Download Incidental Hypertension

INCIDENTAL HYPERTENSION:
How to manage
Dr. Saulat Siddique,
Professor of Cardiology,
Shaikh Zayed Hospital, Lahore.
FAMILYCON 2013,
4-5-6 January, 2013, Lahore.
Q. No.1
Regarding Blood Pressure measurement;
1. SBP is when the first Korotkoff sound is heard
2. DBP is when the sounds become muffled
(Korotkoff phase IV)
3. BP reading should be rounded to the nearest 5
or zero e.g. 130/85mmHg
4. BP reading should be written as 132/86mmHg
i.e. recorded to the nearest even number
BLOOD PRESSURE MEASUREMENT
• Record the result for systolic and diastolic
pressures to the nearest 2mmHg. For the systolic
reading, record the level at which the first (at
least two consecutive) sound is heard.
• For the diastolic reading, use phase V Korotkoff
(disappearance of sound). Only use phase IV
Korotkoff (muffilng of sound) if sound continues
towards zero.
PHL/PCS Hypertension Guidelines, 2009
Q. No. 2. A 43 year old previously healthy male visits his family
practitioner for symptoms of flu. His BP is found to be 146/96.
He should be;
1.
2.
3.
4.
Started on anti-hypertensive medication
Advised life style measures
Given a sedative
Asked to come back for follow-up visit
Q. No. 3
Regarding the BP cuff;
1.
2.
3.
4.
Cuff size is same as bladder size
Length should cover the full arm circumference
Width should be half the arm circumference
Inappropriately small cuff will give a falsely low
reading
BLOOD PRESSURE MEASUREMENT
• The bladder length should be at least 80% and
the width at least 40% of the circumference of
the mid-upper arm. Use of a ‘standard size’ cuff
in people with large arm can result in artificially
high blood pressure reading. If an oversized cuff
cannot be satisfactorily fitted on a large arm then
the utilization of an appropriately sized cuff on
the forearm with radial artery auscultation should
be considered.
PHL/PCS Hypertension Guidelines, 2009
BLOOD PRESSURE MEASUREMENT
• Patients should sit for several minutes in a quiet and
comfortable place
• Use appropriate cuff size for age and weight
• Have cuff at heart level
• Deflate the cuff @2-3mmHg/beat
• Take minimum 2 measurements at least 1-2minutes
apart.
• Ask the patients to return for 1-2 more visits, if BP is
elevated on first visit (to confirm the diagnosis of
hypertension), before starting treatment
PHL/PCS Hypertension Guidelines, 2009
BLOOD PRESSURE MEASUREMENT
• NICE guidelines (2011) state that there should be
complete skin contact of the stethoscope with no
clothing in between
• The Pakistani guidelines state that, “In Pakistani
setting, BP is quite often measured with shirt sleeve
on rather than bare arm, especially in ladies. A
recent Canadian Study indicates that there is no
difference in BP reading if average thickness of
sleeves is 4.3 mm or less.”
Q. No. 4.
Life style measures include;
1.
2.
3.
4.
Low sodium diet
Exercise like weight lifting and push-ups
Diet rich in potassium
Aerobic exercise
LIFESTYLE MODIFICATIONS TO REDUCE BLOOD PRESSURE
• Ask patients about their diet and exercise patterns, and offer guidance
and written or audiovisual information
• Regular aerobic physical activity is recommended for all persons, but
those with advanced or unstable CVD may require a medical evaluation
before initiation of exercise or a medically supervised exercise program.
Isometric exercise such as heavy weight lifting can have a pressor effect
and should be avoided.
• Ask about alcohol consumption and encourage patients to cut down if
they drink excessively
• Discourage excessive consumption of coffee and other caffeine-rich
products
• Encourage patients to reduce their salt intake or use a substitute
• Offer smokers advice and help to stop smoking
• DO NOT OFFER
• Calcium, magnesium or potassium supplements to reduce blood
pressure
• Relaxation therapies can reduce blood pressure and patients may wish
to try them. However, primary care teams are not recommended to
provide them routinely
PHL/PCS, Hypertension Guidelines 2009
IMPACT OF LIFE-STYLE CHANGES ON REDUCTION OF SBP
Intervention
Increased Magnesium (Mg)
Reduction in SBP (mmHg)
0–1
Increased Calcium (Ca)
2
Increased Potassium (K)
4
Fish Oil
6
Reduced Sodium (Na)
6
Reduced Weight
8
Exercise
10
Dash Diet
12
PHL/PCS, Hypertension Guidelines 2009
Q. No. 5.
Follow-up visit after 2 weeks reveals sitting BP of
138/90 in the right arm and 148/92 in the left
arm. He should be;
1. Investigated for stenosis in the right
subclavian/axillary artery.
2. Sent for fundoscopy
3. Checked for waist circumference
4. Checked for postural hypotension
BLOOD PRESSURE MEASUREMENT
• Measure Blood Pressure in both arms. Take
the higher value as baseline
• Difference of 5/10 mm can be considered as
normal
• Waist circumference is an essential part of the
physical examination as is fundoscopy
• Measure BP in standing position in elderly,
diabetes and in case of hypotension inducing
drugs
PHL/PCS, Hypertension Guidelines 2009
Q. No. 6.
The following are essential in his workup;
1.
2.
3.
4.
Serum sodium and potassium
Urine for VMA
Echocardiography
Complete Lipid Profile
INVESTIGATIONS (Minimal)
• Urine analysis for proteins (can be done with a
dipstick as a starter)
• Serum creatinine levels
• Serum potassium and sodium levels
• Random blood sugar
• ECG for evidence of established coronary
artery disease (CAD) or LVH
• Chest X Ray (PA view)
PHL/PCS, Hypertension Guidelines 2009
LIPID PROFILE
• Part of special investigations in Pakistani
guidelines
• ESC guidelines recommend complete Lipid
Profile as an essential test
• NICE guidelines recommend that only total
cholesterol and HDL should be done
SPECIAL INVESTIGATIONS
(On case to case basis)
•
•
•
•
•
•
•
Echocardiogram
Lipid Profile
Carotid (and femoral) ultrasound
C-reactive protein
Microalbuminuria (essential test in diabetics)
Quantitative proteinuria (if dipstick test positive)
Search for secondary hypertension: measurement of
renin, aldosterone, corticosteroids, catecholamines,
arteriography, renal & adrenal ultrasound, computer
assisted tomography (CAT), magnetic resonance
imaging
PHL/PCS, Hypertension Guidelines 2009
Q. No. 7.
He should be started on;
1.
2.
3.
4.
5.
ACEI
ARB
CCB
Diuretic
Combination Tablet
Antihypertensive Drug Treatment: NICE 2011
A = ACEi or ARB
C = CCB
D = Thiazide-like diuretic such
as chlorthalidone (12.5 mg–25
mg once daily) or indapamide
rather than thiazide diuretic
such as bendroflumethiazide
or hydrochlorothiazide.
C* = CCB preferred but consider
thiazide-like diuretics in people with
oedema or a high risk of heart failure
Further diuretic** = low-dose
spironolactone or higher doses of a
thiazide-like diuretic
Q. No. 8.
He should also be prescribed;
1. Aspirin
2. Atorvastatin
3. Bromazepam
75mg OD
10mg OD
3mg OD
• Aspirin is only recommended in those with
IHD, CKD and in high cardiovascular risk
subjects in the ESC guidelines
• Statins are recommended in IHD, DM and in
high cardiovascular risk subjects in the ESC
guidelines or if cholesterol levels are high.
HISTORY
• Detailed history is essential
• Prior history of high BP, kidney disorders, stroke, heart
disease, diabetes, dyslipidemia.
• Complications of pregnancy
• Drug history
– NSAIDs
– Oral Contraceptives
– Previous antihypertensives
• Family history of hypertension, heart disease, diabetes
• Smoking and dietary habits
PHL/PCS, Hypertension Guidelines 2009
SIGNS OF ORGAN DAMAGE
• Brain: murmurs over neck arteries, motor or sensory
defects
• Retina: fundoscopic abnormalities
• Heart: location and characterstics of apical impulse,
abnormal cardiac rhythms, ventricular gallop,
pulmonary rales, dependent edema
• Peripheral arteries: absence, reduction, or
asymmetry
PHL/PCS, Hypertension Guidelines 2009
The importance of 24-hour blood pressure
control in hypertension management
 ESC/ESH Guidelines1
“Drugs which exert their antihypertensive
effect over 24 hours with a once-a-day
administration should be preferred”
 NICE Guidelines 20112
• “If the clinic BP ≥140/90 mm Hg offer 24hour
ambulatory
blood
pressure
monitoring (ABPM) to confirm the
diagnosis of hypertension (NEW 2011)
•
“when possible recommend treatment
with drug taken once a day”
1. Mancia G, et all. J Hypertens. 2007;25:1105-1187. 2. NICE Guidelines 2011.
24
NICE Chart of AB/CD
with de-emphasis on beta-blockers
STEP 1
< 55 years
> 55 years or Asian /
Chinese
A
C or D
STEP 2
A+C
or
A+D
STEP 3
A+C+D
STEP 4
Add: Further D/C
therapy
Alpha Blockers
Beta Blockers etc
A: ACEI/ARB
C: CCB,
D: Diuretic