5. HYPERTENSION - Copy.ppt

• Hypertension (HTN or HT), also known as high blood pressure (HBP), is a long-term medical condition in which the blood pressure in the arteries is persistently elevated. • High blood pressure usually does not cause symptoms. • Long-term high blood pressure, however, is a major risk factor chron...

• Hypertension (HTN or HT), also known as high blood pressure (HBP), is a long-term medical condition in which the blood pressure in the arteries is persistently elevated. • High blood pressure usually does not cause symptoms. • Long-term high blood pressure, however, is a major risk factor chronic complications • Definition? Malaysian CPG BP MEASUREMENT D Use the following procedures when recording BP: 1. Allow the patient to rest - sit or lie down for at least 3 minutes before measuring the BP. 2. Use a suitable cuff with a bladder 12-13 cm x 35 cm in size. A cuff with larger bladder should be used for large upper arms; where a thigh cuff should b used for extremely large arms. 3. When using the auscultatory method, use the disappearance of phase Korotkoff sounds to measure the diastolic BP. 4. Measure the BP in both arms at the first visit; subsequently re-measur on the arm with the higher reading, if applicable. 5. Place the manometer cuff at the level of the heart, regardless of the position of the patient ROUTINE CHECK UP  BP should be measured routinely at least every 1 years until the age of 80 years  seated BP should be measured after 5 minutes' resting  standing BP should be measured in diabetic and elderly subjects to exclude orthostatic hypotension  two consistent BP measurements are needed, and more are recommended if there is variation in the pressure  for assessing the cardiovascular risk, the average BP at separate visits is more accurate than measurements taken at a single visit Evaluation of newly diagnosed hypertensive patients 3 main objectives: 1 To ascertain the presence of target organ damage 2To exclude secondary causes of hypertension 3To assess lifestyle and and identify other cardiovascular risk factors or concomitant disorders that may affect treatment and prognosis. CAUSES  the majority (80-90%) of patients with hypertension have primary elevation of blood pressure (i.e. cause not known – essential hypertension )  Essential hypertension: multifactorial aetiology  Genetic factors: (Runs in families, genetic component largely unidentified)  Environmental factors: Obesity - Alcohol: 14-21 units / week - Sodium intake: > 6 gms / day (high Potassium diet can protect against the effect of high sodium diet) -Stress: acute pain or stress CAUSES contd…. : HTN & Diabetes has strong association, hyperinsulinaemia, glucose intolerance, reduced levels of HDL cholesterol, hypertriglyceridaemia, central obesity with hypertension METABOLIC SYNDROME all of which are related to Insulin resistance) Humoral mechanisms: ANS, Reninangiotensin, Natriuretic peptide & Kallikrein-Kinin system all play vital role in regulation of BP CAUSES contd…. Secondary hypertension  Renal diseases: 80% of S∙HTN , diabetic nephropathy, chronic glomerulonephritis, adult polycystic disease, chronic tubulo interstitial nephritis, and reno vascular disease  Endocrine causes: Conn's syndrome, adrenal hyperplasia, pheochromocytoma, Cushing's syndrome, acromegaly  Congenital cardiovascular causes: coarctation of the aorta  Drugs: NSAIDs, oral contraceptive, steroids, carbenoxolone, liquorice, sympathomimetics and vasopressin  Pregnancy: (disturbance of the uteroplacental circulation & result in intrauterine growth restriction) History 1) Does patient already have hypertension and if so for what duration? 2) Does the patient have complications Heart : congestive heart failure symptoms/ coronary a disease Stroke/CKD/ Peripheral v disease/retinopathy 3 Other co-morbid and risk factors DM/dyslipidaemia/smoking/alcohol 4) Does the patient have family history? 5) Dietary history 6) Review all medications including over the counter and complementary medication 7) Lifestyle: Does patient exercise? Is this a case of secondary hypertension ? i) weight increase , central adiposity, moon facies, buffalo hump,abd.striae Cushings syndrome II)Paroxysms or ‘spells’: headache, palpitations, sweating, pallor, labile blood pressure Pheocromocytoma III) Muscle cramps, muscle ache Conn’s syndrome IV) weight loss, palpitation . Sweating Thyrotoxicosis 8) Physical Examination • The patient should rest quietly for at least 5 minutes before the measurement. Blood pressure should be measured in both the supine and sitting position. • Calculate BMI • Fundoscopic examination : hypertensive retinopathy • Palpate all pulses/peripheral pulse • Neck carotid bruit/ thyroid gland • CVS: Heaving apex • Abdomen- ballotable kidneys/ renal bruit • Edema/ periorbital edema- AGN /CKD Papilledema. Note the swelling of the optic disc, with blurred margins Fundoscopy Keith-Wagener classification:  Grade 1 tortuosity of the retinal arteries (silver wire appearance)  Grade 2 grade 1 plus the appearance of arteriovenous nipping produced when thickened retinal arteries pass over the retinal veins  Grade 3 grade 2 plus flame-shaped haemorrhages and soft ('cotton wool') exudates  Grade 4 grade 3 plus papilloedema  [‘Cotton wool’ exudates are associated with retinal ischemia or infarction] INVESTIGATIONS (for all patient)  ECG  Urinalysis for blood, protein and glucose  Fasting blood for lipids (total and HDL(highdensity lipoprotein cholesterol)) and glucose  Serum urea, creatinine and electrolytes  Thyroid function test https://www.ccjm.org/content/ccjom/ 75/9/663.full.pdf Investigation for selected  Ambulatory BP recording: to assess borderline or patient ‘white coat’ hypertension  Heart Chest X-ray: to detect cardiomegaly, heart failure, coarctation of the aorta  Echocardiogram: to detect or quantify left ventricular hypertrophy  Renal  Renal ultrasound: to detect possible renal disease  Renal angiography: to detect or confirm presence of renal artery stenosis Investigation for selected patient( sec.hypertension Endocrine to detect possible phaeochromocytoma Urinary catecholamines: to detect possible Cushing’s syndrome Urinary cortisol and dexamethasone suppression test: to detect possible Conn’s syndrome Plasma renin activity and aldosterone: TREATMENT Use of non-pharmacological therapy in all hypertensive and borderline hypertensive people: Weight reduction - BMI should be < 25 kg/m2 Low-fat and unsaturated fatty diet Low-sodium diet - < 6 g sodium chloride per day Limited alcohol consumption - ≤ 21 units/week for men and ≤ 14 units/week for women Dynamic exercise - at least 30 minutes' brisk walk per day Increased fruit and vegetable consumption Reduce CVS risk by “STOP smoking” and increase fish oil consumption Choice of antihypertensive drugs The choice of antihypertensive drug should be tailored to the individual patient, taking into account the following factors, in addition to risk profile and cost: 1. Side effects 2. Drug-drug interactions 3. Patient preference Begin first-line antihypertensive treatment with any one, or an appropriate combination, of the five major drug classes available namely: 1. Angiotensin-converting enzyme inhibitor (ACE inhibitor) 2. Angiotensin II receptor blocker (ARB) 3. Calcium-channel blocker (CCB) 4. Diuretic (thiazide, thiazide-like, or loop) Use the following drug combinations to treat hypertension: 1. Calcium-channel blocker (dihydropyridine type) plus ACE inhibitor or ARB 2. Calcium-channel blocker plus diuretic 3. Diuretic plus ACE inhibitor or ARB 4. Beta-blocker plus calcium-channel blocker 5. Beta-blocker plus diuretic DIURETICS  Thiazide diuretics: hydrochlorthiazide(2550 mg )  Loop diuretics: furosemide (40 mg daily)  Potassium-sparing diuretics such as Amiloride (5-10 mg daily) Spironolactone (50-200 mg daily) treatment of hypertension and hypokalaemia associated with primary hyperaldosteronism More common side effects The more common side effects of diuretics include: Hypokalaemia Hyperklaemia(for potassium-sparing diuretics only) Hyonatremia headache dizziness thirst increased blood sugar muscle cramps increased cholesterol skin rash gout diarrhea ACE INHIBITORS  CAPTOPRIL (50-150 MG )  RAMIPRIL (2.5-10 MG )  ENALAPRIL OR LISINOPRIL (10-20 MG)  TRANDOLAPRIL (1-4 MG)  block the conversion of angiotensin I to angiotensin II, which is a potent vasoconstrictor  also block the degradation of bradykinin, a potent vasodilator  particularly useful in diabetics with nephropathy, where they have been shown to slow disease progression  and in those patients with symptomatic or asymptomatic left ventricular dysfunction ACE Inhibitor Side Effects  Cough (15% of patients. Is reversible)  Taste disturbance (reversible)  Angiodema  First-dose hypotension  Hyperkalaemia ( esp. in patients with type II diabetes and renal dysfunction) Angiotensin II receptor antagonists  selectively block the receptors for angiotensin II  their action is similar to ACE inhibitors but do not cause cough as in ACE inhibitors  angioneurotic oedema and renal dysfunction are less with these drugs than with ACE inhibitors.  LOSARTAN (50-100 MG DAILY)  CANDESARTAN (16 MG DAILY)  VALSARTAN (80-160 MG DAILY)  IRBESARTAN (75-300 MG DAILY)  TELMISARTAN (20-80 MG/DAILY) CALCIUM-CHANNEL BLOCKERS ALPHA-BLOCKERS  cause postsynaptic α1-receptor blockade with resulting vasodilatation and blood pressure reduction  the newer longer-acting agents are far better tolerated  Doxazosin (1-4 mg daily)  Prazosin  Labetalol- combined alpha- and beta-blocking properties, but is not commonly used, except in pregnancy-induced hypertension COMMON BETA-BLOCKERS in HTNACEBUTALOL 400 MG ONCE OR TWICE DAILY ATENOLOL 50 MG ONCE DAILY BISOPROLOL 10-20 MG ONCE DAILY CELIPROLOL 200 MG ONCE DAILY OXPRENOLOL 20-80 MG THREE TIMES DAILY METOPROLOL 100-200 MG DAILY PROPRANOLOL 80-160 MG TWICE DAILY TIMOLOL 5-20 MG TWICE DAILY BETA-ADRENOCEPTOR  no longer used as first-line antihypertensive therapy BLOCKERS  are used in * younger people, particularly those with an intolerance or contraindication to ACEI and ARB * women of child-bearing potential or * patients with evidence of increased sympathetic drive  their effect is seen on sympathetic nervous and reninangiotensin systems. They reduce the force of cardiac contraction, as well as resting and exercise-induced increase in heart rate  Cardioselectivity. Less effect on the β2 (non-cardiac) receptors and are therefore said to be relatively cardioselective ( Atenolol & Bisoprolol) Side-effects: bradycardia, bronchospasm, cold extremities, fatigue, bad dreams and hallucinations CENTRALLY ACTING DRUGS  RESERPINE is used in a low dose of 0.05 mg per day, which provides almost all its antihypertensive action with fewer side-effects than higher doses  METHYLDOPA is still widely used despite central and serious hepatic and blood side-effects, acts on central α2-receptors, without slowing the heart  CLONIDINE AND MOXONIDINE provide all the benefits of methyldopa MALIGNANT HYPERTENSION  is characterised by accelerated microvascular damage with necrosis in the walls of small arteries and arterioles (‘fibrinoid necrosis’) and by intravascular thrombosis  diagnosis is based on evidence of high BP and rapidly progressive end organ damage, such as.. * retinopathy (grade 3 or 4), * renal dysfunction (especially proteinuria) * hypertensive encephalopathy  Left ventricular failure may occur and, if this is untreated, death occurs within months MX OF MALIGNANT  HYPERTENSION admitted to hospital for immediate treatment  it is unwise to reduce the blood pressure too rapidly since this may lead to cerebral, renal, retinal or myocardial infarction  BP response to therapy must be carefully monitored, preferably in a high dependency unit  aim is to reduce the diastolic blood pressure to 100–110 mmHg over 24–48 hours  ATENOLOL OR AMLODIPINE - the BP can be normalized in 2-3 days  if rapid control of blood pressure is required (e.g. in an aortic dissection), the agent of choice is INTRAVENOUS SODIUM NITROPRUSSIDE  alternatively, an INFUSION OF LABETALOL HYPERTENSION IN PREGNANCY  many antihypertensive agents are contraindicated in pregnancy  mild hypertension can be treated with methyldopa, which has been established as being safe in pregnancy, or labetalol  more severe hypertension or eclampsia requires treatment with intravenous hydralazine PROGNOSIS  Level of blood pressure  Presence of target-organ changes (retinal, renal, cardiac or vascular)  Coexisting risk factors for cardiovascular disease, such as hyperlipidaemia, diabetes, smoking, obesity, male sex  Age at presentation Hypertensive crisis is an umbrella term for hypertensive urgency and hypertensive emergency. These two conditions occur when blood pressure becomes very high, possibly causing organ damage. A "hypertensive emergency" is diagnosed when there is evidence of direct damage to one or more organs as a result of severely elevated blood pressure greater than 180 or 110 diastolic. •systolic cerebral infarction (24.5%) intracranial hemorrhage • pulmonary edema (22.5%), • hypertensive encephalopathy (16.3%), • congestive heart failure • , • aortic dissection, • and eclampsia, • acute myocardial infarction, and • retinal and renal involvement. These patients: • should be admitted for immediate intervention and monitoring. • need to be reduce their BP rapidly based on clinical scenarios -. • should have their BP reduced by 10%-25% within certain minutes to hours but not lower than 160/90 mmHg. This is best achieved with parenteral drugs. Medication; •IV labetalol •IV Nitroglycerine •IV hydralazine Hypertensive urgency must be distinguished from hypertensive emergency. Urgency is defined as severely elevated BP (ie, systolic BP >180 mm Hg or diastolic BP >110 mm Hg) with no evidence of target organ damage. Management of hypertensive urgency: 1. Rest in quiet room for at least 2 hours 2. Initiate oral anti-hypertensive agents if BP remains >180/110 mmHg The agent of choice for a patient with diabetes is A) propranolol. B) doxazosin. C) amlodipine. D) clonidine. E) enalapril. Which of the following is the most appropriate blood pressure goal for a 65-year-old with hypertension and no other medical problems? A) <140/90 mm Hg B) <130/85 mm Hg C) <130/80 mm Hg D) <125/75 mm Hg THANK YOU History Family history, lifestyle (exercise, salt intake, smoking habit) and other risk factors secondary hypertension Drug or alcohol-induced hypertension phaeochromocytoma - paroxysmal headache, palpitation and sweating  complications such as coronary artery disease (e.g. angina, breathlessness)/stroke/renal /eyes Malignant hypertension- severe headaches, visual disturbances, fits, transient loss of consciousness or symptoms of heart failure EXAMINATION  Elevated blood pressure -the only abnormal sign  CVS Exam: left ventricular hypertrophy, loud A2 - cardiac failure- a sinus tachycardia and a third heart sound  Renal Failure –leg swelling/periorbital swelling/sallow appearance  Fundoscopy Look for secondary causes important risk factors - such as central obesity and hyperlipidaemia (tendon xanthoma and so on)