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HYPERTENSION (2018 ESC/ESH Guidelines)
HOW TO DIAGNOSE HYPERTENSION ● Age
● Smoking (current or past history)
● Hypertension is defined as o ffice SBP values ≥ 140 mmHg ● Total cholesterol and HDL-C
and/or DBP values ≥ 90 mmHg. ● Uric Acid
● Masked hypertension is defined in people whose BP is ● Diabetes
normal in the office but elevated on out-of-office BP ● Overweight/obesity
measurements ● Family history of premature CVD (men aged <5 years and
women aged <65 years)
Abbreviations: ● Family or prenatal history of early-onset hypertension
HMOD: Hypertension-mediated organ damage ● Early-onset menopause
● Sedentary lifestyle
● Psychosocial and socioeconomic factors
● Heart rate (resting values >80 bpm)
FACTORS INFLUENCING CV RISK IN PATIENTS WITH
HYPERTENSION
Demographic characteristics and laboratory parameters
● Sex (M>F)
FAMILY HEALTHCARE PROGRAM NOTES (SERVICE 5) PRIME I/ PRIME 10 CFM September 2020 | 2
BLOOD PRESSURE MEASUREMENT
Conventional Office BP Measurement
● Auscultatory or oscillometric semiautomatic or automatic
sphygmomanometers are preferred for measuring BP in the
doctor’s office
● BP must be initially measured in both upper arms, using an
appropriate cuff size for the arm circumference
● A consistent and significant SBP difference between arms
(ie >15mmHg) is associated with an increased CV risk
● When there is a difference in BP between arms, the arm
with the higher BP values should be used for all subsequent
measurements
● In o
lder people, people with DM, or people with other
causes of orthostatic hypotension, B P should be measured
1 min and 3 min after standing.
● Orthostatic hypotension - reduction in SBP of ≥ 20mmHg of
in DBP of ≥ 10 mmHg within 3 min of standing
● Heart rate must also be recorded at the time of BP
measurements because resting HR is an independent
predictor of CV morbid or fatal events
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● With readings in the morning and the evening
● Taken in a quiet room after 5 min of rest
● Patient seated with their back and arm supported
● 2 measurements taken, performed 1-2 min apart
Ambulatory BP monitoring
● Average BP readings over a defined period, usually 24h
● ABPM is a better predictor of HMOD than office BP
SCREENING AND DIAGNOSIS OF HYPERTENSION
Unattended Office BP Measurement
● White coat effect can be substantially reduced or
eliminated CLINICAL EVALUATION
● BP values are lower than those obtained by conventional Medical History
office BP measurement ● Time of the first diagnosis of hypertension, including
Out-of-office BP Measurement records of any previous medical screening, hospitalization,
● Uses either HBPM or ABPM, the latter usually over 24h etc.
Home BP Monitoring ● Record any current and past BP values
● Average of all BP readings performed with a ● Record current and past antihypertensive medications
semi-automatic, validated BP monitor for at least 3 days and ● Record other medications
preferably for 6-7 consecutive days before each clinic visit. ● Family history of hypertension, CVD, stroke, or renal disease
FAMILY HEALTHCARE PROGRAM NOTES (SERVICE 5) PRIME I/ PRIME 10 CFM September 2020 | 4
● Lifestyle evaluation, including exercise levels, body weight ● Comparison of radial with femoral pulse to detect
changes, diet history, smoking history, alcohol use, radio-femoral delay in aortic coarctation
recreational drug use, sleep history, and impact of any ● Signs of Cushing’s disease or acromegaly
treatments on sexual function ● Signs of thyroid disease
● History of any concomitant CV risk factors
● Details and symptoms of past and present comorbidities ROUTINE WORKUP FOR EVALUATION OF HYPERTENSIVE
● Specific history of potential secondary causes of PATIENTS
hypertension Routine Laboratory Tests
● History of past pregnancies and oral contraceptive use ● Hgb and/or Hct
● History of menopause and hormone replacement therapy ● Fasting blood glucose and HbA1c
● Use of liquorice ● Blood lipids: total cholesterol, LDL, HDL cholesterol
● Use of drugs that may have a pressor effect ● Blood triglycerides
● Blood potassium and sodium
PHYSICAL EXAMINATION AND CLINICAL INVESTIGATIONS ● Blood uric acid
Body Habitus ● Blood creatinine and eGFR
● Weight and height ● Blood liver function tests
● Waist circumference ● Urine analysis (microscopic, dipstick, albumin:creatinine
ratio)
Signs of HMOD ● 12-lead ecg
● Neurological exam and cognitive status
● Fundoscopic exam for hypertensive retinopathy
● Palpation and auscultation of heart and carotid arteries
● Palpation of peripheral arteries
● Comparison of BP in both arms (at least once)
Secondary Hypertension
● Skin inspection (cafe-au-lait patches of
neurofibromatosis//pheochromocytoma)
● Kidney palpation for signs of renal enlargement in
polycystic kidney disease
● Auscultation of heart and renal arteries for murmurs or
bruits indicative of aortic coarctation, or renovascular
hypertension
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ASSESSMENT OF HYPERTENSION-MEDIATED ORGAN DAMAGE Older people with Grade 1 HTN
(HMOD) ● Older people: ≥ 65 years
● Very old: ≥ 80 years
INITIATION OF BP-LOWERING DRUG TREATMENT
TREATMENT OF HYPERTENSION
Lifestyle Changes
● Salt restriction
TREATMENT OF HYPERTENSION ○ <6g a day ~1 teaspoon from Doc Sam; but <5 in ESH
2 Well-established strategies to lower BP: ● Moderation of alcohol consumption
● Lifestyle intervention ○ Men: 14 units per week
● Drug treatment ○ Women: 8 units per week
○ 1 UNIT = 125mL of wine or 250 mL of beer
Drug Treatment: Grade 1 HTN at Low Moderate Cardiovascular ○ Alcohol-free days and avoidance of binge drinking
Risk are also advised
● Lifestyle advice with BP-lowering drug treatment ● High consumption of vegetables and fruits
○ Low-fat dairy products
○ Unsaturated fatty acids (olive oil)
○ Mediterranean Diet
FAMILY HEALTHCARE PROGRAM NOTES (SERVICE 5) PRIME I/ PRIME 10 CFM September 2020 | 6
○ Caffeine has an acute pressor effect
○ Reduce consumption of sugar-sweetened soft
drinks
● Weight reduction
● Maintaining ideal body weight
● Regular physical activity
○ 30 mins of moderate-intensity dynamic aerobic
exercise
○ Walking, jogging, cycling, swimming on 5-7 days per
week
○ Resistance exercises 2-3 days per week of moderate
intensity
○ 150 min a week of vigorous-intensity aerobic
physical activity
● Smoking cessation
○ Nicotine replacement therapy
○ Varenicline
Pharmacological Therapy
● ACE Inhibitors
● Angiotensin-2 receptor blockers
● Beta-blockers
● Calcium channel blockers
● Diuretics
FAMILY HEALTHCARE PROGRAM NOTES (SERVICE 5) PRIME I/ PRIME 10 CFM September 2020 | 7
DRUG TREATMENT ALGORITHM FOR UNCOMPLICATED DRUG TREATMENT ALGORITHM FOR HYPERTENSION AND
HYPERTENSION CHRONIC KIDNEY DISEASE
Device-based Hypertension Treatment
● Carotid baroreceptor stimulation (Pacemaker and Stent)
DRUG TREATMENT ALGORITHM FOR HYPERTENSION AND ○ Lowers BP in patients with resistant hypertension
CORONARY ARTERY DISEASE ● Renal Denervation
○ Lays with the importance of sympathetic nervous
system influences on renal vascular resistance,
● Arteriovenous Fistula
○ Central iliac arteriovenous anastomosis
○ Fixed conduit between external iliac artery and vein
using a stent-like nitinol device
○ Reversible
○ Creates a diversion of arterial blood into the venous
circuit with immediate, verifiable reductions in BP
HYPERTENSION IN SPECIFIC CIRCUMSTANCES
Resistant Hypertension
● When the recommended strategy fails to lower office SBP
and DBP values to <140 mmHg and/or <90 mmHg
FAMILY HEALTHCARE PROGRAM NOTES (SERVICE 5) PRIME I/ PRIME 10 CFM September 2020 | 8
● The inadequate control of BP is confirmed by ABPM or Treatment of Resistant Hypertension
HBPM in patients whose adherence therapy has been ● Lifestyle changes
confirmed. ● Discontinue interfering substances
● Appropriate lifestyle measures ● Sequential addition of antihypertensive drugs to the initial
● Treatment with optimal or best-tolerated doses of three or triple therapy
more drugs, which include a diuretic, typically an ACE
inhibitor or an ARB and a CCB.
Pseudo-resistant Hypertension
● Causes:
○ Poor adherence to prescribed medicines
○ White-coat phenomenon
○ Poor office BP measurement technique
○ Marked brachial artery calcification
○ Clinician inertia
○ Lifestyle factors (obesity, high sodium intake)
○ Obstructive sleep apnea
○ Undetected secondary forms of hypertension
Diagnostic Approach to Resistant Hypertension
● Patient’s history
● Lifestyle characteristics
● Sodium and alcohol intake
● Physical examination, focusing on determining the presence Secondary Hypertension
of HMOD and signs of secondary hypertension ● Hypertension due to an identifiable cause
● Confirmation of treatment resistance by out-of-office BP ● Medication and other substances may cause a sufficient
measurements increase in BP to raise the suspicion of secondary
● Laboratory tests to detect electrolyte abnormalities hypertension.
(hypokalemia), diabetes, organ damage, or secondary ● A careful drug history is important
hypertension ● NSAIDs or glucocorticoids can antagonize the BP-lowering
● Confirmation of adherence to BP-lowering therapy effect of antihypertensive medications in patients treated
for hypertension
FAMILY HEALTHCARE PROGRAM NOTES (SERVICE 5) PRIME I/ PRIME 10 CFM September 2020 | 9
HYPERTENSION IN OLDER PATIENTS (AGE ≥65 YEARS)
● Advanced age has been a barrier to the treatment of
hypertension because of concerns about potential poor
tolerability and even harmful effects of BP-lowering
interventions in people whose vital organ perfusion is
impaired
● Follow treatment algorithm
● In very old patients, initiate monotherapy at the lowest
available doses
Reference:
https://academic.oup.com/eurheartj/article-lookup/doi/10.1093/e
urheartj/ehy339
HYPERTENSION IN YOUNGER ADULTS (AGE <50 YEARS)
● All younger adults with grade 1, grade 2 or more severe
hypertension
○ Lifestyle advice
○ Drug treatment