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INCIDENTAL HYPERTENSION:How to manageDr. Saulat Siddique, Professor of Cardiology, Shaikh Zayed Hospital, Lahore.

FAMILYCON 2013,4-5-6 January, 2013, Lahore.

Q. No.1 Regarding Blood Pressure measurement;

SBP is when the first Korotkoff sound is heardDBP is when the sounds become muffled (Korotkoff phase IV)BP reading should be rounded to the nearest 5 or zero e.g. 130/85mmHgBP reading should be written as 132/86mmHg i.e. recorded to the nearest even number

BLOOD PRESSURE MEASUREMENTRecord the result for systolic and diastolic pressures to the nearest 2mmHg. For the systolic reading, record the level at which the first (at least two consecutive) sound is heard.For the diastolic reading, use phase V Korotkoff (disappearance of sound). Only use phase IV Korotkoff (muffilng of sound) if sound continues towards zero.

PHL/PCS Hypertension Guidelines, 2009

Q. No. 2. A 43 year old previously healthy male visits his family practitioner for symptoms of flu. His BP is found to be 146/96. He should be;Started on anti-hypertensive medicationAdvised life style measuresGiven a sedativeAsked to come back for follow-up visit

Q. No. 3 Regarding the BP cuff;Cuff size is same as bladder sizeLength should cover the full arm circumferenceWidth should be half the arm circumference Inappropriately small cuff will give a falsely low reading

BLOOD PRESSURE MEASUREMENTThe bladder length should be at least 80% and the width at least 40% of the circumference of the mid-upper arm. Use of a standard size cuff in people with large arm can result in artificially high blood pressure reading. If an oversized cuff cannot be satisfactorily fitted on a large arm then the utilization of an appropriately sized cuff on the forearm with radial artery auscultation should be considered.

PHL/PCS Hypertension Guidelines, 2009

BLOOD PRESSURE MEASUREMENTPatients should sit for several minutes in a quiet and comfortable placeUse appropriate cuff size for age and weightHave cuff at heart levelDeflate the cuff @2-3mmHg/beatTake minimum 2 measurements at least 1-2minutes apart. Ask the patients to return for 1-2 more visits, if BP is elevated on first visit (to confirm the diagnosis of hypertension), before starting treatment

PHL/PCS Hypertension Guidelines, 2009

BLOOD PRESSURE MEASUREMENTNICE guidelines (2011) state that there should be complete skin contact of the stethoscope with no clothing in betweenThe Pakistani guidelines state that, In Pakistani setting, BP is quite often measured with shirt sleeve on rather than bare arm, especially in ladies. A recent Canadian Study indicates that there is no difference in BP reading if average thickness of sleeves is 4.3 mm or less.

Q. No. 4.Life style measures include;Low sodium dietExercise like weight lifting and push-upsDiet rich in potassiumAerobic exercise

LIFESTYLE MODIFICATIONS TO REDUCE BLOOD PRESSUREAsk patients about their diet and exercise patterns, and offer guidance and written or audiovisual informationRegular aerobic physical activity is recommended for all persons, but those with advanced or unstable CVD may require a medical evaluation before initiation of exercise or a medically supervised exercise program. Isometric exercise such as heavy weight lifting can have a pressor effect and should be avoided. Ask about alcohol consumption and encourage patients to cut down if they drink excessivelyDiscourage excessive consumption of coffee and other caffeine-rich productsEncourage patients to reduce their salt intake or use a substituteOffer smokers advice and help to stop smokingDO NOT OFFERCalcium, magnesium or potassium supplements to reduce blood pressureRelaxation therapies can reduce blood pressure and patients may wish to try them. However, primary care teams are not recommended to provide them routinelyPHL/PCS, Hypertension Guidelines 2009

IMPACT OF LIFE-STYLE CHANGES ON REDUCTION OF SBPInterventionReduction in SBP (mmHg)Increased Magnesium (Mg)0 1 Increased Calcium (Ca)2Increased Potassium (K)4Fish Oil6Reduced Sodium (Na)6Reduced Weight8Exercise10Dash Diet12PHL/PCS, Hypertension Guidelines 2009

Q. No. 5. Follow-up visit after 2 weeks reveals sitting BP of 138/90 in the right arm and 148/92 in the left arm. He should be;Investigated for stenosis in the right subclavian/axillary artery.Sent for fundoscopyChecked for waist circumferenceChecked for postural hypotension

BLOOD PRESSURE MEASUREMENTMeasure Blood Pressure in both arms. Take the higher value as baselineDifference of 5/10 mm can be considered as normalWaist circumference is an essential part of the physical examination as is fundoscopyMeasure BP in standing position in elderly, diabetes and in case of hypotension inducing drugs

PHL/PCS, Hypertension Guidelines 2009

Q. No. 6. The following are essential in his work-up;Serum sodium and potassiumUrine for VMAEchocardiographyComplete Lipid Profile

INVESTIGATIONS (Minimal)Urine analysis for proteins (can be done with a dipstick as a starter)Serum creatinine levelsSerum potassium and sodium levelsRandom blood sugarECG for evidence of established coronary artery disease (CAD) or LVHChest X Ray (PA view)PHL/PCS, Hypertension Guidelines 2009

LIPID PROFILEPart of special investigations in Pakistani guidelinesESC guidelines recommend complete Lipid Profile as an essential test NICE guidelines recommend that only total cholesterol and HDL should be done

SPECIAL INVESTIGATIONS (On case to case basis)EchocardiogramLipid ProfileCarotid (and femoral) ultrasoundC-reactive proteinMicroalbuminuria (essential test in diabetics)Quantitative proteinuria (if dipstick test positive)Search for secondary hypertension: measurement of renin, aldosterone, corticosteroids, catecholamines, arteriography, renal & adrenal ultrasound, computer assisted tomography (CAT), magnetic resonance imagingPHL/PCS, Hypertension Guidelines 2009

Q. No. 7. He should be started on;ACEIARBCCBDiureticCombination Tablet

Antihypertensive Drug Treatment: NICE 2011A = ACEi or ARB

C = CCB

D = Thiazide-like diuretic such as chlorthalidone (12.5 mg25 mg once daily) or indapamide rather than thiazide diuretic such as bendroflumethiazide or hydrochlorothiazide.

C* = CCB preferred but consider thiazide-like diuretics in people with oedema or a high risk of heart failure

Further diuretic** = low-dose spironolactone or higher doses of a thiazide-like diuretic

Q. No. 8. He should also be prescribed;Aspirin 75mg ODAtorvastatin 10mg ODBromazepam 3mg OD

Aspirin is only recommended in those with IHD, CKD and in high cardiovascular risk subjects in the ESC guidelinesStatins are recommended in IHD, DM and in high cardiovascular risk subjects in the ESC guidelines or if cholesterol levels are high.

HISTORYDetailed history is essentialPrior history of high BP, kidney disorders, stroke, heart disease, diabetes, dyslipidemia. Complications of pregnancyDrug historyNSAIDsOral ContraceptivesPrevious antihypertensivesFamily history of hypertension, heart disease, diabetesSmoking and dietary habitsPHL/PCS, Hypertension Guidelines 2009

SIGNS OF ORGAN DAMAGEBrain: murmurs over neck arteries, motor or sensory defectsRetina: fundoscopic abnormalitiesHeart: location and characterstics of apical impulse, abnormal cardiac rhythms, ventricular gallop, pulmonary rales, dependent edemaPeripheral arteries: absence, reduction, or asymmetryPHL/PCS, Hypertension Guidelines 2009The importance of 24-hour blood pressure control in hypertension managementDrugs which exert their antihypertensive effect over 24 hours with a once-a-day administration should be preferred 1. Mancia G, et all. J Hypertens. 2007;25:1105-1187. 2. NICE Guidelines 2011. ESC/ESH Guidelines1If the clinic BP 140/90 mm Hg offer 24-hour ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis of hypertension (NEW 2011)

when possible recommend treatment with drug taken once a dayNICE Guidelines 20112

24< 55 years > 55 years or Asian / ChineseSTEP 1 A C or DSTEP 2A+C or A+DSTEP 3 A+C+DSTEP 4Add: Further D/C therapyAlpha BlockersBeta Blockers etcA: ACEI/ARB C: CCB, D: Diuretic NICE Chart of AB/CD with de-emphasis on beta-blockersThanks