Transcript Primary Hypertension

Primary
Hypertension
Shiva Seyrafian- 94/2/31
Accurate Measure of Blood Pressure
Assess blood pressure at all appropriate
visits
• When should blood pressure be measured?
(Health care professionals should know the blood
pressure of all of their patients and clients)
(Blood pressure of all adults should be measured
whenever it is appropriate using standardized
techniques)
1. To screen for hypertension
2. To assess cardiovascular risk
3. To monitor antihypertensive treatment
Definitions
A joint AHA/ACC/CDC algorithmNovember 2013
BP: Recommended goal of 139/89 mm Hg or less
• Stage 1 hypertension (systolic BP 140-159 mm Hg
or diastolic BP 90-99 mm Hg).
• Stage 2 hypertension (systolic BP ≥160 mm Hg or
diastolic BP ≥100 mm Hg).
• Severe hypertension Clinic systolic blood pressure is
180 mmHg or higher or clinic diastolic blood pressure is
110 mmHg or higher.
http://emedicine.medscape.com/article/241381-treatment
Management of hypertension
• The 2014 guidelines of the Eighth Joint National
Committee (JNC 8) recommended three important
changes to the 2003 guidelines:
• Setting more conservative blood-pressure goals for
adults 60 years of age or older (150/90),
• And for patients with diabetes or chronic kidney
disease (140/90).
New management of hypertension
• In the general population ages 60 and older,
pharmacologic treatment at a systolic blood pressure
(SBP) of 150 mmHg or higher or a diastolic blood
pressure (DBP) of 90 mmHg or higher.
• Should be treated to a goal SBP lower than 150
mmHg and a goal DBP lower than 90 mmHg.
• Younger than age 60, initiate pharmacologic treatment
at a DBP of 90 mmHg or higher or an SBP of 140
mmHg or higher and treat to goals below these
respective thresholds.
•
2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults: Report From the Panel
Members Appointed to the Eighth Joint National Committee (JNC 8),
Risk Factors for Developing
Hypertension
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Poor dietary habits
High sodium intake
Sedentary lifestyle, physical inactivity
High alcohol consumption
Dyslipidemia,
Dysglycemia (e.g. Impaired fasting glucose,
diabetes)
• Abdominal obesity
2014 Canadian Hypertension Education Program Recommendations
Assessment of the Overall
Cardiovascular Risk
• Search for exogenous potentially modifiable factors that can
induce/aggravate hypertension
-Prescription Drugs:
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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:
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Licorice root
Stimulants including cocaine
Salt
Excessive alcohol use
2013, the European Society of Hypertension
• With diabetes diastolic BP should be below 85 mm
Hg.
• Salt intake should be limited to 5 to 6 g per day
• Body-mass index (BMI) < 25 kg/m2 and waist
circumferences <102 cm in men and < 88 cm in
women.
• Ambulatory BP monitoring (ABPM) should be
incorporated into the assessment of risk
http://emedicine.medscape.com/article/241381-treatment
Epidemiology
• More than 20% of people in Isfahan have
hypertension.(year: 1386-1388)
• Women more than men have hypertension.
• In the USA prevalence is 29.1%,(2011-2012)
and similar between sexes. (NCHS Data Brief ■ No. 133
■ October 2013)
SCORE 10-Year Fatal Cardiovascular
Risk
2014 Canadian HypertEvaluation in Canadaension Education Program
Recommendations
SCORE
Canada : Systematic
Cerebrovascular and cOronary
Risk Evaluation
Find the cell nearest to the
person’s risk factors values :
Age
Sex
Smoking Status
Systolic Blood Pressure
Total-Chol. / HDL-C. Ratio
Indications for ABPM
In addition to patients with suspected white coat
hypertension, ambulatory monitoring should be
considered in the following circumstances:
• Suspected episodic hypertension (eg,
pheochromocytoma)
• Hypertension resistant to increasing medication
• Hypotensive symptoms while taking antihypertensive
medications
• Autonomic dysfunction
White coat hypertension
• In patients diagnosed as being hypertensive on a
first visit to a new physician, there is a mean 15 and
7 mmhg fall in the systolic and diastolic BP,
respectively, by the third visit with some patients not
reaching a stable value until the sixth visit .
• The prevalence of white coat hypertension ranges
from 10 to more than 20 percent, and appears to be
higher in children and the elderly
White coat hypertension
• White coat hypertension can also be seen in
patients with apparently resistant
hypertension
• The likelihood of normal ambulatory
pressures is low (less than 5 percent) in
patients with office diastolic pressures ≥105
mmHg but such patients may still have a
white coat effect underestimates the efficacy
of therapy
Definitions based upon ambulatory
and home readings
The diagnosis of hypertension using ambulatory blood
pressure monitoring :
• A 24-hour average above 135/85 mmHg
• Daytime (awake) average above 140/90 mmHg
• Nighttime (asleep) average above 125/75 mmHg
Home Measurement of Blood
Pressure
Home BP measurement should be
encouraged to increase patient involvement
in care
• Which patients?
– Uncomplicated hypertension
– Suspected non adherence
– Office-induced blood pressure elevation (white coat
effect)
– Masked hypertension
Average BP > 135/85 mm Hg should be considered elevated
2014 Canadian Hypertension Education Program Recommendations
Not all Patients are Suited to Home
Measurement
• Undue anxiety in response to high blood pressure
readings
• Physical or mental disability prevents accurate technique
or recording
• Irregular pulse or arrhythmias prevent accurate readings
• Lack of interest
Most patients can be trained to measure blood pressure
Periodic reassessment of technique and retraining is desirable
Recommended Electronic Blood Pressure Monitors
for Home Blood Pressure Measurement
Home Measurement: Doing it Right
EQUIPMENT
• Validated device
• www.hypertension.ca
• www.heartandstroke.ca/bp
• Size is appropriate
• Ensure the device is accurate in
the patient at purchase and
annually
2014 Canadian Hypertension Education Program Recommendations
Recommended Models
• A&D® or LifeSource® Models: UA651, UA651BLE,
UA705, UA767, UA767Fam, 767PAC, 767Plus, 787EJ,
787AC, 787W, 631, 853, 854, 855, UA 1020CN (UA
1030CN)
• Atico International and Le Groupe Jean Coutu Models:
KD-556, KD-5031, KD-5963, A58H0401
• Beurer North America LP Models: Beurer BM35, Beurer
BM44, Beurer BM60, Beurer BM47, Beurer BM58
• HoMedics® Models:
BPA-040-0CA (BP-A04-00CA)
BPA-060-0CA (BP-A06-00CA)
BPA-110-2CA (BP-A11-02CA)
• iHealth Models: Blood Pressure DOCK-BP 3, iHealth BP5
Recommended Models
• Microlife® or BIOS® Models (also sold as 'private label
brands'): BP 3BTO-A, BP 3AC1-1, BP 3AC1-1 PC, BP
3AC1-2, BP 3AG1, BP 3BTO-1, BP 3BTO-A (2), BP 3BTOAP, RM 100, BP A100 Plus, BP A 100, BP 3AL1 – 3E, BP
3MX1-1, BP3MX1-3, 3AN1-3X, 3MS1-4K
• Omron® Models: HEM-705CPCAN, HEM-741CAN, HEM711DLXCAN, HEM-773ACCAN, HEM-775CAN, HEM790ITCAN, BP742CAN, BP760CAN, BP762CAN,
BP785CAN, BP710CANN, BP742CANN, BP765CAN,
BP761CAN, BP786CAN
• Physio Logic Model: HL868BA, 106-910, 106-915
• Thermor: BIOS Diagnostics BD201, BIOS
Diagnostics BD215, BD209 (BD204), A6PC
• Tremblay Harrison Inc Models : ABP-C1, ABP-C2 and
ABP-C3
Home Measurement of BP: Patient
Education
DO
• Read and carefully
follow the instructions
provided with the device
• Relax in a comfortable
chair with back support
for 5 minutes
• Sit quietly without
talking or distractions
(e.g. TV)
DON’T
•Measure if stressed, cold, in
pain or if your bowel or
bladder are uncomfortable
•Measure within 1 hour of
heavy physical activity
•Measure within 30 minutes of
smoking or drinking coffee
2014 Canadian Hypertension Education Program Recommendations
Laboratory testing in primary
hypertension
The only tests that should be routinely performed
include:
• Hematocrit, urinalysis, routine blood chemistries
(glucose, creatinine, electrolytes), and estimated
glomerular filtration rate (eGFR)
• Lipid profile (total and HDL-cholesterol,
triglycerides)
• Electrocardiogram
2014 Canadian Hypertension Education Program Recommendations
Additional tests in primary
hypertension
May be needed:
• Microalbuminuria is increasingly recognized to be an
independent risk factor for cardiovascular disease.
• Echocardiography is indicated to detect possible
1. end-organ damage in a patient with borderline blood
pressure values, thereby identifying some patients who
would not be treated based upon clinical criteria alone.
(Assessment of left ventricular dysfunction and the
presence of left ventricular hypertrophy)
2014 Canadian Hypertension Education Program Recommendations
Cardiovascular risks of hypertension
• Hypertension accounts for an estimated 54
percent of all strokes and 47 percent of all
ischemic heart disease events globally.
• Hypertension: the most important risk factor for
premature cardiovascular disease,
• More common than cigarette smoking,
dyslipidemia, and diabetes.
Components of cardiovascular risk factors in
patients with hypertension
Major risk factors
Target organ damage
Hypertension
Heart disease
Cigarette smoking
Left ventricular hypertrophy
Obesity (BMI ≥30 kg/m2)
Angina or prior myocardial
infarction
Physical inactivity
Prior coronary revascularization
Dyslipidemia
Heart failure
Diabetes mellitus
Stroke or transient ischemic
attack
Microalbuminuria or estimated GFR <60
mL/min
Chronic kidney disease
Age >55 years for men, >65 years in women Peripheral arterial disease
Family history of premature coronary
disease
Retinopathy
Men - <55 years
Women - <65 years
The JNC 7 report. JAMA 2003; 289:2560.
Routine Laboratory Tests
Follow-up investigations of patients with hypertension
Diabetes develops in 1-3%/year of those with drug treated
hypertension.
Assess for diabetes more frequently in:
1. treated with a diuretic or beta blocker,
2. obese,
3. sedentary,
4. with higher fasting glucose and
5. unhealthy eating patterns.
• For those with diabetes or chronic kidney disease: assess
urinary albumin excretion, since therapeutic
recommendations differ if proteinuria is present.
2014 Canadian Hypertension Education Program Recommendations
Who should be treated?
• In the absence of end-organ damage, a patient should
not be labeled as having hypertension unless: the blood
pressure is persistently elevated after three to six
visits over a several month period.
• All patients should undergo appropriate
nonpharmacologic (lifestyle) modification before
medications.
Who should be treated?...
• Medication: persistently ≥140 mmHg and/or the
diastolic pressure is persistently ≥90 mmHg.
• Starting with two drugs should be considered in
patients with a baseline blood pressure
above160/100 mmHg.
• The benefits of antihypertensive therapy are less
clear or controversial in :
1. mild hypertension (blood pressure less
than 150/90 mmHg) and no preexisting
cardiovascular disease, and
2. elderly patients who are frail.
BEDTIME VERSUS MORNING DOSING
• The average nocturnal blood pressure is
approximately 15 percent lower than daytime
values.
• Failure of the blood pressure to fall by at least 10
percent during sleep is called "nondipping," and is a
stronger predictor of adverse cardiovascular
outcomes than daytime blood pressure.
• Taking at least one medication (non-diuretic) at
bedtime significantly reduced all-cause mortality.
• Similar observations in hypertensive patients with
CKD.
©2013 UpToDate ® Overview of hypertension in adults
Initiation of combination therapy
• Supine and standing pressures prior to the initiation of
combination therapy in patients at increased risk for
orthostatic (postural) hypotension, such as elderly
patients and those with diabetes.
• Orthostatic hypotension: within two to five minutes of
quiet standing, one or more of the following is present:
• At least a 20 mmHg fall in systolic pressure
• At least a 10 mmHg fall in diastolic pressure
• Symptoms of cerebral hypoperfusion, such as
dizziness
©2013 UpToDate ® Overview of hypertension in adults
New management of hypertension
• Referral:
 Goal BP cannot be reached using the above strategy or,
 To manage complicated patients.
• It's certainly not uncommon for elderly patients to
become dizzy on standing because of the
antihypertensive medication or medications they
take. Such patients, are at an increased risk for falls
and their sequelae.
2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults: Report From the Panel
Members Appointed to the Eighth Joint National Committee (JNC 8).
Perioperative management of
hypertension
• Of 76 patients who died of a cardiovascular
cause within 30 days of elective surgery, a
preoperative history of hypertension was four
times more likely than among 76 matched
controls.
BLOOD PRESSURE RESPONSE
DURING ANESTHESIA
• Induction of anesthesia: systolic blood
pressure can increase by 90 mmHg and heart
rate by 40 beats per minute.
• period of anesthesia: The mean arterial
pressure tends to fall, intraoperative
hypotension.
• Immediate postoperative: Blood pressure and
heart rate slowly increase.
Perioperative management of hypertension
PERIOPERATIVE RISKS ASSOCIATED
WITH HYPERTENSION
• Diastolic dysfunction from left ventricular
hypertrophy, systolic dysfunction leading to
congestive heart failure, renal impairment, and
cerebrovascular and coronary occlusive
disease.
Six independent predictors of major cardiac complications
High-risk type of surgery (examples include vascular surgery
and any open intraperitoneal or intrathoracic procedures)
History of ischemic heart disease (history of MI or a positive
exercise test, current complaint of chest pain considered to be
secondary to myocardial ischemia, use of nitrate therapy, or
ECG with pathological Q waves; do not count prior coronary
revascularization procedure unless one of the other criteria
for ischemic heart disease is present)
History of HF
History of cerebrovascular disease
Diabetes mellitus requiring treatment with insulin
Preoperative serum creatinine >2.0 mg/dL (177 µmol/L)
Safety of antihypertensive drugs
preoperatively
• Abruptly discontinuing some medications (eg, beta
blockers, clonidine ) may be associated with
significant rebound hypertension.
• Most antihypertensive agents can be continued until
the time of surgery, taken with small sips of water on
the morning of surgery.
• ACEI,ARB: withhold them on the morning of surgery
in patients who are taking them for congestive heart
failure in whom the baseline blood pressure is low,
OR in renal failure patients to avoid significant
hypotension during the induction of anesthesia.
Safety of antihypertensive drugs
preoperatively…
• Calcium channel blockers : increased
incidence of postoperative bleeding, probably
due to inhibition of platelet aggregation,
• Withdrawal syndromes: clonidine, methyldopa,
guanfacine and the beta blockers are associated
with acute withdrawal syndromes that can lead
to adverse perioperative events.
These
drugs should not be abruptly stopped
perioperatively.
Safety of antihypertensive drugs
preoperatively…
• Centrally acting sympatholytic drugs:
Rebound hypertension usually occurs after
abrupt cessation of fairly large oral doses
(eg, greater than 0.8 mg/day), but has also
been noted with transdermal clonidine.
• Beta blockers: reduce intraoperative
myocardial ischemia, recommended that
patients with one or more risk factor for
CHD be given beta blockers
perioperatively.
POSTOPERATIVE HYPERTENSION
Hypertension usually begins within 30 minutes of
the completion of surgery and lasts
approximately two hours.
• History of hypertension preoperatively
• Pain
• Excitement on emergence from anesthesia
• Hypercarbia
• Type of surgery
Indications for therapy
• A marked rise in blood pressure following surgery
should be treated immediately.
• Remedial causes: pain, agitation, hypercarbia,
hypoxia, hypervolemia, and bladder distention
• Chronic antihypertensive therapy should resume
with their usual medications.
• Therapy should be considered for patients with a
sustained systolic blood pressure above 180 mmHg
or diastolic blood pressure greater than 110 mmHg,
once remedial causes have been excluded or
treated.
Postoperative hypertension
Choice of drugs
• Patients taking diuretics may be given
parenteralfurosemide or bumetanide .
• Patients taking beta blockers may be given
parenteral propranolol , labetalol , or esmolol .
• Patients taking an ACE inhibitor may be given
parenteral enalaprilat .
• Patients taking centrally acting agents can be
given a clonidine patch.
• Patients taking calcium channel blockers can be
given intravenous nicardipine .
Postoperative hypertension
Uptodate® Oct 2013
SUMMARY 1
• The ideal circumstance is to normalize blood
pressure (eg, to less than 140/90 mmHg) for
several months prior to elective surgery.
• It is not necessary to postpone elective
procedures in patients with a blood pressure
below 170/110 mmHg.
• Elective surgery should be postponed in
patients with blood pressures
above 170/110 mmHg.
• Such patients who require urgent surgery
should be treated with a parenteral drug acutely.
Perioperative management of hypertension
SUMMARY 2
• Patients who are taking chronic
antihypertensive medications should continue
taking their medication until the time of surgery.
• The drug can be administered with a sip of
water on the morning of surgery and resumed
postoperatively as needed.
• Alternative parenteral agents can be prescribed
for patients who are unable to resume oral
medications.
Perioperative management of hypertension
SUMMARY 3
• In particular, beta blockers and centrally acting
agents such as clonidine should not
be stopped acutely.
If necessary,
• Intravenous propranolol or labetalol can be
administered to patients taking beta blockers
• Or transdermal clonidine can be administered
to patients taking clonidine.
Perioperative management of hypertension
SUMMARY 4
• Remedial causes of postoperative
hypertension such as pain, agitation,
hypercarbia, hypoxia, hypervolemia,
and bladder distention should be
excluded or treated.
• Once this has been done, therapy
should be considered for patients with a
persistent systolic blood pressure
above 180 mmHg or a diastolic blood
pressure above 110 mmHg.
Perioperative management of hypertension
Thank
you
‫متشکرم‬