Download Guideline for hypertension

Guideline for hypertension
Blood Pressure Classification(JNC7)
BP Classification
SBP mmHg
DBP mmHg
Normal
<120
and
<80
Prehypertension
120–139
or
80–89
Stage 1 Hypertension 140–159
or
90–99
Stage 2 Hypertension >160
or
>100
Etiology
Essential (90%)
Renal : renal artery stenosis ; parenchymal disease
Endocrine : Pheochromocytoma ; Hyperaldosteronism ;
Cushing syndrome ; hyperthyroidism
Exogenous agent
Coarctation of aorta :
Toxemia of pregnancy
Standard work-up
Conformation of real hypertension
Identify Etiology of H/T
Access of End-organ damage
Identify cardiovascular risk
How to record BP
Measure BP several times on several occasions
with the patient in sitting position . including
Self Measurement
Use a mercury sphygmomanometer or other
non-invasive device .including Ambulatory BP
monitorings
BP Measurement Techniques
Method
Brief Description
In-office
Two readings, 5 minutes apart, sitting in
chair. Confirm elevated reading in
contralateral arm.
Ambulatory BP
monitoring
Indicated for evaluation of “white-coat”
HTN. Absence of 10–20% BP decrease
during sleep may indicate increased
CVD risk.
Self-measurement
Provides information on response to
therapy. May help improve adherence
to therapy and evaluate “white-coat”
HTN.
History
Onset of hypertension; Drug history; Family History;
Other major cardiovascular risk factors; major
target organ complications; Exogenous agents
(e.g. oral pills, Licorice)
History
Hisory of flank pain, hematuria, history of renal trauma ->
Renovascular hyprertension;
Histoy of proteinuria, pyelitis of pregnancy, renal stones,
dysuria, fever, or chill -> Parenchymal renal disease as a
cause of hypertension;
History of headache, sweating, palpitations, tachycardia,
thoracic and epigastric distress, and weight loss ….
Pheochromocytoma;
Heat intolence and loss of weight …… Hyperthyroidism,
History of weakness, paralysis, tetany, paresthesia, polyuria…
primary aldosteronism.
Physical Examination
General apperance : eg .Cushing syndrome
Serial blood pressure determinations
Blood pressure in both arms
Funduscopic examination :arteriovenous nicking , hemorrhage, Exudates
Palpation of thyroid
Auscultation
Lungs for wheezing and rales
Cardiac: heart beat; S3 ,S4 murmur , PMI , thrill ….
Abdominal and cervical ( check bruit )
Palpation of pulses, especially femoral artery :delayed pulse and decrease
pressure -> coarctation
Laboratory test
Routine screen ,including CBC/DC ,biochemistry and admission panel
Urinalysis : including specific gravity , albumin , microanalysis
Serum potassium , Calcium ,Creatinine
Thyroid function , Cortisol level
Chlesterol , TG
EKG
Chest X-Ray
Catecholamines only in presence of diastolic pressure >110 mmHg in
patient younger than 30
Echocardiography
Risk factor for Cardiovascular disease
Levels of systolic and diastolic blood pressure
(Grades 1-3)
Men > 55 years
Women > 65 years
Smoking
Total cholesterol > 6.5 mmol / L ( 250 mg / dl)
Diabetes
Family history of premature cardiovascular disease
Homocystine
End –Organ damage
Left ventricular hypertrophy
( electrocardiogram, echocardiogram or radiogram )
Proteinuria and/or slight elevation of Left ventricular
hypertrophy plasma creatinine concentration (1.22.0 mg/dl)
Ultrasound or radiological evidence of
atherosclerotic plaque (carotid, iliac and femoral
arteries, aorta)
Generalized or focal narrowing of the retinal arteries
Associated clinical conditions
Cerebrovascular disease
Renal disease
• Ischaemic stroke
* Diabetic nephropathy
• Cerebral haemorrhage
* Renal failure (plasma creatinine
• Transient ischaemic attack concentration > 2.0 mg/dl)
Heart disease
Vascular disease
• Myocardial infarction
• Angina
* Dissecting aneurysm
* Symptomatic arterial disease
• Coronary revascularization
• Congestive heart failure Advanced hypertensive retinopathy
* Haemorrhages or exudates
* Papilloedema
Goals of Therapy
 Reduce CVD and renal morbidity and mortality.
 Treat to BP <140/90 mmHg or BP <130/80 mmHg in patients
with diabetes or chronic kidney disease.
 Achieve SBP goal especially in persons >50 years of age.
Algorithm for Treatment of Hypertension
Lifestyle Modifications
Not at Goal Blood Pressure (<140/90 mmHg)
(<130/80 mmHg for those with diabetes or chronic kidney disease)
Initial Drug Choices
Without Compelling
Indications
With Compelling
Indications
Stage 1 Hypertension
Stage 2 Hypertension
(SBP 140–159 or DBP 90–99 mmHg)
Thiazide-type diuretics for most.
May consider ACEI, ARB, BB, CCB,
or combination.
(SBP >160 or DBP >100 mmHg)
2-drug combination for most (usually
thiazide-type diuretic and
ACEI, or ARB, or BB, or CCB)
Not at Goal
Blood Pressure
Optimize dosages or add additional drugs
until goal blood pressure is achieved.
Consider consultation with hypertension specialist.
Drug(s) for the compelling
indications
Other antihypertensive drugs
(diuretics, ACEI, ARB, BB, CCB)
as needed.
Classification and Management of BP for adults
DBP*
Lifestyle
BP
SBP* mmHg
modificati
classification mmHg
on
Initial drug therapy
Without compelling
indication
With compelling
indications
Normal
<120
and
<80
Encourage
Prehypertensi
on
120–
139
or 80–
89
Yes
No antihypertensive
drug indicated.
Stage 1
Hypertension
140–
159
or 90–
99
Yes
Stage 2
Hypertension
>160
or
>100
Yes
Thiazide-type diuretics
Drug(s) for the
for most. May consider
compelling
ACEI, ARB, BB, CCB,
indications.‡
or combination.
Other
Two-drug combination
antihypertensive
for most† (usually
drugs (diuretics,
thiazide-type diuretic
ACEI, ARB, BB,
and ACEI or ARB or
CCB) as needed.
BB or CCB).
*
Drug(s) for
compelling
indications. ‡
Lifestyle Modification
Modification
Approximate SBP reduction
(range)
Weight reduction
5–20 mmHg/10 kg weight loss
Adopt DASH eating
plan
Dietary sodium
reduction
Physical activity
8–14 mmHg
Moderation of
alcohol consumption
2–4 mmHg
2–8 mmHg
4–9 mmHg
Considerations For Individualizing
Antihypertensive Drug Theraphy
Indication
Drug Therapy
Compelling Indications Unless Contraindicated
Diabetes mellitus (type 1) with
proteinuria
Heart failure
Isolated systolic hypertension
(older patients)
Myocardial infarction
ACE I
ACE I, diuretics
Diuretics (preferred),
CA (long-acting DHP)
Beta-blockers (non-ISA),
ACE I (with systolic dysfunction)
May Have Favorable Effects on Comorbid Conditions +
Angina
Beta-blockers, CA
Atrial tachycardia and fibrillation
Beta-blockers, CA (non DHP)
Cyclosporine-induced hypertension CA
(caution with the dose of cyclosporine)
Diabetes mellitus (types 1 and 2)
ACE I (preferred), CA
with proteinuria
Diabetes mellitus (type 2)
Low – dose diuretics
Considerations For Individualizing
Antihypertensive Drug Therapy*
Indication
Dyslipidemia
Essential tremor
Heart failure
Hyperthyoidism
Migraine
Myocardial infarction
Drug Therapy
Alpha-blockers
Beta-blockers (non-CS)
Carvedilol, losartan potassium
Beta-blockers
Beta-blockers (non-CS, CA (non-DHP)
Diltiazem hydrochloride, verapamil
hydrochloride
Osteoporosis
Thiazides
Preoperative hypertension Beta-blockers, clonidine
Prostatism (BPH)
Alpha-blockers
Renal Insufficiency
ACE I
(caution in renovascular)
Hypertension and creatinine
 265.2 mmol/L (3mg/dL)
Considerations For Individualizing
Antihypertensive Drug Therapy
Indication
Drug Therapy
May Have Unfavorable Effects on Comorbid Conditions ++
Bronchospastic disease
Depression
Diabetes mellitus
(types 1 and 2)
Dyslipidemia
Gout
2 or 3 heart block
Heart failure
Liver disease
Peripheral vascular disease
Pregnancy
Renal insufficiency
Renovascular disease
Beta-blockers
Beta-blockers, central alpha-agonists,
reserpine
Beta-blockers, high-dose diuretics
Beta-blockers (non-ISA), diuretics (high-dose)
Diruretics
Beta-blockers CA (non-DHP)
Beta-blockers (except carvedilol), CA
(except amlodipine besylate, felodipine)
Labetalol hydrochloride, methyldopa
Beta-blockers
ACE I, angiotension II receptor blockers
Potassium-sparing agents
ACE I, angiotension II receptor blockers