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HYPERTENSION

HIGH BLOOD PRESSURE


ELEVATED BLOOD PRESSURE
RAISED BLOOD PRESSURE
HYPERTENSION

IN A PATIENT WITH HIGH BLOOD PRESSURE:


4 ISSUES:
1. Is the patient truly hypertensive ?
2. Are there any identifiable secondary causes ?
3. is target organ damage present ?
4. Are there co-existing cardiovascular risk factors associated
and/or associated clinical condition present

Routine steps for accurate measurement


of blood pressure

Rest the patient (seated) for at least 5 mins in a quiet


con fortable room
. Use a calibrated aneroid device (a validated and recently
calibrated electronic electronic device may may also be used
. Choose cuff with appropriate width of bladder
. Record with cuff at heart level
. Deflate cuff at 2 mmHg/sec
. First sound = systolic reading, disappearance = diastolic
reading
. Repeat measurement at least x2 (first visit: x3) & take average
value
. Take BP in both arms at least once; record which arm is used;
patient position ( seated, supine, standing) & pulse rate.
. Measure BP at + 1 & 5 mins after standing ( especially in older
patients and those with diabetes).

BP Measurement Techniques
Method

Brief Description

In-office

Two readings, 5 minutes apart, sitting


in chair. Confirm elevated reading in
contralateral arm.

Ambulatory BP
monitoring

Indicated for evaluation of white-coat


HTN. Absence of 1020% BP decrease
during sleep may indicate increased
CVD risk.

Self-measurement

Provides information on response to


therapy. May help improve adherence
to therapy and evaluate white-coat
HTN.
JNC 7 2003

Office BP Measurement
Use auscultatory method with a properly calibrated and validated
instrument.
Patient should be seated quietly for 5 minutes in a chair
(not on an exam table), feet on the floor, and arm supported at heart
level.
Appropriate-sized cuff should be used to ensure accuracy.
At least two measurements should be made.
Clinicians should provide to patients, verbally and in writing,
specific BP numbers and BP goals.
JNC 7 2003

How to measure blood pressure accurately


sphygmomanometer
Patient should be seated and relaxed, preferably for several minutes
prior to to the measurement and in a quiet room.
Appropriate cuff size.
Average the readings. If the first two readings differ by more than 10 mmHg
systolic or 6 mmHg diastolic or if the initial readings are high, take several
readings after five minutes of quiet rest, until consecutive readings do not
vary by greater than these amounts.
Ideally, patients should not take caffeine-containing beverages or
smoke for at least two hours before blood pressure is measured,
..
Australia, 2004

Box 2 Procedures for blood pressure measurement


When measuring blood pressure, care should be taken to
.. to sit for several minutes in a quiet room before beginning blood pressure
measurements.

Take at least two measurements spaced by 1-2 min, .

Use a standard bladder . but have a larger and a smaller bladder available for fat and
thin arms, respectively.

Have the cuff at the heart level, whatever the position of the patient.
Use phase I and V .

Measure blood pressure in both arms at first visit to detect possible differences
..

Measure blood pressure 1 and 5 min after assumption of the standing position in elderly
subjects, diabetic patients,..

Measure heart rate by pulse palpation (30 s) after the second measurement in the sitting
position.

Box 3 Position statement: Blood


pressure measurement
Blood pressure values measured in the doctors office or the clinic should commonly be used as
reference.
Twenty-four-hour ambulatory blood pressure monitoring may be considered of additional
clinical value, when:
- considerable variability of office blood pressure is found over the same or different visits;
- high office blood pressure is measured in subjects otherwise at low global cardiovascular risk;
- there is marked discrepancy between blood pressure values measured in the office and at
home;
- resistance to drug treatment is suspected;
- research is involved.
Self-measurement of blood pressure at home should be encouraged in order to:
- provide more information for the doctors decision;
- improve patients adherence to treatment regimens
Self-measurement of blood pressure at home should be discouraged whenever:
- it causes patients anxiety;
- it induces self-modification of the treatment regimen.
* Normal values are different for office, ambulatory and home blood pressure.

Are there identifiable secondary causes:


1. Clinical and family history
drug intake ( prescription & non-prescription, food
supplement)
2. Full physical examination
3. Laboratory investigation:
urinalysis ( protein, glucose, blood, microscopy)
blood (Hb, creatinin, K+, fasting glucose, lipid
profile)
4. ECG

Is target organ damage present?


Brain

Heart

Stroke
TIA
Vascular dementia

CAD
LV hypertrophy
LV syst. dysfunction

Target organ damage

Vascular system
Kidneys
Hypertensive
nephropathy

Hypertensive retinopathy
Aortic aneurysm
PVD
Overt atherosclerotic

Clinical assessment of target organ damage


Target organ

Damage indicators

HEART

* History of heart failure, angina pectoris , MI,


or coronary revascularization
* Physical/ECG findings of LVH (Confirm with Echo)

BRAIN

* History of TIA, stroke or impaired cognitive function


* Focal neurological impairment: carotid bruits

KIDNEYS

* Elevated serum creatinin


microalbuminuria or proteinuria

RETINA

* Hypertensive retinopathy changes


( copper wiring, a-v nicking etc)

PERIPHERAL
VASCULAR SYSTEM

* History of intermittent or rest claudication


* Abdominal or carotid bruits, reduced peripheral
pulses

WHO-ISH Guidelines for


Management of Hypertension:
Stratification of Cardiovascular Risk
Blood Pressure (mm Hg)
Grade 1

Grade 2

Grade 3

Mild
hypertension

Moderate
hypertension

Severe
hypertension

Other risk factors and


disease history

SBP 140159
or DBP 9099

SBP 160179
or DBP 100109

SBP 180
or DBP 110

I No other risk factors

Low risk

Med risk

High risk

II 12 risk factors

Med risk

Med risk

Very high risk

III 3 or more risk factors


or TOD or diabetes

High risk

High risk

Very high risk

Very high risk

Very high risk

Very high risk

IV ACC

TOD = Target-organ damage


ACC = Associated clinical conditions

Guidelines subcommittee. WHO-ISH


Guidelines. J Hypertens 1999;17:151-183.

2003 ESH / ESC Guidelines:


Stratification of risk to quantify prognosis
Other risk factors
& disease history
__
No other risk factors

Normal
High normal Grade 1
SBP 120-129 130-139
140-159
or DBP 80-84 85-89
90-99
Aver. Risk

Aver.risk

1-2 risk factors

Low added
risk

Low added
risk

> 3 risk factors


or TOD or DM

Mod. added
risk

ACC

Grade 3
> 180
> 110

Mod. added High added


risk
risk

Mod. added Mod. added Very high


risk
risk
added risk

High added High added High added Very high


risk
risk
added risk
risk

High added Very high


risk
added risk

ACC: associated clinical conditions


TOD: target organ damage

Low added
risk

Grade 2
160-179
100-109

Very high
added risk

Very high
added risk

Very high
added risk

2003 ESH/ESC, J Hypertension 2003;21:1011-1053

Threshold for intervention


initial blood pressure (mmHg)

>180/110

160/179
100-109

140/159
90-99

*
180/110

140/159
90-99

Target organ damage or


cardiovascular complications or
diabetes or 10 year risk of
cardiovascular disease 20%
Treat

Treat

Treat

130/139
85-89

<130/85

<140/90

No target organ damage and no


cardiovascular complications
and no diabetes and 10 year risk
of cardiovascular disease
<20%
Observe, reassess risk of
cardiovascular disease yearly

Reassess
yearly

Reassess
in 5 years

* Unless malignant phase of hypertensive emergency confirm over 1-2 weeks then treat.
If can cardiovascular complications, target organ damage, or diabetes is present, confirm over 3-4 weeks then threat, if
absent remeasure weekly threat if blood pressure persists at these levels over 4-12 weeks.
If cardiovascular complications, target organ damage, or diabetes is present, confirm over 12 weeks then threat, if absent
remeasure monthly and threat if these levels are maintained and estimated 10 year cardiovascular disease risk is 20%.
Assessed with risk chart for cardiovascular disease.

JNC 7: Management of Hypertension


by Blood Pressure Classification
Initial Drug Therapy
BP Classification
Normal
<120/80 mm Hg

Lifestyle
Modification

Without Compelling
Indication

With Compelling
Indication

Encourage

Prehypertension
120-139/80-89 mm Hg

Yes

Stage 1 hypertension
140-159/90-99 mm Hg

Yes

Thiazide-type diuretics
for most; may consider
ACE-I, ARB, BB, CCB, or
combination

Drug(s) for the compelling


indications; other
antihypertensive drugs
(diuretics, ACE-I, ARB, BB,
CCB) as needed

Stage 2 hypertension
160/100 mm Hg

Yes

2-drug combination for most


(usually thiazide-type diuretic
and ACE-I, ARB, BB, or
CCB)

Drug(s) for the compelling


indications; other
antihypertensive drugs
(diuretics, ACE-I, ARB,
BB, CCB) as needed

No drug indicated

Drug(s) for the


compelling indications

ACE-I = angiotensin-converting enzyme inhibitor; ARB = angiotensin-receptor blocker; BB = beta


blocker; CCB = calcium channel blocker.
Chobanian AV et al. JAMA. 2003;289:2560-2572.

AUSTRALIA 2003

The major classes of anti-hypertensive drugs


1. Diuretics
. Loop
. K+-sparing
. Thiazide
. Thiazide-like
2. Adrenergic inhibitors
. Alpha-1 blockers
. Beta-blockers
. Combine
3. RAS inhibitots
. ACE-inhibitors
. ARB
4. Ca-channel blockers (CCB)
. Dihydropyridin
. Non-dihydropyridine
5. Imidazoline receptor
agonist
6. Vasodilatation

furosemide, bumetanide
amiloride, spironolactone
hydrochlorothiazide, bendrofluazide
chlorthalodone, indapamide
Doxazosin, Prazosin
Atenolol, Metoprolol, Bioprolol, Carvedilol
Labetalol
Captopril, Enalapril, Perindopril etc
Losartan, Valsartan, Candesartan etc
Nifedipin, Amlodipin
Diltiazem, Verapamil
monoxidine, nilmenidine
hidralazine, minoxidil

Blood pressure treatment thresholds


Recommended blood pressure targets
Patient group
Organisation

Uncomplicatied
hypertension

American Kidney
Assiciation (2001)

+ DM or
Renal disease

+ RF with
proteinuria*

<130/80

<125/75

British Hypertension
Society (1999)

< 140/85

< 140/80

<125/75

Canadian Hypertension
Society (1999)

< 140/90

< 130/80

<125/75

European Hypertension
Society (2003)

< 140/90

< 130/80

<125/75

JNC-VII (2003)

< 140/90

< 130/80

<125/75

National Kidney Foundation


US (2000)

< 140/90

< 130/80

<125/75

WHO-ISH (1999)

< 140/90

< 130/80

<125/75

*Proteinuria : > 1 gram per 24 hours

Recommendations for healthy lifestyle


Recommended for healthy lifestyle
Lifestyle parameter

Health recommendation

Diet

Exercise

Body weight

Alcohol comsumption

Smoking cessation

Eat more whole grain products


Eat more-fresh fruits & vegetarian
Use low-fat milk products
Use low-fat meat & alternatives
Reduce saturated fat content
Reduce salth content (6 g per day max. 1 teaspoon
30-60 min of endurance activies x 4-7 days per week
(e.g. brisk walking, jogging, cycling)
Maintain BMI*@ 20-25

Limit to 0-2 standard drinks per day


People with elevated triglyceride levels should
eliminate alcohol completely
Smokers should be advised to quit ( cessation
programmes, nicotine replacement/drug therapy)
Encourage young people not to start

*BMI = weigth (kg)/height2(m) (Normal : 20-25; overweight ; 25-30; obese : >30)

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