Hypertension

    Based on 2016 CHEP Recommendations

     

     

    How to measure

    • Patient must have back support, arm support, both feet flat on the ground.
    • Deflate cuff 2mmHg/s until hearing phase II sounds (first tap of Korotkoff sounds).
    • For manual measurement: (Royal College exam)
      • First time: palpate the radial pulse.
      • Measure 3 times, disregard the first reading, and average the last two readings.
      • 2016 Guidelines --> Electronic BP measurement recommended
    • As per CHEP Guidelines 2016 - 4 ways to measure BP electronically:

     

       
    Office BP measurement
    (OBPM)
    Measurement using electronic (oscillometric), upper arm devices
    is preferred over auscultation (Grade C)
     
    ≥ 140/90 = HIGH (sBP or dBP)
    130-139 / 85-89 = HIGH-NORMAL

    Automated Office BP

    Measurement

    (AOBP)

    AOBP is the preferred for in-office BP measurement
    (Grade D; new recommendation).

     

    Use Mean Measurements

    ≥ 135 / 85 = HIGH

    Ambulatory BP

    Measurement

    (ABPM)

    Using ABPM patients can be diagnosed as hypertensive if
    the mean awake:
     ≥135 / 85 = Hypertension
    OR
    24hr mean ≥130 / 80 mm Hg (Grade C).

    Home BP monitoring

    (HBPM)

    Mean ≥135 / 85 mm Hg (Grade C).
    If the OBPM is high and the mean home BP is <135/85 mm Hg,
    either repeat home monitoring to confirm the home BP is <135/85 
    or perform 24-hour ABPM to confirm that the mean
    24-hour ABPM is <130/80 mm Hg and the mean awake ABPM is
    <135/85 before diagnosing white coat hypertension (Grade D).

    Diagnosis

    • ≥140/90 --> Trigger investigation

     

    • Reference: CHEP 2016 (Hypertension Canada) "Canadian recommendations for the management of hypertension"

     

     

    Diagnosis-HTN-2016c.png

     

    • Image Credit: Hypertension Canada CHEP 2016 guidelines (red notes added)

     

    • If home BP assessment cannot be performed, can use serial visits:
      • Visit 2 - BP ≥ 140/90 (OR) + macrovascular organ damage, DM, CKD (GFR < 60) --> dx HTN
      • Visit 3 - mean OBPM (across all visits) ≥ 160/100 (OR) --> dx HTN
      • Visit 5 - mean OBPM (across all visits) ≥ 140/90 (OR) --> dx HTN

     

    Causes Overview

    For Details Visit "Secondary Causes of Hypertension" Section

     

    • Primary (Essential) Hypertension vs Secondary Hypertension
    • Essential (Primary HTN) (>90%)
    • Secondary HTN (10%)
      • Young-age onset
      • No family history of HTN
      • Rapid onset of significant HTN
      • Abrupt change in BP in previously well-controlled HTN
      • Resistant HTN
    • "White coat" HTN

     

    Secondary HTN causes

    Renal
    • Renovascular HTN
    • Renal parenchymal disease, glomerulonephritis, pyelonephritis, PKD
    Respiratory
    • Sleep Apnea
    Endocrine
    • 1° hyperaldosteronism
    • Pheochromocytoma
    • Cushing's Syndrome
    • Hyperthyroidism/hyperparathyroidism
    • Hypercalcemia (any cause)
    Vascular
    • Coarcation of aorta
    • Renal artery stenosis
    Drug-induced
    • Estrogens
    • MAOIs
    • Cocaine
    • Steroids
    • Lithium
    • Amphetamines
    • NSAIDs
    • Decongestants
    • Alcohol

    Investigations

    Initial Visit

    • All patients with hypertension require routine labs: (all Grade D recommendations)
      • Assess risk factors, comorbidities, identifiable causes, target organt damage
      • Lab tests:
        • Blood: CBC, lytes, creatinine, calcium, lipid panel, AbA1c)
        • Fasting glucose and/or HbA1c
        • Lipid Panel (fasting or non-fasting)
        • Urine: urinalysis (ACR if protein)
        • 12-lead EKG
    • For specific patients:
      • DM OR renal disease:
        • urinary albumin excretion
      • ↑Cr OR hx of renal disease OR proteinuria OR htn resistant to 3 meds OR abdominal bruit:
        • renal ultrasound, captopril renal scan, MRA/CTA
      • Endocrine causes:
        • plasma aldosterone, plasma renin
      • Pheochromocytoma:
        • 24hr urine metanephrines, catecholamines
    • NOTE: Routine Echocardiogram NOT recommended --> perform only in patients with known or suspected LV dysfunction

     

    Maintenance F/U

     

    • Follow labs (as frequent as needed)
      • Electrolytes
      • Creatinine
      • Fasting lipids

     

    Target Organ Damage

    • Organ Notes
      Cerebrovascular

      - Stroke (ischemic, TIA, cerebran hemorrhage, aneurysmal subaranchnoid hemorrhage)

      - Dementia (Vascular, mixed vascular/alzheimer's)

      Hypertensive Retinopathy  
      LV Dysfunction LVH
      CAD MI, Angina, CHF
      Renal Disease

      CKD (GFR < 60)

      Albuminuria

      Peripheral Arterial Dz Intermittent Claudication

    Treatment

    Targets

    • Start Treatment Thresholds:
      • Threshold to Tx

        (sBP or dBP) 

        Indication
        160/100 NO macrovascular organ damage or CV RF's
        140/90 IF macrovascular organ damage (or other independent CV risk factor), CKD (non-dm)
        sBP ≥ 160 Very Elderly (≥ 80yo) (NO macrovascular damage or DMII)
        130/80 Diabetes

     

    • Treatment Targets:
      • Target Indication Evidence
        < 140/90     MOST CASES     
        sBP < 150 Very Elderly (≥80yo) HYVET Trial
        < 130/80 Diabetes UKPDS-38 Trial and HOT Trial

     

    • NOTE: Combination treatment with two first-line agents can be initiated if sBP >20
      higher or dBP > 10 higher than target (caution in elderly & autonomic neuropathy)

     

     

    Non-Pharmacologic

    1. Exercise
      • 30-60min mod-intensity dynamic exercise (walking, jogging, cycling, swimming) 4-7 days/week
      • Higher intensity are not more effective.
      • For non-HTN or stage 1 HTN pts --> weight training does not increase BP
    2. Weight Reduction
      • Healthy body weight (BMI 18.5 - 25, waist circ < 102cm men and <88cm women)
      • Strategies: multidisciplinary: dietary education, activity, behavioural
    3. Alcohol
      • < 2 drinks/day (<14 drinks/week for men and <9 drinks/week in women)
      • 1 drink (13.6g of EtOH) --> 1.5oz (1.5 shots) of 40% spirits, 355mL (1 beer) 5% beer, 5oz (1 glass) of 12% wine.
      • See Canadian Low-Risk Drinking Guidelines
    4. Dietary
      • Emphasize fruits, vegetables, low-fat dairy, fibre, whole grains, and protein from plant sources (low saturated fats)
    5. Sodium Intake
      • Reduce to < 2000 mg/d (5g of salt or 87mmol)
    6. Potassium
      • Increase to lower BP (except if high risk of hyperkalemia!!!)
    7. Stress Management
      • If stress is a contributor --> Stress management (individualized is better)

     

    • NOTE: Calcium & Magnesium supplementation no longer advised to decrease BP

     

     

    • (Based on AHA guidelines)

      Modification Recommendation Avg SBP Reduction
      Weight Reduction Maintain normal BMI (18.5-24.9) [lose 10-15lb] 5-20 mmHg/10kg
      DASH diet

      Adopt diet rich in fruits, vegetables, lowfat dairy

      products with reduced saturated and total fat

      8-14 mmHg

      Dietary sodium

      reduction

      Reduce to ≤100mmol/day (2.4g sodium or 6g NaCl) 2-8 mmHg

      Aerobic physical 

      activity

      Regular aerobic activity (i.e. brisk walking) at least 

      30min/day most days of week.

      4-9 mmHg

      Moderation of EtOH

      consumption

      Men: limit to ≤2 drinks/day

      Women/light weight: ≤1 drink/day

      2-4 mmHg

      * Cannot do all of them, only expect 9mmHg drop max from all above.

       

       

     

    Pharmacologic

    • Condition Specific Therapies

      DM + one of:

         1. CVD/

         2. CVD Risk Factors

         3. CKD

         4. Microalbuminuria

      ACEi or ARB as initial therapy

             (ACEi + CCB combo preferred)

      CKD + Proteinuria

               (>500mg/24h

      or ACR >30mg/mmol)

      ACEi (or ARB if cannot tolerate ACEi)

           [(ACEi or ARB) + thiazide combo preferred]

           - Loop Diuretic for volume overload

      CKD (Renovascular)

      --> Medical management

           - renal angioplasty = no benefit over medical tx (CORAL Trial)

           - angioplasty only considered if resistant to maximally

             tolerated anti-HTN therapy, progressive CKD and

             acute pulmonary edema

      LVH

      ACEi/ARB/Thiazide/LA-CCB (all cause regression of LVH)

         - B-Blockers inferior, use only if no other options

         - Avoid hydralazine + minoxidil (do not cause LVH regression)

      Stroke

      ACEi + Thiazide combo preferred

         - Avoid ACEi + ARB combo

      Heart Failure

      IF LOW EF (<40%)

       

        - ACEi + BB as initial therapy (achieve trial doses regardless of BP)

        - Use ARB if ACEi not tolerated (CHARM, Val-HeFT, meta-analysis)

        - Use Isosorbide dinitrate + Hydralazine if ACE/ARB not tolerated

           (V-HeFT Trial, V-HeFT II Trial - ACEi are better)

       

        - MRA (i.e. aldo) can be added for: recent CV hosp, acute MI,

           elevated BNP/NT-proBNP, or NYHA II-IV symptoms

           (RALES, EPHESUS, EMPHASIS-HF Trials)

       

        - Caution ACEi/ARB + MRA (hyperkalemia)

        - Can combine ARB+ACEi if uncontrolled HTN (but careful of 

           AKI/potassium) (only for low EF)

       

        - CCB - conflicting data (use other agents first)

      CAD

      - ACEi or ARB

      - Combo: ACEi+CCB better than ACE+TZD

      - Avoid dBP ≤ 60 (concerns of myocardial ischemia)

      Recent MI

      - First Line: BB and ACEi 

          - ARB if intolerant to ACEi

          - CCB can be used if BB contraindicated or ineffective

            (CCB are contraindicated in low EF, or active HF)

     

     

    • Ensure Adherence to therapy:
      • Patient education
      • Empower Patient involvement (monitor own BP)
      • Simplifying medication regimens to one pill (or single combo pill)
      • Unit-of-use packaging (i.e. bubble pack)
      • Multidisciplinary approach
      • Assess compliance at each visit

    Resistant Hypertension

    • Resistant Hypertension Definition:

       

      • Defined as persistently elevated BP despite
        use of ≥ 3 agents, one of which is a diuretic

     

    • 10-15% of pts with HTN
    • Most Common Causes:
      • pts not taking medications (cost, S/E?)  MOST COMMON
      • Not following lifestyle advice
      • White coat HTN (38% have white coat)  -> get home BP measurements.
      • Inadequate use of diuretics in combination therapy.
    • Work up secondary causes of HTN
    • Effective combinations:
      • ACE + Diuretic
      • ACE + CCB  (ACCOMPLISH trial)
      • Switch HCTZ to chlorthalidone.

    Special Populations

    Diabetes

    •  ACCORD Trial
      • 5000pts with DM assigned to standard vs. intensive therapy (sBP 120 vs. 140)
      • Results:
        • Both reached target (IMPRESSIVE!!)
        • Intensive therapy group achieved BP 14mmHg lower than standard therapy group
        • No difference in primary outcome (composite CVD after 8 yrs)
        • Stroke was lower in intensive therapy group
        • Intensive therapy: higher adverse events including renal fucntion (more meds to achieve target) NNH = 50
      • Therefore: May back off on target.

     

    Black

    • Tend to experience worse target organ damage (esp CVD)
    • Unclear reasons --> search for genetic predisposition ongoing. 
    • 4 times more likely to get ESRD
    • AASK Study 
      • Black patients with longstanding HTN and mild proteinuria -
      • Result: ACEi (ramipril) was superior to Beta Blocker (metoprolol) and CCB (amlodipine) in slowing renal disease progression.
    • ISHIB (international society of hypertension in blacks)
      • Consensus statement released: Treatment goals:
        • Primary Prevention: (Absence of target organ damage)
          • Target BP 135/85
        • Secondary Prevention (Presence of target organ damage)
          • Target BP 130/80

     

    Older Patients

    • Generally have higher systolic BP and lower diastolic (due to vascular stiffness)
    • Trials suggest lowering if sBP >160mmHg  (less stroke, CVD etc..)
      • (less data whether 140/90 should be the target)
      • Targeting lower pressures for specific diseases (diabetes, renal disease, etc..) is reasonable if can be achieved with no S/E.
    • Sometimes need to target to orthostatic symptoms
    • Lowering diastolic BP < 70mmHg associated with poor CV outcomes in ANY age.  (perfuses coronaries)

     

    Renal Disease

    • Determine if there is proteinuria --> Use ACEi or ARB b/c have benefit for proteinuria reduction + BP control
    • Target < 130/80
    • If significant proteinuria (>500mg/24hrs) --> target < 125/75
    • If proteinuria is absent - No particular agent is better. 
    • Typically creatinine increases with anti-HTN agent initiation.
      • Accept up to 25% of creatinine rise

    Cost

    • Thiazides Chlorthalidone $7/mo
      ACEi $20-30/mo generic
      BBlockers should not be using anyways
      CCB $40-50/mo
      ARB

      $75/mo

      (Losartan Generic, still $50/mo)

    • Drug with the best outcomes is the cheapest.

     

     

     

     

    Tag page (Edit tags)
    • No tags
    Pages that link here
    Page statistics
    133801 view(s), 89 edit(s) and 23226 character(s)

    Comments

    You must login to post a comment.

    Attach file

    Attachments

    FileSizeDateAttached by 
     BBlockersInHTNCochrane.pdf
    No description
    805.09 kB23:00, 26 Jul 2014apavelActions
     BBlockersOnCoronaryEventsHTN.png
    No description
    176.27 kB21:07, 26 Jul 2014apavelActions
     BblockersOnMortalityinHTN.png
    No description
    171.22 kB21:07, 26 Jul 2014apavelActions
     BBlockersOnStrokeInHTN.png
    No description
    172.89 kB21:07, 26 Jul 2014apavelActions
    CochraneReview2009AntiHTNcompared.png
    No description
    101.27 kB23:03, 26 Jul 2014apavelActions
    Diagnosis-HTN-2016c.png
    No description
    132.26 kB17:18, 9 Apr 2017apavelActions
     FirstLineHTNTxCochrane.pdf
    No description
    610.94 kB23:00, 26 Jul 2014apavelActions
     HtnAlgorithm2.png
    No description
    110.68 kB01:40, 4 Sep 2013apavelActions
     HTNdrugComparisonCochraneReview.xlsx
    No description
    37.23 kB23:00, 26 Jul 2014apavelActions
     HtnGuidelines.jpg
    No description
    160.67 kB00:57, 4 Sep 2013apavelActions
     HtnRecommendations1.png
    No description
    87.52 kB01:23, 4 Sep 2013apavelActions
     HtnRecommendations2.png
    No description
    100.29 kB01:23, 4 Sep 2013apavelActions
     MrFit trial.png
    No description
    237.62 kB02:32, 25 Jul 2014apavelActions
     MrFittrial.png
    No description
    237.62 kB02:34, 25 Jul 2014apavelActions
     Screen Shot 2014-07-26 at 6.59.39 PM.png
    No description
    101.27 kB23:00, 26 Jul 2014apavelActions
     Table2_BPManagement_EN.pdf
    No description
    57.82 kB01:23, 4 Sep 2013apavelActions
     TrascendTrial.png
    No description
    339.68 kB02:01, 25 Jul 2014apavelActions