Download Hypertension: Latest Guidelines - The practical Nurse Practitioner

Annemarie Kallenbach
RN MS CNP
MICHIGAN COUNCIL OF NURSE
PRACTITIONERS
Identify questions of
practice conundrums.
NOTECARDS
Eighth Joint National Committee JNC 8
Last heard weren’t gonna be any BUT if those
Europeans did one well…..
http://jama.jamanetwork.com/ar
ticle.aspx?articleid=1791497/
Google:
2014 Guideline for Management
of High Blood Pressure
GOOGLE: 2013 CHOLESTEROL GUIDELINES
http://circ.ahajournals.org/content/early/2013/
11/11/01.cir.0000437740.48606.d1.citation
 In
age greater than 60 treat to
achieve a BP <150/90
 In age less than 60 treat to a
diastolic < /90
 In age less than 30 – manage
risk
Same recommendations for all disease states
Non black = ACE, ARB, Thiazide diuretic, CCB
In CKD = ACE,ARB
In Blacks, even diabetics = thiazide diuretic CCB
2013 European Society of
Hypertension
(ESH)/European Society of
Cardiology (ESC) Guidelines
for the management of
arterial hypertension
ESC GUIDELINES FOR
ARTERIAL HYPERTENSION




Identify blood pressure recommendations based on
risk.
State important aspects of personal and family
history in interviewing patients for hypertensive
heart disease.
Perform physical examination including essential
system assessment.
List hierarchy of efficacy for diagnostic testing.




Prescribe initial hypertensive management on all
presenting patients needing treatment.
Match categories of pharmacological agents to
populations of patient parameters.
Identify questions of practice conundrums.
Have complete familiarity of resources to guide care
of hypertensive disease at current practice.
HAVE FUN
AND KNOW
THE STUFF
Identify
blood pressure
recommendations based on
risk



Collins R, Mac Mahon S. Blood pressure,
antihypertensive drug treatment and the risks of stroke
and of coronary heart disease. BrMed Bull 1994;
50:272–298.261.
Zanchetti A, Grassi G, Mancia G. When should
antihypertensive drug treatment be initiated and to
what levels should systolic blood pressure be lowered?
A critical re-appraisal. J Hypertens 2009;
Law MR, Morris JK, Wald NJ. Use of blood pressure
lowering drugs in the prevention of cardiovascular
disease: meta-analysis of 147 randomized trials in the
context of expectations from prospective
epidemiological studies. BMJ 2009; 338:b1665.
Zanchetti A, Grassi G, Mancia G. When should antihypertensive drug treatment
be initiated and to what levels should systolic blood pressure be lowered? A
critical re-appraisal. J Hypertens 2009
Mancia G, Laurent S, Agabiti-Rosei E, Ambrosioni E, Burnier M, Caulfield MJ, et
al. Re-appraisal of European guidelines on hypertension management: a
European Society of Hypertension Task Force document. J Hypertens 2009;
27:2121–2158.
JATOS Study Group. Principal results of theJapanese trial to assess optimal systolic
blood
pressure in elderly hypertensive patients (JATOS).Hypertens Res. 2008;31(12):21152127.
Ogihara T, Saruta T, Rakugi H, et al; Valsartan in Elderly Isolated Systolic
Hypertension Study Group.
Target blood pressure for treatment of isolated systolic hypertension in the elderly:
Valsartan in Elderly Isolated Systolic Hypertension Study. Hypertension.
2010;56(2):196-202.

No evidence for different target for


DM,
previous CV events
 (including stroke)

Renal

No evidence
Still a JNC 8 expert panel recommendation.
“On the basis of current evidence, these young
individuals can only receive recommendations on
lifestyle … but should be followed closely.”
European guidelines

 State
important aspects of
personal and family history in
interviewing patients for
hypertensive heart disease.
Current HTN
Duration and previous level of high BP, including
measurements at home.

CAD






PVD
Stroke
Congestive heart failure
DM
CKD
Sudden death
Parenchymal Disease




Family history of CKD (polycystic kidney).
History of renal disease, urinary tract infection,
hematuria, analgesic abuse .
Drug/substance intake, e.g. oral contraceptives, liquorice,
carbenoxolone, vasoconstrictive nasal drops, cocaine,
amphetamines, gluco and mineralocorticosteroids,
erythropoietin, cyclosporine.
Repetitive episodes of sweating, headache, anxiety,
palpitations (pheochromocytoma).
Hyperaldosteronism

Episodes of muscle weakness and tetany .
Renal artery stenosis
How many can you list in 3
minutes????
New patient (healthy)
Family and personal history of
Hypertension
CVD
Dyslipidemia
Diabetes
Smoking habits
Dietary habits
Recent weight changes; Obesity
Amount of physical exercise
Snoring; sleep apnea (information also from partner)
HTN in pregnancy, Low birth-weight child
• Obesity BMI ≥30 kg/m2
waist circumference men
≥102 cm; women ≥88 cm)
(in Caucasians)
TC 190 mg/dL
• Family history of
LDL > 115
premature CVD (men
HDL: men 40 , women 46 ,
aged <55 years;
and/or
women aged <65
Triglycerides (150 mg/dL)
years)
• Fasting plasma glucose
(102–125 mg/dL), GTT,
test,**HGA1C
•
•
•
•
Male gender
Age (men ≥55; women ≥65 )
Smoking
Dyslipidaemia
• Pulse pressure (in the elderly) ≥60 mmHg
• Electrocardiographic LVH (Sokolow–Lyon index
>3.5 mV; RaVL >1.1 mV; Cornell voltage duration
product >244 mV*ms), or
• Echocardiographic LVH [LVM index: men >115
g/m2; women >95 g/m2 (BSA)]a
• Carotid wall thickening (IMT >0.9 mm) or plaque
• Carotid–femoral PWV >10 m/s
• Ankle-brachial index <0.9
• Microalbuminuria (30–300 mg/24 h), or
albumin–creatinine ratio (30–300 mg/g; 3.4–34
mg/mmol)
• Diabetes mellitus (fasting, PP, random, HGA1C)
• How many medical history or
lab values can you list in a
established chronically ill
patient?
• Established CV or renal disease
• Cerebrovascular disease: ischaemic stroke;
cerebral haemorrhage; transient ischaemic attack
• CHD: myocardial infarction; angina; myocardial
revascularization with PCI or CABG
• Heart failure, including heart failure with
preserved EF
• Symptomatic lower extremities peripheral artery
disease
• CKD with eGFR <30 mL/min/1.73m2 (BSA);
proteinuria (>300 mg/24 h).
• Advanced retinopathy: haemorrhages or
exudates, papilloedema
How
many of these can you
name in 3 minutes?






Brain and eyes: headache, vertigo, impaired vision,
TIA, sensory or motor deficit, stroke, carotid
revascularization.
Heart: chest pain, shortness of breath, swollen ankles,
myocardial infarction, revascularization, syncope,
history of palpitations, arrhythmias, especially atrial
fibrillation.
Kidney: thirst, polyuria, nocturia, hematuria.
Peripheral arteries: cold extremities, intermittent
claudication, pain-free walking distance, peripheral
revascularization.
History of snoring/chronic lung disease/sleep apnea.
Cognitive dysfunction.
Hypertension management
 Current and past meds
 Adherence
 Efficacy and adverse effects of drugs.


Premature hypertension < age 30
Premature CVD



Men < 50
Women <60
Diabetes

Perform physical examination including
essential system assessment.



Height, weight, waist circumference
BP
Auscultation




Heart sounds (gallop)
PMI
Carotid and renal arteries
Palpation of radial artery during auscultation

Auscultation




Palpation of radial artery during auscultation



Lungs: Rales (CHF)
Periphery: Edema, pulse strength, ABI
Carotid and renal arteries: Bruits
Arrhythmias
Neuro
Eye fundoscopic exam: next




Grade IV retinopathy
Grade III retinal haemorrhages,
microaneurysms, hard exudates, cotton wool
spots and papilledema and/or macular edema
are indicative of severe hypertensive
retinopathy, with a high predictive value for
mortality
Grade II arteriovenous nicking
Grade I arteriolar narrowing either focal or
general in nature

List hierarchy of efficacy for diagnostic testing
WORKSHEET TO LIST AND THEN RANK
BY COST AND EFFECTIVENESS OF
OFTEN ORDERED FOR HYPERTENSIVE
DISEASE.
Rank on a scale of 4 -1 (higher value better
parameter)
Marker
EKG
Echo
GFR
Urine Micro
Carotid intima
Pulse wave velocity
Ankle brachial index
Fundoscopy
Calcium score
Endothelial
dysfunction
MRI
Predictive
Value
Availa
bility
Reproducibili Cost
ty
effectiveness
Marker
Predictive
Value
Availa
bility
Reproducibili Cost
ty
effectiveness
EKG
3
4
4
4
Echo
4
3
3
3
GFR
4
4
4
4
Urine Micro
3
4
2
4
Carotid intima
3
3
3
3
Pulse wave velocity
3
2
3
3
Ankle brachial index
3
3
3
3
Fundoscopy
3
4
2
3
Calcium score
2
1
3
2
Endothelial
dysfunction
2
1
1
2
MRI
2
1
3
2

Match categories of pharmacological agents
to populations of patient parameters.
TWO VOLUNTEERS WILL COMPETE
HEAD TO HEAD JEOPARDY!!
Isolated systolic hypertension

Identify questions of practice conundrums.
REVIEW COLLECTED NOTECARDS
• Allow
the patients to sit for 3–5 minutes • When adopting the auscultatory
before beginning BP measurements.
method, use phase I and V
(disappearance) Korotkoff sounds to
systolic and diastolic BP,
• Take at least two BP measurements, in identify
the sitting position, spaced 1–2 min apart, respectively.
and additional measurements if the first
two are quite different.
• Measure BP in both arms at first visit to
detect possible differences. In this
take the arm with the higher
• Take repeated measurements of BP to instance,
value as the reference.
improve accuracy in patients with
arrhythmias, such as atrial fibrillation.
• Measure at first visit BP 1 and 3 min
assumption of the standing position
• Use a standard bladder (12–13 cm wide after
elderly subjects, diabetic patients, and
and 35 cm long), but have a larger and a in
other conditions in which orthostatic
smaller bladder available for large (arm in
hypotension may be frequent or
circumference >32 cm) and thin arms,
suspected.
respectively.
• Have the cuff at the heart level,
whatever the position of the patient.
Have complete familiarity of
resources to guide care of
hypertensive disease at current
practice.
155/95
CASE STUDIES
27 year old
Spaniard
Non smoker
Exercises
incessantly
CASE STUDIES
Family history
Recreational
drug use
Herbal
supplement
25 year old
AKA “the
donut man”
Non smoker
Sedentary
Targets
Goals
Interventions
CASE STUDIES
Diabetic
CASE STUDIES
Targets
Goals
Interventions
CASE STUDIES
Targets
140/89 / 130/80
HGA1c 7.0
Negative urine
micro, LDL <70
Goals
Healthy weight,
regular exercise,
yearly eye and
dental exams, happy
with life
Interventions
ACE
CASE STUDIES
CKD
Targets
Goals
Interventions
Targets
140/89
w/proteinuria –
130/80
LDL<100
Goals
Interventions
ACE, No NSAIDS,
low sodium diet,
nephrology
review
CASE STUDIES
CAD/MI
CASE STUDIES
Targets
Goals
Interventions
CASE STUDIES
Targets
Goals
LDL<100
Interventions
Beta Blocker, 20
minutes intense
CV exercise
CASE STUDIES
Heart attack at
age 50
CASE STUDIES
Targets
Goals
Interventions
CASE STUDIES
Heart
Failure
CASE STUDIES
Targets
Goals
Interventions
CASE STUDIES
Targets
Goals
Interventions
Daily weights
ACE, diuretic,
Beta blocker
CASE STUDIES
CVA
CASE STUDIES
Targets
Goals
Interventions
CASE STUDIES
Targets
Stability at onset
Then once stable
<150/90
Goals
Best
rehab/recovery,
happy/resigned
Interventions
ASA
Black
Black-HCTZ
Black-HCTZ
CAD
Black-HCTZ
CAD-BB
SVT
Black-HCTZ
CAD-BB
SVT-CCB
Diabetic
Black-HCTZ
CAD-BB
SVT-CCB
Diabetic-ACE
CKD
Black –HCTZ, CCB
CAD-BB
SVT-CCB
Diabetic - ACE
CKD -ACE
• Suspicion of white-coat hypertension
- Grade I hypertension in the office
- High office BP in individuals without asymptomatic organ damage and at
low total CV risk
• Suspicion of masked hypertension
- High normal BP in the office
- Normal office BP in individuals with asymptomatic organ
damage or at high total CV risk
• Identification of white-coat effect in hypertensive patients
• Considerable variability of office BP over the same or different visits
• Autonomic, postural, post-prandial, siesta- and drug-induced hypotension
• Elevated office BP or suspected pre-eclampsia in pregnant women
• Identification of true and false resistant hypertension
Specific indications for ABPM
• Marked discordance between office BP and home BP
• Assessment of dipping status
• Suspicion of nocturnal hypertension or absence of dipping, such
as in patients with sleep apnoea, CKD, or diabetes
• Assessment of BP variability
Recent meta-analyses of the few prospective
studies in the general population, in primary care
and in hypertensive patients, indicate that the
prediction of CV morbidity and mortality is
significantly better with home BP than with office
BP
Stergiou GS, Siontis KC, Ioannidis JP. Home blood pressure as a
cardiovascular outcome predictor: it’s time to take this method
seriously. Hypertension 2010; 55:1301–1303.
Ward AM, Takahashi O, Stevens R, Heneghan C. Home measurement
of blood pressure and cardiovascular disease: systematic review and
meta-analysis of prospective studies. J Hypertens 2012; 30:449–456.
Mancia G, Facchetti R, Bombelli M, Grassi G, Sega R. Long-term risk of
mortality associated with selective and combined elevation in office,
home and ambulatory blood pressure. Hypertension 2006; 47:846– 853
Meta-analyses of prospective studies indicate that the
incidence of CV events is about two times higher than in
true normotension and is similar to the incidence in
sustained hypertension.
Fagard RH, Cornelissen VA. Incidence of cardiovascular events in
white-coat, masked and sustained hypertension vs. true normotension:
a meta-analysis. J Hypertens 2007; 25:2193–2198.
Pierdomenico SD, Cuccurullo F. Prognostic value of white-coat and
masked hypertension diagnosed by ambulatory monitoring in initially
untreated subjects: an updated meta analysis. Am J Hypertens 2011;
24:52–58.
Bobrie G, Clerson P, Menard J, Postel-Vinay N, Chatellier G, Plouin PF.
Masked hypertension:a systematic review. J Hypertens 2008;
26:1715–1725.
THANKS