HYPERTENSION Detection, Evaluation and Non-pharmacologic Intervention

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HYPERTENSIONDetection, Evaluation and
Non-pharmacologic Intervention

• Misbah Keen, MD, FAAFP
• Act. Asst. Professor Family Medicine
• University of Washington School of Medicine
• Seattle WA

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Problem Magnitude

• Hypertension( HTN) is the most common primary
  diagnosis in America.
• 35 million office visits are as the primary
  diagnosis of HTN.
• 50 million or more Americans have high BP.
• Worldwide prevalence estimates for HTN may be as
  much as 1 billion.
• 7.1 million deaths per year may be attributable
  to hypertension.

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Definition

• A systolic blood pressure ( SBP) gt139 mmHg and/or
• A diastolic (DBP) gt89 mmHg.
• Based on the average of two or more properly
  measured, seated BP readings.
• On each of two or more office visits.

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Accurate Blood Pressure Measurement

• The equipment should be regularly inspected and
  validated.
• The operator should be trained and regularly
  retrained.
• The patient must be properly prepared and
  positioned and seated quietly for at least 5
  minutes in a chair.
• The auscultatory method should be used.
• Caffeine, exercise, and smoking should be avoided
  for at least 30 minutes before BP measurement.
• An appropriately sized cuff should be used.

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BP Measurement

• At least two measurements should be made and the
  average recorded.
• Clinicians should provide to patients their
  specific BP numbers and the BP goal of their
  treatment.

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Follow-up based on initial BPmeasurements for
adults
www.nhlbi.nih.gov
Without acute end-organ damage
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Classification
www.nhlbi.nih.gov
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Prehypertension

• SBP gt120 mmHg and lt139mmHg and/or
• DBP gt80 mmHg and lt89 mmHg.
• Prehypertension is not a disease category rather
  a designation for individuals at high risk of
  developing HTN.

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Pre-HTN

• Individuals who are prehypertensive are not
  candidates for drug therapy but
• Should be firmly and unambiguously advised to
  practice lifestyle modification
• Those with pre-HTN, who also have diabetes or
  kidney disease, drug therapy is indicated if a
  trial of lifestyle modification fails to reduce
  their BP to 130/80 mmHg or less.

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Isolated Systolic Hypertension

• Not distinguished as a separate entity as far as
  management is concerned.
• SBP should be primarily considered during
  treatment and not just diastolic BP.
• Systolic BP is more important cardiovascular risk
  factor after age 50.
• Diastolic BP is more important before age 50.

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Frequency Distribution of Untreated HTN by Age
Isolated Systolic HTN
Systolic Diastolic HTN
Isolated Diastolic HTN
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Hypertensive Crises

• Hypertensive Urgencies No progressive
  target-organ dysfunction. (Accelerated
  Hypertension)
• Hypertensive Emergencies Progressive end-organ
  dysfunction. (Malignant Hypertension)
• 
  

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Hypertensive Urgencies

• Severe elevated BP in the upper range of stage II
  hypertension.
• Without progressive end-organ dysfunction.
• Examples Highly elevated BP without severe
  headache, shortness of breath or chest pain.
• Usually due to under-controlled HTN.

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Hypertensive Emergencies

• Severely elevated BP (gt180/120mmHg).
• With progressive target organ dysfunction.
• Require emergent lowering of BP.
• Examples Severely elevated BP with
• Hypertensive encephalopathy
• Acute left ventricular failure with pulmonary
  edema
• Acute MI or unstable angina pectoris
• Dissecting aortic aneurysm

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Types of Hypertension

• Primary HTN
• also known as essential HTN.
• accounts for 95 cases of HTN.
• no universally established cause known.

• Secondary HTN
• less common cause of HTN ( 5).
• secondary to other potentially rectifiable
  causes.

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Causes of Secondary HTN

• Common
• Intrinsic renal disease
• Renovascular disease
• Mineralocorticoid excess
• Sleep Breathing disorder

• Uncommon
• Pheochromocytoma
• Glucocorticoid excess
• Coarctation of Aorta
• Hyper/hypothyroidism

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Secondary HTN-Clues in Medical History

• Onset at age lt 30 yrs ( Fibromuscular dysplasi)
  or gt 55 (athelosclerotic renal artery stenosis),
  sudden onset (thrombus or cholesterol embolism).
• Severity Grade II, unresponsive to treatment.
• Episodic, headache and chest pain/palpitation
  (pheochromocytoma, thyroid dysfunction).
• Morbid obesity with history of snoring and
  daytime sleepiness (sleep disorders)

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Secondary HTN-clues on Exam

• Pallor, edema, other signs of renal disease.
• Abdominal bruit especially with a diastolic
  component (renovascular)
• Truncal obesity, purple striae, buffalo hump
  (hypercortisolism)

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Secondary HTN-Clues on Routine Labs

• Increased creatinine, abnormal urinalysis
  ( renovascular and renal parenchymal disease)
• Unexplained hypokalemia (hyperaldosteronism)
• Impaired blood glucose
• ( hypercortisolism)
• Impaired TFT (Hypo-/hyper- thyroidism)

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Secondary HTN-Screening Tests
www.nhlbi.nih.gov
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Renal Parenchymal Disease

• Common cause of secondary HTN (2-5)
• HTN is both cause and consequence of renal
  disease
• Multifactorial cause for HTN including
  disturbances in Na/water balance,
  vasodepressors/ prostaglandins imbalance
• Renal disease from multiple etiologies.

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Renovascular HTN

• Atherosclerosis 75-90 ( more common in older
  patients)
• Fibromuscular dysplasia 10-25 (more common in
  young patients, especially females)
• Other
• Aortic/renal dissection
• Takayasus arteritis
• Thrombotic/cholesterol emboli
• CVD
• Post transplantation stenosis
• Post radiation

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Complications of Prolonged Uncontrolled HTN

• Changes in the vessel wall leading to vessel
  trauma and arteriosclerosis throughout the
  vasculature
• Complications arise due to the target organ
  dysfunction and ultimately failure.
• Damage to the blood vessels can be seen on
  fundoscopy.

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Target Organs

• CVS (Heart and Blood Vessels)
• The kidneys
• Nervous system
• The Eyes

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Effects On CVS

• Ventricular hypertrophy, dysfunction and failure.
• Arrhithymias
• Coronary artery disease, Acute MI
• Arterial aneurysm, dissection, and rupture.

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Effects on The Kidneys

• Glomerular sclerosis leading to impaired kidney
  function and finally end stage kidney disease.
• Ischemic kidney disease especially when renal
  artery stenosis is the cause of HTN

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Nervous System

• Stroke, intracerebral and subaracnoid hemorrhage.
• Cerebral atrophy and dementia

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The Eyes

• Retinopathy, retinal hemorrhages and impaired
  vision.
• Vitreous hemorrhage, retinal detachment
• Neuropathy of the nerves leading to extraoccular
  muscle paralysis and dysfunction

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Retina Normal and Hypertensive Retinopathy
A
B
C
Normal Retina
Hypertensive Retinopathy
A Hemorrhages B Exudates (Fatty Deposits) C
Cotton Wool Spots (Micro Strokes)
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Stage I- Arteriolar Narrowing
Arteriolar Narrowing
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Stage II- AV Nicking
AV Nicking
AV Nicking
AV Nicking
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AV Nicking
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Stage III- Hemorrhages (H), Cotton Wool Spots and
Exudats (E)
H
E
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Stage IV- Stage IIIPapilledema
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Patient Evaluation Objectives

• (1) To assess lifestyle and identify other
  cardiovascular risk factors or concomitant
  disorders that may affect prognosis and guide
  treatment
• (2) To reveal identifiable causes of high BP
• (3) To assess the presence or absence of target
  organ damage and CVD

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(1) Cardiovascular Risk factors

• Hypertension
• Cigarette smoking
• Obesity (body mass index 30 kg/m2)
• Physical inactivity
• Dyslipidemia
• Diabetes mellitus
• Microalbuminuria or estimated GFR lt60 mL/min
• Age (older than 55 for men, 65 for women)
• Family history of premature cardiovascular
  disease (men under age 55 or women under age 65)

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(2) Identifiable Causes of HTN

• Sleep apnea
• Drug-induced or related causes
• Chronic kidney disease
• Primary aldosteronism
• Renovascular disease
• Chronic steroid therapy and Cushings syndrome
• Pheochromocytoma
• Coarctation of the aorta
• Thyroid or parathyroid disease

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(3) Target Organ Damage

• Heart
• Left ventricular hypertrophy
• Angina or prior myocardial infarction
• Prior coronary revascularization
• Heart failure
• Brain
• Stroke or transient ischemic attack
• Chronic kidney disease
• Peripheral arterial disease
• Retinopathy

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History

• Angina/MI Stroke Complications of HTN, Angina
  may improve with b-blokers
• Asthma, COPD Preclude the use of b-blockers
• Heart failure ACE inhibitors indication
  
• DM ACE preferred
• Polyuria and nocturia Suggest renal impairment

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History-contd.

• Claudication May be aggravated by b-blockers,
  atheromatous RAS may be present
• Gout May be aggravated by diuretics
• Use of NSAIDs May cause or aggravate HTN
• Family history of HTN Important risk factor
• Family history of premature death May have been
  due to HTN

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History-contd.

• Family history of DM Patient may also be
  Diabetic
• Cigarette smoker Aggravate HTN, independently a
  risk factor for CAD and stroke
• High alcohol A cause of HTN
• High salt intake Advice low salt intake

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Examination

• Appropriate measurement of BP in both arms
• Optic fundi
• Calculation of BMI ( waist circumference also may
  be useful)
• Auscultation for carotid, abdominal, and femoral
  bruits
• Palpation of the thyroid gland.

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Examination-contd.

• Thorough examination of the heart and lungs
• Abdomen for enlarged kidneys, masses, and
  abnormal aortic pulsation
• Lower extremities for edema and pulses
• Neurological assessment

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Routine Labs

• EKG.
• Urinalysis.
• Blood glucose and hematocrit serum potassium,
  creatinine ( or estimated GFR), and calcium.
• HDL cholesterol, LDL cholesterol, and
  triglycerides.
• Optional tests
• urinary albumin excretion.
• albumin/creatinine ratio.

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Goals of Treatment

• Treating SBP and DBP to targets that are lt140/90
  mmHg
• Patients with diabetes or renal disease, the BP
  goal is lt130/80 mmHg
• The primary focus should be on attaining the SBP
  goal.
• To reduce cardiovascular and renal morbidity and
  mortality

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Benefits of Treatment

• Reductions in stroke incidence, averaging 3540
  percent
• Reductions in MI, averaging 2025 percent
• Reductions in HF, averaging gt50 percent.

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Lifestyle modifications
www.nhlbi.nih.gov
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Lifestyle Changes Beneficial in Reducing Weight

• Decrease time in sedentary behaviors such as
  watching television, playing video games, or
  spending time online.
• Increase physical activity such as walking,
  biking, aerobic dancing, tennis, soccer,
  basketball, etc.
• Decrease portion sizes for meals and snacks.
• Reduce portion sizes or frequency of consumption
  of calorie containing beverages.

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DASH Diet

• Dietary approaches to Stop Hypertension
• As effective as one medication

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JNC 7 Summary

• Joint National Commission 7th Report
• PDF File on website
• 50 page document

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Other JNC 7 Resources

• Software for use with Palm and Pocket PC

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JNC 7 Reference Card
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Other Resources

• Chronic Kidney Disease Information
• GFR Calculator
• www.nephron.com
• Hyperlipedemia Information
• Adult Treatment Panel 3 Guidelines
• www.nhlbi.nih.gov/guidelines/cholesterol/index.htm

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Questions

• mkeen_at_fammed.washington.edu