SYSTEMIC HYPERTENSIONRATIONAL MANAGEMENT IN GENERAL PRACTICEDr Anidu PathiranaMBBS(Col.) MD(Col.) MRCP(UK)

SOME DIFFICULTIES GP’S HAVE WITH HYPERTENSION

MANAGEMENT When to inform a patient as hypertensive

When to refer to a Specialist

How to control high BP to the target

How to convince & persuade a patient to take medication (often several) lifelong, for an asymptomatic condition and where drugs may have significant side effects.

TAKE HOME MESSAGES Measure BP accurately and record Take adequate time to diagnose

hypertension Decide BP target, try to hit it, tell

target to patient Use low cost, tolerated drugs in

effective combination Address CV risk reduction, decide on

LDL, HbA1c targets and try to hit Convince the patient for follow up

SYSTEMIC HYPERTENSION DEFINITION

Blood pressure elevation Systolic above 139 mmHg

and/or Diastolic above 89 mmHg

on repeated measurements in adults >18y

‘NORMAL’ DISTRIBUTION OF DIASTOLIC BP WITHIN A POPULATION

0

5

10

15

20

50 60 70 80 90 100 110 120 130

Diastolic BP, mmHg

% o

f sc

reen

ed p

opul

atio

n

HYPERTENSION: A PRACTICAL DEFINITION

That level of blood pressure at which investigation and

treatment do less harm than good

HYPERTENSION IS COMMON

Prevalence 25% adult populations

Normotensive at 55 year has a 90% lifetime risk of developing hypertension

HYPERTENSION IS SERIOUS

Global mortality 2000Health risk factors

HYPERTENSION IS SERIOUS

Untreated hypertension reduces life expectancy by 5 years

Hypertension is responsible for - 25% of all premature deaths - 25% of all CAD deaths - 50% of all stroke deaths - 50% of all Congestive Heart

Failure - Commonest cause of CKD overall

TARGET ORGAN DAMAGE

Memory Loss or Stroke

Angina, Heart AttackHeart failure

Kidney damageImpaired vision

or Blindness

Decreased sexual ability

TREATMENT IS EFFECTIVE

HYPERTENSION IS TREATABLE

Antihypertensive drug therapy (almost) always

Lifestyle changes Assist in hypertension control and

reduce number of drugs

2 mm Hg decrease in mean SBP

7% reduction in risk of ischemic heart disease mortality

10% reduction in risk of stroke mortality

SBP REDUCTIONS AS LITTLE 2 MMHG REDUCES CV RISK BY 10%

140/90 mmHg

GOAL IS TO HIT THE TARGET High risk < 130 and 80

mmHg (CVD,CKD,DM) Others < 140 and 90

mmHg

>80y < 150 and 90 mmHg

Patients should know their starting BP & Goal BP

Hypertension is mostly asymptomatic

Need for opportunistic screening

CASE HISTORY

A 38y old man BP 154/96 mmHg

WHAT TO DO

Diagnostic pathway

Treatment pathway

IMPORTANT QUESTIONS

When should I tell him as having Hypertension?

Can I manage him or should I refer him to a Specialist?

When should I start him on drugs?

What are the best drugs?

When should I see him next?

ACCURATE BLOOD PRESSURE MEASUREMENT

Equipment should be regularly inspected and validated.

Operator should be trained and regularly retrained.

Patient must be properly prepared

TECHNIQUES OF BP MEASUREMENT

Clinic measurements (doctor or nurse)

Home BP measurement (patient)

24h ambulatory BP measurement (automatically)

TYPES OF B P MONITORS

Mercury sphygmomanometers

Android ( Mercury-free)

Automated upper arm devices

What size cuff?

Size does matter

Using too small a cuff/bladdercan overestimate the blood pressureBladder should encircle arm by 80-100%

5

Too tight clothing

If the sleeves are too tight or bulky they act as a tourniquet giving inaccurate readings

6

MYTH:The position of the arm is immaterialDuring BP measurement?

FACT:

The arm should be well supported at HEART level (both sitting & standing)

An unsupported arm is performing isometric exercise thus raising BP

4

MYTH:Mercury sphygmomanometer shouldbe positioned level with the patients heart?

It should be level with eye

9

At what rate should the cuff be deflated

on a Mercury sphygmomanometer?

FACT:

2mm/Hg per second

FACT: BP should be recorded to

the nearest 2mm/Hg on

mercury sphygmomanometer

RULES FOR MEASUREMENT

Seated for 5 min in a quite place No exercise, smoking, caffeine within 30 min. Measure in both arms on first visit. If

difference >20 mmHg repeat measurements in both arms. If remains so measure subsequent BP in arm with higher reading.

If BP >140/90: Take a second reading during same consultation. At least 1-2 min. apart. If it differs > 20 take a third measurement. Record lower of the last two measurement as the clinic BP

Care Pathway

FOLLOW-UP BASED ON INITIAL BPMEASUREMENTS FOR ADULTS

Initial B P value Follow-up recommendation

Normal <130/85 Re check in2 years

Pre hypertension or high normal130-139/85-89

Re check in 1 years

140-159/90-99 Confirm within 2 months

160-179/100-109 Confirm within 1 month

>180/110 Evaluate & treat immediately or within 1 week

HypertensiveUrgency /

Emergency

HypertensiveUrgency /

Emergency

Diagnosisof HTN

Diagnosisof HTN

Elevated Out of the Clinic BP

measurement

Elevated Out of the Clinic BP

measurement

Elevated Random Clinic BP

Measurement

Elevated Random Clinic BP

Measurement

Hypertension Visit 1BP Measurement,

History and Physical examination

Hypertension Visit 1BP Measurement,

History and Physical examination

Diagnostic tests orderingat visit 1 or 2

Diagnostic tests orderingat visit 1 or 2

Visit 1

Urgent referral for urgent treatment

• Impending complications (e.g. TIA, LVF, angina)

• Particularly severe hypertension (>220/120mmHg)

• Accelerated hypertension (severe hypertension and grade III-IV retinopathy)

HISTORY&

EXAMINATION

Hypertension risk factorsWeight

Family historySalt, Alcohol, Stress, Sleep

Target organ damageHeart: angina,MI,HF

Brain: TIAEyes

Kidneys

Clues to 2o HTSymptoms

Drugs:OCP,NSAIDSSigns

Other CV risk factorsLipids

SmokingDiabetesExercise

Concurrent conditionsAsthma

GoutPregnancy

INVESTIGATIONS Urinalysisprotein,blood,microalbuminuri

a

ECGFBSFasting lipidsSerum creatinine & e-GFRSerum electrolyteHb%, PCVTSH, Ionized calciumSerum uric acid

ASYMPTOMATIC TARGET ORGAN DAMAGE

ECG & Echo evidence of LVH CKD with eGFR <60 ml/min/1.76 m2

BSA Microalbuminuria- 30 mg/ g

creatinine or 30-300 mg/24h Pulse pressure >60 mmHg in elderly Increased pulse wave velocity carotid-

femoral Carotid IMT or plaque Ankle brachial index < 0.9

Yes

BP ≥ 140/90 mmHg +

TOD,DM,CKDor

BP ≥ 180/110?

BP ≥ 140/90 mmHg +

TOD,DM,CKDor

BP ≥ 180/110?

Diagnosisof HTN

Diagnosisof HTN

No

Visit 2

DIAGNOSTIC ALGORITHM CONT.

BP: 140-179 / 90-109BP: 140-179 / 90-109

ABPM (If available)ABPM (If available)Clinic BPClinic BP HBPM HBPM

Diagnosisof HTN

Awake BP≥ 135 SBP or

≥ 85 DBPOr 24-hour

≥ 130 SBP or≥ 80 DBP

Awake BP≥ 135 SBP or

≥ 85 DBPOr 24-hour

≥ 130 SBP or≥ 80 DBP

Awake BP< 135/85 and

24-hour< 130/80

Awake BP< 135/85 and

24-hour< 130/80

Continue to follow-up

Diagnosisof HTN

Hypertension visit 3

≥ 160 SBP or ≥ 100 DBP

≥ 140 SBP or≥ 90 DBP

< 140 / 90

Diagnosisof HTN

Continue to follow-up

< 160 / 100

Hypertension visit 4-5

ABPM or HBPMor

≥ 135 SBP or ≥ DBP 85

≥ 135 SBP or ≥ DBP 85

< 135/85 < 135/85

Diagnosisof HTN

Continue to follow-up

or

DEFINITION BY OFFICE & OUT-OF-OFFICE B P LEVELS

HOME/SELF BP MONITORING

Advise patients on accurate, independently validated, well maintained monitors

Advise use of appropriate cuff sizeSuggested measurement routine for patients Two consecutive measurements 1 min apart, seated Measure BP for 7 days prior to appointment Record BP twice a day. Morning and evening Discard first 24 hours of readings Take an average of at least 12 of these readings

Indications for ABPM

24 hour BP monitoring (ABPM)

• Possible ‘white coat’ hypertension

• Informing equivocal decisions

• Determining efficacy of drug treatment over 24 hours

• Evaluation of symptomatic hypotension

• Unusual BP variability

• Evaluation of drug resistant hypertension

THE CONCEPT OF MASKED / WHITE COAT HYPERTENSION

From Pickering, Hypertension 1992

Clinic SBP mmHg

Hom

e o

r dayti

me A

BPM

SB

P

mm

Hg

Truehypertensive

TrueNormotensive White Coat HTN

Masked HTN

135

140

135

140

CLASSIFICATION OF CLINIC B P LEVELS

Category Systolic Diastolic

Stage 1 140-159 and/or 90-99

Stage 2 160-179 and/or 100-109

Stage 3 >180 and/or 110

Isolated systolic hypertension

>139 and <90

WAYS TO LOWER “PRESSURE”

• Get 30 to 60 minutes of exercise per day

• Eat a healthy diet: fresh fruits & vegetables, low-fat dairy, whole grains, low-fat meat, fish, poultry

• Stop smoking forever

LIFE STYLE MEASURES TO ALL

Physically Active

Eat Healthy

Smoke-Free

• If you are overweight, losing 10 lbs (5 Kg) will reduce high blood pressure

LIFE STYLE MEASURES TO ALL

• Reduce stress• You can control your blood pressure:

• If you are on medications: take them as directed by your doctor

• Limit alcohol to less than 2 drinks a day for men and approximately 1 drink a day for women

Less Salt

Less Stress

Medications

Less Alcohol

• Processed and restaurant foods contain high amounts of salt

• Hidden Salt

INDICATIONS FOR DRUG THERAPY

Grade 2 & 3 High risk Grade 1 with TOD,DM,CKD or

high CV risk Arguments for drug treatment for all Grade

1 -No need to wait till become high risk. That

high risk may not be reversible then. -Safe drugs are now available at low cost Elderly patients drug therapy > 160 mmHg

target 150 mmHg

RISK FACTORS

Male sex Age >55 y in male, >65 y in female Smoking Dyslipidemia ( total >190 mg/dl, LDL >115,

HDL <40 in male & <46 in female, TG >150) FBS 102-125 mg/dl or abnormal IGT BMI > 30, Abdominal obesity > 90 cm in

male & > 80 cm in female Family history of premature CV disease <55

y in male, <65 y in female

INITIATION OF LIFE STYLE CHANGES & DRUGS

DRUG THERAPYEffective: Proven in trials

Tolerance: Minimal side effects

Cost: LowFour main classes: ACEI/ARA, BB, CCB, Diuretics

TAILORED THERAPY

Compelling indications

Compelling contra indications

MOST PATIENTS NEED COMBINATION OF DRUGS TO

ACHIEVE TARGET

On average each medication will reduce blood pressure 10/5 (“Rule of 10/5”)

Stage1: start ONE drugStage2: start COMBINATION of two

Even in stage 1 hypertension two classes of drugs needed to BP goals

DRUG COMBINATIONS

GENERAL PRINCIPLE DRUG THERAPY

Low dose and titrate up Long acting drugs 24h efficacy with

once a day dosing at least 50% drug effect remaining at the end of 24h

Each medication may require 2-3 dose adjustments

Recommended interval between adjustments (new or dose increase) is 2 weeks

Usually one adjustment per visit

STEP-UP

Step 4

Aged over 55 years

Aged under

55 years

C2A

A + C2

A + C + D

Resistant hypertension

A + C + D + consider further diuretic3, 4 or alpha- or

beta-blocker5

Consider seeking expert advice

Step 1

Step 2

Step 3

KeyA – ACEI or low-cost ARB C – Calcium-channel blocker (CCB) D – Thiazide-like diuretic

Stepwise Ladder Approach

Possible underlying cause

• Any clue in history or examination of a secondary cause, eg. low potassium, proteinuria, hematuria

• Raised serum creatinine

• Sudden onset or worsening of hypertension

• Resistant to multi-drug regimen (> 3 drugs)

• Young age (<40 years)

Indications for Specialist referral

Therapeutic problems• Multiple drug intolerance

• Multiple drug contraindications

• Persistent non-compliance

Special situations• Unusual blood pressure variability

• Possible ‘white coat’ hypertension

• Hypertension in pregnancy

Indications for Specialist referral

GLOBAL RISK REDUCTION

ADD-ON TREATMENT

Aspirin 75 mg/d if high renal and CV risk,TOD,DM with BP controlled <150/90

Statin: Without previous CVD moderately high CV risk to target LDL 115 mg/dl Overt CHD target LDL 70 mg/dl

FOLLOW UP Once a month initially.More often if high

risk

If BP at goal and stable review at 3-6 m

Serum creatinine & electrolyte in 6-12 m

Consider reducing doses and number of agents after one year at or below goal BP

TAKE HOME MESSAGES Measure BP accurately and record Take adequate time to diagnose

hypertension Decide BP target, try to hit it, tell

target to patient Use low cost, tolerated drugs in a

effective combination Address CV risk reduction, decide on

LDL, HbA1c targets and try to hit Convince the patient for follow up

Compelling and possible indications, contraindications, and cautions for the major classes of antihypertensive drugs Class of drug

Compelling indications

Possible indications

Caution

Compelling contraindications

Beta-blockers MI, Angina

Heart failure Heart failure, PVD,

Diabetes (except with CHD)

Asthma/COPD, Heart block

CCBs (dihydropyridine)

Elderly, ISH Angina - -

CCBs (rate limiting)

Angina Elderly Combination with beta-blockade

Heart block Heart failure

Thiazide/thiazide-like diuretics

Elderly ISH Heart failure 2 o stroke prevention

Gout

BP NOT CONTROLLED Improper BP measurement (large cuff) Poor compliance Volume overload- Inadequate diuretic,

Excessive salt intake, progressive renal failure Failure to modify lifestyle- Weight gain,

Stressful life, Excessive alcohol Drugs- NSAIDs, OCP, herbal medicine Obstructive sleep apnoea Unsuspected secondary cause

INFORMATION TO A NEWLY DIAGNOSED PATIENT

“You are at significant risk of heart attack, stroke and kidney damage.

“This risk can be significantly reduced by reducing your BP to target level”

“Your target blood pressure is 140/90 (or less)”

INFORMATION TO A NEWLY DIAGNOSED PATIENT

Most people need 2 or more drugs to control their blood pressure and need to stay on them for life

Most medications take several weeks to show their full effect so be patient

You need to visit every two weeks to adjust drug doses

INFORMATION TO A NEWLY DIAGNOSED PATIENT

Medications only work if you take them!

Stopping a treatment when blood pressure returns to normal can cause your blood pressure to rise again to dangerous levels

INFORMATION TO A NEWLY DIAGNOSED PATIENT

Because the medications have controlled the blood pressure does not mean that the blood pressure has been completely cured

Your treatment is life longLife style changes, healthy diet,

physical activity and reduce mental stress are helpful

CARE PATHWAY

CBPM ≥160/100 mmHg & ABPM/HBPM

≥ 150/95 mmHg

Stage 2 hypertension

Consider specialist referral

Offer antihypertensive drug treatment

Offer lifestyle interventions

If younger than 40 years

If TOD, established CVD,CKD,DM or 10-year CV risk > 20%

Offer review of care to monitor blood pressure, provide support and discuss lifestyle, symptoms and medication

Offer patient education to support adherence to treatment

CBPM ≥140/90 mmHg & ABPM/HBPM ≥ 135/85 mmHg

Stage 1 hypertension

HEALTHY DIET A high sodium diet can increase blood

pressure

Choose more often• Fresh fruits and vegetables• Low-fat milk products• Whole grains• Low-fat meat, fish, chicken

and turkey• Use herbs and spices to

replace salt• Foods with 5% or less of the

daily value of sodium

Choose less often• Fast food, restaurant and

packaged foods• Foods with more than the

15% daily value of sodium• Ketchup, mustard, soy

sauce, gravy• Pickled foods, olives, salsa,

chips• Cured/smoked meat or fish

HOW TO READ FOOD LABELS

Check the serving size

Aim for less than 5% Sodium