Hypertension(Primary Care Medicine)

7/31/2019 Hypertension(Primary Care Medicine)

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Management of Hypertension

Professor Datin Dr Chia Yook Chin MBBS FRCP

Dept of Primary Care Medicine, UM

Unscheduled Universities Lecture

IKU, KL 20 August 2009


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History of Hypertension:

19th

century 19th century, knowledge about blood

pressure regulation had grown significantly

Claude Bernard, a French scientist,

discovered the existence of vascular nerves

and reasoned out their role in controlling

the diameter of the blood vessels.


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19th

century Richard Bright:established a co-relation

between high blood pressure and kidney

disease.

Sir William Gowers highlighted the link

between contractions of the arterioles of the

retina and increased arterial blood pressure


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20th century: McLeod described the main factors

controlling blood pressure.

In 1950s, life insurance companies observedthat persons suffering from high blood

pressure died earlier than those with lowerblood pressure levels.

Thus, a link was established between high

blood pressure and mortality rate.


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Definition of Hypertension

BP 140/90 mm Hg

Systolic BP 140 and/ or

Diastolic 90 mm Hg


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Differences with JNC VII

Category Systolic Diastolic JNC VII*

Optimal


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Prognosis of Prehypertension

Pre HT associated with

increased risk of CVD RR 1.79 (95% CI

1.4-2.24) cf normotensive

HT vs NT for CVD RR 2.64 (CI 2.18-3.19)

Associated with increase of

27% in all cause mortality,

66 % in CVD mortality cf normotensive


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Isolated Systolic

Hypertension (ISH)

Systolic 140 mm Hg and

Diastolic < 80 mm Hg

ISH: 160/82 mm Hg


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Complications of

Hypertension Cardiovascular Disease

Entire vascular tree

Heart, (Cardiomegaly, Heart Failure)

Brain, (cerebral infarction, intracerebral

haemorrahge -> Strokes CVA, TIA),

Kidneys, (renal failure)

Eyes, (blindness,)

peripheral blood vessels (claudication LL)


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How to Diagnose

Hypertension?

Definition: BP 140/90 mm Hg

Measure Blood Pressure


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Measurement of Blood

Pressure Mercury column sphygmomanometer

Anaeroid sphygmomanometer Electronic devices (oscillatory method)

Automated ambulatory BP devices


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Measurement of BP

Correct cuff size

Bladder length must cover at least 80% of the

circumference of arm

Width should be 40% of the circumference of the

arm

Standard size: 13cmX 24 cm Too small -> higher reading

Too big -> lower reading


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Measurement of BP

Patient seated and adequately rested

Arm supported should not smoke or drink caffeine

within 30 mins of measurement


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Measurement of BP

Systolic BP estimated by palpation

Pulse disappears, inflate by a further 20 mm Hg

Deflate and feel pulse, when felt this is estimate of

Systolic BP

Reinflate till 20 mm Hg estimated Systolic BP

Deflate slowly, 1-2 mm Hg per second whileascultating

Important to palpate because of silent gap

Korotkoff sounds disappears and reappears later


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Measurement of Blood

Pressure Mercury sphagnomanometer

Korotkoff 1=SBP

Korotkoff 5=DBP

Measure both arms, take higher reading (20mmHg difference Sitting, average of at least 2 readings

Confirm on at least 2 separate occasions


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Measurement of BloodPressure

White coat hypertension

BP at home is less than office readings

Confirm by home blood pressure

monitoring or ambulatory BP

measurement


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Assessment of Patients withHypertension

Look for a cause (look for secondary causes)

Ascertain presence or absence of target organ

damage

Identify other risk factors eg smoking, diabetes,

dyslipidaemia, f/h CHD


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damage




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Causes of Hypertension

Primary/Essential (80%)

Secondary (20%)


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Primary/Essential (80%)

No identifiable cause

Family history

later age of onset


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Secondary causes (20%)

Renal

Chronic kidney disease/failure

Glomerulonephritis eg post strep GN

Endocrine

Cushings Disease, phaechromocytoma Primary aldosteronism, acromegaly

Thyroid or parathyroid disease


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Secondary causes (20%)

Cardiac causes

Coarctation of Aorta

Primary arteritis (Takayasus Disease)

Renal stenosis (reno-vascular disease)

Drug induced

Steriods NSAIDs

OCP

Others

Sleep apnoea


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Ascertain presence or absence of target

organ damage




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Target Organ Damage

Heart

Left ventricular hypertrophy (Cardiomegaly, ECG)

Angina, old MI

Prior coronary revascularisation Brain

Stroke or TIA

Kidney

Microalbuminuria Chronic kidney failure

Eye

Retinopathy

Peripheral vascular Disease


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damage

Identify other risk factors eg smoking,

diabetes, dyslipidaemia, f/h CHD


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Major CVD Risk Factors

Smoking

Diabetes

Central obesity Dyslipidaemia

Physical inactivity

Microalbuminuria Age Men> 55 , women >65 yrs

Family history of premature CVD (men


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History Identify cause, Risk factors

Target organ damage

Physical examination 20 causes eg Cushings,

Heart size, Pulses, coarctation, PAD

Renal bruit: renal stenosis

Eyes: retinopathy


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Ix:

FBC

urinalysis (microalbuminuria) renal function

FBS

Lipids

ECG

CXR


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National Health and Morbidity Survey II, 1996:

Prevalence: 32%

High normal: 17%

Stage 1: 20 %

Stage 2: 8 %

Stage 3: 4 %

-Rule of halves-half not diagnosed

-half not treated

-half not controlled

Magnitude of Hypertension


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Aims and Targets of Hypertension

Management

Reduce CV morbidity and mortality

Reduce BP levels


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Effect of Antihypertensive Therapy

%

Reduction

MacMahon SW et al. Prog Cardiovasc Dis. 1986;29(suppl 1):99118.

60

50

40

30

20

10

0

48%

16%

Cerebrovascular

Disease

Coronary Heart

Disease

12 mmHg reduction

50%

Heart

Failure


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Treatment of

Hypertension

Non-phramacological

Pharmacological


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Treatment of

Hypertension Non-pharmacological

Lose weight

Regular exercise 30 mins three times per

week

Low salt diet

Avoid alcohol

Healthy eating


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Drugs for Treatment of

Hypertension PharmacologicalACE inhibitors eg lisnopril

Calcium channel blockers eg amlodipine

Diuretics eg hydrochlorothiazide

AIIA ( ARBs: angitensin receptor blocker) eg

lorsartan

blockers eg atenolol

(alpha) blockers eg prazosin

blockers eg labetalol


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Drugs for Treatment of

Hypertension Pharmacological Centrally acting eg methldopa

Direct vasodilators eg minoxidil

Aldosterone anatgonist: eg aldosterone

Renin inhibitors eg aliskerin


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Hypertension in Other

Groups Elderly

Pregnant Women

Children


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Hypertension in the

Elderly Definition: same as adults 140/90 mm

Hg

Assessment and management is thesame

Drugs: start low go slow

Postural hypotension


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Hypertension in the

Pregnant Women Pregnancy induced hypertension

Definition: 140/90 mm Hg

Korotkoff V as cutoff for Diastolic BP

If korotkoff V does not end, then usekorotkoff IV

Pre-eclampsia and eclampsia


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Hypertension in Children

Increasing in prevalence

Def: based on age, gender and height

Defined as BP >95% for age, gender andheight

Normative tables for BP for children based onage, sex and height (NCHS: Nat Health

Statistics for Growth Chart) Appropriate cuff size

Refer to paediatrician


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Summary: HypertensionManagement

Definition: 140/90 mm Hg adults

Associated with increased CVD risk and

mortality Proper measurement of BP

Assessment of Hypertension:

Cause

Target organ damage

Associated CVD risk factors


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Summary: HypertensionManagement

Definition: 140/90 mm Hg adults

BP is a continumum

Associated with increased CVD risk andmortality

Proper measurement of BP

Assessment of Hypertension:

Cause

Target organ damage

Associated CVD risk factors


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Primary Aim ofHypertension Management

Reduce CV morbidity and mortality

Reduce BP levels


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Case Discussion

Encik Ahmad, 56 retired clerk

Comes for running nose

BP 148/86 mmHg


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Case Discussion

Has he got hypertension?

Measure it twice at one sitting

Rested Not smoked, no coffee, coke,

Arm supported

Cuff size correct

BP 148/88 mm Hg

Need to reconfirm on another occasion


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Case Discussion

Come back in a month

BP 146/86 mm Hg (2X) 148/84 mm Hg

Has he got hypertension


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What next?

1. Cause

2. Target organ damage

3. Associated CVD risk factors


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How to do that?

1. History

2. Physical examination

3. Investigations


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What exactly?

1. History

Cause

p/h of HT

f/h HT

p/h of kidney disease, haematuria, kidney stones,

ankle oedema, puffiness

Drugs eg NSAIDs, steroids Thyroid disease eg thyrotoxicosis


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What exactly

1. History

Target organ damage

Cardiac complications eg chest pain, difficulty in

breathing, orthopnoea

TIA, strokes, intermittent claudication

Kidneys: facial puffiness, ankle oedema, polyuria,

nocturia Eyes: visual problems

PAD: intermittent claudication


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What exactly

1. History

Associated CVD risk Factors

f/h premature cardiac problems

Smoke

Dyslipidaemia

Diabetes

Physical inactivity

Ph i l E i ti


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Physical Examination:What to examine?

Cause:

Endocrine disease eg Cushings

Kidney disease: facial puffiness, ankleoedema, anaemai, acidotic, sallow

Renal Artery stenosis; renal bruit

Primary aretritis Coarcatation of aorta

Ph i l E i ti


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Target organ damage:

Heart size (LVH)

Heart failure

Eyes: retinopathy

Evidence of kidney disease

Peripheral pulses

Ph i l E i ti


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Associated CVD Risk factors:

Obesity, BMI, waist circumference

Nicotine stains

Xanthomas

Evidence of diabetes mellitus

I ti ti


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Investigations:What to order?

Cause, target organ damage, assoc CVD RF

Hb (anaemia: renal failure)

Urine FEME (caused and target organ damage)

Renal functions (cause and target organ damage)

Lipids (associated risk factors)

FBG: assocaited risk factors

ECG ( Target organ damage)

CXR (cause and target organ damage)

In estigations


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Investigations:What to order?

Cause, target organ damage, assoc CVD RF

Hb (anaemia: renal failure)

Urine FEME (caused and target organ damage)

Renal functions (cause and target organ damage)

Lipids (associated risk factors)

FBG: assocaited risk factors

ECG ( Target organ damage)

CXR (cause and target organ damage)

C Di i


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Case Discussion

Encik Ahmad, 56 yr man Non-smoker, no significant p/h otherwise well Not on any drugs no premature CVD Father and one older brother HT

C Di i


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Case Discussion

BMI 25, waist 96 cm

Not Cushingnoid

No cardiomegaly, no retinopathy, pulses all felt,

equal and normal

No renal bruit

No retinopathy

Case Disc ssion


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Case Discussion

Tg 1.7 mmol/l

total chol 6.2 mmol

ldl chol 4.5 mmolhdl 0.9 mmol/l

FBS 6.1 mmol/l

Renal functions: normal Urine: proteinuria 1+ no cells

CXR: no cardiomegaly

ECG: No LVH

Summary of Encik Ahmad


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Summary of Encik Ahmad

Essential hypertension

Target organ damage: proteinuria

Assoc CVD risk: hypercholesterolaemia

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Hypertension(Primary Care Medicine)

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