Hypertension

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Presentation of Hypertension Management at CRPF Trivandrum on 27-01-2012

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Management of Hypertension: 

Management of Hypertension

What is the normal blood pressure in an adult?: 

What is the normal blood pressure in an adult? Range of Blood Pressure in an adult: 110-140 systolic and 60-90 diastolic Hypertension: >140/90 Hypotension: <100/70 Shock: <90/70 Isolated systolic: >140 systolic

What are the pre-requisites for measuring Blood Pressure?: 

What are the pre-requisites for measuring Blood Pressure? When measuring the blood pressure in the clinic or in the home, always standardise the environment Provide a relaxed, temperate setting with the person quiet and seated, arm outstretched and supported

Which Sphygmomanometer will you use routinely?: 

Which Sphygmomanometer will you use routinely? Whenever applicable use a standard mercury sphygmomanometer Never use an aneroid BP apparatus, if possible For Home BP monitoring and ABPM may use electronic Ensure that the device is validated cuff size appropriate

Which blood pressure to record in case of suspected Orthostatic Hypotension?: 

Which blood pressure to record in case of suspected O rthostatic Hypotension? In people with symptoms of postural hypotension (falls or postural dizziness) measure BP with the person either supine or seated measure BP again with the person standing for at least 1’

Precautions that one should take while recording Blood Pressure: 

Precautions that one should take while recording Blood Pressure Cuff appropriate size for patient Arm free of restrictive clothing Only deflated cuff placed on arm Center of cuff over brachial artery Lower edge 1 ½ inch above elbow Hold securely with slight pressure Never discuss any thing with pt Do not use arm with IV /paralysis

Various factors cause increase in or decrease in BP over 24 hours: 

Various factors cause increase in or decrease in BP over 24 hours Factors which cause increase in BP Excitement Anxiety Nervous tension Exercise Eating Smoking Factors which cause decrease in BP Rest Sleep Fasting Shock Depressant drugs Anti- hypertensives Factors which influence blood pressure Force of heart beat and Heart rate Resistance of arterial system Elasticity of vessels Amount of blood in the vessels

Hypertension - Classification: 

Hypertension - Classification Category Systolic Diastolic (mm Hg) (mm Hg) Normal below 120 and below 80 Pre-Hypertension 120–139 or 80–89 Hypertension Stage 1 140–159 or 90–99 Stage 2 160 and above or 100 & above Severe Hypertension 180 and 100 Isolated Systolic Hypertension >140 and <90 8

What do You infer from these blood pressure Values?: 

What do You infer from these blood pressure Values? BP: 120/80 BP: 150/100 BP: 190//120 BP: 230/120 BP: 240/140 BP: 120/110 Normal Blood Pressure Essential Hypertension Severe Hypertension Accelerated Hypertension Malignant hypertension Decapitated Blood Pressure

Diagnosis of Essential Hypertension based on Diurnal variation in BP: 

Diagnosis of Essential Hypertension based on Diurnal variation in BP Both systolic and diastolic blood pressures are elevated Blood pressures may peak during evenings or early mornings

What is white coat Hypertension and what do you do about it?: 

What is white coat Hypertension and what do you do about it? Blood pressure measured in clinic is always in HBP range Blood pressure to be measured as HBPM or ABPM if patient can tolerate it as OP

Ambulatory blood pressure monitoring for diagnosis of HTN: 

Ambulatory blood pressure monitoring for diagnosis of HTN At least two measurements per hour during the person’s usual waking hours (08:00 and 22:00 ). Use the average value of at least 14 measurements for diagnosis But not all persons can tolerate it continuously

What are the target organ damage You look for in Hypertension?: 

What are the target organ damage You look for in Hypertension? Hypertensive Retinopathy Hypertensive Renal failure Hypertensive Cardiac Failure Hypertensive Vascular Disease Accelerated Atherosclerosis

What are the situations when you will consider secondary hypertension?: 

What are the situations when you will consider secondary hypertension? Age at onset younger than 30 years and older than 60 years Hypertension that is difficult to control after therapy Stable hypertension that becomes difficult to control Clinical occurrence of hypertensive crisis Presence of signs and symptoms of secondary cause Hypokalemia metabolic alkalosis

Examining for Evidence of Secondary Hypertension/Target organ failure: 

Examining for Evidence of Secondary Hypertension/Target organ failure Obesity Body mass index Unequal pulse Carotid bruit Raised JVP Cushingoid features Cardiomegaly Cardiac murmurs Enlarged kidneys Small kidneys Abdominal bruits Neurological deficits

What are the investigations you would send routinely in HBP?: 

What are the investigations you would send routinely in HBP? Urinanalysis Hematocrit Blood glucose Serum Potassium Serum Creatinine Serum Calcium Uric acid Fasting lipids ECG CXR ECHO CT Scan

What are the Non-pharmacological measures you would adopt to control HBP?: 

What are the Non-pharmacological measures you would adopt to control HBP? Reduction of body weight Reduction of sodium intake Increase in physical activity Regular planned exercise Adequate nutritional intake Vitamins and minerals Cessation of smoking Judicious intake of alcohol Yoga and meditation Reduction of stress Weekend relaxation

Mechanism of Hypertension and Targets for Drug Treatment: 

Mechanism of Hypertension and Targets for Drug Treatment

Choosing a drug for starting antihypertensive treatment : 

Choosing a drug for starting antihypertensive treatment

Initiating and monitoring drug treatment in Essential Hypertension: 

Initiating and monitoring drug treatment in Essential Hypertension Offer antihypertensive drug treatment to people of any age with stage 2 hypertension with stage 1 hypertension who have one or more of the following: target organ damage E stablished CVD, renal disease , diabetes and a 10-year CV risk equivalent to 20% or greater Indications for Treatment

Initiating and monitoring drug treatment in Essential Hypertension: 

Initiating and monitoring drug treatment in Essential Hypertension For people aged under 40 years with stage 1 HTN + no evidence of target organ damage, CVD, renal disease or diabetes Implement life style modifications only and keep under close observation Non-Indications for Treatment Specialist evaluation of secondary causes of hypertension and a more detailed assessment of potential target organ damage.

Initiating and monitoring drug treatment in Essential Hypertension: 

Initiating and monitoring drug treatment in Essential Hypertension Aim for a target clinic blood pressure below 140/90 mmHg in people aged below 80 years and, with treated hypertension Aim for a target clinic blood pressure below 150/90 mmHg in people aged 80 years and over, with treated hypertension Aim for a target clinic blood pressure below 130/90 mmHg in people with Diabetes M ellitus Monitoring Treatment

Step 1 in Treating Hypertension - Choosing the correct drug : 

Step 1 in Treating Hypertension - Choosing the correct drug Where possible, recommend treatment with drugs taken only once a day Prescribe non-proprietary drugs where these are appropriate and minimise cost Offer people with isolated systolic hypertension ( i.e. systolic blood pressure 160 mmHg or more) T he same treatment as people with both raised systolic and diastolic BP

Step 1 in Treating Hypertension - Choosing the correct drug : 

Step 1 in Treating Hypertension - Choosing the correct drug Offer people aged under 55 years step1 antihypertensive treatment Angiotensin-converting enzyme (ACE) inhibitor or a low-cost ARB. If an ACE inhibitor is prescribed and is not tolerated ( for example, because of cough), offer a low-cost ARB Enalapril 2.5-5mg BID Telmesartan 20-40mg OD

Step 1 in Treating Hypertension - Choosing the correct drug : 

Step 1 in Treating Hypertension - Choosing the correct drug Beta-blockers are not a preferred initial therapy for hypertension. However , beta-blockers may be considered in younger people, particularly: Those with an intolerance or contraindication to ACEi or ARB Women of child-bearing potential or people with evidence of increased sympathetic drive Atenelol 25-50mg OD Metoprolol 25-50mg OD

Step 1 in Treating Hypertension - Choosing the correct drug : 

Step 1 in Treating Hypertension - Choosing the correct drug Offer people aged above 55 years step1 antihypertensive treatment Start with a calcium-channel blocker (CCB) If a CCB is not suitable , because of oedema or intolerance, or if there is evidence of HF or a high risk of HF, offer a thiazide Amlodipine 2.5-5mg BID Cilnidipine 10-20mg OD

Step 2 in Treating Resistant Hypertension - Choosing the correct drug : 

Step 2 in Treating Resistant Hypertension - Choosing the correct drug If blood pressure is not controlled by step 1 treatment Offer step 2 treatment W ith a CCB in combination with either an ACE inhibitor or an ARB Amlodipine 5mg OD or Nifedipine 5mg BD Enalapril 2.5-5.0mg OD or Ramipril 5-10mg OD Perindopril 4-8mg OD Losartan 25-50mg OD or Telmisartan20-40mg OD Olmesartan 10-20mg OD

Step 2 in Treating Resistant Hypertension - Choosing the correct drug : 

Step 2 in Treating Resistant Hypertension - Choosing the correct drug If a CCB is not suitable for step 2 treatment, for example because of oedema or intolerance, or if there is evidence of heart failure or a high risk of heart failure, Offer a thiazide-like diuretic Indapamide 1.5 2.5mg BID Chlorthalidone 12.5-25mg OD

Step 3 in Treating Resistant Hypertension - Choosing the correct drug : 

Step 3 in Treating Resistant Hypertension - Choosing the correct drug R eview medication to ensure step 2 treatment is at optimal or best tolerated doses The combination of ACE inhibitor or ARB, calcium-channel blocker and thiazide-like diuretic Enalapril / Ramipril Losartan/ Telme / Olmesartan Amlodipine / Cilinidipine Indapamide Chlorthalidone Hydrochlorthiazide

Step 4 in Treating Resistant Hypertension - Choosing the correct drug : 

Step 4 in Treating Resistant Hypertension - Choosing the correct drug R eview medication to ensure step 3 treatment is at optimal or with best tolerated doses The combination of ACE inhibitor or ARB, calcium-channel blocker and thiazide-like diuretic Further diuretic therapy with Spironolactone 25mg BID Only id Serum K+ is lower than 4.5meq/L Consider higher dose diuretic if Serum K= is >4.5 Consider adding an Alpha blocker, B Blocker or Centrally acting drug

Step 4 in Treating Resistant Hypertension - Choosing the correct drug : 

Step 4 in Treating Resistant Hypertension - Choosing the correct drug R eview medication to ensure step 3 treatment is at optimal or with best tolerated doses The combination of ACE inhibitor or ARB, calcium-channel blocker and thiazide-like diuretic Further diuretic therapy with Spironolactone 25mg BID Only id Serum K+ is lower than 4.5meq/L Consider higher dose diuretic if Serum K= is >4.5 Consider adding an Alpha blocker, B Blocker or Centrally acting drug

Step 5. Patient Education: 

Step 5. Patient Education Give guidance regarding benefits of drugs Advice regarding unwanted side effects Help patient make informed choices Stress the need to continue medications Edema in CCBs, Cough in ACEIs and First dose syncope in  Bs Discuss the risk of suddenly stopping drugs

Classification and Management of High Blood Pressure for adults: 

Classification and Management of High Blood Pressure for adults

Parenteral Medications that may be used for Hypertensive Emergencies: 

Parenteral Medications that may be used for Hypertensive Emergencies

PowerPoint Presentation: 

Thank You