B2B - Hypertension

Dr Jen Leppard, MD, CCFP-EMMarch 28, 2014

LMCC Objectives – HTN

1. Diagnose HTN and determine its severity2. Investigate target organ damage and 2o causes3. List medical management4. Recognition and management of HTN urgencies

and emergencies

1a. Diagnosis• 2014 Canadian

Guidelines:

o >160/>100 X 3

o OR

o >140/>90 X 5

o can use office, ambulatory, or home BP cuffs to measure

BP: 140-179 / 90-109

ABPM (If available)

Office BPM

Office BPM

Home BPM (If available)

Yes

Hypertension Visit 2

Target Organ Damageor Diabetes

or BP ≥ 180/110?

Hypertension Visit 1

BP Measurement,History and Physical

examination

Hypertensive

Urgency / Emergency

Diagnosisof HTN

No

Diagnostic algorithm for hypertension

2014

Criteria for Diagnosis of HTN and Criteria for F/UBP: 140-179 / 90-109

ABPM (If available)

Diagnosisof HTN

Awake BP>135 SBP or>85 DBP or

24-hour>130 SBP or

>80 DBP

Awake BP<135/85

and24-hour<130/80

Continue to follow-up

Office BP

Diagnosisof HTN

Hypertension visit 3 >160 SBP or >100 DBP

>140 SBP or>90 DBP

< 140 / 90

Diagnosisof HTN

Continue to follow-up

<160 / 100

Hypertension visit 4-5

ABPM or HBPMor

Home BPMHome BPM

>135/85>135/85 < 135/85 < 135/85

Diagnosisof HTN

Continue to follow-up

Patients with high normal blood pressure (office SBP

130-139 and/or DBP 85-89) should be followed annually.

Repeat Home BPM

Repeat Home BPM

If<

135/85

If<

135/85

or

2014

1b. Severity• End organ damage

o Acute vs Chronic

• Acute - discussed with hypertensive emergencies• Chronic Target Organ Damage

2a. Investigations of Target Organ

Damage

MCQ 10: What test is not needed in ambulatory testing for HTN?

A. Urine, urine albumin (DM)B. Lytes + creatinineC. Fasting glucose + cholesterolD. CBC + diff E. ECG

Routine Laboratory TestsPreliminary Investigations of patients with hypertension

1. Urinalysis2. Blood chemistry (potassium, sodium and creatinine)3. Fasting glucose and/or glycated hemoglobin (A1c) 4. Fasting total cholesterol and high density lipoprotein cholesterol

(HDL), low density lipoprotein cholesterol (LDL), triglycerides5. Standard 12-leads ECG

Currently there is insufficient evidence to recommend routine testing of microalbuminuria in people with hypertension who do not have diabetes

2014

Types of HTN• Secondary HTN• 5-10%• Identifiable Cause• ABCDE

• Essential HTN• Most common (90%)• Cause unknown

2b. Secondary HTN• A – Apnea, Aldosterone

o Obstructive Sleep Apneao Hyperaldosteronism

• B – Bruits, Bad kidneyso Renovascular disease (atherosclerosis, fibromuscular dysplasia)o Renal parenchymal disease

• C – Catecholamines, Coarct, Cushing’so Pheochromocytomao Coarctation of the Aortao Cushing’s Disease

• D – Drugs, Diet

• E – Erythropoietin, Endocrine Disorderso Increased EPO from endogenous or exogenous sourceso Hypo or Hyperthyroid, Hyperparathyroid,

CDMQ: What are the clinical

clues and investigations

for 2o causes?

Secondary HTNObstructive Sleep Apnea

Body habitusBed partner complaintsDaytime somnolence

Sleep study

Hyperaldosteronism May look cushingoid Low K+, high Na+24 hour urinary aldosterone level

Renovascular Disease

Abdominal bruitOnset before 30 or after 55 years old

Doppler US, MRA

Renal Parenchymal Disease

Peripheral Edema, ascites, pulm edemaPoor urine output

Elevated BUN, CreatUrinalysis, incl. ACRUltrasound, CXR

Secondary HTN

Pheochromocytoma

Headache, labile or paroxysmal HTNPalpitations, pallor, diaphoresis

24 hour urine metanephrines

Aortic Coarctation

Decreased BP in lower extremitiesDelayed femoral pulse

ECHOCT Angio

Cushing’s Disease

Cushingoid Dexamethasone suppression test

Stimulant Drugs

Sympathomimetic toxidrome

Urine toxECG

Secondary HTN

Hypothyroid Weight gain, constipation, hair loss, fatigue

Serum TSH

Hyperthyroid Weight loss, temperature intolerance, tachycardia, tremors

Serum TSH

Hyperparathyroid Signs of hypercalcemia

Serum PTHCalcium

Drugs NSAIDS, steroids, estrogens decongestants, EPO, MAOIs, SNRIs, SSRIs, stimulants, excessive EtOH, licorice root, immunosuppresants

Diet ObesityHigh salt intake

Ambulatory Management

Non-Pharmacologic• Physical Exercise – 30-60min 4-7X/day• Weight Reduction• Alcohol Consumption - < 2 drinks/day• DASH Diet – (Dietary Approach to Stop HTN)• Sodium Intake - < 2000mg Sodium/day (5g salt)• Stress Management

Ambulatory Management

Pharmacotherapy

AACEi (Ramipril)

ARBs (Candsartan)

BBeta-Blockers(Metoprolol)

CCCB

(Amlodipine)

DDiuretic(HCTZ)

Specific Pharmacotherapy

CAD• ACEI /ARB • Angina/recent MI: Beta-blocker

DM• + Renal: ACEI/ARB• CCB• Thiazide

Specific Pharmacotherapy

Asthma• Avoid Beta-Blocker

CKD (no DM)• ACEI/ARB• Thiazide

Improving Compliance

• Tailor pill-taking to fit patients’ daily habits• Once Daily Dosing• Combination pills• Dosettes/Blister Packs

4. HTN Emergencies

HTN Emergency=

ACUTE Target Organ Damage

What are the target organs?

MCQ 9: Which is not an HTN

emergency?

A. 35 M 220/140, dizzy, normal neuro examB. 50 M 200/120, chest pain, CXR wide mediastinumC. 25 F 28 wks pregnant, 150/80, seizureD. 80 F 220/120, left arm weaknessE. 45 F 200/120, crackles to apex, JVP 6cm

ACS

Pulmonary edema

Aortic Dissectio

n

HTN emergencies are…

Bleeds, seizures Encephalopathy (not just headache,

dizzy)

Acute Kidney Injury

Investigations for HTN emergency

ACS

Pulmonary edema

Aortic Dissection

Bleeds, seizure,

encephalopathy

AKI

Treat HTN emergency: General Management

• BP: Reduce MAP by 25%

• Iv medications:• Labetolol• Nitroprusside• Hydralazine

CDMQ: 45 F 220/120, bilateral crackles,

JVP 6cm, Sat 80%. List specific treatment

(3)?

Specific Treatment: Pulmonary Edema

• BiPAP• Nitro Drip IV• Furosemide iv

Specific Treatment: ACS

• Nitro*• (Beta Blocker)• ASA• Anti-platelet

Specific TreatmentAortic Dissection

Type A – Ascending – Surgical Mgt

Type B – Descending – Medical

Nitroprusside + beta blocker (esmolol)OR

Labetalol

Specific Treatment: Seizure+ preg (Eclampsia)