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1 HYPERTENSION :SHMS GUIDELINE Prof. Sulaiman Al-Shammari Department of Family & Community Medicine , College of Medicine King Saud University , Riyadh, Saudi Arabia 2 Why Should We be Interested in Hypertension? 1.High prevalence of HTN & preHTN & poor control 2.Lacking Public and professional awareness 3.Open market for all possible drugs 4.Public misconceptions Re HTN, Rx & herbs 5.Many professionals “schools” with diverse traditions 6.HTN not adequately recognized as life-long risk for CRF, Stroke and MI 3 auth region year Prev % % Aware/ Or contr Abo alfotoh SouthWest 1996 11 Contr 20 Saeed Riyadh 1996 13 Awareness Synnowo Gasim 1996(94) 22-26 AlNuzha Nationwide 1998 20.4 sys 27 ? ? 4 Prevalence, Awareness, Treatment and Control of High Blood Pressure in the US Adult NHANES II % 1976-80 III (Phase 1) 1988-91 III (Phase 2) 1991-94 KSA 1999-00 Prevalence 32 20.2 19.8 18 20% Awareness 51.0 71.2 68.4 70 27%? Treated 31.4 53.6 53.6 59 ? Controlled 9.9 27.2 27.4 34 20%? Burt V et al, Hypertension 1996 & Unpublished data NHLBI (NHANES III, Phase 2) JNC-VII 2003 Hazmi 2001; Kalanta 2001; Warsy 1999; Wahid Saeed 1996& Al-Nozha 1997 5 Prevalence in some countries Country Prev % Contr % USA 18 34 Canada 22 16 Egypt 26 8 China 14 3 6 Worldwide Worldwide 20% of adults Worldwide 50% over 60 years 7 8 9 SHMS Clinical Guideline 10 Classification Normal < 120/ < 80 Prehypertension 120-139/80-89 Hypertension ; stage -1 : 140-159/90-99 Hypertension ; stage -2 : > 160+/ 100 + 11 Aims of Clinical Evaluation Accurate Measurement of BP to establish the diagnosis of Hypertension. Look for other risk factors. Assess for Co morbidities. Look for Target Organ Damage or associated clinical conditions. Be alert for clues of secondary cause. – Thorough history, physical exam & simple tests. 12 History-1 General medical history; allergies, surgeries,…etc. Hypertension: duration , medications. Personal history of DM, Dyslipidemia, CAD. Family history of hypertension, CAD, Dyslipidemia, DM. Style of living: occupation, smoking, activities, eating habits. 13 History-2 Palpitations ,sweating, tremors; pheo. Weight gain; cushings, hypothyroid. Weight loss; hyperthyroid, DM, pheo. Renal stones; Hyperparathyroidism, PKD. Symptoms of TOD related to organ. 14 History-3 Drug history : – – – – – – – – – – – – NSAID. Steroids; oral contraceptive pill, corticosteroids. Nasal decongestants-ephedrine. Appetite Supressants-phenylpropanolamine. Street drugs; cocaine. Tricyclic antidepressants. Erythropoietin. Cyclosporine and Tacrolimus. Alcohol. Drug withdrawal; Clonidine, Beta-blockers. Licorice. Herbs ( dietary supplements). 15 Measurement of BP-1 A diagnosis of HTN is made on multiple (3)measurement made on several occasions. Five minutes rest before measurement. Patient position-sitting, standing if Elderly, DM, autonomic disturbance. Appropriate cuff size. Calibrated & validated device. No exertion or smoking before measurement. Two readings. 16 Measurement of BP-2 Methods of BP measurements : – Clinic or office BP measurements. – Self BP measurements. – Ambulatory BP measurements. 17 Examination-1 General medical examination. BP; at the first visit, in both arms, if discrepancy think of Coarctation, dissection. FU visit check BP in the higher arm. BP in lower limb; discrepancy suggests Coarctation. Pulse; at first visit, compare R & L arm, any radiafemoral delay. Weight, Height, BMI, Waist Circumference. 18 Examination-2 Neck; raised JVP. Heart ; displaced apex, normal sounds, added sounds, murmur. Lung ; check for any rales or wheezes. Abdomen; masses, striae . Lower limbs; swellings, trophic changes, pulses. Fundus examination. 19 Examination-3 Moon face, buffalo hump; Cushing. Hirsutism; Cushing. Bruits; carotid or abdominal. Exophthalmus; hyperthyroid. Café au lait spots, neurofibromatosis; pheo. Goitre. 20 Risk Factors -1 Levels of SBP and DBP. Dyslipidemia :TC >250 mg/dl(6.5 mmol/L), LDL C>155 mg/dl(4 mmol/L), HDLC < 40 mg/dl(1mmol/L) in men,< 1.3 mmol/L in women. DM. Smoking. 21 Risk Factors -2 Age (men >55, women > 65). Family history of Premature CVD (men < 55 women < 65). Obesity (BMI 30 + kg/m2)-abdominal obesity( WC -M>102 cm, F>88 cm) CRP >1 mg/dl 22 Target Organ Damage-1 Ultrasound or radiological evidence of atherosclerotic plaque. Heart ; LVH. Proteinuria or raised plasma creatinine. Retinal arteries narrowing . 23 Associated Clinical Conditions Cerebrovascular Disease (ischemic stroke, cerebral hemorrhage, TIA). Heart disease; MI, angina, Coronary vascularization, CHF. Renal disease; Cr. Men 1.34-1.6 mg/dl, women 1.25-1.45 mg/dl. Vascular Disease (PAD, Dissecting aneurysm). Advanced retinopathy; hemorrhage, exudates, papilledema. 24 Secondary Causes Chronic kidney disease. Renovascular disease. Primary aldosteronism. Pheochromocytoma. Cushing’s syndrome and steroid therapy. Coarctation of aorta. Thyroid or parathyroid disease. Drug therapy. Sleep apnea. Alcohol 25 Clues to Secondary Causes of HTN Age of onset. Poor response to therapy. Significant Target organ Damage. No family history of Hypertension. Examinations clues. Laboratory tests 26 Laboratory Investigation Urine analysis. CBC.-hematocrit. Blood chemistry; electrolytes, sugar, lipids, creatinine. Electrocardiogram. Optional; urine albumin creatinine ratio, CRP. 27 Risk Stratification normal SBP120 139 or DBP 80-89 high normal SBP140 159 or DBP 90-99 Stage 1 SBP160 179 or DBP 100-109 Stage 2 SBP180 - or DBP 110 Stage 3 no risk factors average average Low added Moderate added High added 1-2 risk factors except DM Low added Low added Moderate added Moderate added Very high added 3 or more,TOD, DM Moderate added High added High added High added Very high added 28 BP levels Risk factors, TOD, ACC SBP<120 & DBP <80 Management Plan Establish Good patient Doctor relationship. Educate patient & family on the consequences of hypertension. Encourage Self monitoring. BP goal. Non pharmacological therapy. Pharmacological therapy. 29 Life Style Modification Stop smoking. Lose weight if overweight. No alcohol intake. Reduce sodium intake to 110 mmol/day (2.4 g sodium or 6 g sodium chloride). Maintain adequate dietary potassium, calcium, and magnesium intake. Healthy diet; High in fresh fruits, vegetables and low fat dairy products, low in saturated fat. Regular physical activity: optimum 30-45 minutes of moderate cardiorespiratory activity 3-5/week or more 30 31 32 33 34 35 Statins PRIMARY PREVENTION 1) Total cholesterol > 5 mmol/l, 2) < 70 Y., and 3) 10 Y. CHD-R > 30%. SECONDARY PREVENTION 1) Total cholesterol > 5 mmol/l, 2) < 75 Y., and 3) CV complication: – (Coronary Heart Diseases, Peripheral Vascular Diseases, Non- hemorrhagic CerebroVascular Diseases, or Atherosclerotic renovascular diseases.) 36 Antiplatelet Therapy only when BP control has been achieved For Primary Prevention: Hypertensive patients above the age of 50 years and at high or very high absolute cardiovascular risk, or Hypertensive patients with moderate increase in serum creatinine > 1.3 mg/dl i.e. > 107 mmol/L. For Secondary Prevention: Patients with post MI, ischemic stroke, angioplasty, or coronary bypass 37 When you need to question compliance When the treatment response is judged inadequate, the patient can be asked about compliance. If the patient reports less than complete compliance, the clinician can proceed with compliance interventions. If the patient reports full compliance, problems with the treatment itself can be considered along with application of more sophisticated methods of measuring compliance. 38 Forms of Non-compliance Not having the prescription filled, Taking the incorrect dose, Taking the medication at the wrong time, Not taking one or more doses, Stopping the medication too soon, Relying on herbal meds 39 How/Can we measure? 1• Pharmacological measures ( concentrations of drugs or using biological markers integrated into the tablets) (difficult) 2• Clinical measures: a) evaluation of promptness for appointments or b) the use of questionnaires c) or taking the amount of side effects into account) 3• Physical measures ( pill counting ) 40 Recommendations for Improving compliance using a multi-faceted approach Understanding the reasons for these forms of non-compliance is of key importance to the successful development of potential programs and their implementation - Simplify medication regimens to once daily dosing – Tailor pill-taking to fit patients’ daily habits – Encourage greater patient responsibility/autonomy in monitoring their BP management (including monitoring) – Coordinate with worksite health care givers to improve monitoring of adherence with pharmacological and lifestyle modification prescriptions – Educate patients and educate/involve patients’ families about their disease/treatment regimens – Minimize side-effects, make taking it more appealing High standard educated and motivated health care providers, 41 Indications for specialist referral 1.Urgent treatment needed 2.Possible underlying cause 3.Therapeutic problems 4.Special situations Other Indications 42 Hypertension &Ramadan “Based on the scarce available data, the following recommendations can be reasonably made” medical advice before fasting in order to adjust their medications, if needed. management should be individualized in fasting patients. emphasize compliance with non-pharmacological and pharmacological measures. Diuretics are better avoided, especially in hot climates or to be administered in the early evening. emergency should be treated appropriately regardless of fasting. Many questions are awaiting answers. 43 Hypertension in the Elderly Hypertension occurs in more than half of individuals aged 65 are HTN & poor control Follow same Rx principles outlined for the general care of hypertension Lower initial drug doses may be indicated to avoid symptoms Standard doses and multiple drugs are needed in the majority of older people to reach appropriate BP targets 44 Hypertension in Pregnancy Chronic hypertension Preeclampsia-eclampsia: preeclampsia occur in 23%; and eclampsia in 5-6/10,000 pregnancies that progress beyond 20 weeks. Preeclampsia Superimposed upon chronic hypertension or Renal Disease Gestational hypertension (only during pregnancy): occur in 8-10% of nulliparous women Transient hypertension (only after pregnancy) 45 Treatment during pregnancy Shared care with obstetrician for proper evaluation Lifestyle changes: restrict activity and exercise during pregnancy. Weight reduction is not recommended. Limit Sodium intake. Methyldopa and ß-blockers can be used. Be ware of the possible growth restriction An alternative would be nifedipine Diuretic are not usually used in pregnancy ACEI and ARBare contraindicated. If a patient becomes pregnant while on these agents, she should have her medication changed. The “cure” for preeclampsia is delivery 46 Anticonvulsive Therapy Breast Feeding All antihypertensives studied have been found in breast milk. Long-term neonatal effects have not been studied. Methyldopa as a first-line oral agent is reasonable unless contraindicated, and then labetolol may become first-line therapy. If the patient has renal disease, then calcium channel blockers are the drugs of choice. ACE inhibitors and angiotensin II receptor antagonists should not be used due to neonatal renal effects. Diuretics may decrease milk production. Certain beta blockers are concentrated in breast milk (atenolol and metoprolol), while others are not (labetolol and propranolol). 47 Hypertension and the Pill Oral contraception usually shifts the blood pressure moderately upwards, but hypertension appears in less than 5% of women (1% to 2%). Stopping OC is an effective antihypertensive intervention in a clinical setting. keeping careful check on women taking these pills. 48 المملكة العربية السعودية kingdom of Saudi Arabia 'Saudi Commission of Health Specialtiesالهيئة السعودية للتخصصات الصحية Saudi Hypertension Management Societyالجمعية السعودية لرعاية ضغط الدم )(SHMS ندعوكم لإلنظمام إلى الجمعية كعضو علما أن رسوم العضوية السنوية 200لاير . لمزيد من المعلومات يرجى االتصال: http://www.saudi-hypertension.orgالموقع اإللكتروني للجمعية : main@saudi-hypertension-orgالبريد اإللكتروني للجمعية : 49 50