Hypertension (MOH guidelines 2005)

R/s between BP and risk of cardiovascular disease (CVD) is continuous, consistent & independent of other risk factors. The higher the BP, the greater the risk of MI, heart failure, stroke and kidney disease. Each increment of 20mmHg in SBP or 10mmHg in DBP doubles the risk of CVD from 115/75 to 185/115

Drugs

Oestrogen containing OCP Steroids NSAIDs Sympathomimetics

o

Classification (JNC VII guidelines)

SBP Normal Highnormal BP Grade 1 HPT Grade 2 HPT Isolated systolic HPT <130 130-139
And Or

Factors indicating likely 2 HPT (and therefore need for extra invxs) o Clinical or biochemical features of a specific disorder o Young PTs (<30YO) o Accelerated HPT o Refractory HPT

DBP
Lifestyle modification

Management Initial drug Rx

w/o compelling indication With compelling indication

Patient Evaluation
Aims: 1. 2. 3. 4. Assess lifestyle exercise, diet, smoking, alcohol intake Identify cardiovascular risk factors or concomitant disorders (TOD) Identify possible causes of hypertension (secondary HPT) Assess presence or absence of target-organ damage and CVD (eg angina, CVA)

<80 80-89

Encourage

Yes

No Rx needed Thiazide diuretic other anti-HPT 2 drug combo: thiazides + one other

Drug for compelling indication Drug for compelling indication other anti-HPT as needed

140-159 160 140

Or Or

90-99 100

Yes yes

and

<90

Measurement of BP
Seat pt for 5 mins with feet on floor and arm supported at heart level Measure standing BP if postural hypotension is suspected. Cuff bladder should encircle 80% of arm. At least 2 measurements should be made. Ambulatory BP monitoring indicated for white-coat HPT, and pts with drug resistance, hypotensive symptoms while on anti-HPT med, episodic HPT & autonomic dysfunction.

Examination Measure BP BMI Assess for risk factors: obesity, hyperlipidaemia (xanthomata, xanthelasma) Optic fundi Neurological examination Palpate for thyroid gland Auscultate for carotid, abdominal (renal artery stenosis) & femoral bruits Examine CVS radio-femoral delay (coarctation of the aorta) Examine lungs Examine abdomen for PKD, masses & abN aortic pulsation (AAA) Lower limbs: edema and pulses (PVD) Other causes of secondary HPT: Cushingoid features

Cardiovascular Risk factors

Major risk factors Components of Metabolic syndrome HPT grades 1-2 Obesity (BMI27.5 for Asians, or else 30) Total chol >6.2mmol/L (240mg/dL) Raised LDL chol > 4.1mmol/L (160mg/dL) Reduced HDL chol <1.0mmol/L (40mg/dL) DM Age (males>55, females>65) Smoking Physical inactivity Family Hx of premature CVD (men<55, women <65)

Causes
Primary (essential) Hypertension (95%) Secondary Hypertension (5%) Alcohol Pregnancy Pre-eclampsia Renal disease Renal vascular disease Parenchymal renal disease (eg glomerulonephritis) PKD Endocrine disease Phaeochromocytoma Acromegaly Cushings syndrome Hyperparathyroidism o Conns syndrome (1 Primary hypothyroidism hyperaldosteronism) Thyrotoxicosis Congenital adrenal hyperplasia Coarctation of aorta

Target-Organ Damage (TOD) / Associated clinical conditions Heart LVH (by ECG/echo/CXR) Angina / previous MI Prior coronary revascularization Heart failure

Brain

Renal

Retinopathy

Atherosclerosis Vascular Malignant HPT

Ischemic Stroke Cerebral hemorrhage TIA Hypertensive encephalopathy HPT, neuro deficits, papilloedema. Reversible if HPT is controlled Proteinuria >0.5g/24h Microalbuminaemia (albumin:creatinine ratio >30mg/g) renal impairment (plasma creatinine concentration >132 mmol/L) Diabetic nephropathy Grade 1: arteriolar thickening, tortuosity, silver wiring Grade 2: Grade 1 + arteriovenous nipping Grade 3: Grade 2 + flame or blot hemorrhages & cotton wool exudates Grade 4: Grade 3 + papilloedema U/S or radiological evidence of atherosclerotic plaques (carotids, iliac, femoral & peripheral arteries, aorta) Dissecting aneurysm Symptomatic arterial disease Accelerated microvascular damage with necrosis in the walls of small arteries and arterioles. Intravascular thrombosis Dx: HPT + rapidly progressive end-organ damage (retinopathy, renal failure, HPT encephalopathy) L. ventricular failure may result. Poor Px if untreated.

Treatment
Aim: reduce cardiovascular and renal morbidity and mortality Target: <140/90mmHg; <130/80mmHg for DM or chronic renal disease at least high-normal (<140/90mmHg) for elderly, provided no orthostatic hypotension occurs

Algorithm for Rx of HPT

Lifestyle modification Target BP not achieved Initial drug choices

HPT w/o compelling indications Stage 1 HPT Thiazide diuretic for most Consider adding ACEI, ARB, -blocker or CCB if target not achieved Stage 2 HPT 2 drug combination for most (usually thiazide diuretic + ACEI, ARB, -blocker or CCB)

HPT w compelling indications Use drug for compelling reason Add diuretics, ACEI, ARB, -blocker and CCB as needed

Investigations
Routine Investigations ECG Left ventricular hypertrophy Coronary artery disease FBC Haematocrit + U/E/Cr S. potassium hypoK alkalosis may indicate Conns syndrome Creatinine for GFR estimation Calcium Urinalysis Blood, protein & glucose Fasting lipids Blood glucose Additional investigation if indicated CXR Cardiomegaly Heart failure Coarctation of aorta Ambulatory BP recording White-coat HPT Borderline HPT 2D echo Detect & quantify LVH Renal U/S Renal disease Renal angiography Renal artery stenosis Urinary catecholamines Phaeochromocytoma Urinary cortisol & Assessment of Cushings syndrome dexamethasone suppression test Plasma renin activity & Detect primary hyperaldosteronism (Conns syndrome) aldosterone

Follow-up & Monitoring Monthly f/u until BP goal is reached. 3 to 6 mthly f/u thereafter. S. potassium & creatinine monitoring 1-2X per year

1) Lifestyle modification Diet: moderation of alcohol consumption, low sodium diet, lower intake of chol and saturated fats Rx of hyperlipidaemia, maintenance of adequate intake of dietary K Weight reduction, increased physical activity Smoking cessation

2) Pharmacological Rx Drug choice for compelling indications Diuretic ACE-I ARB -blocker

CCB

Heart failure X XX XX X Post-MI X X High coronary dz X X X X risk Diabetes X X *X *X X Chronic renal dz X X Recurrent stroke X X prevention** *ACE-I & ARB based Rx slow progression of diabetic & non-diabetic nephropathy **Add anti-platelet agents (eg aspirin, ticlopidine, clopidogrel) Drug Diuretic (chlorothiazide, hydrochlorothiazide) -blocker (atenolol, propanolol) Absolute CI / use with caution Gout + Hx of hypoNa Dyslipidaemia Asthma COPD Heart block Dyslipidaemia Athletes / physically active PTs Peripheral vascular disease Pregnancy Bilat renal art stenosis + HyperK Side Effects

Aldosterone antagonist X X

Pharmacological Rx in pregnancy Use methyldopa, -blockers & vasodilators. th Monitor for devt of pre-eclampsia after 20 wk of gestation (new onset/worsening HPT, albuminuria, hyperuricaemia, coagulation abNs) Management of Hypertensive Emergencies Do not lower BP too quickly may compromise tissue perfusion With acute TOD: hospitalize, parenteral drug therapy (labetalol, nitroglycerin, hydralazine, Na nitroprusside) Without acute TOD: immediate combination PO anti-HPT Rx, monitoring for TOD.

Hypertensive Emergencies Definitions:

Hypertensive crisis no definite BP level used to define a hypertensive crisis. DBP of 120-130 mmHg used as a guide. Includes: o Hypertensive emergency elevated BP a/w acute or ongoing end-organ dysfunction or damage o Hypertensive urgency elevated BP a/w imminent end-organ dysfunction or damage

Hyperuricaemia Impotence Glucose intolerance Raise concentration of cholesterol Aggravate asthma, HF, PVD

Types of Hypertensive emergencies

First dose hypotension Cough Rash Proteinuria Hyper K+ Renal dysfunction Unpleasant metallic taste *monitor U/E/Cr before and after starting Rx *does not cause cough c.f ACEI Flushing Palpitation Fluid retention Bradycardia (for diltiazem & verapamil) + May cause hyperK : avoid in + Pts with K >5.0 mEq/L while not on med 1. Hypertensive encephalopathy need to d/dx from stroke, as reduction of BP is contraindicated in stroke. BP is significantly in HPT encephalopathy, but only mildly in stroke Acute pulmonary oedema (Hypertensive left ventricular failure) due to decompensation secondary to excessive afterload Acute aortic dissection new AR murmur may be heard AMI / acute coronary syndrome due to increased myocardial O2 demand Haemorrhagic/ischaemic stroke or SAH Acute renal failure Eclampsia / preeclampsia Phaechromocytoma crises Recreational drugs (eg ectasy)

ACE-I (Captopril)

2. 3. 4. 5. 6. 7. 8. 9.

ARB (losartan) CCB (nifidepine, amlodipine, diltiazem) Aldosterone antagonist (Spironolactone)

Pregnancy Bilat renal art stenosis + HyperK Heart block CCF

Types of Hypertensive urgencies

1. 2. 3. Elevated BP with retinal changes CRF Preeclampsia

Management
A) Initial Mx Stabilize ABC Low flow supplemental O2 Monitor ECG Pulse oximetry Vital signs q5-10 mins Manual BP taking Use correct cuff size Check other arm Recheck later Clinical exam Fundoscopy haemorrhage, exudates, papilloedema Neuro exam AMS, focal neuro deficits CVS exam LVFailure, AR murmur (aortic dissectn) Bedside tests ECG Urine dipstick haematuria & proteinuria for renal dz UPT eclampsia, preeclampsia FBC U/E/Cr Cardiac enzymes & Troponin T CXR LV failure, widened mediastinum CT head if AMS or stroke suspected (IMPT: rule out stroke before lowering BP!) CT thorax if aortic dissection suspected

Check BP

o Use with phentolamine for catecholamine crises Dose: IV 1mg boluses & titrate Esmolol Indications: aortic dissection Dose: IV 250-500g/kg/min for 1 min, then 50-100g/kg/min for 4mins. Repeat as required. Phentolamine Indications: Use with phentolamine for catecholamine crises Dose: IV 5-15mg Hydralazine Indications: Rx of choice for predelivery eclampsia Dose: IV 5-10mg boluses q15min & titrate Disposition admit ICU

D/dx btwn HPT emergency & urgency look for signs of endorgan damage

Lab invx

B2) Mx of HPT Urgencies (ie end-organ dysfunction imminent) o Target Lower BP over 24-48 hrs to DBP of 100mmHg Felodipine Dose: o >65YO: 2.5mg PO o <65YO: 5.0mg PO, then 5.0mg bd Captopril Dose: 25.0mg stat, then bd or tds Disposition Responsive to Rx & BP acceptable after 4 hrs of monitoring discharge with F/U w/in 48 hrs Newly dxed HPT with uncertain cause admit to Gen Med for evaluation of secondary causes of HPT

Summary of Drugs used in Hypertensive Crises

Drug Dose HPT Emergencies Na Nitroprusside IV 0.25/kg/min Special indications All except eclampsia Others SE: Thiocynate / cyanide toxicity CI: asthma, COLD, CCF, HR, heartblk

B1) Mx of HPT Emergencies (ie end-organ dysfunction present) Target o Lower MAP to by 20-25% or DBP to no less than 100 mmHg within a few hrs o Then aim for 160/100 mmHg over the next 2-6 hrs Na Indication: all HPT emergencies except predelivery eclampsia nitroprusside Dose: IV 0.25/kg/min, titrate to response. (Max 10g/kg/min for only 10mins) SE: cyanide & thiocynate toxicity after prolonged used lactic acidosis, AMS, clinical deterioration. Therefore monitor closely if used Labetalol Indications: failure of nitroprusside. Good for IHD (HR & O2 demand) & aortic dissection ( systolic ejection force & shear stress) CI: asthma, COLD, CCF, bradycardia, heart block Dose: o IV 25-50 mg bolus, o followed by 25-50 mg q5-10 mins (max 300mg) OR infusion rate 0.5-2.0 mg/min Nitroglycerine Indications: HPT complicating unstable angina Dose: IV 5-100g/min, titrate to response SE: headache, vomiting Propanolol Indications: o Use with nitroprusside for thoracic aortic dissection

Labetalol

Nitroglycerine Propanolol Esmolol Phentolamine Hydralazine HPT Urgencies Felodipine

IV 25-50 mg bolus Followed by 25-50 mg q5-10 mins IV 5-100g/min IV 1mg boluses IV 250-500g/kg/min for 1 min, then 50-100g/kg/min for 4mins IV 5-15mg IV 5-10mg boluses q15min >65YO: 2.5mg PO <65YO: 5.0mg PO, then 5.0mg bd 25.0mg stat, then bd or tds

IHD Aortic dissection

Unstable angina Thoracic aortic dissect (Prop. + nitroprus) Catecholamine crises (Prop. + phentol.) Aortic dissection Catecholamine crises (Prop. + Phentol.) Eclampsia

Captopril

Digitally signed by DR WANA HLA SHWE DN: cn=DR WANA HLA SHWE, c=MY, o=UCSI University, School of Medicine, KT-Campus, Terengganu, ou=Internal Medicine Group, email=wunna.hlashwe@gmail.com Reason: This document is for UCSI year 4 students. Date: 2009.02.24 10:08:40 +08'00'