Dr birtwhistle hypertension PGY2 review 2014

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 histor

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

• 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

From 26 to 33 12 x 23 (standard adult model)

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

ABPM (If available)

Hypertension Visit 1

BP Measurement, History and Physical examination

Hypertensive Urgency / Emergency

Hypertensive Urgency / Emergency

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

≥ 135 SBP or ≥ DBP 85 < 135/85

< 135/85

Diagnosis

of HTN

Continue to follow-up

or

CFPC Objectives

Hypertension

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

patients requiring multiple medications, patients with an abdominal bruit, patients with hypokalemia in the

absence of diuretics):

a) Suspect secondary hypertension

b) Investigate appropriately

Diagnostic Work-Up

• History and physical

– Review for CV risk factors,

evidence of TOD and HTN

and monitor treatment

• Routine laboratory tests (grade D)

– Standard 12-lead ECG

• Lab tests for specific subgroups

– Diabetes & renal disease:

protein excretion

– Elevated creatinine, hx of

renal disease or proteinuria -

renal ultrasound

Search for Target Organ Damage

• Left ventricular dysfunction

• Coronary artery disease

– Angina or prior MI

– CHF

• Chronic kidney disease

• Peripheral arterial disease

Search for Cardiovascular Risk Factors

• Hypertension

• Male

• Increasing age

• Peripheral arterial disease

• Previous stroke or TIA

• Microalbuminuria or proteinuria

• Diabetes mellitus

• Smoking Source: 2011 CHEP Recommendations

• Family history of premature CVD

• Chronic kidney disease

• Abnormal lipid profile

• Sedentary lifestyle

• Left ventricular hypertrophy

Search for exogenous potentially modifiable 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

– Excessive alcohol use

III Assessment of the overall cardiovascular risk

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 disorders, other cardiovascular risk factors)

Lifestyle Recommendations for Prevention and

Treatment of Hypertension

To reduce the possibility of becoming hypertensive,

Reduce sodium intake to less than 1500 mg/day

• Healthy diet: high in fresh fruits, vegetables, low fat dairy products,

dietary and soluble fibre, whole grains and protein from plant sources, low in saturated fat, cholesterol and salt in accordance with Canada's Guide to Healthy Eating

I Regular physical activity: accumulation of 30-60 minutes of moderate

intensity dynamic exercise 4-7 days per week in addition to daily

activities; For non-hypertensive or stage 1 hypertensive

individuals, the use of resistance or weight training exercise (such

as free weight lifting, fixed-weight lifting, or handgrip exercise) does not adversely influence blood pressure

• Low risk alcohol consumption: (≤2 standard drinks/day and less

than 14/week for men and less than 9/week for women)

• Attaining and maintaining ideal body weight (BMI 18.5-24.9 kg/m 2 )

• Waist Circumference: Men <102 cm Women <88 cm

Usual blood pressure threshold values for initiation of

pharmacological treatment of hypertension

I Indications for Pharmacotherapy

General population (including

I Indications for Pharmacotherapy

after diagnosis of hypertension (1)

• Patients at low risk with stage 1 hypertension

(140-159/90-99 mmHg)

• lifestyle modification can be the sole

therapy

• Patients with target organ damage (e.g left

ventricular hypertrophy) or chronic kidney disease

(140-159/90-99 mmHg)

• Treat with pharmacotherapy

• Patients with diabetes should continue to be

considered for pharmacotherapy if the blood pressure

is equal or over 130/80 mmHg

V Treatment of Adults with Systolic/Diastolic Hypertension

without Other Compelling Indications

TARGET <140/90 mmHg

INITIAL TREATMENT AND MONOTHERAPY

• BBs are not indicated as first line therapy for age 60 and above

blocker*

Beta-Long acting CCBThiazide ACEI ARB

Lifestyle modification therapy

ACEI, ARB and direct renin inhibitors are contraindicated in pregnancy and

caution is required in prescribing to women of child bearing potential

A combination of 2 first line drugs may be considered as initial therapy if the blood pressure

is >20 mmHg systolic or >10 mmHg diastolic above target

V Considerations Regarding the Choice of

First-Line 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

over without another compelling indication.

• Diuretic-induced hypokalemia should be avoided through the use of

potassium sparing agents if required.

• The use of dual therapy with an ACE inhibitor and an ARB should only be

considered in selected and closely monitored people with advanced heart

failure or proteinuric nephropathy.

• ACE-inhibitors are not recommended (as monotherapy)

for black patients without another compelling indication.

V Add-on Therapy for Systolic/Diastolic Hypertension

without Other Compelling Indications

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 (such as alpha blockers or centrally

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

lowering) indication

• Combinations of an ACEI with an ARB do not reduce

cardiovascular events more than the ACEI alone and

have more adverse effects therefore are not generally recommended

Drug Combinations cont’d

• Caution should be exercised in combining a non

dihydropyridine CCB (eg verapamil or diltiazem) and a beta blocker to reduce the risk of bradycardia or heart block.

• Monitor serum creatinine and potassium when combining K sparing diuretics, ACE inhibitors and/or angiotensin

receptor blockers.

• If a diuretic is not used as first or second line therapy, triple dose therapy should include a diuretic, when not

contraindicated

III Treatment Algorithm for Isolated Systolic

Hypertension without Other Compelling Indications

INITIAL TREATMENT AND MONOTHERAPY

Thiazide diuretic

Long-acting DHP CCB

Lifestyle modification

therapy

ARBTARGET <140 mmHg (< 150 mmHg if age > 80 years)

VI Treatment of Hypertension in Patients with

Ischemic Heart Disease

• Caution should be exercised when combining a non DHP-CCB

and a beta-blocker

• If abnormal systolic left ventricular function: avoid non

DHP-CCB (Verapamil or Diltiazem)

• Dual therapy with an ACEI and an ARB are not recommended

in the absence of refractory heart failure

• The combination of an ACEi and CCB is preferred

1 Beta-blocker

2 Long-acting CCB Stable angina

ACEI are recommended for most

patients with established CAD*

ARBs are not inferior to ACEI in IHD

Short-acting nifedipine

*Those at low risk with well controlled risk factors may not benefit from ACEI therapy

VI Treatment of Hypertension in Patients with Recent

ST Segment Elevation-MI or non-ST Segment

Elevation-MI

Long-acting Dihydropyridine CCB*

Beta-blocker and ACEI or ARB

Recent

myocardial

infarction

Heart Failure

? NO

YES

Long-acting CCB

If beta-blocker contraindicated or not effective

*Avoid non dihydropyridine CCBs (diltiazem, verapamil)

VII Treatment of Hypertension with Left Ventricular

Systolic Dysfunction

Beta-blockers used in clinical trials were bisoprolol, carvedilol and metoprolol

If additional therapy is needed:

• Diuretic (Thiazide for hypertension; Loop for volume control)

• for CHF class III-IV or post MI: Aldosterone Antagonist

Systolic

cardiac

dysfunction

• ACEI and Beta blocker

• if ACEI intolerant: ARBTitrate doses of ACEI or ARB to those used in clinical trials

If ACEI and ARB are contraindicated: Hydralazine and Isosorbide dinitrate in combination

If additional antihypertensive therapy is needed:

• ACEI / ARB Combination

• Long-acting DHP-CCB (Amlodipine)

Non

dihydropyridine

CCB

VIII Treatment of Hypertension

for Patients with Cerebrovascular Disease

Strongly consider blood pressure reduction

in all patients after the acute phase of

stroke or TIA

An ACEI / diuretic combination is preferred

Stroke

TIA

Combinations of an ACEI with an ARB are not recommended

IX Treatment of Hypertension in Patients with Left

Hypertensive patients with left ventricular hypertrophy should be

treated with antihypertensive therapy to lower the rate of subsequent cardiovascular events.

X Treatment of Hypertension in Patients with Non

Diabetic Chronic Kidney Disease

Chronic kidney disease

and proteinuria *

ACEI/ARB:

Bilateral renal artery stenosis

ACEI or ARB (if ACEI tolerated)

Combination with other agents

Additive therapy: Thiazide diuretic.

Alternate: If volume overload: loop diuretic

Target BP: < 140/80 mmHg

* albumin:creatinine ratio [ACR] > 30 mg/mmol

or urinary protein > 500 mg/24hr

Monitor serum potassium and creatinine carefully in patients with CKD prescribed an ACEI or ARB

Combinations of a ACEI and a ARB are specifically not recommended in the absence of proteinuria

XI Treatment of Hypertension in Patients with

Renovascular Disease

Does not imply specific treatment choice

Renovascular disease

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, or deteriorating renal function, or bilateral atherosclerotic renal artery lesions (or tight atherosclerotic stenosis in a single kidney), or recurrent episodes of flash pulmonary edema