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Approach To Hypertension
Approach To Hypertension
Approach To Hypertension
DEFINITION
Persistent elevation of
Systolic BP of 140 mmHg or greater
And/ or
Diastolic BP of 90 mmHg or greater
BP (mmHg) Normal Pre hypertension HPT Stage 1 HPT Stage 2 systolic <120 120-139 140-159 160 diastolic <80 80-89 90-99 100
Based on average of two or more properly measured, seated BP readings on 2 or more office readings
Patient Evaluation
Objectives:
To assess lifestyle and identify cardiovascular risk factors or concomittant disorder that may affect prognosis and treatment To reveal identifiable cause of HPT To assess the presence of target organ damage.
SECONDARY CAUSES
Sleep apnoea Drug-induced or drug-related Chronic kidney disease Renovascular disease Endocrinopathies
Primary aldosteronism Phaeochromocytoma Cushing syndrome Acromegaly Thyroid and parathyroid disease
HISTORY
Duration and level of elevated BP if known Symptoms of secondary causes of HPT Symptoms of target organ damage Symptoms of concomitant disease Family history Dietary history Drug history Lifestyle and social history
PHYSICAL EXAMINATION
General (height, weight, waist circumference) Appropriate BP measurements Fundoscopy-hypertensive retinopathy:
grade 1: tortous artery grade 2: A-V nipping, grade 3: flame hemorrhage and cotton woolspots, grade 4: papillloedema
Bruit and peripheral pulses Systems examination (cardiovascular, respiratory, abdomen, neurological examinations) Lower limb edema
INVESTIGATIONS
Full blood count Renal function tests ( urea, creatinine, serum electrolytes, and uric acid) Urinalysis ECG Chest x-ray
JNC 7
Lifestyle modification
Stage I -Thiazide diuretics -May consider ACE-I, ARB, BB, CCB or combinations
Not at Goal BP Optimize dosage, add additional drugs, consider consultation with HPT specialist
TREATMENT
LIFESTYLE MODIFICATION
Reduction of weight Adopt DASH eating plan Dietary sodium reduction Physical activity Reduction of alcohol consumption
Lifestyle Modification
Weight reduction
As far as possible, aim ideal BMI Asians 18.5 23.5 kg/m2 Reduction of 5-10% in 6-12 months As little as 4.5 kg significantly reduce BP
Lifestyle Modification
Avoidance of alcohol
Intake 21 units (men) and 14 units (women) per week.
Lifestyle Modification
Healthy eating
Diet rich in fruits, vegetables and dairy products with reduced saturated and total fat can lower BP BP 11/6 mmHg in hypertensive patients
Post-MI
High CAD risk Diabetes Chronic renal disease 2 Stroke prevention X X X
X
X X
X
X X X X X X X
Non-DHP
X
Non-DHP
ACE- Inhibitor
ACEi captopril enalapril fosinopril lisinopril Starting daily dose 25mg bd 2.5mg od 10mg od 5mg od Maximum daily dose 50 mg tds 20 mg bd 40 mg od 80 mg od
2) Angiotensin Receptor Blocker - Recommended in ACEi intolerance patient - Preventing progression of diabetic retinopathy, and reduce major cardiac events. - Less side effect of dry cough
ARB
ARBs Candesartan Irbesartan losartan Valsartan telmisartan Starting dose 8 mg od 150mg od 50 mg od 80 mg od 20 mg od Maximum daily dose 16 mg od 300 mg od 100 mg od 100 mg od 160 mg od
3) Beta blocker - Useful in hypertensive patient with angina, tachyarrhytmia, or previous myocardial infarction - Contraindicated in obstructive airway disease, severe peripheral vascular disease and heart block. - Side effect: dyslipidemia, hypoglycemia, increase incidence of new onset of DM, erectile dysfunction and cold extremities.
Beta blockers
B Blockers acebutolol atenolol betaxolol bisoprolol metoprolol propanolol Starting dose 200mg bd 50 mg od 10 mg od 5mg od 50 mg bd 40 mg bd Maximum daily dose 400mg bd 100mg od 40mg od 200mg bd 200 mg bd 320 mg bd
4) Calcium channel blocker - Use as first line treatment and other combination with other drug - No undesirable adverse metabolic effect - Adverse effect: initial tachycardia, headache, flushing, constipation and ankle edema
CCB
CCBs Amilodipine Starting dose 5mg od Maximum daily dose 10 mg od
Diltiazem
felodipine
30mg tds
2.5mg od
60 mg tds
10 mg od
nifedipine
verapamil Verapamil CR
10 mg tds
80 mg bd 200mg od
30mg tds
240mg tds 200 mg bd
5) Diuretics
- most widely used antihypertensive agents - Patient with essential hypertension and normal renal function, thiazide are more potent than loop diuretics - Patient with renal insufficiency, thiazide are less effective, and loop diuretics are to be used instead. - Potassium sparing diuretics may cause hyperkalemia if given together with ACEi or ARBs - Side effets: increased serum cholesterol, glucose and uric acid. Decreased potassium, sodium and magnesium level
DIURETICS
diuretics Starting dose Maximum dose daily
chlorothiazide
hydrocholorothiazide Amiloride 5g/ 50 mg
250 mg od
25mg od 1 table t od
500mg od
200mg od 4 tablet od
indaparamide
Triamterene 50 mg/ 25 mg
2.5 mg od
1 tablet bd
2.5 mg od
2 tablet bd
In ED
HPT Emergency HPT Urgency
HYPERTENSIVE EMERGENCY
Severe elevation in BP (usually >180/120) complicated by evidence of progressive target organ dysfunction Target organ dysfunction includes:
I. Hypertensive encephalopathy II. Hypertensive Lt ventricular failure(acute pulmonary edema) III. Acute aortic dissection IV. ACS / Acute MI V. Haemorrhagic / Ischaemic Stroke / SAH VI. Acute renal failure VII. Eclampsia
JNC 7
HYPERTENSIVE URGENCY
Situations associated with severe elevation in BP without progressive target organ dysfunction
JNC 7
Bedside ix
ECG Urine dipstick-proteinuria UPT in woman of child bearing age
Management
Hypertensive emergency
BP to be reduced by 25% over 3 to 12 hours but not lower than 160/90 mmHg best achieved with parenteral drugs
HYPERTENSIVE EMERGENCIES
DRUGS DOSE
ONSET OF ACTION
DURATION
REMARKS
0.25-10 g/kg/min Sec. IV bolus 50mg <5min (over at least 1 minute) at 5 min intervals to max of 200mg then 2mg/min IVI 5-100/min 2-5min
1-5min 3-6hrs
Nitrates
3-5min
DRUGS
DOSE
ONSET OF ACTION
DURATION
REMARKS
Hydralazine
IV 5-10mg maybe 10-20min 3-8hrs repeated after 2030min of IVI 200300g/min.Mainte nance 50150g/min IV bolus 1030g/kg over 1min IVI 210g/kg/min IV bolus 1-2min, 250-500 g/kg over I min. IVI 50200g/kg/min for 4 min. May repeat sequence 5-10min 1-4 hrs
Nicardipine
Caution in heart failure and coronary ischaemia Used in perioperative situations and tachyarrythmia
Esmolol
3-10min
Management
Hypertensive urgency
aim for about 25% reduction in BP over 24 hours but not lower than 160/90 mmHg Oral drugs proven to be effective
HYPERTENSIVE URGENCY
DRUG DOSE ONSET OF ACTION DURATION
FREQUENCY
Captopril Nifedipine
25mg 10-20mg
hour hour
Labetalol
200-400mg
2 hours
6 hour
4 hours
Disposition
HPT emergency
Admit to ICU in consultation with general medicine and respective subspecialities
HPT urgency
Can be discharge if response is prompt and BP acceptable after 4hours monitoring, but must arrange for follow up within 48 hours Newly diagnosed HPT with uncertain cause, admit for further evaluation and exclusion of 2ry causes
REFERRENCE
JNC 7 CPG on HPT Guide to essentials in emergency medicineShirley Ooi