© Copyright Annals of Internal Medicine, 2014 Ann Int Med. 161 (6): ITC6-1. * For Best Viewing:...

© Copyright Annals of Internal Medicine, 2014Ann Int Med. 161 (6): ITC6-1.

* For Best Viewing:

Open in Slide Show Mode Click on icon or

From the View menu, select the Slide Show option

* To help you as you prepare a talk, we have included the relevant text from ITC in the notes pages of each slide


Terms of Use

The In the Clinic® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for-profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as e-mail attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the In the Clinic slide sets constitutes copyright infringement.


in the clinic

Hypertension


Cardiovascular disease

Retinopathy

Cerebrovascular disease

Ischemic heart disease

Left ventricular hypertrophy

Atrial fibrillation

Heart failure

Chronic kidney disease

Peripheral vascular disease

What long-term health risks are associated with hypertension?


Should clinicians screen for hypertension?

USPS Task Force

Screen the general adult population

No specific screening interval recommended

JNC 7 Guidelines

Screen every 2 years if <120/80 mm Hg

Annually if >139/89 mm Hg


What is prehypertension, and what is its proper management?

Blood pressure 120/80 to 139/89 mm Hg

“Prehypertension” is not in 2014 evidence-based guideline for management of adult high blood pressure

Drug therapy is not recommended for prehypertension

Evidence lacking on whether it decreases or prevents cardiovascular events


CLINICAL BOTTOM LINE: Screening and Prevention... Cardiovascular risk increases as blood pressure increases

Screen all adults for hypertension at 1- to 2-yr intervals

Lifestyle modification can delay hypertension + CVD onset

No evidence for adding pharmacotherapy for prevention


How should clinicians diagnose and stage hypertension?

When to diagnose hypertension:

≥2 readings obtained at 3 visits 2-4 wk apart

Average ≥140mmHg (systolic) or ≥90mmHg (diastolic)

Hypertension stages (JNC 7)

Normal blood pressure: ≤120/80 mm Hg

Prehypertensive: 120/80 to 139/89 mm Hg

Stage 1: 140/90 to 159/99 mm Hg

Stage 2: ≥160/100 mm Hg

If >50y, systolic blood pressure >140 mmHg more important CVD risk factor than diastolic hypertension


Instructions for Taking Blood Pressure

Have patient relax, sitting for >5 min

Support patient’s arm

Use stethoscope bell, not diaphragm, for auscultation

Check blood pressure first in both arms: Use arm with higher reading for all other + future readings

Measure blood pressure in sitting, standing, and lying positions (separate measurements by 2 min)

Use correct cuff size and note if special cuff size needed

Record systolic and diastolic pressures

Record exact results to nearest even number


Common errors that lead to falsely increased readings

Failure to have patient sit quietly for 5 min before reading

Failure to support limb

Using a cuff that is too small or deflating cuff too rapidly

To detect pseudohypertension, use Osler’s maneuver


What is white coat hypertension?

Elevated blood pressure at the office

Lower blood pressure at home or with 24-h ambulatory blood pressure monitor

Prevalence: 10% to 20%

Poses elevated risk for overt hypertension and CVD

Lifestyle modifications and regular follow-up recommended

Pharmacologic treatment not recommended


What is masked hypertension?

Normotensive in the office but elevated blood pressure out of the office

Prevalence: 10% to 40%

Increases sustained hypertension and CV death risk

Screen for suspected masked hypertension

Home readings

Ambulatory blood pressure monitoring


When is ambulatory blood pressure monitoring indicated?

Possible white coat hypertension

Unusual variability of blood pressure

Evaluation of nocturnal hypertension

Evaluation of drug-resistant hypertension

Determining the efficacy of drug treatment over 24h

Diagnosis and treatment of hypertension in pregnancy

Evaluation of symptomatic hypotension on various medications

Evaluation of episodic hypertension or autonomic dysfunction

Possible masked hypertension


What are the key elements of the history?

Assess duration, rapidity of onset, hypertension severity

Ask about cardiovascular risk factors, concomitant medical conditions, symptoms of target organ damage

Ask about past treatment and its effects

Ask about lifestyle

Ask about increased stress, physical inactivity, salt

Note any family history of hypertension, renal disease, cardiovascular problems, stroke, and diabetes

Review current medications (including OTC)


What are the essential elements of the physical examination?

Height, weight, BMI, waist circumference, skin lesions

Fundoscopy

Examination of neck

Cardiopulmonary examination

Abdominal examination

Neurologic examination

Peripheral pulses


Which laboratory tests should be done in newly diagnosed cases?

Newly diagnosed hypertension

Measure hemoglobin or hematocrit, serum electrolytes, serum creatinine, serum glucose, and fasting lipid levels

Urinalysis with microscopic examination

12-lead electrocardiography

Tests indicated by clinical factors or anticipated treatment

Echocardiography (more sensitive than EKG for LVH)

Serum uric acid levels (if patient has gout)

Microalbuminuria (if patient has diabetes)


Which patients should be evaluated for secondary hypertension, and how should they be evaluated?

Symptoms and Signs that Suggest Secondary Hypertension

New-onset hypertension at age <25 or >55 years

Drug-resistant hypertension

Spontaneous hypokalemia

Palpitations, headaches, and sweating

Severe vascular disease

Epigastric bruit

Radial-femoral pulse delay


Work-up for Possible Secondary Hypertension

Coarctation of aorta

The Cushing syndrome

Primary aldosteronism

Pheochromocytoma

Renal vascular disease

Renal parenchymal disease

Parathyroid disorders

Thyroid disease


CLINICAL BOTTOM LINE: Diagnosis...

≥140mmHg systolic or ≥90mmHg diastolic Measure blood pressure on several occasions, then average

Goals of the diagnostic evaluation Search for a secondary cause Detect other CVD risk factors Detect damage to target organs

History: past treatment, current meds, lifestyle factors Physical: eyegrounds, cardiovascular and nervous system Routine labs: hemoglobin, serum creatinine, glucose, lipid,

and electrolyte levels; urinalysis; EKG


What are treatment goals for patients with hypertension?

Goal: <140/90mmHg in patients with hypertension

Guidelines for Blood Pressure Goals from JNC 7

<140/90mmHg if <60 years old

<150/90mmHg if ≥60 years old

Kidney Disease Improving Global Outcomes (KDGO)

130/80mmHg for patients with CKD

<130/80mmHg if excreting >30 mg urine albumin/d

AHA/ACC

<140/90mmHg


What are the recommended lifestyle modifications for treating hypertension?

Salt restriction

Weight loss (to <20% above ideal weight for height)

Exercise (≥30 minutes aerobic exercise most days)

Smoking cessation

Alcohol intake limited to no more than 2 drinks daily


When is antihypertensive drug therapy indicated, and which drugs should clinicians prescribe as initial therapy?

Diuretics (thiazide)

ACE-inhibitors

Angiotensin-receptor blocker

Potassium-sparing diuretics

β-blockers

Calcium-channel blockers

Reserpine

Central β-agonists

Guanethidine

α-blockers

Hydralazine

Direct renin inhibitor

Drug treatments for hypertension



How should clinicians modify treatment on the basis of patient characteristics and comorbid conditions?

Compelling Indications for Individual Drug Classes

Heart failure: Diuretic, ß-blocker, ACE inhibitor, ARB, aldosterone antagonist

Postmyocardial infarction: ß-blocker, ACE inhibitor, aldosterone antagonist

High coronary disease risk: Diuretic, ß-blocker, ACE inhibitor, ARB + CCB

Diabetes: Diuretic, ß-blocker, ACE inhibitor, ARB, CCB

Chronic kidney disease: ACE inhibitor, ARB

Recurrent stroke prevention: Diuretic, ACE inhibitor


What is the role of combination therapies?

Advantages

Better adherence

May cost less for patients than individual prescriptions

ACE inhibitors or ARBs + hydrochlorothiazide

Good initial therapy if blood pressure >160/100mmHg

ACE inhibitors and ARBs + nonhydropyridine CCBs

Adding ACE inhibitor or ARB avoids edema of amlodipine monotherapy

ACE inhibitor-ARB combination therapy

ACE inhibitor-ARB combinations don’t seem to have clinical advantages


When blood pressure is poorly controlled, how should clinicians decide among increasing dose, adding an additional agent, or switching to another drug class?

Consider ambulatory blood pressure monitoring

Ask about co-medication with blood pressure-increasing drugs

Ask about excessive alcohol or salt intake

Reconsider secondary causes of hypertension

Evaluate medication adherence

Treat uncontrolled hypertension: use several drugs, each targeting different disease mechanism


Drug therapy for specific disease mechanisms of hypertension

Volume overload

Thiazide; loop diuretic; aldosterone antagonist

Sympathetic overactivity

ß-blocker (use to counteract reflex tachycardia from vasodilators or in heart failure)

Increased vascular resistance

ACE inhibitor or ARB (use in heart failure)

Smooth-muscle contraction

Dihydropyridine CCBs; ß-blocker; hydralazine


How often should patients with hypertension be seen?

Stable, well-controlled hypertension

Recheck at 6- to 12-month intervals

Blood pressure 140/90 to 159/99mmHg

Recheck at 2 months intervals

Blood pressure ≥160100mmHg

Recheck at ≤1 month intervals

After adjusting medications: allow 2-4 weeks for blood pressure to stabilize

Lab testing: intervals depend on number and type of medications and medical comorbidity


What is the value of home blood pressure monitoring?

Inexpensive way to monitor blood pressure

Especially before and after changing therapy

More accurate than in-office measurement

Instruct on correct technique

Have patient chart blood pressure once or twice per day

Brachial artery blood pressure cuff measurements more accurate than wrist cuff measurements

Helps confirm diagnosis in untreated patient


When should clinicians consider hospitalization?

Situations in which severe hypertension constitutes crisis

Cardiovascular

Left-ventricular failure; myocardial infarction

Unstable angina; aortic dissection

After vascular surgery or coronary artery bypass grafting

Neurologic

Hypertensive encephalopathy; thrombotic stroke

Subarachnoid or intracranial hemorrhage

Other

Severe catecholamine excess

Eclampsia in pregnancy


Drug-resistant hypertension uncontrolled with ≥3 drugs

Uncertainty about how to evaluate or manage suspected secondary hypertension

Need for assistance assessing target organ damage

When should clinicians consider referral to a hypertension specialist?


How should clinicians distinguish between a hypertensive emergency and a pseudocrisis?

Hypertensive urgency

Blood pressure >180/110mmHg w/o target organ damage

Patients can usually be managed with oral medications

Usually sent home after a few hours of observation

Hypertensive emergency

Elevated blood pressure with impending or acute progressive target organ damage

Usually requires admission to ICU and IV medication

Several drugs available to decrease blood pressure quickly


CLINICAL BOTTOM LINE: Treatment...

Blood pressure goal if patient <60y: <140/90 mmHg

Blood pressure goal if patient >60y: <150/90 mmHg

Lifestyle modifications can decrease blood pressure

Most patients also need at least 1 drug to reach goal

Severe hypertension requires urgent treatment if:

Acute cardiovascular or neurologic events are present

Patient is pregnant

Severe catecholamine excess is present

Date post:	21-Dec-2015
Category:	Documents
Upload:	angel-carr
View:	218 times
Download:	1 times

© Copyright Annals of Internal Medicine, 2014 Ann Int Med. 161 (6): ITC6-1. * For Best Viewing:...

Documents