E' Gimon MD CCFP

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• E. Gimon MD CCFP
• February 2007

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Key CHEP messages for the management of
hypertension

• Assess BP at all appropriate visits.
• Those with blood pressure 130-139/85-89 will
  require annual reassessment.
• Assess global cardiovascular risk
• Lifestyle modification are essential
• Treat to target (lt140/90 mmHg130/80 mmHg).
• Follow patients at least monthly until blood
  pressure targets are achieved.

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Classification of Hypertension
(Pre Hypertension) 120-139 / 80-89
The category pertains to the highest risk blood
pressure ISHInternational Society of
Hypertension. Chalmers J et al. J Hypertens
199917151-85.
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HTN Grade 3
HTN Grade 2
HTN Grade 1
prehypertension
Urgency gt125/220 Emergency dBPgt130
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Criteria for the diagnosis of hypertension and
recommendations for follow-up
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Criteria for the diagnosis of hypertension and
recommendations for follow-up
BP 140-179 / 90-109
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Patient Evaluation

• Assess lifestyle and Presence of CV Risk Factors
• Reveal Identifiable causes of HTN
• Assess evidence of TOD

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Cardiovascular Risk Factors
Assessment of the overall cardiovascular risk

• Presence of Risk Factors
• - Age
• Male gender
• Smoking
• FHx of premature CVD
• Dyslipidemia
• Sedentary lifestyle
• Abdominal obesity
• Presence of Diabetes
• Presence of TOD
• Presence of atherosclerotic vascular disease

CV Risk Factors that may alter thresholds and
targets in the treatment of HTN
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Search for exogenous factors that can
induce/aggravate hypertension
Assessment of the overall cardiovascular risk

• Presription Drugs
• NSAIDs
• Corticosteroids
• OCP
• Vasoconstricting decongestants
• Calcineurin inhibitors (cyclosporin, tacrolimus)
• Erythropoietin and analogues
• Monoamine oxidase inhibitors (MAOIs)
• Other
• Licorice root
• Stimulants including cocaine
• Salt
• Excessive alcohol use
• Sleep apnea

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Target Organ Damage
Assessment of the overall cardiovascular risk
CVD Left ventricular dysfunction CAD CKD PAD
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Routine Laboratory Tests
Investigation of all patients with hypertension
1. U/A 2. Renal Panel (K.Na,Creat) 3. Fasting
glucose 4. Lipid Panel 5. Standard 12-lead ECG
Deleted routine CBC as a recommendation
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Systematic Coronary Risk Evaluation10-Year Risk
of Fatal CVDin High-Risk Regions like Canada
Women
Men
SC?RE
Canada
15 and over 1014 59 34 2 1 lt1
Systolic blood pressure (mmHg)
10-year risk of fatal CVD in populations at high
CVD risk Calibrated according to the 2002
Canadian mortality data
Adapted from De Backer et al. Eur Heart J.
2003241601-1610.
(Total Cholesterol / HDL-Cholesterol) Ratio
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Optional Laboratory Tests
albumincreatinine ratio ACR gt 30 mg/mmol is
abnormal
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Screening for Renovascular Hypertension

• If gt1 of the following
• sudden onset or worsening of hypertension and lt30
  or gt55
• abdominal bruit
• HTN resistant to 3 or more drugs
• a rise in creatinine of 30 or more associated
  with use of an ACE inh or ARB
• other atherosclerotic vascular disease
• recurrent pulmonary edema associated with
  hypertensive surges

captopril-enhanced radioisotope renal
scan Doppler sonography magnetic resonance
angiography CT-angiography
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Screening for Hyperaldosteronism
If

• Spontaneous hypokalemia (lt3.5 mmol/L).
• Profound diuretic-induced hypokalemia (lt3.0
  mmol/L).
• Hypertension refractory to treatment with 3 or
  more drugs.
• Incidental adrenal adenomas.

plasma aldosterone plasma renin activity
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Screening for Pheochromocytoma
If

• Paroxysmal and/or severe sustained HTN refractory
  to usual antihypertensive therapy
• symptoms suggestive of catecholamine excess
• Hypertension triggered by bb, MAOinh,
  micturition, or changes in abdominal pressure
• Incidentally discovered adrenal mass
• MEN 2A or 2B von Recklinghausens
  neurofibromatosis

24 hour urine for metanephrines and creatinine.
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Indications for Pharmacotherapy
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Recommendations for follow-up
Dx of HTN
Non Pharmacological Tx /- Pharmacological
treatment
BP readings under target in 2 consecutive visits?
No
Yes
F/U q3-6
Sx, G3area, Intolerance to meds or TOD
Yes
No
More frequentvisits
Visits q1-2m
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Lifestyle Recommendations for Prevention of
Hypertension for NON-Hypertensive Individuals.

• Restriction of sodium intake to less than 100
  mmol (2300 mg) / day
• Healthy diet
• Regular physical activity
• Low risk alcohol consumption
• Maintenance of ideal body weight
• Waist Circumference
• Smoke free environment

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Lifestyle Recommendations for the Treatment of
Hypertension

• Restriction of sodium intake to less than 100
  mmol (2300 mg) / day
• Healthy diet
• Regular physical activity
• Low risk alcohol consumption Maintenance of ideal
  body weight
• Weight loss (gt 5 Kg) in those who are over weight
  (BMIgt25)
• Waist Circumference
• Smoke free environment

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Waist circumference measurement
Last rib margin
Mid distance
Iliac crest
Courtesy J.P. Després 2006
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Treatment of Systolic-Diastolic Hypertension
without Other Compelling Indications
TARGET lt140/90 mmHg
Lifestyle modification therapy
Dual Combination

• CONSIDER
• Nonadherence?
• Secondary HTN?
• Interfering drugs or lifestyle?
• White coat effect?

ACEI and ARB are contraindicated in pregnancy
Triple or Quadruple Therapy
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Combination Therapy
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Choice of Pharmacological Treatment for
Hypertension

• Compelling indications
• IHD
• CHF
• Cerebrovascular Disease
• Non Diabetic CKD
• Renovascular Disease
• Diabetes Mellitus
• With Diabetic Nephropathy
• Without Diabetic Nephropathy
• Global Vascular Protection for Hypertensive
  Patients
• Statins if 3 or more additional cardiovascular
  risks
• Aspirin once blood pressure is controlled

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Treatment of Hypertension in Patients with
Ischemic Heart Disease
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Treatment of Hypertension in Patients with Recent
ST Segment Elevation-MI or non-ST Segment
Elevation-MI
Beta-blocker and ACE-I
Recent myocardial infarction
If beta-blocker contraindicated or not effective
Long-acting DHP CCB
YES
Heart Failure ?
NO
Long-acting CCB
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Treatment of Hypertension with CHF Left
Ventricular Systolic Dysfunction
Systolic cardiac dysfunction
ACE-I if ACE-I intolerant ARB
and Beta-Blocker
If ACE-I and ARB contraindicated Hydralazine
and Isosorbide dinitrate in combination

• Then
• Diuretic
• for CHF class III-IV Aldosterone Antagonist

Then ACE-I / ARB Combination Long-acting
DHP-CCB
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Treatment of Hypertensionfor Patients with
Cerebrovascular Disease
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Treatment of Hypertension in Patients with Left
Ventricular Hypertrophy

• ACE-I
• ARB,
• CCB
• Thiazide Diuretic
• - BB (if age below 60)

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Treatment of Hypertension in Patients with Non
Diabetic Chronic Kidney Disease
albumincreatinine ratio ACR gt 30 mg/mmol or
urinary protein gt 500 mg/24hr
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Treatment of Hypertension in Patients with
Renovascular Disease
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Treatment of Hypertension in association with
Diabetes Mellitus
Urinary albumin to creatinine ratio gt 2.0
mg/mmol in men or gt 2.8mg/mmol in women or CKD
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Treatment of Hypertension in association with
Diabetic Nephropathy
Monitor potassium and creatinine carefully in
patients with CKD prescribed an ACEI or ARB
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Vascular Protection for Hypertensive Patients
Statins

• high-risk hypertensive patients with established
  atherosclerotic disease or with at least 3 of the
  following criteria

ASCOT-LLA Lancet 20033611149-58
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Vascular Protection for Hypertensive Patients
ASA
Consider low dose ASA
Caution should be exercised if BP is not
controlled.
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References

• Canadian Hypertension Education Program
  Recommendations for the Management of
  Hypertension 2007. www.hypertension.ca
• Hypertension highlights.European Society of
  Hypertension. www.esohonline.org
• The Seventh Report of the Joint National
  Committee on Prevention, Detection,Evaluation and
  Treatment of High Blood