INCIDENTAL HYPERTENSION: How to manage

1. INCIDENTAL HYPERTENSION:How to manage Dr. SaulatSiddique, Professor of Cardiology, ShaikhZayed Hospital, Lahore. FAMILYCON 2013, 4-5-6 January, 2013, Lahore.

2. Q. No.1Regarding Blood Pressure measurement; • SBP is when the first Korotkoff sound is heard • DBP is when the sounds become muffled (Korotkoff phase IV) • BP reading should be rounded to the nearest 5 or zero e.g. 130/85mmHg • BP reading should be written as 132/86mmHg i.e. recorded to the nearest even number

3. BLOOD PRESSURE MEASUREMENT • Record 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

4. 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 medication • Advised life style measures • Given a sedative • Asked to come back for follow-up visit

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

6. BLOOD PRESSURE MEASUREMENT • The 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

7. BLOOD PRESSURE MEASUREMENT • Patients should sit for several minutes in a quiet and comfortable place • Use appropriate cuff size for age and weight • Have cuff at heart level • Deflate the cuff @2-3mmHg/beat • Take 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

8. BLOOD PRESSURE MEASUREMENT • NICE guidelines (2011) state that there should be complete skin contact of the stethoscope with no clothing in between • The 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.”

9. Q. No. 4.Life style measures include; • Low sodium diet • Exercise like weight lifting and push-ups • Diet rich in potassium • Aerobic exercise

10. LIFESTYLE MODIFICATIONS TO REDUCE BLOOD PRESSURE • Ask patients about their diet and exercise patterns, and offer guidance and written or audiovisual information • Regular 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 excessively • Discourage excessive consumption of coffee and other caffeine-rich products • Encourage patients to reduce their salt intake or use a substitute • Offer smokers advice and help to stop smoking • DO NOT OFFER • Calcium, magnesium or potassium supplements to reduce blood pressure • Relaxation therapies can reduce blood pressure and patients may wish to try them. However, primary care teams are not recommended to provide them routinely PHL/PCS, Hypertension Guidelines 2009

11. IMPACT OF LIFE-STYLE CHANGES ON REDUCTION OF SBP PHL/PCS, Hypertension Guidelines 2009

12. 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 fundoscopy • Checked for waist circumference • Checked for postural hypotension

13. BLOOD PRESSURE MEASUREMENT • Measure Blood Pressure in both arms. Take the higher value as baseline • Difference of 5/10 mm can be considered as normal • Waist circumference is an essential part of the physical examination as is fundoscopy • Measure BP in standing position in elderly, diabetes and in case of hypotension inducing drugs PHL/PCS, Hypertension Guidelines 2009

14. Q. No. 6. The following are essential in his work-up; • Serum sodium and potassium • Urine for VMA • Echocardiography • Complete Lipid Profile

15. INVESTIGATIONS (Minimal) • Urine analysis for proteins (can be done with a dipstick as a starter) • Serum creatinine levels • Serum potassium and sodium levels • Random blood sugar • ECG for evidence of established coronary artery disease (CAD) or LVH • Chest X Ray (PA view) PHL/PCS, Hypertension Guidelines 2009

16. LIPID PROFILE • Part of special investigations in Pakistani guidelines • ESC guidelines recommend complete Lipid Profile as an essential test • NICE guidelines recommend that only total cholesterol and HDL should be done

17. SPECIAL INVESTIGATIONS (On case to case basis) • Echocardiogram • Lipid Profile • Carotid (and femoral) ultrasound • C-reactive protein • Microalbuminuria (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 imaging PHL/PCS, Hypertension Guidelines 2009

18. Q. No. 7. He should be started on; • ACEI • ARB • CCB • Diuretic • Combination Tablet

19. Antihypertensive Drug Treatment: NICE 2011 A = ACEior ARB C = CCB D = Thiazide-likediureticsuch as chlorthalidone (12.5 mg–25 mg once daily) or indapamide rather than thiazide diuretic such as bendroflumethiazide or hydrochlorothiazide. C* = CCB preferred but considerthiazide-likediuretics in people withoedema or a highrisk of heartfailure Furtherdiuretic** = low-dose spironolactone or higher doses of a thiazide-likediuretic

20. Q. No. 8. He should also be prescribed; • Aspirin 75mg OD • Atorvastatin 10mg OD • Bromazepam 3mg OD

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

22. HISTORY • Detailed history is essential • Prior history of high BP, kidney disorders, stroke, heart disease, diabetes, dyslipidemia. • Complications of pregnancy • Drug history • NSAIDs • Oral Contraceptives • Previous antihypertensives • Family history of hypertension, heart disease, diabetes • Smoking and dietary habits PHL/PCS, Hypertension Guidelines 2009

23. SIGNS OF ORGAN DAMAGE • Brain: murmurs over neck arteries, motor or sensory defects • Retina: fundoscopic abnormalities • Heart: location and characterstics of apical impulse, abnormal cardiac rhythms, ventricular gallop, pulmonary rales, dependent edema • Peripheral arteries: absence, reduction, or asymmetry PHL/PCS, Hypertension Guidelines 2009

24. The importance of 24-hour blood pressure control in hypertension management • ESC/ESH Guidelines1 • NICE Guidelines 20112 • “If 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 day” • “Drugs which exert their antihypertensive effect over 24 hours with a once-a-day administration should be preferred” 24 1. Mancia G, et all. J Hypertens. 2007;25:1105-1187. 2. NICE Guidelines 2011.

25. NICE Chart of AB/CD with de-emphasis on beta-blockers

26. Thanks