Monitoring hypertensive patient in

the current practice of a GP

 The most common serious disease in adults in Europe
and the U.S., over 50% of the population elder than 60
years has hypertension.
Major cardiovascular risk-factor.
If untreated, decreases the length of life.
Aplying the correct treatment increases lifespan and
decreases the risk of stroke and coronary disease.
Romania-4th place in mortality caused by cardiovascular
disease.
The second most frequent pathology in Romania;
placed in the top five diseases with the highest
hospitalization .
 Definition and Classification of BP levels
for adults patients- 2009
Category Systolic BP Diastolic BP
Optimal BP Less than 120 and Less than 80

Normal BP 120-129 and/or 80-84

High normal BP 130-139 and/or 85-89

1st degree hypertension 140-159 and/or 90-99

2nd degree hypertension 160-179 and/or 100-109

3rd degree hypertension Over 180 and/or Over 110

Isolated systolic hypertension Over 140 and Less than 90

 BP MEASUREMENT

Patient sitting, resting for 5 min;

Authorised and adequate BP measurement device;
At least two measurements at 1-2 min interval;
3 measurements during a week;
No coffee 1 hour before, no smoking 15 min before,no
sympathomimetic medication ;
In supine and standing (at 1 and 5 min)-old patients;
Both arms;
Both legs-young patients;
Children echografic measurement;
BP measurement at home (before meals or medication);
BP-Holter measurement (dipper/nondipper patients profile).
Ankle-arm index measurement.
 MANAGEMENT OF
HYPERTENSIVE PATIENTS
Anamnesis;
Clinical exam;
Laboratory exam;
Cardiovascular risk stratification ( the risk of
cardiovascular events in 10 years):
Cardiovascular risk factors;
Diabetes;
Subclinical organ damage or cardiovascular disease or
renal hypertension;
The complex treatment of hypertension;
Hypertensive patient monitoring (3 months-high and
very high additional risk, 6 months small and
medium additional risk) .
 Anamnesis and clinical
examination
BP values;
Lifestyle : salt, alcohol, smoking, physical activity, obesity in young
patients;
NSAIDs, corticosteroids, oral contraceptives;
Family history;
Personal history: stroke, CHF, CAD, diabetes, kidney disease, gout,
dyslipidemia;
The presence and the results of previous antihypertensive treatments;
Symptoms: dizziness, visual disturbances, palpitations,
breathlessness, chest pain, headache, etc.
Clinical exam:
the correct BP measurement;
BMI;
Waist circumference;
Heart examination;
Peripheral arteries examination;
Lungs examination.
 Laboratory examination
Plasma Glucose (fasting) ;
Total cholesterol, HDL, LDL, triglycerides;
Uric acid;
Serum creatinine and potassium ;
CBC;
Urinalysis;
EKG SS-Sokolov-Lyon> 38 mm;
Echocardiography;
Carotid and femoral ultrasonography;
Postprandial Plasma Glucose
CRP;
Creatinine clearance;
Microalbuminuria;
Eye fundus exam;
 Secondary hypertension-causes
Renal parenchymal disease: polycystic kidney,
hydronephrosis, acute and chronic glomerulonephritis,
chronic pyelonephritis , diabetic nephropathy;
Renovascular hypertension (abdominal murmurs
paraumbilical) ;
Endocrine: pheochromocytoma, Cushing syndrome ,
hyperthyroidism, primary aldosteronism, acromegaly;
Cardiovascular: coarctation of the aorta , aortic
insufficiency;
Neurological tumors, encephalitis;
Medicines: contraceptive, corticosteroids .
 Cardiovascular Risk Factors
a. uninfluenced:
Sex (male);
Age (male aged over 55 years, female aged over 65 years);
Black race;
Family history (cardiovascular diseases , male over 55 years,female over 65
years).
b. amenable:
Smoking;
Diet (fat, alcohol, salt, less vegetables);
Physical activity ( sedentary);
Stress;
Obesity (BMI over 30 kg/square meter, abdominal circumference over 102cm M,
over 88cm F );
Dyslipidemia (Chol over 190 mg/dl, LDL over 115 mg/dl, HDL less than 40 mg/dl
M, 46 mg/dl F, triglycerides over 150 mg/dl) ;
Diabetes (over 126 mg/dl, over 198 mg/dl after meal);
Kidney disease .
 Sub clinical ORGAN CHANGES
Left ventricular hypertrophy (LVH) (ECG-
Sokolov-Lyon index over 38mm, echo);
Arterial wall thickening (carotid) or
atherosclerotic plaques;
Ankle-arm index over 0.9;
Kidneys (microalbuminuria over 300mg/24h,
clearance (Cl) over 60 ml per min, creatinine
between 1.3 to 1.5 M / 1.2 to 1.4 F);
Brain (lacunar infarcts, leukoaraiosis).
 Cardiovascular risk stratification
Normal High 1st degree 2nd degree 3rd degree
BP normal HT HT HT
BP

Without risk Medium Medium Low added risk Moderate Additional

factors risk risk added risk high-risk

1/ 2 risk Low added Low added Moderate Moderate Very high

factors risk risk added risk added risk additional
risk

3 risk Moderate Additional Additional Additional Very high

factors/diabe added risk high-risk high-risk high-risk additional
tes/subclinic risk
al organ
damage

Cardiovascul Very high Very high Very high Very high Very high
ar/kidney additional additional additional risk additional risk additional
disease risk risk risk
Clinical target organ damage
Cerebrovascular disease (TIA, stroke);
Cardiac Pathology (myocardial infarction ,
angina, reperfusion injury, Chronic heart
failure ) ;
Kidney disease (nephropathy, creatinine over
1.4 / 1.5 mg / ml F / M, proteinuria over 300
mg per 24h);
Peripheral vascular disease;
Advanced retinopathy: hemorrhage,
papilledema, exudates.
 Predictive factors for
unfavorable evolution
SBP (Systolic blood pressure) over 180mmHg and / or DBP(diastolic
blood pressure) over 110mmHg;
DBP less than 70mmHg;
Nondipper profile (nocturnal decline by more than 10%, or increasing
nocturnal BP);
Pulse pressure over 53mmHg (SBP-DBP mean 24 hours) ;
Diabetes;
Metabolic syndrome;
Hyperuricemia (over 7/6mg/ml M / F);
Sleep-apnea;
Subclinical organ damage;
Microalbuminuria;
Drugs (NSAIDs, steroidal anti-inflammatory , erythropoietin,
cyclosporin);
Kidney damage (reduced number of nephrons ), renal agenesis,
subponderabilitate birth-
CRP;
 Hypertension Treatment
Target values: SBP 130 to 139 mmHg, DBP 80 to 85 mm Hg;
Complex ( changing lifestyle, drugs, risk factor treatment);
Whitout medication: normal to high hypertension= 1st degree
hypertension+ low additional risk;
Early medication:2nd and 3rd degree of hypertension ; 1st degree of
hypertension + additional risk, high or very high;
Combined therapy from the beginning of treatment;
monotherapy :patient over 80 years;
Influenced by: age, race, pregnancy status, clinical profile (diabetes
obesity, Metabolic syndrome ) sub clinical organ damage,
cardiovascular events.
Treatment of hypertension, non-
pharmacological measures
Weight loss;
Reducing salt intake less than 5g daily;
Limiting alcohol consumption at less than
20-30ml daily;
Physical activity (30-45 min / day)
Increased intake of vegetables and fruits (K);
Stop smoking;
Reduced fat intake ;
Fish oil consumption (omega 3 PUFAs).
 Medications
Thiazide diuretics: hydrochlorothiazide;thiazide-like diuretics:
indapamide; potassium sparing diuretcis; loop diuretics :
furosemide;
Calcium channel blockers (nifedipine, amlodipine, felodipine,
nitrendipina, verapamil, diltiazem);
ACE inhibitors (captoprilum, enalaprilum, perindoprilum,
fosinoprilum, ramiprilum, quinalaprilum, zofenoprilum);
Angiotensin receptor blockers (telmisartanum,
candesartanum, losartanum, irbesartanum);
Renin inhibitors (aliskiren);
Blockers (nebivololum, carvedilolum);
Other classes:alpha-blockers doxazosin, prazosin; centrally
acting antiadrenergic: clonidine, methyldopa , moxonidine-R
modulators of imidazole (rilmenidine) .
 Thiazide diuretics: systolic hypertension, black race, congestive heart
failure;
Medical history : age, LVH, angina, pregnancy, black race,
atherosclerosis;
ACE inhibitors: heart failure post myocardial infarction , diabetes,
microalbuminuria, LVH, metabolic syndrome ;
Angiotensin receptor blockers (ARB) : idem, if cough with ACE
inhibitors;
Blockers : angina, myocardial infarction , heart failure ,
tachyarrhythmias;
Most common associations: ACE inhibitors+ AC , AC + ARB, ACE
inhibitors + diuretics , diuretics + ARB, gliptine+ ARB, ACE inhibitors +
diuretics + AC , BB or centrally acting agents;unsuitable then:
blockers + diuretics; ARB+ ACE inhibitors;
Treating diabetes;
Statins;
Antiplatelet treatment.
 Planned care for patients with
hypertension
Evaluation of the patient perception of disease;
Initial evaluation of the hypertensive patient;
Providing information on disease and treatment ;
Initiation of therapy considering the degree of hypertension;
Correct measurement of BP at home and physician's cabinet;
Measures to increase compliance to treatment regimen;
Advices for lifestyle change;
Scheduling chronic patients control for adverse reactions;
Referral hypertensive patients with complications;
Reassessment from the target values at 3 months (additional
high or very high risk) and 6 months (moderate or low added
risk) ;
Reference to the specialist doctor in the situations mentioned.
Hypertensive patient dispensary
Accurate measurement of BP-staff training, patients
education;
Regular clinical examination according to the
classification of hypertension and the stratification
of cardiovascular risk;
Laboratory examinations to track risk factors target
organs damage, adverse reactions to medication;
Educational materials for patients;
Patients records in the registration documents ;
Increase compliance to treatment .
 METABOLIC SYNDROME
FID 2005
Abdominal Obesity (abdominal circumference over
94cm M, over 80 cm F);
Plus at least two criteria:
- triglycerides over 150mg/dl ;
- HDL less than 40mg/dl M, less than 46mg/dl F
- BP 135/85mmHg ;
- fasting glucose over 100mg/dl, or diagnosed
diabetes;
- inflammatory biomarkers (CRP);
- chemicals synthesized by adipocytes (TNF-, IL
6, leptin, adiponectin).