hypertension s. danish hasan md march 2 nd 2013. objectives basic concepts definitions screening and...
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HypertensioHypertensionn
S. Danish Hasan MDMarch 2nd 2013
ObjectivesObjectivesBasic ConceptsDefinitionsScreening and DiagnosisGuidelines Risk FactorsComplicationsTreatment and Adverse Effects
Basic ConceptsBasic ConceptsBlood Pressure
◦Amount of pressure on the arterial walls as the blood is pumped through them by the heart and circulated through the body
Systolic Blood Pressure◦Pressure on the walls when the heart
contractsDiastolic Blood Pressure
◦Pressure on the walls when the heart is relaxed (in between heart beats)
Basic ConceptsBasic Concepts
SystolicDiastolic
12080
Example
=
Systolic goes on top and Diastolic on the Botton
DefinitionsDefinitionsNormal Blood PressurePre HypertensionStage 1 HypertensionStage 2 HypertensionIsolated Systolic
HypertensionIsolated Diastolic
HypertensionMalignant
HypertensionHypertensive Urgency
<120/<80120-139/80-89140-159/90-99>159/99>139/<90
<140/>89
End organ damage>179/>119
DefinitionsDefinitionsPrimary/Essential Hypertension
Secondary/Identifiable Hypertension
Hypertension without a known or identifiable cause
Hypertension with a known or identifiable cause. Some causes include:1. Primary Renal Disease – AKD/CKD with glomerular or vascular disorders2. OCPs3. Drug induced – Chronic NSAID/Alcohol use/abuse, Antidepressants.4. Pheochromocytoma (adrenal tumor) - paroxysmal hypertension5. Primary hyperaldosteronism – htn(specially resistant), unexplained hypoK6. Renovascular dz – pt. with atherosclerosis ex. Renal artery stenosis7. Other Endocrine issues – hypo/hyperthyroidism, hyperparathyroid8. Cushing’s Syndrome9. OSA10. Coarctation of aorta
Screening and DiagnosisScreening and DiagnosisScreening
◦ Every 2 years for those in normal category◦ Every year for pre-hypertensive category
Who is diagnosed with HTN?◦ Initial screen +◦ 2 or more visits with documented high blood
pressure◦ Over a period of weeks to months◦ Should be measured in both arms
(>15mmHg difference = Subclavian stenosis/PAD)
◦ Postural BPs in >65, diabetics, dizziness weakness upon standing. Difference >20mmHg from supine to standing(Orthostatic Hypotension)
Guidelines for proper blood Guidelines for proper blood pressure measurementpressure measurementPatient Conditions
◦Posture◦Circumstances
Equipment◦Cuff◦Manometer
Technique◦Number of Readings◦Performance
Recordings
Guidelines – PostureGuidelines – PostureSitting pressures are recommended
for routine follow-up; the patient should sit quietly with the back supported for five minutes and the arm supported at the level of the heart
Check for postural changes by taking readings after five minutes supine, then immediately and two minutes after standing; this is particularly important in patients over age 65 years, diabetics, or those taking antihypertensive drugs
Guidelines - Guidelines - CircumstancesCircumstancesNo caffeine during the hour
preceding the readingno smoking during the preceding 30
minutesNo exogenous adrenergic
stimulants, such as phenylephrine in decongestants or eye drops for pupillary dilatation
A quiet, warm settingHome readings should be taken
upon varying circumstances (patient might be asked to keep a home log)
Guidelines - EquipmentGuidelines - EquipmentCuff size
◦length of the bladder should be 80 percent
◦width of the bladder should be at least 40 percent of the circumference of the upper arm
Manometer◦Aneroid gauges should be calibrated
every six months against a mercury manometer
Guidelines – Number of Guidelines – Number of ReadingsReadingsTake at least two readings on each visitseparated by as much time as possibleif readings vary by more than 5 mmHg,
take additional reading until two consecutive readings are close
For the diagnosis of hypertensiontake three readings at least one week
apartInitially, take blood pressure in both
arms; if pressures differ, use the higher arm
If the arm pressure is elevated, take the pressure in one leg, particularly in patients under age 30 years
Korotkoff Sounds–Reviewing Korotkoff Sounds–Reviewing BP 101BP 1015 PhasesPhase 1 – Clear Tapping Sound (SBP)Phase II – Swishing sound/soft
murmur onsetPhase III – Loup slapping/instense
soundPhase IV – Sudden Muffling SoundPhase V – Silence
Phase/Disappearance of Sound“Tap – Murmur – Slap – Muffle –
Silence”
Guidelines - PerformanceGuidelines - PerformanceInflate the bladder quickly to 20 mmHg
above the systolic pressure as estimated from loss of radial pulse
Deflate the bladder 3 mmHg per second
Record the Korotkoff phase V (disappearance) as the diastolic pressure except in children in whom use of phase IV (muffling) may be preferable
If the Korotkoff sounds are weak, have the patient raise the arm, open and close the hand five to ten times, and then inflate the bladder quickly
Guidelines - RecordingGuidelines - RecordingRecordingsNote the pressure, patient
position, arm, and cuff size: eg, 140/90, seated, right arm, large adult cuff
Risk Factors – Non Risk Factors – Non ModifiableModifiableEthnicity - Asian, Inuit, First
Nations/Aboriginal, African Americans◦Tends to be most common and most
severe in BlacksFamily History – mother, father or
both parentsAge >65Certain personality traits, such as
hostile attitudes and time urgency/impatience, as well as among those with depression
Risk Factors - ModifiableRisk Factors - ModifiableSmokingExcessive alcohol use (>14 drinks for
M and >9 drinks for F per week)Diet high in fat and salt (AHA <1500
mg)Weight / obesityDyslipidemia regardless of
obesity/weightLack of exerciseVitamin D DeficiencyOther medication
Prime suspects are canned soups and lunch meat
ComplciationsComplciations
ComplicationsComplications CVD - Hypertension is quantitatively the major risk factor for
premature CVD, being more common than cigarette smoking, dyslipidemia, or diabetes, the other major risk factors. In older patients, systolic pressure and pulse pressure are more powerful determinants of risk than diastolic pressure .
CHF - The risk of heart failure increases with the degree of blood pressure elevation.
Dysrythmias, MI, Sudden Cardiac Death – LVH is a common finding in patients with hypertension, and is associated with an enhanced incidence of heart failure, ventricular arrhythmias, death following myocardial infarction, and sudden cardiac death.
Ischemic Stroke - Hypertension is the most common and most important risk factor for ischemic stroke, the incidence of which can be markedly reduced by effective antihypertensive therapy.
Intracerebral hemorrhage - Hypertension is the most important risk factor for the development of intracerebral hemorrhage.
CKD/ESRD - Hypertension is a risk factor for chronic kidney disease and end-stage renal disease. It can both directly cause kidney disease, called hypertensive nephrosclerosis, and accelerate the progression of a variety of underlying renal diseases.
TreatmentsTreatmentsDietExerciseDieureticsBeta BlockersACE-InhibitorsARBsCalcium Channel BlockersOther MedicationsComplementary Therapies
Treatment – Lifestyle, Diet Treatment – Lifestyle, Diet and Exerciseand ExerciseDASH Diet – Dietary Approaches to Stop
Hypertension◦ eating more fruits, vegetables, whole-grain
foods, low-fat dairy, fish, poultry, and nuts. You should eat less red meat, saturated fats, and sweets. Reducing sodium in your diet can also have a significant effect.
Exercise◦ 50 minutes of moderate exercise per week -
gardening, walking briskly, bicycling, or other aerobic exercise. Muscle-strengthening activities are recommended at least two days a week and should work all major muscle groups.
Lifestyle◦ Quit smoking and alcohol
Treatment - DiureticsTreatment - DiureticsOften the first choice if diet and exercise
changes aren't enoughAlso called "water pills”Help the body shed excess sodium and water Side Effects:
◦ urinate more often◦ some may deplete potassium, causing muscle
weakness, leg cramps, and fatigue◦ Some can increase blood sugar levels in diabetics◦ Erectile dysfunction is a less common side effect
hydrochlorothiazide (HydroDiuril), furosemide (Lasix), spironolactone (Aldactone)
Treatment – beta-BlockersTreatment – beta-BlockersSlows the heart rateUsed to treat other heart conditionsMay be prescribed along with other
medicationsSide effects: insomnia, dizziness,
fatigue, cold hands and feet, and erectile dysfunction.
atenolol (Tenormin), metoprolol (Betaloc/Lopressor), bisoprolol
Treatment – ACE InhibitorsTreatment – ACE InhibitorsACE inhibitors reduce your body's supply
of angiotensin II -- a substance that makes blood vessels contract and narrow.
The result is more relaxed, open (dilated) arteries,
Side effects: dry cough, skin rash, or dizziness, and high levels of potassium. Women should not become pregnant while taking an ACE inhibitor(teratogenic).
lisinopril (Zestril), perindopril, enalapril, ramipril (Altace)
Treatment - ARBsTreatment - ARBsBlock receptors for angiotensin -- as
if placing a shield over a lockPrevents artery-tightening effects,
and lowers your blood pressure.ARBs can take several weeks to
become fully effective. Side effects: dizziness, muscle
cramps, insomnia, and high levels of potassium Teratogenic as well.
candesartan (Atacand), losartan (Cozaar), valsartan (Diovan)
Treatment – Calcium Treatment – Calcium Channel BlockersChannel BlockersSlow the movement of calcium into the
cells of the heart and blood vessels. Since calcium causes stronger heart contractions, these medications ease the heart's contraction and relax the blood vessels.
Side Effects: dizziness, heart palpitations, swelling of the ankles, and constipation.
Take with food or milk and avoid grapefruit juice and alcohol because of possible interactions.
amlodipine (Norvasc), diltiazem (Cardizem), felodipine (Renedil)
Other MedicationsOther MedicationsOther medications that relax the
blood vessels include vasodilators, alpha blockers, and central agonists.
Side effects: dizziness, a fast heart beat or heart palpitations, headaches, or diarrhea.
Usually if HTN is not controlled or if another comorbitity
Complimentary TherapiesComplimentary TherapiesAlong with lifestyle, diet and
exercise these help for HTNYogatai chideep breathing exercisesOther relaxation techniquesHerbal Remedies? Unproven
benefits and some actually increase blood pressure.
Questions?Questions?