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“Practical Update on Hypertension”
Dr. Babu Shersad, MD, MACP (USA)
Specialist Internal Medicine & Nephrologist
Date: 5th December 2006
Venue : Renaissance Hotel
Time : 12:30 PM
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Contents:
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What is Hypertension?
Classification of Hypertension.
Detection.
Evaluation.
Treatment.
The JNC Algorithm.
Hypertension in Diabetes.
Resistant Hypertension.
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What is Hypertension?
Pre Hypertension:
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blood pressure 120/80 mmHg to 139/89 mmHg
not a disease category
Hypertension:
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blood pressure of 140/90 mmHg or above
The diagnosis of hypertension should be made only after noting a mean elevation on
three readings 6 hours apart
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Classification of Hypertension
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Detection of Hypertension
A. Symptoms of Hypertension
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No symptoms
Non-specific symptoms
Headache
Morning headache
Tinnitus
Dizziness
Confusion
Sleepiness
Vision problems
Angina
Difficulty breathing
Irregular heartbeat
Blood in the urine
Epistaxis
Many symptoms occur from complications of hypertension
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Contd.
B. Signs of Hypertension
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Vital Signs - Elevated blood pressure, bradycardia, bounding pulse
Skin - Flushed, diaphoresis, pallor
Cardio-Vascular - Distended neck veins, extremity edema, pulmonary edema
Neurologic - Decreased level of consciousness, impaired movement, symmetry
of face and extremities, seizures, unequal pupils
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Evaluation of Hypertension
Three main objectives:
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To asses lifestyle and other cardiovascular risk or
concomitant disorders that may affect prognosis and
guide treatment.
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To reveal identifiable causes of BP
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To asses the presence or absence of target organ
damage and CVD
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Identifiable causes of hypertension
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Sleep apnea
Drug induced or related disease
Primary aldosteronism
Chronic kidney disease
Reno-vascular diseases
Chronic steroid therapy
Cushing’s syndrome
Pheochromocytoma
Coarctation of aorta
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Physical Evaluation
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Appropriate BP measurement
With verification in the contra-lateral arm
Examination of optic fundi
BMI
Auscultation of carotid, abdominal and
femoral bruits
Examination of heart, lungs and kidneys
Seek abnormal aortic pulse
Examination of edema and abnormal pulses in
the lower extreme ties
Neurological examination
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Laboratory tests and diagnostics
These are a must (Rule of 9)
 ECG
 Urine analysis
 Blood glucose (9 to 12 hr fasting)
 Hematocrit
 Serum potassium
 Serum creatinine
 Serum calcium
 Lipid profile (LDL & HDL with triglycerides) (9 to 12 hr fasting)
 Albumin creatinine ratio
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Treatment of hypertension
1. Non pharmacological management:
Life Style changes:
reducing salt intake: reduce dietary sodium intake to no more than 100 m mol per
day (2.4gm sodium of 6 gm sodium chloride)
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reducing fat intake
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losing weight : maintain normal body weight (BMI 18.5-24.5 kg/meter square)
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getting regular exercise : 30 minutes of daily aerobic exercise
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quitting smoking : strictly
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reducing alcohol consumption : not more than 2 drinks / day for men and 1 drink
per day for women
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managing stress
DASH Diet: Dietary Approaches to Stop Hypertension - low in saturated fat,
cholesterol, and total fat, and that emphasizes fruits, vegetables, and low fat dairy
foods, whole grain products, fish, poultry, and nuts
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2. Pharmacological management of Hypertension
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diuretics
beta-blockers
calcium channel blockers
angiotensin converting enzyme inhibitors (ACE inhibitors)
alpha-blockers
alpha-beta blockers
vasodilators
peripheral acting adrenergic antagonists
centrally acting agonists
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Hypertension in Diabetes
Diabetes considerably increases the risk of cardiovascular disease if
hypertension is also present, so the targets for blood pressure
control in diabetes are tighter.
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For people who don't have diabetes, the treatment goals for
blood pressure– 140 / 85 mmHg
For people with diabetes, the goals are:
if proteinuria is less than 1 gm/24 hrs. – 130 / 80 mmHg
if proteinuria is greater than 1 gm/24 hrs. – 125 / 75 mmHg
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What is resistant hypertension?
“Failure to reach goal BP
in patients who are adhering to full doses of
an appropriate three drug regimen that
includes a diuretic ”
Note: This is very common and less tried by clinicians and paramedics.
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At the Clinician’s consulting room:
Doctor: I have some bad news and some very bad news.
Patient: Well, might as well give me the bad news first.
Doctor: The lab called with your test results. They said you have 24 hours to live.
Patient: 24 HOURS! That's terrible! WHAT could be WORSE? What's the very bad
news?
Doctor: I've been trying to reach you since yesterday.
“ I Hope that I conveyed the message” – Dr. Babu Shersad
All references from: Joint National Committee’s 7th Report
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