 antihypertension medications adverse drug effects, psychological effects of misdiagnosis, and unnecessary cost. 9. Assessment of Hypertension 1. Assess for risk factors and co-morbidities. 2. Look for Target organ damage 3. Look for secondary cause for hypertension. 10. 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. 11. Window to Vascular Health 12. Secondary Causes 13. 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. 14. Hypertensive Crisis 58/m presents to ER with chest pain and SOB. Clinically in acute pulmonary edema ECG ischemic BP : 240/120 mmHg What is the diagnosis ? A.Hypertensive Urgency. B.Hypertensive Emergency. 15. 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 16. Hypertensive CRISIS Hypertensive Emergency BP > 220/120 Target organ damage BP to be normalized within one hour Intravenous therapy Treated as In patientHypertensive Urgency BP > 220/120 No target organ damage BP to be normalized 4872hours Oral Therapy. Treated as Out Patient 17. 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. 18. 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 19. 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 ? 20. Which Drug to Choose ? MI : Beta- Blocker Acute Pulmonary Edema : NTG Aortic Dissection : Labetalol Intracranial Hemorrhage : Nicardipine Acute Kidney Injury : Fenoldopam Pre-Eclampsia : Labetalol 21. 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 22. 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 23. 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. 24. FIXED DOSE COMBINATION A+C A+D B+D x Recommendation for Stage 2 Hypertension. 25. Life Style Modification 26. How Low is Low Salt? 27. Recommendation for Salt Intake 2.3 gm per day 1.5 gm per day if a. Hypertension b.Diabetes c. > 51 d.Black e.Renal Disease 28. 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