EMERGENCY MEETING FOR PHILHEALTH REQUIREMENTS CLINICAL PRACTICE GUIDELINES ON HYPERTENSION CLINICAL PATHWAYS ON HYPERTENSION

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EMERGENCY MEETINGFOR PHILHEALTH
REQUIREMENTSCLINICAL PRACTICE GUIDELINES ON
HYPERTENSIONCLINICAL PATHWAYS ON HYPERTENSION

• MAKATI MEDICAL CENTER
• DEPARTMENT OF MEDICINE
• SECTION OF CARDIOLOGY

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DIAGNOSIS OF HYPERTENSION

• Patients with a blood pressure of 140/90 mm Hg or
  higher, recorded on at least 2 separate occasions
  at rest.

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BP MEASUREMENTS

• Steps in taking blood pressure
• Snug application of compression cuff
• Palpation of radial artery as compression cuff is
  inflated
• Palpation of radial artery as cuff is deflated as
  2 3 mm Hg per heartbeat
• Careful placement of stethoscope bell
• Inflation of compression cuff above systolic
  pressure
• Deflation of the cuff at a rate of 2 3 mm Hg
  per heartbeat to determine systolic and diastolic
  blood pressure.

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BP MEASUREMENTS

• Must Remember
• Position of the patient.
• The patient may be sitting or lying. When the
  patient is recumbent, the cuff is essentially at
  cardiac level. If the patient is sitting, the
  arm and forearm should be supported on a tabletop
  at heart level.
• If the patient can rest for a while before the
  blood pressure is taken, it would seem preferable
  to use the lying position.
• The difference in the reading obtained in both
  positions ordinarily should not be significant.
  At times the pressure may be much lower when the
  patient is standing and whenever this condition
  is suspected, readings should be taken in the
  lying, sitting and standing positions

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DIAGNOSTIC EVALUATION
FAMILY AND CLINICAL HISTORY
Duration and previous level of high BP Indications of secondary hypertension Risk Factors Symptoms of Organ Damage Previous antihypertensive therapy (efficacy, adverse events) Personal, Family, Environmental Factors
PHYSICAL EXAMINATIONS
Signs suggesting secondary hypertension Signs of organ damage Evidence of visceral obesity
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CLASSIFICATION OF HYPERTENSIONAdapted from JNC
VII Guidelines for Hypertension
BLOOD PRESSURE (BP) STAGE SYSTOLIC BP (mm Hg) DIASTOLIC BP (mm Hg)
NORMAL lt 120 lt 80
PREHYPERTENSION 120 139 80 -89
STAGE 1 HYPERTENSION 140 159 90 99
STAGE 2 HYPERTENSION gt 160 gt 100
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LAB INVESTIGATIONS (FOR NEW PATIENTS OR PATIENTS
LOST TO FOLLOW UP)
ROUTINE TESTS
Fasting Plasma Glucose Serum total cholesterol, LDL cholesterol, HDL cholesterol, Triglycerides Serum Potassium, Uric Acid, Creatinine Estimated creatinine clearance (cockgraft-Fault formula) or glomerular filtration rate (MDRD) Formula Complete Blood Count Urinalysis (Complemented by microalbuminuria dipstick test and microscopic examination) Electrocardiogram Chest X-Ray
Adapted from the Compendium of Abridged ESC
Guidelines 2008.
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LAB INVESTIGATIONS (FOR NEW PATIENTS OR PATIENTS
LOST TO FOLLOW UP)
RECOMMENDED TESTS
Echocardiogram Carotid Ultrasound Quantitative proteinuria (if dipstick test is positive) Ankle Brachial Index (ABI) Fundoscopy Glucose Tolerance Test (If fasting plasma glucose gt 5.6 mmol/L ) (100 mg/dL) Home and 24 hour ambulatory BP monitoring Pulse wave velocity measurement (where available)
if clinically indicated
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LAB INVESTIGATIONS (FOR NEW PATIENTS OR PATIENTS
LOST TO FOLLOW UP)
EXTENDED EVALUATION
Further search for cerebral, cardiac, renal and vascular damage Mandatory in complicated hypertension Search for secondary hypertension when suggested by history, physical examination or routine tests measurement of renin, aldosterone, corticosteroids, catecholamines in plasma and/or urine arteriographies renal and adrenal ultrasound, computer assisted tomography magnetic resonance imaging
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CRITERIA FOR HOSPITAL ADMISSION

• Patients with hypertensive emergencies/ urgency
  should be admitted to the hospital
• 2. Symptomatic Stage 2 Hypertension
• (associated with severe headache, shortness of
  breath, epistaxis or severe anxiety)

HYPERTENSIVE EMERGENCY Severe elevations in blood pressure (BP) that are complicated by evidence of progressive target organ dysfunction, and will require immediate BP reduction
HYPERTENSIVE URGENCY Severe elevations of BP but without evidence of progressive target organ dysfunction and would be better defined as severe elevations in BP without acute, progressive target organ damage
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Clinical Characteristics of the Hypertensive
Emergency
BLOOD PRESSURE Usually gt 220/140 mm Hg
FUNDOSCOPIC FINDINGS Hemorrhages, exudates, papilledema
NEUROLOGIC STATUS Headache, Confusion, Somnolence, Stupor, Visual loss, Seizures, Foacl neurologic deficits, coma
CARDIAC FINDINGS Prominent apical pulsation, cardiac enlargement, congestive heart failure
RENAL SYMPTOMS Azotemia, Proteinuria, Oliguria
GI SYMPTOMS Nausea, Vomiting
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TREATMENT For Stage I Hypertension
THIAZIDE DIURETICS (for most) May consider ACE-I, ARB, BB, CCB Are the drugs of choice (if without compelling indications)
A SECOND DRUG POTASSIUM SPARING DIURETICS ALDOSTERONE RECEPTOR BLOCKERS BETA BLOCKERS ACE INHIBITORS ANGIOTENSIN II ANTAGONIST CALCIUM CHANNEL BLOCKERS ALPHA I BLOCKERS CENTRAL ALPHA II AGONISTS DIRECT VASODILATORS ADDITIONAL COMBINATION DRUG ACE I CCB Either as a separate prescription or in fixed dose combinations with thiazide diuretics may be used when the BP remains uncontrolled or when BP is gt 20 mm Hg above systolic goal or 10 mm Hg above diastolic goal.
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TREATMENT For Hypertension with Compelling
Indications
DRUG COMPELLING INDICATIONS
DIURETICS Heart failure, High coronary disease risk, diabetes, recurrent stroke prevention
BETA BLOCKERS Post Myocardial Infarction, Heart Failure, High Coronary Disease Risk, Diabetes
ACE INHIBITORS Heart Failure, High coronary disease risk, diabetes, Recurrent stroke prevention, Chronic kidney disease, post MI
ANGIOTENSIN RECEPTOR BLOCKER HCeart Failure, diabetes, chronic kidney disease
CALCIUM CHANNEL BLOCKER High coronary disease risk, Diabetes
ALDOSTERONE ANTAGONIST Heart Failure, Post MI
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For Stage 2 Hypertension (JNC VII) SBP gt 160 mm
Hg/ DBP gt 100 mm Hg we may use initially the
following medicationsCLONIDINE or CAPTOPRIL
CLONIDINE 75 mcg tablet sublingual every 15 mintues for a maximum of 3 doses Is a centrally acting alpha-adrenergic agonist with onset of action 30 to 60 minutes after oral administration, and maximal effects are usually seen within 2 to 4 hours. The most common adverse effect in the acute setting is drowsiness affecting up to 45 of patients. Clonidine may be a poor choice monitoring of mental status is important. Dry mouth is a common complaint, and lightheadedness is occasionally observed.
CAPTOPRIL 25 mg tabletSublingual every 15 minutes for a maxiumum of 3 doses An angiotensin-converting enzyme inhibitor, is well tolerated and can effectively reduce BP in a hypertensive urgency. Given by mouth, captopril is usually effective within 15 to 30 minutes and may be repeated in 1 to 2 hours, depending on the response. The drug has been administered sublingually. In which case the onset of action is within 10 to 20 minutes with a maximal effect reached within 1 hour. Administration may lead to acute renal failure in patients with high grade bilateral renal artery stenosis, and some reflex tachycardia may be observed.
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If unresponsive to sublingual medications then
the following formulary parenteral drugs may be
used for hypertensive emergencies, vasodilators
(Sodium nitroprusside, nicardipine HCl,
Nitroglycerine, Hydralazine Hcl and adrenergic
inhibitor Esmolol Hcl) and titrate accordingly
AGENT DOSE ONSET/ DURATION OF ACTION (AFTER DISCONTINUATION) PRECAUTIONS
NITROGLYCERINE 5 100 ug as IV infusion 2 5 minutes/ 5 10 minutes Headache, tachycardia, vomiting, flushing, methemoglobinemia
NICARDIPINE 5 15 mg/ hr IV infusion 1 5 minutes/ 15 30 minutes, but may exceed 12 hours after prolonged infucion Tachycardias, nausea, vomiting, headache, increased intracranial pressure hypotension protracted after prolonged infusions
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If unresponsive to sublingual medications then
the following formulary parenteral drugs may be
used for hypertensive emergencies, vasodilators
(Sodium nitroprusside, nicardipine HCl,
Nitroglycerine, Hydralazine Hcl and adrenergic
inhibitor Esmolol Hcl) and titrate accordingly
AGENT DOSE ONSET/ DURATION OF ACTION (AFTER DISCONTINUATION) PRECAUTIONS
HYDRALAZINE 5 20 mg as IV bolus or 10 to 40 mg IM repeat every 4 6 hours 10 minutes IV gt 1 hour 20 - 30 minutes IM/ 4 6 hours Tachycardia, headache, vomiting, aggravation of angina pectoris, sodium and water retention and increased intracranial pressure
ESMOLOL 500 ug/ kg bolus injection IV or 50 to 100 ug/kg/minute by infusion. May repeat bolus after 5 minutes or increase infusion rate to 300 ug/ kg/ min 1 5 minutes/ 15 30 minutes First degree heart block, congestive heart failure, asthma
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• For HYPERTENSIVE EMERGENCIES The 1st drug to be
  given ASAP to lower Blood Pressure to 2/3 of
  Systolic Blood Pressure
• For HYPERTENSIVE PATIENTS with suspected
  NEUROLOGIC COMPONENT Keep Blood pressure at
  least 140 160 mm Hg until patient stabilizes
• OVERLAP
• Shift if FIRST DRUG of choice is not effective
  and patient is not responding.

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Clinical Pathways for Hypertension Stage 2 SBP
gt 160 mm Hg/ DBP gt 100 mm Hg
1st 15 minutes 2nd 15 minutes 3rd 15 minutes
ASSESSMENT Initial evaluation Include Neurologic Evaluation Assessed Severity Hypertensive Urgency Hypertensive Emergency Stage 2 Hypertension Risk Factors Assessed Response to treatment assessed
DIAGNOSTICS Baseline Laboratory tests Stat 5 (Na, K, FBS, Hb, Hct) 12 Lead ECG Additional hypertensive work-up upon consultants discretion Additional hypertensive work-up upon consultants discretion
TREATMENTS/ MEDICATIONS Clonidine 75 mcg tablet sublingual or Captopril 25 mg tablet sublingual Insert IV access Clonidine 75 mcg tablet sublingual or Captopril 25 mg tablet sublingual Start parenteral anti-hypertensive
TEACHING Patients are oriented briefed on the signs and symptoms of hypertension Patients are oriented briefed on the signs and symptoms of hypertension Patients are oriented briefed on the signs and symptoms of hypertension
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• For Hypertensive urgency, control BP to at least
  2/3 of SBP within 24 hours
• For Symptomatic Stage 2 Hypertension, control
  symptoms and discharge with maintenance
  medications
• Upon discharge
• Patient education lifestyle management
• Home medications (anti-hypertensive medications)
• Schedule for follow-up

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Clinical Pathway Hypertensive Emergencies and
Urgencies
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Hypertensive Urgency
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Algorithm for Treatment of Hypertension