Hypertension 2014 Family Medicine Richard Birtwhistle MD CFPC Objectives- Hypertension 1 Screen for hypertension. 2 Use correct technique and equipment to measure blood pressure. 3 Make the diagnosis of hypertension only after multiple BP readings (i.e., at different times and during different visits). 4 In patients with an established diagnosis of hypertension, assess and re-evaluate periodically the overall cardiovascular risk and end-organ complications: a) Take an appropriate history. b) Do the appropriate physical examination. c) Arrange appropriate laboratory investigations. 5 In appropriate patients with hypertension (e.g., young patients requiring multiple medications, patients with an abdominal bruit, patients with hypokalemia in the absence of diuretics): a) Suspect secondary hypertension. b) Investigate appropriately. 6 Suggest individualized lifestyle modifications to patients with hypertension. (e.g., weight loss, exercise, limit alcohol consumption, dietary changes). 7 In a patient diagnosed with hypertension, treat the hypertension with appropriate pharmacologic therapy (e.g., consider the patient’s age, concomitant disorders, other cardiovascular risk factors). 8 Given a patient with the signs and symptoms of hypertensive urgency or crisis, make the diagnosis and treat promptly. 9 In all patients diagnosed with hypertension, assess response to treatment, medication compliance, and side effects at follow-up visits. CFPC Objectives Hypertension 1. Screen for hypertension 2012 Canadian Task Force on Preventive Health Care Recommendations • We recommend blood pressure measurement at all appropriate primary care visitsi,ii). (Strong recommendation; moderate quality evidence) • We recommend that blood pressure be measured according to the current techniques described in the Canadian Hypertension Education Program (CHEP) recommendations for office and out-of- office (ambulatory) blood pressure measurement). (Strong recommendation; moderate quality evidence) • For people who are found to have an elevated blood pressure during screening, the CHEP criteria for assessment and diagnosis of hypertension should be applied to determine whether the patient meets diagnostic criteria for hypertension. (Strong recommendation; moderate quality evidence) 2. Use correct technique and equipment to measure blood pressure Blood Pressure Assessment: Patient preparation and posture Standardized Preparation: Patient 1. No acute anxiety, stress or pain. 2. No caffeine, smoking or nicotine in the preceding 30 minutes. 3. No use of substances containing adrenergic stimulants such as phenylephrine or pseudoephedrine (may be present in nasal decongestants or ophthalmic drops). 4. Bladder and bowel comfortable. 5. No tight clothing on arm or forearm. 6. Quiet room with comfortable temperature 7. Rest for at least 5 minutes before measurement 8. Patient should stay silent prior and during the procedure. Blood Pressure Assessment: Patient preparation and posture Standardized technique: Posture The patient should be calmly seated with his or her back well supported and arm supported at the level of the heart. His or her feet should touch the floor and legs should not be crossed. Recommended Equipment for Measuring Blood Pressure Automated oscillometric devices: • Use a validated automated device according to BHS, AAMI or IP clinical protocols. • For home blood pressure measurement devices, a logo on the packaging ensures that this type of device and model meets the international standards for accurate blood pressure measurement. AAMI=Association for the Advancement of Medical Instrumentation; BHS=British Hypertension Society; IP: International Protocol. Use an appropriate size cuff Arm circumference (cm) Size of Cuff (cm) From 18 to 26 9 x 18 (child) From 26 to 33 12 x 23 (standard adult model) From 33 to 41 15 x 33 (large) More than 41 18 x 36 (extra large, obese) For automated devices, follow the manufacturer’s directions. For manual readings using a stethoscope and sphygmomanometer, use the table as a guide. CFPC Objectives Hypertension 1. Screen for hypertension 2. Use correct technique and equipment to measure blood pressure 3. Make the diagnosis of hypertension only after multiple BP readings (i.e., at different times and during different visits). Criteria for the diagnosis of hypertension and recommendations for follow-up BP: 140-179 / 90-109 BP: 140-179 / 90-109 ABPM (If available) ABPM (If available) Clinic BPM Clinic BPM Home BPM (If available) Home BPM (If available) Yes Hypertension Visit 2 Target Organ Damage or Diabetes or Chronic Kidney Disease or BP >180/110? Hypertension Visit 2 Target Organ Damage or Diabetes or Chronic Kidney Disease or BP >180/110? Hypertension Visit 1 BP Measurement, History and Physical examination Hypertension Visit 1 BP Measurement, History and Physical examination Hypertensive Urgency / Emergency Hypertensive Urgency / Emergency Diagnosis of HTN Diagnosis of HTN No Elevated Out of the Office BP measurement Elevated Out of the Office BP measurement Elevated Random Office BP Measurement Elevated Random Office BP Measurement Diagnostic algorithm for high Blood Pressure including Office, ABPM and Home Blood Pressure Measurement BP: 140-179 / 90-109 BP: 140-179 / 90-109 ABPM (If available) ABPM (If available) Clinic BP Clinic BP HBPM HBPM Diagnosis of HTN Awake BP ≥ 135 SBP or ≥ 85 DBP Or 24-hour ≥ 130 SBP or ≥ 80 DBP Awake BP ≥ 135 SBP or ≥ 85 DBP Or 24-hour ≥ 130 SBP or ≥ 80 DBP Awake BP < 135/85 and 24-hour < 130/80 Awake BP < 135/85 and 24-hour < 130/80 Continue to follow-up Diagnosis of HTN Hypertension visit 3 ≥ 160 SBP or ≥ 100 DBP ≥ 140 SBP or ≥ 90 DBP < 140 / 90 Diagnosis of HTN Continue to follow-up < 160 / 100 Hypertension visit 4-5 ABPM or HBPM or ≥ 135 SBP or ≥ DBP 85 ≥ 135 SBP or ≥ DBP 85 < 135/85 < 135/85 Diagnosis of HTN Continue to follow-up or [...]... Licorice root – Stimulants including cocaine – Salt – Excessive alcohol use CFPC Objectives Hypertension 6 Suggest individualized lifestyle modifications to patients with hypertension (e.g., weight loss, exercise, limit alcohol consumption, dietary changes) 7 In a patient diagnosed with hypertension, treat the hypertension with appropriate pharmacologic therapy (e.g., consider the patient’s age, concomitant... Systolic/Diastolic Hypertension without Other Compelling Indications If partial response to monotherapy 1 Add-on Therapy 2 Triple or Quadruple Therapy IF BLOOD PRESSURE IS NOT CONTROLLED CONSIDER • Nonadherence • Secondary HTN • Interfering drugs or lifestyle • White coat effect If blood pressure is still not controlled, or there are adverse effects, other classes of antihypertensive drugs may be combined... antihypertensive drugs may be combined (such as alpha blockers or centrally acting agents) Drug Combinations When combining drugs, use first-line therapies • Two drug combinations of beta blockers, ACE inhibitors and angiotensin receptor blockers have not been proven to have additive hypotensive effects Therefore these potential two drug combinations should not be used unless there is a compelling (non blood pressure... Short-acting nifedipine VI Treatment of Hypertension in Patients with Recent ST Segment Elevation-MI or non-ST Segment Elevation-MI Recent myocardial infarction Beta-blocker and ACEI or ARB If beta-blocker contraindicated or not effective Heart Failure ? YES Long-acting Dihydropyridine CCB* NO Long-acting CCB *Avoid non dihydropyridine CCBs (diltiazem, verapamil) VII Treatment of Hypertension with Left Ventricular... factors that can induce/aggravate hypertension • Prescription Drugs: – NSAIDs, including coxibs – Corticosteroids and anabolic steroids – Oral contraceptive and sex hormones – Vasoconstricting/sympathomimetic decongestants – Calcineurin inhibitors (cyclosporin, tacrolimus) – Erythropoietin and analogues – Antidepressants: Monoamine oxidase inhibitors (MAOIs), SNRIs, SSRIs – Midodrine • Other: – Licorice root...CFPC Objectives Hypertension 4 In patients with an established diagnosis of hypertension, assess and re-evaluate periodically the overall cardiovascular risk and end-organ complications: a) Take an appropriate history b) Do the appropriate physical examination c) Arrange appropriate laboratory investigations 5 In appropriate patients with hypertension (e.g., young patients requiring... FirstLine Therapy • Use caution in initiating therapy with 2 drugs in whom adverse events are more likely (e.g frail elderly, those with postural hypotension or who are dehydrated) • ACE inhibitors, renin inhibitors and ARBs are contraindicated in pregnancy and caution is required in prescribing to women of child bearing potential • Beta adrenergic blockers are not recommended for patients age 60 and... ACEI or ARB to those used in clinical trials If additional therapy is needed: • Diuretic (Thiazide for hypertension; Loop for volume control) • for CHF class III-IV or post MI: Aldosterone Antagonist If ACEI and ARB are contraindicated: Hydralazine and Isosorbide dinitrate in combination Non dihydropyridine CCB If additional antihypertensive therapy is needed: • ACEI / ARB Combination • Long-acting... of Hypertension in Patients with Renovascular Disease Renovascular disease Does not imply specific treatment choice Caution in the use of ACEI or ARB in bilateral renal artery stenosis or unilateral disease with solitary kidney Close follow-up and intervention (angioplasty and stenting or surgery) should be considered for patients with: uncontrolled hypertension despite therapy with three or more drugs,... 2011**) 140/90 Very elderly (>80) (CHEP 2013**) Diabetes (CHEP 2000**) Very low CV risk (CHEP 2000**) 150 130/80 160/100 I Indications for Pharmacotherapy after diagnosis of hypertension (1) • Patients at low risk with stage 1 hypertension (140159/90-99 mmHg) • lifestyle modification can be the sole therapy • Patients with target organ damage (e.g left ventricular hypertrophy) or chronic kidney disease . Hypertension 2014 Family Medicine Richard Birtwhistle MD CFPC Objectives- Hypertension 1 Screen for hypertension. 2 Use correct technique and equipment. modifications to patients with hypertension. (e.g., weight loss, exercise, limit alcohol consumption, dietary changes). 7 In a patient diagnosed with hypertension, treat the hypertension with appropriate. patients diagnosed with hypertension, assess response to treatment, medication compliance, and side effects at follow-up visits. CFPC Objectives Hypertension 1. Screen for hypertension 2012 Canadian