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Hypertension Review & Updates

Hypertension Review & Updates. Tehran Arrhythmia Center Feb. 2006. Case. A 40 y/o sedentary man with a FH of stroke sees you for a health maintenance visit. His BP=150/100 mmHg and an LDL cholesterol of 170 mg/dl

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Hypertension Review & Updates

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  1. HypertensionReview&Updates Tehran Arrhythmia Center Feb. 2006

  2. Case • A 40 y/o sedentary man with a FH of stroke sees you for a health maintenance visit. His BP=150/100 mmHg and an LDL cholesterol of 170 mg/dl • Which one of the following would have the greatest impact on decreasing his future risk of stroke? • A) A program of regular physical exercise • B) Aspirin 81 mg daily • C) Reduction of LDL to <130 mg/dl • D) Reduction of BP to normal Tehran Arrhythmia Center

  3. Answer: D) Reduction of BP to normal General Facts • Stroke is the 3rd leading cause of death in the US • HTN is the most consistently powerful predictor of stroke • Primary prevention of stroke. N Engl J Med 1995 • Lowering BP results in 35-40% reduction in stroke incidence Tehran Arrhythmia Center

  4. Leading diagnoses resulting in visits to physician offices 25 20 Routine medical exams Acute respiratory tract infection Depression 15 Million visits/year Diabetes Hypertension 10 5 0 Source: IMS HEALTH Canada 2002. http://www.imshealthcanada.com/ Tehran Arrhythmia Center

  5. HTN: The Silent Killer • 50 million Americans & 1 billion worldwide affected • Most common primary care diagnosis (35 million visits annually) • Normotensive at age 55 have 90% lifetime risk of HTN • Continuous & consistent relationship with CVD • Between ages 40-70, starting from 115/75 • CVD risk doubles with each increment of 20/10 Tehran Arrhythmia Center

  6. Men Women 150 150 130 130 PP PP 110 110 80 80 70 70 30-39 40-49 50-59 60-69 70-79 30-39 40-49 50-59 60-69 70-79 80 80 Age Age PP=Pulse Pressure. Adapted from : Third National Health and Nutrition. Examination Survey, Hypertension 1995;25:305-13 Blood Pressure Distribution in the Population According to Age Tehran Arrhythmia Center

  7. 14 16 18 20 14 16 18 20 0 4 6 8 10 12 0 4 6 8 10 12 2 2 1976-98 Cumulative Incidence of Hypertension in Women and Men aged 65 years Risk of Hypertension % Risk of Hypertension % 100 100 Women Men 80 80 60 60 40 40 20 20 0 0 Years to Follow-up Years to Follow-up JAMA 2002: Framingham data. Tehran Arrhythmia Center

  8. Hypertension as a Risk Factor Hypertension is a significant risk factor for: • cerebrovascular disease • coronary artery disease • congestive heart failure • renal failure • peripheral vascular disease • dementia • atrial fibrillation Tehran Arrhythmia Center

  9. High blood pressure Tobacco High cholesterol Underweight Unsafe sex High BMI Physical inactivity High mortality, developing region Lower mortality, developing region Developed region Alcohol Indoor smoke from solid fuels Iron deficiency 0 1 2 3 4 5 6 7 8 Attributable Mortality (In millions; total 55,861,000) Proportion of deaths attributable to leading risk factors worldwide (2000) Ezzati et al. WHO 2000 Report. Lancet. 2002;360:1347-1360. Tehran Arrhythmia Center

  10. Multiple Risk Factor Intervention Trial (MRFIT); n=347,978 men. Neaton et al. Arch Intern Med 1992;152:56-64 Blood Pressure and Risk of CAD Mortality Tehran Arrhythmia Center

  11. Multiple Risk Factor Intervention Trial (MRFIT); n=347,978 men. Neaton et al. In: Laragh et al (eds). Hypertension: Pathophysiology, Diagnosis, and Management.2 ed. NY: Raven, 1995:127 Blood Pressure and Risk of Stroke Mortality Tehran Arrhythmia Center

  12. Impact of High-Normal Blood Pressure on the Risk of Cardiovascular Disease CUMULATIVE INCIDENCE OF CV EVENTS IN MEN WITHOUT HYPERTENSION ACCORDING TO BASELINE BLOOD PRESSURE mmHg (130-139) (121-129) (< 120) N Engl J Med 2001;345:1291-7 Tehran Arrhythmia Center

  13. CAD Death Rate per 10,000 Person-years 80.6 48.3 43.8 38.1 37.4 34.7 31.0 25.3 25.8 25.2 24.9 24.6 23.8 160+ 16.9 13.9 12.6 12.8 11.8 20.6 140-159 10.3 11.8 8.8 8.5 9.2 120-139 Systolic BP (mmHg) <120 100+ 90-99 80-89 75-79 70-74 <70 Diastolic BP (mmHg) Neaton et al. Arch Intern Med 1992; 152:56-64. Effect of SBP and DBP onAge-Adjusted CAD Mortality: MRFIT Tehran Arrhythmia Center

  14. We CAN make a difference! • Over 10 years, prevent one death in every 11 patients whose SBP is lowered by 12mmHg. • Effective treatment can decrease: • Heart failure by 50% • CVA by 35-40% • MI by 25% Tehran Arrhythmia Center

  15. Benefits of Treating Hypertension • Younger than 60 • reduces the risk of stroke by 42% • reduces the risk of coronary event by 14% • Older than 60 • reduces overall mortality by 20% • reduces cardiovascular mortality by 33% • reduces incidence of stroke by 40% • reduces coronary artery disease by 15% Tehran Arrhythmia Center

  16. Cardiovascular mortality Cardiovascular events Staessen et al. Lancet 2001;358:1305-15. Correlation Between Reduction in SBP and Cardiovascular Mortality or Events Tehran Arrhythmia Center

  17. We are not doing a good job… • 70% of those with HTN are aware of their diagnosis • 59% of those with HTN are treated • 34% of those with HTN are treated to a SBP < 140 Tehran Arrhythmia Center

  18. Hypertensive patients who are treated and BP controlled Hypertensive patients who are treated but BP uncontrolled 13% 9% 21% Diabetic patients who are treated and BP controlled 43% 22% Patients who are aware but remain untreated and BP uncontrolled Hypertensive patients who are unaware Joffres et al. Am J Hyper 2001;14:1099 –1105 The Challenge In Canada 22% of Canadians 18-70 years of age have hypertension 50% of Canadians >65 years of age have hypertension Tehran Arrhythmia Center

  19. Results of a survey on awareness on hypertension (Canada 2002) 67% of aware hypertensive patients believe that their BP was their own primary responsibility Two thirds of these patients stated that high BP was not a serious concern. Thus the mandate to improve public awareness of the consequences of hypertension is clear. Tehran Arrhythmia Center

  20. BP Control Rates Trends in awareness, treatment, and control of high blood pressure in adults ages 18–74 Sources: Unpublished data for 1999–2000 computed by M. Wolz, National Heart, Lung, and Blood Institute; JNC 6. Tehran Arrhythmia Center

  21. Tehran Arrhythmia Center

  22. BP MEASUREMENT Which of the following factors can lower blood pressure readings? A)Obese extremities B)Caffeine ingestion C)Narrow BP cuff D)Supporting the patient’s back http://www.mco.edu/org/whl/images/belissi.jpg Tehran Arrhythmia Center

  23. BP MEASUREMENT Answer: D)Supporting the patient’s back • relaxes the body, lowering BP an avg of 8 mmHg SBP and DBP Obese extremities Caffeine ingestion can result in false Narrow BP cuff elevations Tehran Arrhythmia Center

  24. BP MEASUREMENT • Measurement of BP should be obtained: • In all adults (age >18) at each visit • > 30 minutes after use of nicotine or caffeine • After 5 minutes of rest with arm supported at heart level • With appropriate sized cuff • bladder should encircle 80% of the arm Tehran Arrhythmia Center

  25. BP MEASUREMENT • Measurement of BP should be obtained: • 2X, >2min apart • repeat if >5 mm pressure difference • Seated, feet flat on floor • Back and arm supported, Arm at heart level • Manual mercury sphygmomanometer or Recently calibrated aneroid manometer or Validated automated device (JNCVI and VII) Tehran Arrhythmia Center

  26. Blood Pressure Assessment:Patient preparation and posture Standardized technique: Patient 1. No caffeine in the preceding hour. 2. No smoking or nicotine in the preceding 15-30 minutes. 3. No use of substances containing adrenergic stimulants such as phenylephrine or pseudoephedrine (may be present in nasal decongestants or ophthalmic drops). 4. Bladder and bowel comfortable. 5. Quiet environment. Comfortable room temperature. 6. No tight clothing on arm or forearm. 7. No acute anxiety, stress or pain. 8. Patient should stay silent prior and during the procedure. Tehran Arrhythmia Center

  27. Blood Pressure Assessment:Patient preparation and posture Standardized technique: Posture The patient should be calmly seated for at least 5 minutes, with his or her back well supported and arm supported at the level of the heart. His or her feet should touch the floor and legs should not be crossed. The patient should be instructed not to talk prior and during the procedure. Tehran Arrhythmia Center

  28. Blood Pressure Assessment:Patient position Tehran Arrhythmia Center

  29. Recommended Technique for Measuring Blood Pressure Standardized technique: • Use a mercury manometer or a recently calibrated aneroid or a validated electronic device. • Aneroid devices should only be used if there is an established calibration check every 6-12 months. Tehran Arrhythmia Center

  30. Recommended Technique for Measuring Blood Pressure Electronic oscillometric devices: • Use a validated electronic device according to BHS, AAMI or IP standards. • For self blood pressure measurement devices, a logo on the packaging ensures that this type of device and model meets the international standards for accurate blood pressure measurement. Office Home / Self AAMI=Association for the Advancement of Medical Instrumentation; BHS=British Hypertension Society; IP: International Protocol. Tehran Arrhythmia Center

  31. Recommended Technique for Measuring Blood Pressure (cont.) Select a cuff with the appropriate size Tehran Arrhythmia Center

  32. Cuff size Tehran Arrhythmia Center

  33. Recommended Technique for Measuring Blood Pressure (cont.) • Locate brachial and radial pulse • Positioncuff at the heart level • Arm should be supported Tehran Arrhythmia Center

  34. Recommended Technique for Measuring Blood Pressure (cont.) • To exclude possibility of auscultatory gap, increase cuff pressure rapidly to 20-30 mmHg above level of disappearance of radial pulse • Place stethoscope over the brachial artery Tehran Arrhythmia Center

  35. Recommended Technique for Measuring Blood Pressure (cont.) • Drop pressure by 2 mmHg / sec • Appearance of sound (phase I Korotkoff) = systolic pressure • Record measurement • Drop pressure by 2 mmHg / beat • Disappearance of sound (phase V Korotkoff) = diastolic pressure • Record measurement • Take 2 blood pressure measurements, 1 minute apart Tehran Arrhythmia Center

  36. Korotkoff sounds 200 No sound 180 Clear sound Phase 1 160 Muffling Phase 2 Auscultatory gap No sound 140 120 Muffled sound Phase 3 100 Muffled sound Phase 4 80 60 Possible readings: No sound Phase 5 40 184 / 100 136 / 100 20 184 / 86 = correct 136 / 86 0 mm Hg Recommended Technique for Measuring Blood Pressure (cont.) Systolic BP Diastolic BP Tehran Arrhythmia Center

  37. Recommended Technique for Measuring Blood Pressure Standardized technique: • For initial readings, take the blood pressure in both arms and subsequently measure it in the arm with the highest reading. • Thereafter, take two measurements on the side where BP is highest. Tehran Arrhythmia Center

  38. Recommended Technique for Measuring Blood Pressure (cont.) Record the blood pressure to the closest 2 mmHg on the manometer as well as the arm used and whether the patient was supine, sitting or standing. Tehran Arrhythmia Center

  39. Recommended Technique for Measuring Blood Pressure (cont.) • Avoid digit preference for five (5) or zeros (0) by not rounding up or down. • Record the heart rate. Tehran Arrhythmia Center

  40. Blood pressure measurement with specific devices • Mercury Blood Pressure Monitor • Aneroid Blood Pressure Monitor • Electronic Blood Pressure Monitor Tehran Arrhythmia Center

  41. Blood Pressure Measurement with Mercury Blood Pressure Monitor • The patient should be calmly seated for at least 5 minutes, with his or her back well supported and arm supported at the level of the heart. His or her feet should touch the floor and legs should not be crossed. The patient should be instructed not to talk prior and during the procedure. • The column of mercury must be vertical, and at the observers eye level • Use a cuff with the appropriate size • Estimate the systolic beforehand: • a) Palpate the brachial artery • b) Inflate cuff until pulsation disappears • c) Deflate cuff • d) Estimate systolic pressure • Inflate to 30mmHg above the estimated systolic level needed to occlude the pulse • Place the stethoscope diaphragm over the brachial artery and deflate at a rate of 2-3mm/sec until you hear regular tapping sounds. Measure systolic (first sound) to nearest 2mmHg • Deflate at a rate of 2-3mm/heart beat until disappearance. Measure diastolic blood pressure to nearest 2mmHg. Tehran Arrhythmia Center

  42. Blood Pressure Measurement with Aneroid Blood Pressure Monitor Aneroid devices should not be used if there is not an established calibration check every 6-12 months. Tehran Arrhythmia Center

  43. Blood Pressure Measurement with Electronic Blood Pressure Monitor • The patient should be calmly seated for at least 5 minutes, with his or her back well supported and arm supported at the level of the heart. His or her feet should touch the floor and legs should not be crossed. The patient should be instructed not to talk prior and during the procedure. • The arm must be supported • Ensure no tight clothing constricts the arm • Use a cuff with the appropriate size • Place the cuff on neatly with the indicator mark on the cuff over the brachial artery • Most monitors will automatically inflate and re-inflate at the appropriate level • Take two blood pressure measurements one minute apart • Record measurement as displayed Tehran Arrhythmia Center

  44. Recommended Technique for Measuring Blood Pressure (cont.) The seated blood pressure is used to determine and monitor treatment decisions. The standing blood pressure is used to test for postural hypotension, if present, which may modify the treatment. Tehran Arrhythmia Center

  45. Blood Pressure Assessment:Patient preparation and posture Standing position For patients over age 65, diabetics and patients being treated with antihypertensives, check if there are postural changes while taking blood pressure reading, i.e. after one to five minutes in the standing position and under circumstances when the patients complains of symptoms suggestive of hypotension. Tehran Arrhythmia Center

  46. Home/Self measurement of blood pressure Beyond diagnosis, Home/Self BP measurement may also be considered for selected patients for the management of hypertension Which patients? • Non adherence • Hypertension and diabetes • Office-induced blood pressure elevation(white coat effect) Further assess using 24-h ambulatory blood pressure monitoring If office BP measurement is elevated and Home BP is normal Daytime average BP over 135/85 mm Hg should be considered elevated Tehran Arrhythmia Center

  47. Suggested Protocol for Home (Self) Measurement of Blood Pressure Home blood pressure values should be based on: • duplicate measures, • morning and evening, • for an initial 7-day period. Singular and first day home BP values should not be considered. For patients treated for hypertension Morning measurement should be done before medication taking Tehran Arrhythmia Center

  48. BP MEASUREMENT • Self measurement of BP • Avg BP > 135/85at home = HTN • Wrist and finger manometers are not recommended http://www.familymedshop.com/prod_img/pc0007.jpg Tehran Arrhythmia Center

  49. Ambulatory BP Monitoring:Specific Role in Selected Patients Which patients? Those with suspected office-induced BP elevation • Untreated • Mild to moderate clinic BP elevation and without target organ damage • Treated patients • Blood pressure that is not below target values despite receiving appropriate chronic antihypertensive therapy • Symptoms suggestive of hypotension • Fluctuating office blood pressure readings Tehran Arrhythmia Center

  50. Ambulatory BP MonitoringSpecific Role in Selected Patients How to ? Use validated devices How to interpret? Average daytime ambulatory blood pressure >135/85 mmHg is considered elevated A drop in nocturnal BP of <10% is associated with increased risk of CV events Tehran Arrhythmia Center

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