hypertension(primary care medicine)
TRANSCRIPT
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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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History of Hypertension:
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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History of Hypertension:
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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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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Causes of Hypertension
Primary/Essential (80%)
Secondary (20%)
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Causes of Hypertension
Primary/Essential (80%)
No identifiable cause
Family history
later age of onset
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Causes of Hypertension
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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Causes of Hypertension
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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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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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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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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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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Assessment of Patients withHypertension
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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Assessment of Patients withHypertension
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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Physical Examination:What to examine?
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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Physical Examination:What to examine?
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