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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