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.
- Risk factor for heart disease
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 Over 140 and Less than 90

hypertension
 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
HYPERTENSION
Anamnesis;
Clinical exam;
Laboratory exam;
Cardiovascular risk stratification ( the risk of
cardiovascular events in 10 years):
Cardiovascular risk factors;
Diabetes;
Subclinical organ damage
cardiovascular disease / renal disease
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, 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:
Check Blood Pressure
BMI ( body mass index)
Waist circumference;
Heart examination;
Peripheral arteries examination;
Lungs examination.
 Laboratory examination
Plasma Glucose
Lipid profile
Uric acid
Serum creatinine
Urine : protein,glucose
EKG -left ventricular hypertrophy(Sokolov-Lyon> 38
mm)
Echocardiography
Carotid and femoral ultrasonography
Postprandial Plasma Glucose
CRP
Creatinine clearance
Examine the fundi
 Secondary hypertension-
causes
Renal parenchymal disease: polycystic kidneys,
hydronephrosis, glomerulonephritis, interstitial
nephritis,chronic pyelonephritis,diabetic
nephropathy,amyloid
Renovascular disease
Endocrine disease: phaeochromocytoma,
Cushing syndrome , hyperthyroidism, Conns
syndrome, acromegaly,hyprparathyroidism
Cardiovascular: coarctation of the aorta
Neurological tumors, encephalitis;
Pregnancy
Medicines: contraceptive, corticosteroids .
 Risk Factors for heart
disease
a. non-modificable:
Sex (male);
Age (male aged over 55 years, female aged over 65 years);
Ethnic origin ( black race )
Family history (cardiovascular disease, male over 55 years,female over 65
years).
Personal history of cardiovascular disease
Low birth weight
b. amenable:
Smoking;
Diet ( fat,sugar, alcohol, salt, less vegetables);
Physical inactivity
Stress;
Obesity abdominal obesity( abdominal circumference over 102cm M, over
88cm F
Hyperlipidaemia (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);
Hypertension >140/90 mm Hg
Kidney disease .
 Subclinical organ
damage
Left ventricular hypertrophy (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
Normal High risk stratification
1 degree 2 st
3 nd rd

BP normal HT degree degree

BP HT HT
Without Medium Medium Low added Moderate Additional
risk factors risk risk risk added risk high-risk

1/ 2 risk Low Low Moderate Moderate Very high

factors added added risk added risk added risk additional
risk risk

3 risk Moderate Additional Additional Additional Very high

factors/dia added high-risk high-risk high-risk additional
betes/subc risk risk
linical
organ
damage
Cardiovasc Very high Very high Very high Very high Very high
ular/kidne additional additional additional additional additional
y disease risk risk risk risk risk
 Clinical target organ
damage
Cerebrovascular disease ( 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= 1 st
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

Advise a weight loss diet

Avoid adding salt to foods( less than 5g daily)
Avoid adding sugar and cut down sweets
Avoid excessive alcohol intake (< 20-30ml daily)
Physical activity (>30 min moderate intensity
exercise/ day,>5d/week )
Eat plenty of vegetables and fruits (>5
portions/day);
Eat plenty of fibre(cereals,beans,wholemeal bread)
Eat fish,at least 2/week
Reduced fat intake
Stop smoking
 Medications
Diuretics:
iuretics hydrochlorothiazide;thiazide-like diuretics:
indapamide; potassium sparing diuretics; 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:-blockers
classes: :doxazosin, prazosin; centrally acting
antiadrenergic: clonidine, methyldopa , moxonidine-R modulators
of imidazole (rilmenidine) .
Aspirin 75mg
Statin terapy
 General rules
<55 y first choice is an ACE inhibitor or ARB if
ACE inhib.is not tolerated
>55 y or black-skinned-first choice is a
dihydropyridine calcium channel blocker /or
thiazide-type diuretic
Combine an ACE inhibitor/ARB inhib.
+dihydropyridine calcium blocker /or a thiazide-
type diuretic
Combine ACE inhibitor/ARB+dihydropyridine
calcium chanel blocker+diuretic
If treatment with four drugs is nedded +-
blockers or -blockers
Where possible-drugs taken once a day
 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;
-uric acid (>5mg/dl F,>7mg/dl M )
- inflammatory biomarkers (CRP);
- chemicals synthesized by adipocytes (TNF-, IL
6, leptin, adiponectin).