Hypertension in a nutshell - med.uottawa.ca

Hypertension in a nutshell Sohil Rangwala MDCM, CCFP Quick facts 1 in 5 Canadians have hypertension Over 40% of Canadians aged 55-65 have hypertension All adults with borderline BP 130-139/80-89 should get annual screening Prevalence of Hypertension in Canada 21.8% Number of Canadian

adults Number of 18+ suffering from Canadian adults hypertension 18+ suffering from hypertension *Interpret with caution; coefficient of variation between 16.6% and 33.3%. Data are from the Canadian Health Measures Survey, Cycle 2, Statistics Canada. 3.3 3.3

* % %* 21.8 21.8 % % 52.4 52.4 % % of those age 18 to 39 of those age 40 to

59 of those age 60 to 70 have hypertension. Questions to ask on historyReview of systems headache visual changes chest pain, dyspnea, PND leg swelling, exertional calf pain neurological deficits, vertigo Obstructive Sleep Apnea palpitations, excessive sweating, weight changes Questions to ask on History PMHX

CAD PAD CKD DM2 dyslipidemia obesity cognitive changes Questions to ask on historyMedications NSAIDs COX-2 inhibitors anabolic steroids SSRIs, SNRIs OCPs decongestants Questions to ask on historySocial/habits- i.e risk factors Age >55 Male

Family history Smoker Obesity Poor diet, salt intake Diabetes/ Prediabetes Stress ETOH, drugs Physical Exam- How to take a BP Physical exam Neuro: check for abnormal cranial nerve exam ,papilledema, cotton wool spots, retinal hemorrhages CVS: heart murmurs, renovascular bruits, carotid bruits,

decreased or absent peripheral pulses, extremity swelling Diagnostic algorithm for hypertension 2014 Diagnostic tests after first visit Urinalysis Fasting blood sugar Electrolytes and creatinine Fasting lipid profile ECG ACR( only if DM) End organ damage? Cerbrovascular disease (Stroke,TIA)

Vascular Dementia Hypertensive retinopathy LVH CAD-MI, angina CKD -Egfr less than 60 or albuminuria PAD- intermittent claudication, ABI less than 0.9 Hypertensive urgency and emergency Urgency: Asymptomatic diastolic BP 130 mmHg Emergency: Hypertensive encephalopathy Acute aortic dissection Acute left ventricular failure Acute myocardial ischemia Secondary causes of Hypertension

Renal artery stenosis Sleep apnea Hypothyroidism, Hyperthyroidism Coarctition of aorta Hyperaldosteronism Cushings disease Hyperparatyhroidism Drug side effects Investigations for secondary HTN TSH Calcium, albumin, PTH Renal doppler Dexamethasone suppression test Sleep study Plasma aldosterone: plasma renin ratio Urine for metanephrines Echocardiogram

Usual blood pressure threshold values for initiation of pharmacological treatment Population SBP DBP Diabetes 130 80 High risk (TOD or CV risk factors) 140

90 Low risk (no TOD or CV risk factors) 160 100 Very elderly 160 NA TOD=target organ damage *This higher treatment target for the very elderly reflects current evidence and heightened concerns of precipitating adverse effects, particularly in frail patients.

Decisions regarding initiating and intensifying pharmacotherapy in the very elderly should be based upon an individualized risk-benefit analysis. 2014 What are the Targets? Treatment consists of health behaviour pharmacological management Population SBP DBP Diabetes <130 <80

All others < 80 y.a. (including CKD) <140 <90 Very elderly ( 80 years) <150* NA *This higher treatment target for the very elderly reflects current evidence and heightened concerns of precipitating adverse effects, particularly in frail patients. Decisions regarding initiating and intensifying pharmacotherapy in the very elderly should be based upon an individualized risk-benefit analysis.

2014 Impact of health behaviours on blood pressure Intervention Systolic BP (mmHg) Diastolic BP (mmHg) Diet and weight control -6.0 -4.8 Reduced salt/sodium intake

- 5.4 - 2.8 Reduced alcohol intake (heavy drinkers) -3.4 -3.4 DASH diet -11.4 -5.5 Physical activity Relaxation therapies

-3.1 -3.7 -1.8 -3.5 Multiple interventions -5.5 -4.5 Clinical Guideline : Methods, evidence and recommendations National Institute for Health and Clinical Excellence (NICE) May 2011 2014 Health Behaviours in Adults with Hypertension:

Summary Intervention Reduce foods with added sodium Target 2000 mg /day Weight loss BMI <25 kg/m2 Alcohol restriction < 2 drinks/day

Physical activity Dietary patterns 30-60 minutes 4-7 days/week DASH diet Smoking cessation Smoke free environment Waist circumference Men <102 cm Women <88 cm 2014 Treatment of Systolic-Diastolic Hypertension without Other Compelling Indications TARGET <140/90 mmHg Lifestyle modification

Initial therapy Thiazide diuretic CONSIDER Nonadherence Secondary HTN Interfering drugs or lifestyle White coat effect ACEI ARB Long-acting CCB

A combination of 2 first line drugs may be considered as initial therapy if the blood pressure is >20 mmHg systolic or >10 mmHg diastolic above target Betablocker* Dual Combination Triple or Quadruple Therapy *Not indicated as first line therapy over 60 y Treatment

Thiazide Diuretic HCTZ- risk Hypokalemia ACE Ramipril- cough, monitor renal function, can cause hyperkalemia ARB Telmesartan- , monitor renal function, can cause hyperkalemia CCB Amlodipine- Leg swelling, constipation B-Blocker metoprolol- fatigue, not generally for use over age 60 The treatment of hypertension is all about vascular protection Statins are recommended in high risk hypertensive patients based on having established atherosclerotic disease or at least 3 of the following: Male

Previous Stroke or TIA 55 y or older LVH Smoking ECG abnormalities Type 2 Diabetes Microalbuminuria or Total-C/HDL-C ratio of 6 or higher Premature Family History

of CV disease Proteinuria Peripheral Vascular Disease ASCOT-LLA Lancet 2003;361:1149-58 2014 Vascular Protection for Hypertensive Patients: ASA Low dose ASA in patients >50 years Caution should be exercised if BP is not controlled. Hansson L, Zanchetti A, Carruthers SG, et al. Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal

Treatment (HOT) randomised trial. Lancet 1998; 351: 1755-1762. 2014 Conclusion High prevalence, with significant mortality and morbidity Routine screening and monitoring is important Lifestyle and pharmacological therapies available! References www. hypertension.ca- CHEP 2016 guidelines

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