Hypertension Part 1 Flashcards
Prevalence of Hypertension in Canada
23.1%
Number of Canadian adults 18+ suffering from hypertension
61 is avg age
Hypertension Awareness, Treatment and Control
Hypertension Awareness, Treatment and Control
Reduction in control from 2007-2009 to 2016-17
Good awareness and treatment
Can improve control
definition of bp
BP = carfiac output x peripheral resistance
CO x PVR
PVR = SVR (systemic vascular resistance)
CO = HR x stroke volume (SV)
Pain, scared can make cardiac output go up
Anything impacting CO or PVR can make it go up
Thresholds for Initiating Drug Therapy and
Goals of Treatment:
define SPRINT population
SPRINT population = high risk patients ≥ 50yo, at high-risk for CVD including
known CVD, CKD, Framingham >15%, age ≥ 75
Thresholds for Initiating Drug Therapy and
Goals of Treatment:
high risk when to initiate and goal of Tx
High risk (based on SPRINT pop’n)* (based on AOBP)
initiate:
sbp: ≥ 130 dbp: n/a
goal:
sbp: <120 dbp: n/a
Thresholds for Initiating Drug Therapy and
Goals of Treatment:
low risk when to initiate and goal of Tx
Would not start drug unless you are above 160/100 if you are low risk
Must have is less than 160/100 for everyone
Higher risk patients, may want lower targets
140/90 is 135/85 with different method
Table is using stethoscope and bp cuff
(no target organ damage or CV risk factors)
initiate:
sbp: ≥ 160 dbp: ≥ 100
goal:
sbp: <140dbp: <90
** Target BP with AOBP < 135/85
Thresholds for Initiating Drug Therapy and
Goals of Treatment:
diabetes when to initiate and goal of Tx
initiate:
sbp: ≥ 130 dbp: ≥ 80
goal:
sbp: <130 dbp: <80
Thresholds for Initiating Drug Therapy and
Goals of Treatment:
all others (intermediate, dont fit into other categories)
initiate ≥ 140 ≥ 90 goal: sbp: <140**dbp: <90** ** Target BP with AOBP < 135/85
Blood Pressures: Equivalence Numbers
An office blood pressure of 140/90 mmHg is comparable to:
Home BP 135 / 85
Automated office BP 135 / 85
White Coat and Masked Hypertension
masked: Normal when in office
High at home
Above 140 at office (135 in home, htn)
20% of time leads to white coat
20% masked, the only way to know is if you are measuring bp at home or ambulatory setting
see table on slide 9
Orthostatic Hypotension
• Sudden drop in BP when you stand from a seated or lying position dizziness.
• Defined as a BP drop of ≥ 20/10 mmHg within 2-3 minutes of standing. In patients with a normal autonomic system, this is unlikely.
• Most common in elderly.
• Does not appear to be associated with increased risk of falling, but requires strategies to manage.
Do it after 5 minutes of standing to confirm othor hypotension
Resistant Hypertension
• Failure to achieve BP target despite treatment
with three antihypertensive drugs (including a
diuretic) at optimal doses.
– Important to check adherence (remember, drugs
don’t work in people who don’t take them!)
– Important to measure BP properly
• Prevalence is not well studied. Appears to be
about 10-30% of hypertensive patients.
Hypertensive Emergency and Urgency
emergency vs urgency
Emergency
– Target organ damage such as acute left ventricular
failure, acute myocardial ischemia, aortic
dissection, encephalopathy, papilledema in
conjunction with high BP
Urgency – Asymptomatic – DBP>130 mmHg very high • NOTE: Lower BP slowly Lower bp extremely high slowly Dont want stroke or cerebral event Emerg: IV durgs Urgent: use oral drugs to bring it down slowly over period of time
Primary Hypertension
Initial therapies dor HTN targetted central receptors whereas therapies in last 30 years target kidney or heart such as BB or CCB
• Poorly understood; cause not known
• 85-90% of those with hypertension have primary hypertension.
• Factors felt to be implicated:
– Increased sympathetic neural activity
– Increased angiotensin II and aldosterone activity
• Risk factors play a role in development
– Obesity increasingly common factor
Secondary Hypertension
Causes
Prevalence likely 10-15%
• Renovascular disease
• Drugs (OCPs, NSAIDs, corticosteroids,
decongestants, cocaine, etc) Oral contraceptive pills
• Hyperaldosteronism: Tumors, cells that excrete too much aldosteronism
• Pheochromocytoma: Cells hyperproducee NA and A
• Endocrine disorders
– Cushing’s, hypo- and hyperthyroidism,
hyperparathyroidism
• Sleep apnea: Not dramatically usually, no therapy usually
Who gets hypertension?
May appear healthy OR May have additional CV risk factors – Age (≧45 for men, and ≧55 for women) – DM (type 1 or 2) – Dyslipidemia – Proteinuria – Family history of premature CV disease – Overweight – Physical inactivity – Tobacco use
The age cut-points for positive family history of premature CVD are if a primary relative is less than 55 (men) or less than 65 (women) as being pre-menopausal in women is protective.
Rationale for Reduction of Elevated BP
4 reasons
Natural History of Untreated Hypertension
Don’t know whyt some ppl have complicated course
- CVD morbidity and mortality are directly
related to the level of BP - BP rises most in those whose BP is already
high - In humans, there is less vascular damage
where BP is lower. - Antihypertensive therapy reduces CVD and
death
Benefits of Treating Hypertension
Younger than 60
Older than 60
• Younger than 60 (reducing BP 10/5-6 mmHg)
– reduces the risk of stroke by 42%
– reduces the risk of coronary event by 14%
• Older than 60 (reducing BP 15/6 mmHg)
– reduces overall mortality by 15%
– reduces cardiovascular mortality by 36%
– reduces incidence of stroke by 35%
– reduces coronary artery disease by 18%
BP and Stroke Mortality
Log-linear increase in risk
• Risk increase begins at 115/75 mmHg
• Risk of stroke and CHD mortality doubles for every 20/10 mmHg increase
Targets in 140 range to keep risk factors low
Assessment of Overall Cardiovascular Risk
Search for target organ damage
see slide 24
Prior history of clinically overt atherosclerotic
disease indicates a very high risk for a recurrent
atherosclerotic event (e.g. CAD, PAD, previous
stroke or transient ischemic attack).
In people without overt atherosclerotic disease,
risk stratification can be done with risk
estimation tools – for example, FRS.
4 catgeories of Secondary Causes for Hypertension
diseases
common meds
excessive food consumption
street drugs and other pdts
Cyclosporin, prevent transplant rejection
- Can’t stop these drugs
Tylenol or physical modalities to relieve pain to minimize NSAID one of leading causes of increasing bp
Topical is usually ok
Black licorice is really salty, bad choice
Withdrawing contraceptives may not alter it
Blood Pressure Distribution in the Population
According to Age
Systolic bp naturally goes up through lifetime
Diastolic goes up in early years due to hyperreflexive response, middle aged it starts to drop down
Isolated systolic hypertension
160/70
Normal diastolic but elevated systolic
Correlations b/w stroke, heart disease correlated with systolic bp
Auscultatory OBPM is inaccurate- why?
outine auscultatory OBPMs are _________ higher than standardized research BPs
(primarily using oscillometric devices)
• In real world, the accuracy of auscultatory OBPM can
be adversely affected by provider, patient and device
factors such as:
– too rapid deflation of the cuff
– digit preference with rounding off of readings to 0 or 5
– also, mercury sphygmomanometers are being phased out
and aneroid devices are less likely to remain calibrated
• 9/6 mm Hg
Hierarchy of “best methods” for BP
Measurement
out of office
out of office ABPM • Gold standard • More expensive compared to other methods (may not be accessible for all • Gives nighttime readings Ambulatory is still gold standard
HBPM
• Easily accessible
• Most patients can do
• Affordable (machine $60-80
Hierarchy of “best methods” for BP
Measurement
in office
AOBP
OBPM
• Should use electronic (oscillometric) machine. (multiple readings, provider can be outside room) • Allows for clinician measurement • ~expensive (relative to HBPM) • AOBP addresses whitecoat HTN better than OBPM
Out-Of-Office Measurements Preferred for
Diagnosis Because
• Office visits rarely accurately performed
• Can assess for both whitecoat and masked
hypertension
• ABPM and HBPM have better prognostic ability for
CV events than conventional office BP readings
• ABPM preferred over HBPM due to:
– Greater number of measurements per day
– Improved adherence to measurement regimen
– Daytime and nighttime values considered
• However, HBPM has demonstrated reliability, and with more
study, may be recommended preferentially in future
When to consider using ABPM?
- Interested in daytime AND nighttime readings
- Concerned about BP fluctuations (and want many readings)
- Patient has symptoms that may be correlated to BP and want to track across day/night
Suggested Protocol for Home Measurement of Blood
Pressure
• Home blood pressure values should be based on:
– Two measures separated by one minute,
– Morning and evening,
– For an initial 7-day period.
• First day home BP values should not be
considered.
• The following six days blood pressure readings
should be averaged.
• Average BP equal to or over 135/85 mmHg should
be considered elevated (for those patients whose
clinic BP target is less than 140/90 mmHg).
Pharmacist Role
• Screening for hypertension
– “Know your Blood Pressure”; integrate into preventative
care discussions
• Helping patients measure BP properly
– So that the BP values are reliable to inform decisions
• Appropriate BP monitor selection
see algorithm on slide 43
ok
: When to contact a
health care professional based on home blood
pressure readings
130-179/85-109 Check reading again using the correct technique. If the readings remain high, discuss with your healthcare provider at your next regularly scheduled appointment
180 – 199*/110-119 Check reading again using the correct technique. If the readings remain high, schedule an appointment with your doctor to discuss your treatment plan.
More than 200* More than 120 Check reading again using the correct technique. If the readings remain high, schedule an urgent appointment with your doctor to discuss your treatment plan
Routine Laboratory Tests
- Urinalysis (looking for proteinuria; urinalysis is sufficient for this, and do not need to routinely screen for ACR in people who do not have diabetes)
- Blood chemistry (potassium, sodium and creatinine)
- Fasting glucose and/or glycated hemoglobin (A1c)
- Fasting total cholesterol and high density lipoprotein cholesterol (HDL), low density lipoprotein cholesterol (LDL), triglycerides
- Standard 12-leads ECG
- If woman of child-bearing age, ask about pregnancy (pregnancy test could be done if woman is not certain of status, and treatment being considered.)
Who should be screened for
secondary causes of hypertension?
• Severe or refractory hypertension (defined as
resistant to 3 or more drugs at maximum-tolerated
doses)
• Acute rise in BP with a previously stable BP
• Proven age of onset before puberty
• Age <30
Health Behaviour Management
Extent of each is not additivie if pt does more than a few of these
Reduce foods with added sodium → 2000 mg /day
Weight loss BMI <25 kg/m2
Alcohol restriction < 2 drinks/day
Physical activity 30-60 minutes 4-7 days/week
Dietary patterns DASH diet
Smoking cessation Smoke-free environment
Waist circumference Men < 102 cm Women < 88 cm
Increase dietary potassium intake >2.5g daily (75-125 mmol/K per day)
Stress management To reduce stress
DASH diet has greatest reduction -11.4 -5.5
Weight loss -6.0 -4.8
dietay recommendations
what does DASH stand for?
DASH Diet = Dietary Approaches to Stop Hypertension
High in: •Fresh fruits •Fresh vegetables • Low fat dairy products •Dietary and soluble fibre •Plant protein Low in: •Saturated fat and cholesterol •Sodium
higherpotassium
no concluisive studies for calcium or magnesium supplements
80% of average sodium intake is in processed foods •Only 10% is added at the table or in cooking
potassium intake
In patients not at risk of hyperkalemia, increase dietary
potassium intake to reduce blood pressure.
• As this leads to a decrease in BP
• Effect most consistently seen in patients with HTN
• Who is at risk of developing hyperkalemia?
• People taking ACEi or ARB, or any other drug that
↑potassium (spironolactone, amiloride,
triamterene)
• CKD with GFR ≤ 45mL/min
• Baseline K+ level ≥ 4.5 mmol/L
